PCOS/Infertility

Question 1

PCOS/Infertility workup

Scenario 1/2 - 28yo G0P0, referred by GP for irregular menses with clinical features of hyper-androgenism

Scenario 3 - 23yo primary infertility ix

Answer 1

DDx
- PCOS
- Ovarian tumor
- Adrenal tumor
- NCCAH
- Cushing’s

Ix (PI & Precon bloods)
- FBE/UEC/LFT/G&S…
- FSH/LH/E/P/PRL/TSH/AMH
- Free T/FAI/SHBG/DHEAS/17-OHP
+/- 24/24 urine cortisol
+/- dex suppression
+/- STI screen + MSU
+ Pelvic USS (AFC)
+/- HyCoSy (Tubal)

Question 2

PCOS education

Answer 2

• Dx - Rotterdam
• Fertility - anovulation
• Preg impact - GDM
• Health risk - CVD/DM/OSA
• Cancer risk - EAC
• Psych - body image

Question 3

PCOS mx

Answer 3

• Confirm Dx
• MDI - Gyn/Endo/GP/Diet/Wt mx clinic
• Short term issues
  1. Infertility (anovulation) - LOW, OI +/- IVF (BMI<35) - >=35 sig preg risk to M&F
  2. Hirsut - laser/wax/electro
  3. Acne - topical/systemic
• Long term issues
  1. CVD/Met syndrom - HbA1c/Lipid/BP
  2. EH/EAC risks - COCP/cyclical P/IUD
  (low E+4th gen P4) - COCP CI if BMI>=35
  3. OSA - sleep study
  4. Psych - body image/fertility

Weight loss mx
- lifestyle/medical- GLP1 agonist/surgical - gastric sleeve
- improve PCOS
- improve ovulatory function
- pregnancy rate
- reduce preg cx
M AN risk - GDM/PIH/PET/IOL/CS/PPH…
M PN risk - BF issues/VTE/Depression
F risk - MC/FGR/LGA/PTB/SB/SD

Refer to CREI
OI options +/- Timed IC/IUI/IVF
- letrozole (1st line)
- clomiphene + metformin (alt 1st line)
(low cost, low efficacy, no monitoring)

• FSH/hCG (2nd line) + monitoring
  (high cost, high efficacy, multiple, OHSS)
• Ovarian drilling (alt 2nd line)
  (limited facility and experience)

Preconception supplements/vax/bloods
- Folate/iodine
- Vaccinations
- Bloods + MCS