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PCOS – Relevance to Health
and Fertility
Dr Sarah Wakeman
FRANZCOG, CREI
PCOS – what is it?
• Endocrine disorder affecting 8-10% women in
reproductive age group
• Diagnosis – Rotterdam criteria 2003
– 2 of 3
• Hyperandrogenism
• Irregular periods – oligo or anovulation
• Polycystic ovarian morphology on USS
• and exclusion of other related disorders such as Cushing ’ s
syndrome,congenital adrenal hyperplasia, hyperprolactinemia
and androgen-secreting tumors
PCOS – what is it?
• Diagnostic criteria
– Debated
– Androgen Excess,PCOS Society criteria
• Hyperandrogenism
• Oligo or an ovulation or PCO on USS
• Pathophysiologic defect unknown
• Insulin R exacerbates or causes
hyperandrogenism and vice versa
PCOS – Relevance to Health
PCOS presentation
• Reproductive age group
– Irregular periods
– Hirsutism
– Infertility
• Women with PCOS often have
– Impaired glucose tolerance
– Dyslipidaemia
– Increased risk Type 2 diabetes and metabolic
syndrome
PCOS presentation
• 60-80% have IR
• 95% who are obese have IR
• IGT predictor of later Type 2 diabetes and
GDM
• Obesity 30-70% - usually abdominal
PCOS in adolescents
• No definite agreed diagnostic criteria
• Hyperandrogenism and oligo or amenorrhoea
– Agreed by most that need both
– Oligomenorrhoea persisting for 2 years
– PCO on USS and irreg periods alone not enough
• Very common in young women
• Should have enlarged ovaries as well as PCO
– Important to rule out other conditions
• CAH, Cushings, inc prl, hypothyroidism, ovarian or
adrenal tumours
• Often family history of PCOS, diabetes etc
PCOS in adolescents
• Presentation
– Irregular periods
– Hirsutism,acne
– High proportion overweight or obese
• Obesity often predates anovulation and
hyperandrogenism
– HbA1C not a good screening test in adolescents
and should have OGT
• High rate of IGT, some will have Type 2 diabetes
PCOS in adolescents
• Lab tests
– Rule out other diagnoses
– Metabolic evaluation
• Testosterone, SHBG, FSH, LH, DHEAS, 17
hydroxyprogesterone, androstenedione,
TSH/T4, prl, lipids, HbA1C, OGTT, ALT and
AST
• ? Pelvic USS
PCOS after menopause
• Hyperandrogenism persists
• Insulin resistance so increased risk Type 2
diabetes
• Those with metabolic syndrome increased
risk CVS disease
– PCOS increased risk metabolic syndrome
• Unclear if PCOS associated with greater risk
CVS disease
PCOS after menopause
• No definite phenotype or diagnostic criteria
• Studies include women with history of PCOS
signs and symptoms
• Classic PCOS phenotype often improves
towards menopause
– AMH decreases, less ovarian follicles
PCOS in GP
• Diagnosis
– Excluding other conditions
• Managing current symptoms
– Menstrual problems, acne, hirsutism, infertility
• Assessing risk factors for long term problems
– Weight, BMI, waist circumference
– BP
– IGT/diabetes
– Lipids
– Endometrium – needs protection
PCOS in GP
• Endometrial protection
– Risk of endometrial hyperplasia and cancer
– If oligo or amenorrhoea
– Pelvic USS – endometrial thickness more than
7mm in early part of cycle or with low estrogen
and progesterone levels on blood test
• Need endometrial biopsy
PCOS treatment
• Weight loss, diet, exercise
– Mainstay
• Insulin sensitisers – Metformin
– For IGT,diabetes, dyslipidaemia
– Side effects – start low and increase slowly
– May assist weight loss
• COCP
– Irregular periods, endometrial protection, hirsutism
PCOS – Relevance to fertility
PCOS and fertility
• Difficulty conceiving
– Anovulation or infrequent ovulation
– Obesity
• Most common cause of ovulatory problems in
women
PCOS and fertility
• Treatment
–Lifestyle modification• Wt loss – diet and exercise
• Even small amounts of weight loss (5-
10kg) can cause big changes in
frequency of ovulation, pregnancy
PCOS and fertility
• Treatment
– 1st line ovulation induction
– Letrozole now rather than clomiphene citrate
• More single ovulations – less risk multiple pregnancy
• Higher pregnancy rates
• Off label use
– 2nd line
• Metformin
• FSH ovulation induction
• Laparoscopic ovarian drilling
• IVF
PCOS and fertility
• Overweight
– Lower chance of pregnancy
– Higher risk complications in pregnancy
• Hypertension, GDM, large baby, operative delivery, pre
term delivery
– Long term effects on child
PCOS – risks in pregnancy
• 3-4 x increased risk PIH and PET
• 3x increased risk gestation diabetes
• 2x increased risk premature delivery
• ?increased risk of miscarriage
– Debated
• Obesity – increased risk congenital
malformations in babies
PCOS – offspring health
• Probably increased risk endocrine and
cardiovascular dysfunction
– Genetic
– Environmental – pregnancy and early childhood
• If mother overweight inc risk child will be
Summary
• PCOS very relevant
– General Health
• Current
• Long term risks
– Fertility
• Current – becoming pregnant
• Pregnancy
• Future child
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