QuestionSBA
QuestionChoice
The progestogen-only subdermal implant contains etonogestrel, which, although is less androgenic than levonorgestrel, can also have the side effect of causing or worsening acne. In addition, a common side effect of the contraceptive implant is irregular bleeding, which may be unacceptable to this woman.
49819
c
Progestogen-only subdermal implant
QuestionChoice
There may be an increased risk of acne worsening with the levonorgestrel-releasing intrauterine system. In addition, the levonorgestrel-releasing intrauterine system is associated with irregular menstrual bleeding or spotting, which may be unacceptable for this woman.
49821
e
Levonorgestrel-releasing intrauterine system
QuestionChoice
Most women with acne find that their skin improves when they take the combined oral contraceptive pill, however different formulations have different effects. Co-cyprindiol (ethinylestradiol and cyproterone) has anti-androgenic properties, and is licenced for treating acne in women who have not responded to antibiotics. Levonorgestrel has androgenic properties and may worsen acne.
49817
a
A combined oral contraceptive pill containing ethinyloestradiol and cyproterone acetate
QuestionChoice
Levonorgestrel has androgenic properties, so may make acne worse. In addition, progestogen-only pills can often result in irregular bleeding. The stem of the question states she started the combined oral contraceptive pill to regulate menstrual bleeding, so this side effect may be unacceptable.
49818
b
A progestogen-only pill containing 30 micrograms levonorgestrel
QuestionChoice
The copper intrauterine device will not have any effect on acne, as it does not contain any hormones. The copper intrauterine device is associated with increased menstrual blood flow, which may be an unacceptable side effect in a woman who had started the combined oral contraceptive pill for menorrhagia.
49820
d
Copper intrauterine device
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/)
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980
Polycystic ovary syndrome
Topic
26
Gynaecology
10000
A 22-year-old woman attends her general practice troubled by acne and hirsutism. On examination, she has significant pustular facial acne and facial hair. She has trialled topical and oral antibiotics; however, she feels her acne has not improved.

She has been taking a combined oral contraceptive pill containing 30 micrograms ethinyloestradiol and 150 micrograms levonorgestrel for the past six months, which she started to regulate her menstrual cycle and alleviate menorrhagia. She feels her acne has worsened since starting this.

She asks if there is a different contraceptive that she can switch to, to improve her acne.

Which of the following contraceptive options is most likely to alleviate acne?
a