D. Polycystic ovary syndrome Explanation

Polycystic ovary syndrome (PCOS) would fit the best among the answers. Cushing’s
would be a consideration here as it can sometimes cause amenorrhoea too.

FSH LH OESTRADIOL PROLACTIN TABLE

Polycystic ovary syndrome
Slowly progressive symptoms, hirsutism, acne, oligomenorrhoea or amenorrhoea,
weight gain, reduced fertility

• Serum Oestradiol: Normal to mildly increased

• Serum AMH: Increased

• Serum TSH: Normal

• Serum Prolactin: Normal to mildly increased

• Serum Dehydroepiandrosterone (DHEAS): Increased

• Total Serum Testosterone: Increased

• Pelvic Ultrasound: Polycystic ovaries

Premature ovarian insufficiency (Premature ovarian failure)
Menopausal symptoms and elevated gonadotropin levels before the age of 40 years

• Serum FSH: Increased → Diagnostic criteria: An elevated FSH level > 25 IU/l on
  two occasions > 4 weeks apart
• Serum LH: Increased
• Serum oestradiol: Decreased

Prolactinoma
Galactorrhoea, amenorrhoea or oligomenorrhoea, headache or visual disturbances →
Bitemporal heminanopsia
 MRI brain: Pituitary tumour
 Serum prolactin: Extremely increased (> 5000 mU/L) is highly suggestive of
prolactinoma
 Serum FSH: Decreased
 Serum LH: Decreased
 Serum Oestradiol: Decreased
Anorexia nervosa
Low BMI, pathological desire for thinness, normal secondary sexual characteristics,
normal external and internal genitalia
 Serum FSH: Decreased to normal
 Serum oestradiol: Decreased
 Serum AMH: Decreased to normal
 Serum TSH: Normal
 Serum Prolactin: Normal
 Pelvic Ultrasound: Thin endometrial stripe
Sheehan’s syndrome
Severe obstetric haemorrhage, hypotension, and shock with postnatal
panhypopituitarism caused by necrosis of pituitary gland. Nausea, vomiting, lethargy,
failure to breastfeed (agalactorrhoea), postural hypotension. Late features:
Hypothyroidism features, adrenal crisis (with skin depigmentation)
 Serum FSH: Decreased
 Serum Oestradiol: Decreased
 Serum TSH: Decreased
 Serum T4: Decreased
 Serum Prolactin: Decreased
 Serum Growh hormone: Decreased
 Serum ACTH: Decreased
 Serum Sodium: Decreased
 Serum Cortisol: Decreased
 MRI Brain: Sella empty or filled with CSF, pituitary gland may be small
Congenital adrenal hyperplasia (non-classic)
Presents with hyperandrogenism in late childhood to early adult life. Obesity, hirsutism,
acne, weight gain, history of premature pubarche, oligomenorrhoea or amenorrhoea,
infertility
 Serum 17-hydroxyprogesterone (17-OHP) fasting levels > 200 nanograms/dL (>
6.06 nanomol/L)
 Total Serum Testosterone: Increased
 Serum DHEAS: Increased
 Serum FSH: Normal
 Serum LH: Normal

 Serum TSH: Normal
 Serum Prolactin: Normal
 Serum Oestradiol: Normal to increased
POLYCYSTIC OVARIAN SYNDROME (PCOS)
Polycystic ovary syndrome (PCOS) is a complex endocrine disorder with clinical
featuresthat include hirsutism and acne (due to excess androgens), oligomenorrhoea
oramenorrhoea, and multiple cysts in the ovary.
Symptoms:
 Oligomenorrhoea or amenorrhoea
 Hirsutism
 Alopecia
 Obesity
 Acne
 Subfertility
Diagnosis → Rotterdam consensus criteria
Two out of three of the following criteria being diagnostic of the condition:
1.Ultrasound → polycystic ovaries (either 12 or more follicles or increased ovarian
volume
2. oligo-ovulation or anovulation
3. clinical and/or biochemical signs of hyperandrogenism
Around 20% of women have the appearance suggestive of polycystic ovaries on
ultrasound but unless they fulfill the criteria of PCOS, they should not be treated
Biochemical abnormalities
 Hyperadrenogenism → Biochemical hyperadrogenism is considered an elevated
free androgen index (FAI) of more than 5
 Hyperinsulinemia
 Increase in serum LH
General management
• Weight loss
Management for menstrual irregularities
• Weight loss
•Combined oral contraceptive pills, cyclical progestogen or levonorgestrel intrauterine
system.
Management of infertility
• Weight loss → weight loss alone may achieve spontaneous ovulation
• Clomifene Citrate
•If clomifene citrate fails, add on metformin or gonadotrophins or Laparoscopicovarian
drilling
Note regarding metformin:
 The RCOG published an opinion paper in 2008 and concluded that on current
evidence metformin is not a first line treatment of choice in the management of
PCOS

 Metformin is however still used, either combined with clomifene or alone,
particularly in patients who are obese
 The rationale behind metformin use is that it improves insulin sensitivity and
reduces hyperinsulinaemia
 Metformin is not currently licensed for PCOS