chapter  7
Gynaecology, endocrinology
Pages 14

PCOS ● Management of infertility and menstrual abnormalities ● Defining hirsutism and the use of Gallwey and Ferriman classification of hirsutism ● Advising the patient to lose weight – not told that she is obese ● Treating all the associated symptoms of PCOS, e.g. menstrual abnormalities, acne, infer-

tility, obesity, etc. ● Use of trade names of very unfamiliar drugs

(a) What important clinical signs will you look for? (6 marks)

● Body habitus (height, weight): ● Signs of virilisation, and in some cases features of classic endocrine disorders –

Cushing’s syndrome or acromegaly ● Breast examination – galactorrhoea (especially if menstrual abnormalities), atrophy ● Thyroid gland – enlargement ● Abdomen and pelvis for masses – adrenal or ovarian ● Acanthosis nigricans – back of neck and vulva ● Hair distribution:

● Semi-quantitative assessment of degree of hirsutism – Ferriman-Gallwey score ● Baldness, acne

● Secondary sexual characteristics

(b) Justify the investigations you will undertake on her. (6 marks)

● Blood: ● Serum testosterone – elevated in only 40 per cent of cases:

● Mainly to exclude serious disorders of androgen secretion (e.g. congenital adrenal hyperplasia, Cushing’s syndrome, adrenal or ovarian tumours)

● Testosterone levels <3 nm/L in those with idiopathic hirsutism; levels >5 nmol/L are rare in those with PCOS

● If >5 nmol/L, further test for adrenal function must be undertaken (computerised tomography (CT)/magnetic resonance imaging (MRI))

● Sex-hormone-binding globulin ● Follicle-stimulating hormone (FSH)/luteinising hormone (LH) ● Free androgen index ● Dehydroepiandrostendione sulphate (DHEAS),

● Radiological: ● Ultrasound scan of the ovaries and adrenals; best performed in the early follicular

phase to define ovarian morphology and exclude rare tumours ● MRI/CT scan if raised testosterone

(c) Evaluate the treatment options for this young woman, if no obvious cause is found after investigating. (8 marks)

● Reassurance – especially if familiar; no treatment needed and patient feels normal ● Mechanical (cosmetic) – waxing, shaving, electrolysis, depilatory creams, bleaching and

laser; most are cheap, patient feels normal and that she does not have a disease, not medicalised

● Medical: ● Antiandrogens:

● Cyproterone acetate (CPA) alone or in combination with oestrogens (Dianette®) ● Spironolactone ● Flutamide

● Ovarian suppression: ● Combined oral contraceptive pill ● Gonadotropin-releasing hormone (GnRH) analogues

● Eflornithine hydrochroride (Vaniqa®) ● 5-Alpha-reductase inhibitor:

● Finasteride

(a) What important clinical signs will you look for? (6 marks)

Physical examination will first determine her weight, height and therefore body mass index and muscle distribution. The aim of this is to identify obesity and if present whether it is central or not. Acanthosis nigricans should be noted. Other features that may be identified on examination include those of virilisation and, in some cases, those of the classical endocrinopathies such a Cushing’s syndrome (moon-face appearance). Hair distribution and the type of hair should be noted and scored by the Ferriman-Gallwey method of semi-quantification. Any acne or degree of baldness should also be noted. All secondary sexual char-

acteristics including the Tanner stage of breast development should also be recorded. The breasts should be examined for atrophy and discharge, while the thyroid gland is examined for enlargement and features of thyrotoxicosis. Examination of the abdomen should aim to identify masses such as adrenal and ovarian, while a pelvic examination will confirm the presence of ovarian masses, which may be the source of androgens causing the hirsutism.