Studydroid is shutting down on January 1st, 2019

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How do you diagnose patients with PCOS? (3) *
Patients need 2 of 3 of the following:
  • Oligo/amenorrhea
  • Clinical or lab evidence of elevated androgens
  • Polycystic ovaries on ultrasound 
What are other causes of irregular periods (and/or other symptoms of PCOS)? (4) *
  • In other words, what do we need to rule out?
  • Congenital Adrenal Hyperplasia
  • Cushing's Syndrome (clinical signs and AM cortisol)
  • Hyperprolactinemia (galactorrhea, elevated prolactin)
  • Hypothyroidism (TSH)
What symptoms do patients complain of in PCOS? (4) *
  • Infertility
  • Hirsutism/male pattern baldness
  • Acne
  • Irregular cycles
Explain the mechanism of the acne and hirsutism in PCOS.
There are excess androgens in patients with PCOS.
  • Androgens lead to hirsutism and acne 
The pathogenesis is not simple or fully understood in PCOS.
  • What hormones are elevated in PCOS? (3) *
The following hormones are elevated:
  • LH
  • Androgens
  • Insulin
What is a key pathological change relating to GnRH that is the primary cause of PCOS? *
Rapid GnRH pulsatility
  • The fact that it is rapid seems to preferentially cause an increased production of LH 
How does the increased LH due to rapid GnRH pulsatility cause problems in PCOS? *
The LH causes preferential stimulation of Theca cells. This leads to excess androgens.
  • Recall that Theca and Granulosa cells work together.
  • Theca cells create androgens (ie. androstenedione) and granulosa cells produce estrogens (ie. estradiol) via aromatases.
  • In PCOS, the ability of the aromatases to keep up with the androgen substrate is exceeded
How does insulin contribute to PCOS? (2)
  • Works synergistically with LH to increase theca cell androgen production
  • Decerases sex-hormone binding globulin to increase circulating testosterone
Do we known which of the following elements of PCOS causes the disease?
  • Elevated insulin
  • Abnormal GnRH pulsatility
  • Abnormal theca cells
Trick question!
  • Nobody knows what is the originating factor
  • Nobody knows exactly what causes it
What causes PCOS in terms of epidemiology?
Unknown
  • Some genes contribute
  • Intrauterine environment may contribute 
Are patients with PCOS fertile?
  • Explain 
No
  • They are not ovulating 
Why are patients with PCOS not ovulating?
  • Explain 
The excess androgens stop ovulation
  • Mechanism is unknown 
For PCOS in an overweight patient, what is the first line of treatment?
Weight loss!
What is the gold standard test to see if a woman is ovulating?
Mid-luteal progesterone test
There are 3 phases, which one is fixed in length?
  • Follicular
  • Ovulation
  • Luteal 
Luteal phase is fixed length of approximately 14 days
  • Follicular phase may be somewhat variable in length 
What is the 1st line medication for PCOS?
Clomiphene citrate
How does clomiphene work?
  • Blocks estrogen feedback at hypothalamus (acts as an anti-androgen)
  • Causes hypothalamus to release more FSH which may lead to ovulation 
How can you medically induce a period?
10 days of progesterone
Besides clomiphene, what is a medication that you can use to treat insulin-related issues in PCOS?
Metformin
How does metformin work in PCOS? (1)  *
  • Give the mechanism of action of metformin in general as well (3) 
Reduces insulin levels which decreases the effect of LH on theca cells
  • Decreases hepatic glucose production
  • Decrease intestinal flucose absorption
  • Increases insulin sensitivity
Explain the outcomes when combining clomiphene and metformin
  • Clomiphene + Metformin are better than metformin alone for causing pregnancy
  • Metformin alone does not seem to cause pregnancy effectively on its own
Besides clomiphene, what are other options for PCOS? (3)
  • FSH injections
  • IVF
  • Ovarian drilling 
What are medications in PCOS specifically for the androgen-related symptoms?
  • Oral contraceptives
  • Anti-androgens
What are benefits of OCPs in PCOS patients who are not trying to conceive? (3)
  • Regulates cycles
  • Reduces hirsutism/acne
  • Contraceptive
What are estrogen levels like in a chronic PCOS patient? *
  • Estrogen levels are at a sort of "medium" basal level for very long periods of time
  • They do not go up and down as in a normal menstrual cycle 
What is the serious health risk associated with chronic basal level of estrogen? *
  • Explain 
  • Very thick endometrial layer
  • This can lead to cancer

Women with PCOS should be given OCPs or progesterone so they cycle at least every 3 months
What are 3 very important medical conditions that must be monitored in every PCOS patient?
  • Hypertension
  • Dyslipidemias
  • Type II DM
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