4: Hyperandrogenic Disorders (PCOS)

Question 1

T/F Glitazones lower glucose levels by increasing the utilization of glucose, which decreases hepatic glucose synthesis. Because of this, they are recommended when metformin does not work.

Answer 1

False. They are not recommended for use in PCOS.

Question 2

What is the hallmark feature of PCOS?

Answer 2

Menstrual irregularity

Question 3

_____ is a pure antiandrogen without progestogenic effects that has shown some benefit in treating hirsutism. Unfortunately, this medication is associated with hepatotoxicity that can cause liver failure and rarely death. It is not recommended for hirsutism treatment.

Answer 3

Flutamide is a pure antiandrogen without progestogenic effects that has shown some benefit in treating hirsutism. Unfortunately, this medication is associated with hepatotoxicity that can cause liver failure and rarely death. It is not recommended for hirsutism treatment.

Question 4

In contrast to hirsutism, circulating androgens can also cause this.

Answer 4

Alopecia

Question 5

If a virilizing tumor is suspected but an adnexal mass is not palpable, what is the procedure?

Answer 5

Transvaginal US. If no ovarian tumor is identified, adrenal CT should be performed. Routine adrenal imaging should be avoided because it can lead to unnecessary evaluation of nonfunctioning adrenal masses (incidentalomas).

Question 6

A rapid progression of which PCOS symptoms is cause for concern for a possible androgen-producing tumor?

Answer 6

1. Increased libido
2. Increased muscle bulk
3. Voice deepening
4. Breast atrophy
5. Clitoromegaly

Question 7

Why would bleeding be heavy in PCOS?

Answer 7

Bleeding is generally irregular and unpredictable, and can be heavy as a result of continuous estrogenic stimulation of the endometrium and resultant endometrial hyperplasia.

Question 8

Onset of breast development.

Answer 8

Thelarche

Question 9

How long does it take for COC use to help with PCOS?

Answer 9

The maximal effect of COCs on acne is usually observed within 2 months. In contrast, the maximal effect on hair growth may take as long as 9 to 12 months for its realization because of the length of the hair growth cycle. COCs as monotherapy may be insufficient to treat hirsutism.

Question 10

A dose of 5 mg/day is effective in treating hirsutism without engendering any adverse effects.

Answer 10

Finasteride

Question 11

T/F Insulin resistance in PCOS is a problem of obesity.

Answer 11

False. Insulin resistance occurs in both normal-weight and overweight women with PCOS, but its frequency and magnitude are increased in obese women with PCOS.

Question 12

These medications work by inhibiting gonadotropin secretion and subsequent ovarian hormone secretion, which results in not only a slowing of hair growth, but also severe estrogen deficiency.

Answer 12

Gonadotropin-releasing hormone (GnRH) analogs

Question 13

T/F Insulin resistance can contribute to hyperandrogenism.

Answer 13

True. Increased insulin levels stimulate androgen production in the ovaries, both in isolation and by potentiating LH, and suppress SHBG production in the liver. A vicious cycle is created in which the elevated androgens and insulin suppress SHBG synthesis, resulting in an increase in free testosterone, which in turn exacerbates the insulin resistance.

Question 14

T/F Women with PCOS are unable to conceive without fertility interventions.

Answer 14

False. More than half of women with PCOS are fertile (i.e., they will become pregnant within 12 months of trying), although it may take them longer to conceive.

Question 15

When would the criteria for polycystic ovaries not apply in women with PCOS?

Answer 15

Women who take COCs because they can modify ovarian morphology.

Question 16

T/F Antiandrogens are effective in the treatment of hirsutism. When used with COCs, they are more effective than either med alone.

Answer 16

True

Question 17

Why has PCOS been designated a non-modifiable risk factor for PCOS?

Answer 17

Women with PCOS have:

• 2x the odds of impaired glucose intolerance
• 4x the odds of DMT2

Question 18

Cycle length greater than 199 days.

Answer 18

Amenorrhea

Question 19

What are the major circulating androgens found in women?

Answer 19

1. Dehydroepiandrosterone sulfate (DHEA-S)
2. Dehydroepiandrosterone (DHEA)
3. Androstenedione
4. Testosterone
5. Dihydrotestosterone (DHT), which is the active metabolite of testosterone.

Question 20

What scale is used to measure hirsutism and what number corresponds with it?

Answer 20

• Ferriman-Gallwey
• 8 or greater in general
• 9 or greater for Mediterranean
• 2 or greater for Asian

Question 21

Finasteride is considered when COCs and spirolactone are ineffective for hirsutism. However, it must be used with contraceptives. What sort of teratogenic effect does it have?

Answer 21

Affect the development of the genital tract in male fetuses.

Question 22

How does SHBG play a role in PCOS?

Answer 22

The bioactivity and androgenicity of testosterone are determined by sex hormone–binding globulin (SHBG). Circulating testosterone is bound to SHBG, which is produced in the liver. It is normal for approximately 80% of circulating testosterone to be bound to SHBG, 19% to be loosely bound to albumin, and the remaining 1% to be left unbound. The unbound, free testosterone is mainly responsible for androgenicity, although the fraction associated with albumin makes some contribution to this condition. SHBG levels are increased by estrogens and thyroid hormone, and suppressed by androgens and insulin. Therefore, in the presence of high levels of thyroid hormone or estrogen, more testosterone is bound, making less biologically available. If SHBG is suppressed or androgen production increases, the amount of free (unbound) testosterone will increase without necessarily increasing the total testosterone level, and the woman may develop symptoms of hyperandrogenism. Thus, because of the interplay among SHBG, insulin, thyroid hormone, estrogen, and androgen production, the total testosterone concentration may remain in the normal range, with symptoms reflecting only the decreased binding capacity of the SHBG and the increased percentage of unbound testosterone.

Question 23

When trying to diagnose PCOS, which labs tests are necessary?

Answer 23

All women who have hyperandrogenism with ovulatory dysfunction should have:

1. serum prolactin (r/o hyperprolactinemia)
2. serum thyroid-stimulating hormone (TSH) (r/o thryoid disorders)
3. fasting lipid profile (increased risk for lipid disorders)
4. 2-hour oral glucose tolerance test (increased risk for DMT2)
5. free testosterone (some agree, some think to reserve only for mod/severe hirsutism, sudden/rapid hirsutism, and signs of virilization)
6. 17-OHP (r/o congential adrenal hyperplasia)
7. Anti-Mullerian hormone (AMH) (esp when accurate US is not available. 4.5+ ng/mL are associated with PCOS).

• Women who have hyperandrogenism signs but regular menstrual cycles should have a serum progesterone level (between days 20-24 of cycle).
• Women who have signs of Cushing syndrome (buffalo hump, moon face, abd striae) need screening: 1 mg of dexamethasone orally between 11 p.m. and 12 a.m., and then drawing a serum cortisol at 8 a.m. the next morning. Values less than 1.8 mcg/dL are considered normal.

Question 24

What are the most common side effects of metformin and which is the most serious?

Answer 24

• The most serious side effect of metformin is the development of lactic acidosis, although this is rare.
• Vitamin B12 deficiency can also occur.
• Gastrointestinal side effects, which are more common, include nausea, abdominal discomfort, diarrhea, and anorexia

Question 25

Treatment of PCOS.

Answer 25

1. Lifestyle modifications:
   
   1. Healthy diet
   2. Weight loss. Most important strategy for weight loss is decreased calories.
   3. Exercise. 30+ minutes/day.
2. Mechanical hair removal
3. Pharmacological management:
   
   1. COCs (1st-line pharm treatment)
   2. Progestins
   3. Antiandrogens (Spironolactone, Finasterid, Flutamide)
   4. Topicals (Eflornithine/Vaniqa)
   5. GnRH analogs (Leuprolide)
   6. Insulin-sensitizing agents (Metformin)

Question 26

Which is the most potent androgen?

Answer 26

Testosterone

Question 27

What is the progestin dose in PCOS?

Answer 27

• Women who need contraception can use the levonorgestrel-releasing intrauterine system (LNG-IUS), progestin-only pills (POPs), the depot medroxyprogesterone acetate injection, or the subdermal implant.
• Women who do not need contraception can take a dose of 5 to 10 mg medroxyprogesterone acetate or 200 mg micronized progesterone daily for the first 14 days of each month.
• Progestational therapy alone will not treat hirsutism, however.

Question 28

When should a woman be referred to an endocrinologist?

Answer 28

• If diagnostic testing reveals that a woman has congenital adrenal hyperplasia, HAIR-AN syndrome, Cushing syndrome, hyperprolactinemia, or androgen-producing tumors, she should be referred to an endocrinologist.
• Consultation should also be considered for women who are refractory to treatment for PCOS.
• Clinicians who are not experienced in the management of metabolic syndrome should seek appropriate consultation for treating women with PCOS who meet the criteria for metabolic syndrome.

Question 29

Premature _____ may be a consequence of hyperinsulinemia.

Answer 29

Premature adrenarche may be a consequence of hyperinsulinemia.

Question 30

Hyperandrogenism is both a complex endocrine disorder and a _____ problem.

Answer 30

Hyperandrogenism is both a complex endocrine disorder and a cosmetic problem.

Question 31

When is virilization most concerning for neoplasm?

Answer 31

If the onset is sudden or the progression is rapid.

Question 32

What is the etiology of the S/S of PCOS?

Answer 32

The symptoms of hyperandrogenism—that is, hirsutism, acne, alopecia, and frequently, anovulation—can all be traced to an increase in androgen levels, a decrease in production of SHBG, or an increase in 5α-reductase activity in the skin and hair follicles that has caused an initial stimulus to androgen-sensitive areas and subsequently acts to sustain continued sensitivity.

Question 33

S/S include:

1. hirsutism
2. acne
3. androgenic alopecia
4. menstrual irregularity
5. subfertility/infertility

Answer 33

PCOS

Question 34

What is a limitation of the Ferriman-Gallwey scale?

Answer 34

Many women with hirsutism are using a form of hair removal. Assessment of the types and frequency of hair removal methods can be more useful for assessment and follow-up of the response to therapy.

Question 35

T/F PCOS can be prevented by maintaining normal weight.

Answer 35

False. PCOS cannot be prevented.

Question 36

What is an important sequela of polymenorrhea?

Answer 36

Iron-deficiency anemia

Question 37

T/F Metformin is recommended for routine treatment in PCOS.

Answer 37

False. It should be considered for women with impaired glucose intolerance whose weight does not respond to diet and exercise or whose weight is normal, such that weight loss is not appropriate.

Question 38

Why do the ovaries produce more androgen in PCOS?

Answer 38

Most of the increased androgen production seen with PCOS occurs in the ovaries as a result of increased LH stimulation, as increased LH pulse frequency stimulates ovarian theca cell production of androgens.

Question 39

Which hormone is responsible for clinical expression of androgen stimulation in many androgen-sensitive tissues (skin, pilosebaceous unit, hair follicles)?

Answer 39

DHT. Conversion of testosterone to DHT is accomplished by 5α-reductase, an enzyme that is present in these target tissues. Racial and ethnic differences have been noted both in the number of hair follicles present on the body and in the degree of 5α-reductase activity present in the hair follicles. The sensitivity of the hair follicle to the effect of androgens depends on the degree of 5α-reductase activity and is genetically predetermined. In women who are genetically predisposed to excessive 5α-reductase activity, even normal levels of androgen can stimulate hair growth, leading to idiopathic hirsutism.

Question 40

T/F While not mandatory for diagnosis, women who have polycystic ovaries meet diagnostic criteria for PCOS.

Answer 40

False. Women who do not meet the diagnostic criteria for PCOS can have polycystic-appearing ovaries on ultrasound.

Question 41

Onset of pubic hair.

Answer 41

Adrenarche

Question 42

What types of ovulatory disfunction happen in PCOS and which is most common?

Answer 42

1. Oligomenorrhea (most common)
2. Amenorrhea
3. Polymenorrhea

Question 43

T/F Rates of depressive disorders, anxiety disorders, and binge eating are higher among women with PCOS than among those without the condition.

Answer 43

True

Question 44

T/F Insulin resistance increases the risk for both impaired glucose tolerance and type 2 diabetes.

Answer 44

True

Question 45

When would you use total instead of free testosterone testing and what does this indicate?

Answer 45

When suspicion of a tumor is present. Levels of 150 ng/dL or greater (100 in postmenopausal women) need evaluation for an androgen-producing tumor.

Question 46

Virilization presenting in pregnancy should raise the suspicion for a _____.

Answer 46

Virilization presenting in pregnancy should raise the suspicion for a luteoma—a condition that is an exaggerated reaction of the ovarian stroma to normal levels of chorionic gonadotropin and not a true tumor.

Question 47

When should endometrial biopsy be used?

Answer 47

Longstanding anovulation. The decision to perform an endometrial biopsy should not be based on a woman’s age, as endometrial cancer can be encountered in young anovulatory women. It is the duration of exposure to unopposed estrogen that is critical, rather than the woman’s age.

Question 48

What med is useful for both hirsutism and androgenic alopecia?

Answer 48

Spironolactone (antiandrogen). It works by inhibiting testosterone from binding to its receptors, thereby inhibiting its action. The usual dose is 50 to 100 mg twice daily, with the effects being dose dependent. It can take 6 months or longer to see the full clinical effect from this therapy. Side effects may include lightheadedness, dizziness, fatigue, diuresis, and increased risk of hyperkalemia. Spironolactone may also cause menstrual irregularity when used as monotherapy. Combination therapy with COCs reduces this side effect, and improves clinical response.

Question 49

Women normally produce amounts of testosterone in the range of 0.2 to 0.3 mg per day, 50% of which is derived from the peripheral conversion of _____.

Answer 49

Women normally produce amounts of testosterone in the range of 0.2 to 0.3 mg per day, 50% of which is derived from the peripheral conversion of androstenedione.

Question 50

Women with PCOS have what additional risk factors during pregnancy?

Answer 50

1. Preeclampsia
2. Gestational diabetes
3. Preterm birth

Question 51

What is the morphology of a polycystic ovary?

Answer 51

• One or both ovaries with 25 (used to be 12) or more follicles measuring 2 to 9 mm in diameter

and/or

• Increased ovarian volume of more than 10 mL

Question 52

T/F Regular menses do not rule out the possibility of oligo-anovulation.

Answer 52

True. Subclinical menstrual dysfunction, in which women have regularly occurring menses but chronic anovulation, is common in individuals with PCOS.

Question 53

Why is Eflornithine HCl 13.9% (Vaniqa) used in PCOS and what is the dose?

Answer 53

1. Facial hirsutism
2. Apply to affected areas BID. Noticable improvement in 6-8 weeks.

Question 54

What is the most common pattern of alopecia in PCOS?

Answer 54

Diffuse alopecia that includes hair loss at the vertex and crown with preservation of the frontal hairline, although bitemporal and frontal hair loss can be seen with more severe hyperandrogenemia.

Question 55

_____ is an oral antihyperglycemic agent whose primary mechanisms of action are inhibition of hepatic glucose production and increased peripheral insulin sensitivity.

Answer 55

Metformin is an oral antihyperglycemic agent whose primary mechanisms of action are inhibition of hepatic glucose production and increased peripheral insulin sensitivity.

Question 56

A product of the interaction between circulating androgens, local androgen concentrations, hormonal variables including insulin resistance, and the sensitivity of hair follicles to androgens.

Answer 56

Hirsutism

Question 57

T/F The severity of hirsutism correlates with the severity of androgen excess, and women with significant biochemical hyperandrogenemia present with obvious hirsutism.

Answer 57

False. The severity of hirsutism does not correlate with the severity of androgen excess, and women with significant biochemical hyperandrogenemia may present with only mild or no hirsutism

Question 58

T/F Though not recommended for all women with PCOS, metformin is recommended in pregnancy to help reduce the risk of gestational diabetes.

Answer 58

False. Although metformin may prove beneficial during pregnancy by reducing the risk of gestational diabetes mellitus, evidence is insufficient to recommend its routine use during pregnancy.

Question 59

How does hyperinsulinemia play a role in the etiology of PCOS?

Answer 59

By stimulating ovarian androgen production and decreasing serum SHBG concentrations. Obesity further complicates the condition by increasing insulin resistance due to excess adiposity.

Question 60

What is the recommended dose and type of COC?

Answer 60

• A COC with a 20 to 35 mcg dose of ethinyl estradiol and a nonandrogenic progestin component is recommended.
• Formulations containing desogestrel, norgestimate, or drospirenone are commonly used because of their low androgenic effects.
• Drospirenone functions as an androgen receptor agonist. Its dose in COCs (3 mg) is equivalent to approximately 25 mg of spironolactone, which may not be enough for hirsutism treatment, but should be considered if additional spironolactone is given due to the potential for hyperkalemia with such therapy

Question 61

What luteal phase progesterone level is considered oligo-anovulatory?

Answer 61

Less than 3 ng/mL

Question 62

T/F The solid luteoma is associated with a normal pregnancy and is usually bilateral.

Answer 62

False. The solid luteoma is associated with a normal pregnancy and is usually unilateral.

Question 63

While not recommended for this, why has metformin been used in the past to help with fertility?

Answer 63

Metformin has been shown to increase ovulatory frequency.

Question 64

_____ inhibits 5α-reductase activity, which blocks the conversion of testosterone to DHT in the skin.

Answer 64

Finasteride inhibits 5α-reductase activity, which blocks the conversion of testosterone to DHT in the skin.

Question 65

What is the most common source of increased testosterone?

Answer 65

Ovaries. Adrenal causes are rare.

Question 66

If the mother is virilized as a result of the luteoma, there is a 60% to 70% chance that her female fetus will show some signs of _____. The luteoma does not cause other maternal effects and regresses postpartum. Virilization may be recurrent in subsequent pregnancies

Answer 66

If the mother is virilized as a result of the luteoma, there is a 60% to 70% chance that her female fetus will show some signs of masculinization. The luteoma does not cause other maternal effects and regresses postpartum. Virilization may be recurrent in subsequent pregnancies

Question 67

Why are obese women thought to have the greatest risk for endometrial cancer?

Answer 67

Women who are obese are thought to be at the greatest risk of developing endometrial cancer because the peripheral conversion of androgens to estrogen occurs in adipose tissue.

Question 68

What is the etiology of acne in PCOS?

Answer 68

Androgen stimulation of the pilosebaceous unit can cause enlargement of the sebaceous glands and increased secretion of sebum, leading to acne.

Question 69

What is the primary precaution with antiandrogens?

Answer 69

They must be used with contraception because of their teratogenic effect.

Question 70

Which increased risk factors for CV disease occur in PCOS?

Answer 70

Women with PCOS have been found to have an excess of numerous biochemical inflammatory and thrombotic markers of cardiovascular disease, including:

1. Circulating cytokines and pro-arthrogenic factors, such as C-reactive protein, homocysteine, vascular endothelial growth factor, and plasminogen activator inhibitor-1.
2. Increased systemic inflammation associated with endothelial vascular dysfunction.
3. Higher incidence of coronary artery calcification.

Question 71

What 3 alterations cause obesity to interfere with normal ovulation?

Answer 71

1. Increased peripheral aromatization of androgens, resulting in chronically elevated estrogen concentrations
2. Decreased levels of hepatic SHBG, resulting in increased circulating concentrations of free estradiol and testosterone
3. Insulin resistance, leading to a compensatory increase in insulin levels that stimulates androgen production in the ovarian stroma, resulting in high local androgen concentrations that impair follicular development

Question 72

Two women come into your office. One has hirsutism. One has alopecia. Which one is more likely to have PCOS?

Answer 72

The woman with hirsutism. The majority of women who present with hirsutism will be found to have PCOS, whereas only 10% of women who present with alopecia alone will be found to have PCOS. Thus, isolated alopecia is not a clear marker of hyperandrogenemia.

Question 73

Approximately half of women with PCOS are obese, and obesity increases the risk for developing PCOS. Where does this obesity usually occur?

Answer 73

Typically the obesity occurs in the abdominal region (android obesity or “apple shape”), with an increase in the waist–hip ratio (WHR), as opposed to the lower body (gynoid obesity or “pear shape”).

Question 74

What causes virilization?

Answer 74

This condition may indicate the presence of one of the less common causes of hyperandrogenism, such as adrenal or ovarian tumor, congenital adrenal hyperplasia, or hyperthecosis. It may also be associated with severe hyperinsulinemia.

Question 75

Excessive terminal hair growth in women occurring in anatomic areas where the hair follicles are most androgen sensitive.

Answer 75

Hirsutism

Question 76

T/F Polycystic ovaries are a mandatory sign of PCOS.

Answer 76

False. They are not required if other diagnostic criteria are met.

Question 77

Why would PCOS cause a woman to have no idea when menses will begin?

Answer 77

Due to a lack of premenstrual symptoms, which is a clinical indicator of anovulation.

Question 78

How do DHEA-S, DHEA, and androstenedione work to cause androgenic effects?

Answer 78

DHEA-S, DHEA, and androstenedione must be converted to testosterone to cause androgenic effects.

Question 79

T/F While dyslipidemias are typically more severe in women with PCOS who have a higher body mass index (BMI), the prevalence of dyslipidemias is higher in women with PCOS regardless of BMI than in women without PCOS.

Answer 79

True

Question 80

T/F The hyperandrogenic state is associated with cardiometabolic dysfunction and psychological distress. As a result, hyperandrogenism is a driver for dyslipidemias, hypertension, diabetes mellitus, and mood disorders, in addition to infertility/subfertility and clinical signs of hyperandrogenemia.

Answer 80

True

Question 81

What is the dose for metformin and what are the contraindications?

Answer 81

• The usual dose of metformin is 1,500 to 2,550 mg per day, with the dose being started low (500 mg per day) and then gradually increased over 4 to 6 weeks.
• It is contraindicated in cases of impaired renal function, congestive heart failure, hepatic dysfunction, sepsis, or history of alcohol abuse.

Question 82

Name the 4 phenotypes of PCOS.

Answer 82

1. Androgen excess + ovulatory dysfunction
2. Androgen excess + polycystic ovarian morphology
3. Ovulatory dysfunction + polycystic ovarian morphology
4. Androgen excess + ovulatory dysfunction + polycystic ovarian morphology

Question 83

Why does PCOS increase risk of endometrial cancer?

Answer 83

Chronic, unopposed estrogen stimulation of the endometrium

Question 84

Is routine screening for insulin resistance in PCOS recommended?

Answer 84

No. Routine screening for insulin resistance is not recommended due to the lack of a uniformly accepted test.

Question 85

T/F Obesity in PCOS causes worsened outcomes.

Answer 85

True. Women with PCOS who are obese are more likely to develop impaired glucose tolerance, type 2 diabetes, hypertension, dyslipidemias, and estrogen-dependent tumors than women with PCOS who are of normal or low weight.

Question 86

A theca-lutein cyst or hyperreactio luteinalis is usually bilateral and is seen with trophoblastic disease or with _____. Maternal virilization occurs in 30% of pregnancies affected with a theca-lutein cyst, but does not carry any risk of fetal masculinization.

Answer 86

A theca-lutein cyst or hyperreactio luteinalis is usually bilateral and is seen with trophoblastic disease or with the high human chorionic gonadotropin levels associated with a multiple gestation. Maternal virilization occurs in 30% of pregnancies affected with a theca-lutein cyst, but does not carry any risk of fetal masculinization.

Question 87

T/F Women with PCOS often develop improved menstrual function with age, and evidence indicates that women with PCOS have prolonged reproductive function and increased ovarian reserve when compared to women who do not have PCOS. Age may improve other manifestations of PCOS, including ovarian morphology and serum testosterone levels.

Answer 87

True

Question 88

Which of these is not a differential diagnosis for androgen disorders?

1. PCOS
2. Adrenal hyperplasia
3. Androgen-producing tumors
4. Cardiovascular disease

Answer 88

CV disease. It is a potential sequela.

Question 89

What is the most common hyperandrogenetic and endocrinopathic condition in women of reproductive age?

Answer 89

PCOS

Question 90

T/F Menstrual irregularity is common soon after menarche but warrants investigation if it persists for more than 2 years.

Answer 90

True

Question 91

Diagnosis of PCOS is one of exclusion. What are the criteria for diagnosis according to Rotterdam (most endorsed b/c it contains broader criteria) and Androgen Excess and PCOS Society?

Answer 91

• Rotterdam:
  
  • Exclusion of other etiologies and 2/3:
    
    • Oligo- or anovulation
    • Hyperandrogenism
    • Polycystic ovaries
• Androgen Excess and PCOS Society:
  
  • Exclusion of other etiologies and both of:
    
    • Hyperandrogenism (hirsutism and/or hyperandrogenimia)
    • Ovarian dysfunction (Oligo-anovulation and/or polycystic ovaries)

Question 92

How do circulating androgens cause alopecia?

Answer 92

1. Miniaturization of androgen-sensitive scalp hair (decreased density)
2. Reduced scalp coverage (decreased volume)

Question 93

T/F Women with PCOS have increased risk for DVTs and should be carefully questioned before using COCs.

Answer 93

True. Women with PCOS should be questioned about additional risk factors for venous thromboembolism.

Question 94

Cycle length of 35-199 days.

Answer 94

Oligomenorrhea

Question 95

If a woman is experiencing virilization during pregnancy, a pelvic ultrasound can be very helpful in making the diagnosis. If a solid unilateral ovarian lesion is present, _____ is likely.

Answer 95

If a woman is experiencing virilization during pregnancy, a pelvic ultrasound can be very helpful in making the diagnosis. If a solid unilateral ovarian lesion is present, malignancy is likely.

Question 96

T/F PCOS is related to an increased risk for endometrial, breast, and ovarian cancers.

Answer 96

False. Although some data collected in earlier studies suggested the possibility of a link between PCOS and ovarian cancer, a recent meta-analysis reveals no increased risk for ovarian or breast cancer in women with PCOS.

Question 97

PCOS puts women at increased risk for which 3 diseases?

Answer 97

1. Endometrial cancer
2. DMT2
3. Cardiovascular disease

Question 98

Why is ovulation impaired in PCOS?

Answer 98

The lower FSH levels found in women with PCOS impair follicle maturation and ovulation.

Question 99

Women with PCOS have more than 3x the odds of developing metabolic syndrome. What are the diagnostic criteria?

Answer 99

Three or more of the following:

1. Waist circumference ≥ 88 cm (35 in.)
2. Triglycerides ≥ 150 mg/dL or drug treatment for elevated triglycerides
3. HDL-C < 50 mg/dL or drug treatment for reduced HDL-C
4. Systolic BP ≥ 130 mm Hg and/or diastolic BP of ≥ 85 mm Hg or drug treatment for hypertension
5. Fasting glucose ≥ 100 mg/dL or drug treatment for elevated glucose

Question 100

When do irregular cycles in PCOS usually begin?

Answer 100

Menarche, but they can occur after a regular cycle.

Question 101

Which medications might be the cause of PCOS-like symptoms instead of PCOS?

Answer 101

1. Testosterone
2. Anabolic steroids
3. Danazol
4. Certain progestins
5. Glucocorticoids
6. Valproic acid

Question 102

What are the benefits of using progestin in PCOS?

Answer 102

Prevent endometrial hyperplasia and cancer .

Question 103

What causes increased LH pulse frequency?

Answer 103

The increased LH pulse frequency is caused by increased gonadotropin-releasing hormone (GnRH) pulse frequency, which also causes follicle-stimulating hormone (FSH) levels to be at the low end of the normal range.

Question 104

_____ is characterized by clitoral hypertrophy, severe hirsutism, deepening of the voice, increased muscle mass, breast atrophy, and male pattern baldness.

Answer 104

Virilization is characterized by clitoral hypertrophy, severe hirsutism, deepening of the voice, increased muscle mass, breast atrophy, and male pattern baldness.

Question 105

Which ovulatory disfunction causes more significant endocrinopathies (more severe hyperandrogenemia, increased serum LH and cortisol levels, and increased incidence of hyperinsulinemia)?

Answer 105

Amenorrhea

Question 106

GnRH analogs may be no more effective than COCs and antiandrogens. They are expensive and require injections and estrogen therapy. Who should they be reserved for?

Answer 106

Severe hyperandrogenemia (such as ovarian hyperthecosis) that has not responded to COCs and antiandrogens.

Question 107

Primary mechanism of action is inhibition of the enzyme ornithine decarboxylase in human skin, which slows the rate of hair growth.

Answer 107

• Eflornithine HCl 13.9% (Vaniqa)
• It is not a depilatory and hair growth returns after discontinuation.

Question 108

T/F A randomized controlled trial investigated the effect of electro-acupuncture and physical exercise on hyperandrogenism and oligo-anovulation in women with PCOS and found that both low-frequency electro-
acupuncture and physical exercise improved hyperandrogenism and oligo-anovulation in women with PCOS better than no intervention, and low-frequency electro-acupuncture was superior to physical exercise.

Answer 108

True

Question 109

What are the biochemical features of women with PCOS?

Answer 109

1. Predominantly anovulatory
2. Typically maintain relatively steady levels of gonadotropins and sex steroids instead of experiencing the fluctuations in these levels characteristic of the normal menstrual cycle.
3. Serum concentrations of luteinizing hormone (LH) are higher d/t increased pulse frequency and amplitude (1 pulse/hour).
4. FSH levels are at the low end of the normal range d/t GnRH and increased estrone levels resulting from peripheral conversion of increased androstenedione.
5. Increased LH:FSH ratio.