QuestionSBA
QuestionChoice
This patient is rightly concerned about her risk of endometrial cancer - having PCOS and having two family members who developed endometrial cancer places her at high risk. It would be reasonable to refer to genetic screening to determine if she, or her family, was genetically predisposed to endometrial cancer e.g. Lynch syndrome (mutation in MLH1 mismatch repair gene) or Cowden Syndrome (Mutations in PTEN tumour suppressor gene). The priority at this stage, however, is to investigate and manage her secondary amenorrhoea, and to reassure her there are no signs of malignancy
33017
e
Refer for genetic screening
QuestionChoice
This would be a reasonable option to help regulate this patient's menstrual cycle and additionally provide hormonal contraception (although this patient did not state contraception was her main priority). It would be useful for this patient to have an ultrasound scan after a withdrawal bleed to assess the endometrium and so a short daily course of oral medroxyprogesterone would be used to achieve this. The three-monthly depo injection is less likely to induce a withdrawal bleed as quickly as a two week course of oral medroxyprogesterone because the progestogen dose is spread over a longer period of time. If the patient's ultrasound scan showed an endometrium of normal thickness and morphology, then a three-monthly progesterone injection would be an option - although the patient would not benefit from the anti-androgen effects of oestrogen within the COCP
33014
b
Intramuscular injection of medroxyprogesterone (Depo Provera) every three months
QuestionChoice
This patient does require a TVUS to assess endometrial thickness and morphology, although a withdrawal bleed would need to be induced prior to scanning to accurately measure the endometrial thickness. For this the patient should be provided with oral medroxyprogesterone (Provera) for 14 days to induce a withdrawal bleed
33015
c
Transvaginal ultrasound scan (TVUS)
QuestionChoice
This would be a reasonable option to help regulate this patient's menstrual cycle and additionally provide hormonal contraception (although this patient did not state contraception was her main priority). It would be useful for this patient to have an ultrasound scan after a withdrawal bleed to assess the endometrium and so a short daily course of oral medroxyprogesterone would be used to achieve this. The three-monthly depo injection is less likely to induce a withdrawal bleed as quickly as a two week course of oral medroxyprogesterone because the progestogen dose is spread over a longer period of time. If the patient's ultrasound scan showed an endometrium of normal thickness and morphology, then a three-monthly progesterone injection would be an option - although the patient would not benefit from the anti-androgen effects of oestrogen within the COCP
33016
d
Insertion of levonorgestrel-releasing intrauterine system (e.g. Mirena®)
QuestionChoice
The most likely cause for this patient's secondary amenorrhoea (less that one period every three months) is her PCOS. Her LH:FSH Ratio is 3.5 and so makes PCOS more likely than premature ovarian failure (elevated FSH and LH), hypothalamic/hypopituitary amenorrhoea (low FSH, LH, testosterone, and prolactin), Hypothyroidism (low or high TSH), or androgen-secreting tumour/late onset congenital adrenal hyperplasia (raised testosterone). There is nothing in the question pointing to her amenorrhoea being weight, exercise, or stress-related.
 

 She is rightly concerned about her increased risk of endometrial cancer with PCOS and amenorrhoea. This is due to prolonged exposure of the endometrium to unopposed oestrogen. She will need referral for a transvaginal ultrasound (TVUS) to assess for endometrial thickness, although prior to this she will need to induce a withdrawal bleed to correctly interpret the ultrasound findings as her endometrium will be thickened given she has not menstruated for two months. To induce a withdrawal bleed in this patient, an oral cyclical progestogen such as medroxyprogesterone is given for 14 consecutive days. Following this, a TVUS should be conducted.
 

 If endometrial thickening is present (greater than 10mm) or the endometrium has an abnormal appearance, then she will need referral for endometrial sampling to exclude endometrial hyperplasia or cancer (unlikely in this patient's case). If the endometrium is of normal thickness and appearance, then the options to reduce risk of endometrial cancer are either:
 

 - An oral cyclical progestogen e.g. medroxyprogesterone for 14 days every 1-3 months
 - Low-dose combined oral contraceptive pill (COCP)
 - Levonorgestrel-releasing intrauterine system (e.g. Mirena®)
 

 If the patient is unwilling to take these, then they would likely need regular ultrasound scans every 6-12 months to assess the endometrium
33013
a
Oral medroxyprogesterone (Provera) for 14 days
QuestionComment
bruh
9706
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Endoscope Hematoma
QuestionComment
actually a pretty clever question! its so easy to forget about the fact that you have to induce the withdrawal bleed!! 
10173
QuestionComment
shut up man
28186
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Conor  mcgregor
QuestionComment
LOOOL
28397
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Lateral Kinase
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DNA Tachycardia
QuestionComment
actually a hard question, props to the author
10751
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Kinin Biopsy
QuestionComment
YOU NEED TO SAY CYCLICAL IN THE ANSWER - IT MAKES IT LOOK LIKE IT'S JUST A ONE-OFF 14 DAY COURSE OF PROGESTERONE

16051
QuestionComment
It's meant to be a one off in this case as they're doing it is in prep for a TVUS to assess the endometrium reliably for any hyperplasia. In the future, yes she may need cyclical progesterone to reduce her future risk of cancer. 
20389
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Monoclonal Polyps
QuestionComment
m8 it is a one off...
43114
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Ale
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CT Metabolism
QuestionComment
excellent question + excellent explanations
22489
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Kinase Power
QuestionComment
do they still need to take it if they have post-menopausal bleeding?

43109
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Neoplasia Nightshift
Concept
Chapter
# Summary
  
 
Polycystic ovary syndrome (PCOS) is a disorder characterised by hyperandrogenism, ovulation disorders, and polycystic ovarian morphology. It is common among women of child-bearing age. Key signs and symptoms include oligomenorrhoea, hirsutism, acne, and subfertility among others. Investigations such as hormonal assays and imaging techniques are used in diagnosis. Management strategies encompass lifestyle modifications and a range of pharmacological treatments tailored to patient preferences, such as conception.
  
 
# Definition
  
 
Polycystic ovary syndrome (PCOS) is a disorder characterised by hyperandrogenism (manifesting as oligomenorrhoea, hirsutism, and acne), ovulation disorders, and polycystic ovarian morphology.
  
 
# Epidemiology
  
 
Polycystic ovary syndrome is a common endocrine condition, affecting up to a quarter of women during their reproductive years.
  
 
# Aetiology
  
 
The precise aetiology of PCOS remains undetermined. However, potential hormonal imbalances implicated in this syndrome include hyperandrogenism, insulin resistance, elevated levels of luteinizing hormone (LH) and raised oestrogen levels.
  
 
# Signs and Symptoms
  
 
The clinical presentation of PCOS is largely attributed to the hormonal imbalances, with symptoms including:
  
 
  - Oligomenorrhoea
  - Subfertility
  - Acne
  - Hirsuitism
  - Obesity
  - Mood changes including depression and anxiety
  - Male pattern baldness
  - Acanthosis nigricans (secondary to insulin resistance)
  
 
# Differential Diagnosis
  
 
For accurate diagnosis, other endocrine disorders presenting similar clinical features must be excluded. These include:
  
 
  - Menopause: Characterised by cessation of menstruation, hot flashes, vaginal dryness, mood changes, and sleep problems.
  - Congenital adrenal hyperplasia (CAH): Presenting with signs of androgen excess like hirsutism, acne, and irregular periods. Presents earlier on and can lead to ambiguous genitalia (for affected females). 
  - Hyperprolactinaemia: Symptoms include irregular periods, galactorrhoea, and infertility.
  - Androgen-secreting tumours: May cause virilisation, amenorrhoea, and hirsutism.
  - Cushing's syndrome: Characterised by weight gain, purple stretch marks, and easy bruising.
  
 
# Investigations
  
 
Biochemical assays and imaging techniques play a pivotal role in the diagnosis of PCOS:
  
**Bedside:**

- Clinical examination to identify features of hyperandrogenism (e.g. hirsutism) or features of insulin resistance (e.g. acanthosis nigricans, raised BMI)

**Bloods:**

- LH:FSH ratio: An increase (>2) aids in differentiating from menopause where the ratio is normal.
- Total testosterone: May be normal or slightly elevated.
- Fasting and oral glucose tolerance tests: Used to diagnose insulin resistance.
- Other tests may include TFTs (for thyroid dysfunction), 17-hydroxyprogesterone levels (for CAH), prolactin (for hyperprolactinaemia), DHEA-S and free androgen index (for androgen-secreting tumours), and 24-hour urinary cortisol (for Cushing's syndrome).

**Imaging:**

- Transabdominal and transvaginal ultrasound: Reveals increased ovarian volume and multiple cysts. May be important for fulfilling Rotterdam Diagnostic Criteria (See below) 


No **invasive tests** are required for diagnosis. 

 
 **Rotterdam Diagnostic Criteria:**
  
 
Upon exclusion of other causes, PCOS can be diagnosed if at least two of the following criteria are met:
  
 
  - Polycystic ovaries (defined as a follicle number per ovary of 20 or more in at least one ovary)
  - Oligo-/anovulation
  - Clinical or biochemical features of hyperandrogenism
  
 
# Management
  
 
The management of PCOS primarily focuses on symptom control and prevention of complications, with endometrial cancer risk reduction achieved through regular menstruation.
  
 
**Conservative:**
  
 
  - Encouragement of weight loss and exercise
  - Education on increased risks of cardiovascular disease, diabetes, and endometrial cancer
  
 
**Medical, for women not planning pregnancy:**
  
 
  - Co-cyprindrol: Reduces hirsutism and promotes regular menstruation.
  - Combined oral contraceptive pill (COCP): Decreases irregular bleeding and offers protection against endometrial cancer.
  - Metformin: Aids in regularising menstruation, reducing hirsutism, and acne.
  
 
**Medical, for women wishing to conceive:**
  
 
  - Clomiphene: Induces ovulation and enhances conception rates.
  - Metformin: Can be used alone or in combination with clomiphene to improve chances of pregnancy.
  - Gonadotrophins: Utilised to induce ovulation if clomiphene and metformin prove ineffective.

**Surgical, for women wishing to conceive:**

  - Ovarian drilling: A second-line laparoscopic surgical procedure that damages the hormone-producing cells of the ovary. 
  
# Complications


- Infertility: Caused by impaired or dysregulated ovulation.
- Metabolic syndrome and dyslipidaemia: PCOS leads to raised triglycerides and LDL and fall in HDL. 
- Type 2 diabetes: PCOS increases risk of T2DM by approximately two fold as a result of insulin resistance 
- Cardiovascular disease: This is likely a consequence of metabolic complications of PCOS and hormonal alterations. 
- Hypertension: Greater risk of hypertension seen in premenopausal as opposed to postmenopausal women. 
- Obstructive sleep apnoea: This occurs as a result of obesity (usually secondary insulin resistance and metabolic changes). 

# NICE Guidelines

[Click here for NICE guidelines on PCOS](https://cks.nice.org.uk/topics/polycystic-ovary-syndrome/)

# References 

[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/141)

[RCOG page](https://www.rcog.org.uk/for-the-public/browse-our-patient-information/polycystic-ovary-syndrome-pcos-what-it-means-for-your-long-term-health/)
920
980
Polycystic ovary syndrome
Topic
26
Gynaecology
Oral medroxyprogesterone (Provera) for 14 days
6603
Prolonged anovulation in PCOS increases endometrial cancer risk due to unopposed oestrogen
A 25-year-old woman presents with prolonged amenorrhoea, having had only three periods in the last year, with the most recent two months ago. She has a history of irregular periods since menarche and was diagnosed with polycystic ovary syndrome (PCOS) as a teenager. She has a family history of endometrial cancer in her mother and maternal aunt.


She denies abdominal pain, bloating, fatigue, early satiety, or intermenstrual bleeding. Her medical history is unremarkable, and her BMI is 21.




Urine dip is clear with negative beta-hCG.

||||
|---------------------------|:-------:|------------------------------|
|Thyroid Stimulating Hormone|2.1 mU/L|0.3 - 4.2|
|Luteinising Hormone|10.85 IU/L|1 - 11 (Luteal)|
|Follicle Stimulating Hormone|3.1 IU/L|2 - 8 (Luteal)|
|Testosterone|2.6 nmol/L|(M) 9.9 - 27.8, (F) 0.2 - 2.9|
|Prolactin|450 IU/L|(M) 90 - 320, (F) 100 - 500||



What is the best next management step for this patient?
a