O&G SAQs · Gynaecological health — menstrual disorders and androgen excess
Polycystic ovary syndrome — structured SAQ (15 marks)
FRANZCOG-format structured SAQ on polycystic ovary syndrome: the Rotterdam criteria and exclusion of mimics, lifestyle and metabolic management with endometrial protection, the letrozole-first fertility pathway (PPCOS), and the depression/anxiety comorbidity. Per-sub-part marking rubric included.
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Prompt
A 28-year-old woman presents with oligomenorrhoea (cycles every 45 to 60 days), hirsutism, and difficulty losing weight. She is not currently seeking pregnancy. Her BMI is 33. (a) State the diagnostic criteria you would apply and the investigations you would order to confirm the diagnosis and exclude mimics. (4 marks) (b) Outline your initial management, including metabolic screening and endometrial protection. (5 marks) (c) Three years later she wishes to conceive. Describe your fertility management pathway with the first-line agent and the supporting evidence. (4 marks) (d) Describe the psychological comorbidity of PCOS and how you would address it. (2 marks)
How this SAQ is marked
Twelve SAQs, 180 marks, two 2-hour papers — roughly 15 marks and 20 minutes each. Marks come from specifics: named criteria, named agent with dose and evidence, named exclusion test, named screening test. Write in short labelled points, not prose paragraphs. Answer the sub-part you are asked. [1]
Reveal model answer and mark schemeShowHide
(a) Diagnostic criteria and investigations (4 marks)
One mark for the criteria, then one mark per investigation grouping. [1][2]
- Rotterdam criteria: any two of three — oligo/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology (or elevated anti-Mullerian hormone) — after exclusion of mimics. This woman already has oligomenorrhoea and hirsutism, so she meets two of three.[1][2]
- Exclusion panel: morning 17-hydroxyprogesterone (to exclude non-classic congenital adrenal hyperplasia), TSH, and prolactin.[7]
- Androgens: calculated free testosterone or free androgen index (preferred over total testosterone).[2]
- Ultrasound: transvaginal ultrasound for polycystic ovarian morphology — though not required if two other criteria are met; AMH can substitute in adults.[2]
(b) Initial management (5 marks)
One mark per point, maximum five. [2][4]
- Lifestyle first-line: energy-restricted balanced diet and regular physical activity for weight loss; the 2023 International Guideline emphasises healthy lifestyle, emotional wellbeing, and awareness of weight stigma.[2]
- Combined oral contraceptive pill: first-line for cycle regulation, endometrial protection, and hirsutism or acne in a woman not seeking conception.[7]
- Metabolic screening: a 75 g oral glucose tolerance test (fasting and 2-hour glucose) — women with PCOS have a higher prevalence of impaired glucose tolerance (OR 3.26) and type 2 diabetes (OR 2.87) versus controls, modified by ethnicity.[4]
- Lipid profile and blood pressure to complete the cardiometabolic assessment.
- Endometrial protection: with cycles over 90 days or prolonged amenorrhoea, protect the endometrium with the COCP or regular progestogen-induced withdrawal bleeds — endometrial cancer risk is increased (OR about 2.79, Barry).[5][2]
(c) Fertility management pathway (4 marks)
One mark per point, maximum four. The first-line agent and the PPCOS evidence are mandatory for full marks. [2][3]
- Lifestyle optimisation first, then letrozole as first-line ovulation induction, with ovulation tracking.[2]
- PPCOS evidence: the Legro 2014 trial found letrozole achieved a higher cumulative live birth rate than clomiphene — 27.5% versus 19.1% (rate ratio 1.44, 95% CI 1.10 to 1.87) — with a higher ovulation rate (61.7% versus 48.3%).[3]
- Second-line: low-dose gonadotrophins with careful monitoring and OHSS mitigation; laparoscopic ovarian drilling as an alternative.[2]
- IVF with OHSS-prevention protocols (antagonist with agonist trigger) if the above fail; counsel on the higher OHSS risk in PCOS.[2]
(d) Psychological comorbidity (2 marks)
Two marks for the evidence and the action. [6]
- The Cooney 2017 meta-analysis found women with PCOS have markedly increased odds of depressive symptoms (OR 3.78, 95% CI 3.03 to 4.72) and anxiety symptoms (OR 5.62, 95% CI 3.22 to 9.80), persisting after controlling for BMI.[6]
- Screen for depression and anxiety at diagnosis and at every visit with a validated tool (such as PHQ-9 and GAD-7), and refer to psychological support — this is a guideline recommendation, not an option.[2][6]
References7ShowHide
- [1]Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome Fertil Steril, 2004.PMID 14711538
- [2]Teede HJ, Tay CT, Laven JJE, Dokras A, Moran LJ, Piltonen TT, et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome Fertil Steril, 2023.PMID 37589624
- [3]Legro RS, Brzyski RG, Diamond MP, et al. Letrozole versus clomiphene for infertility in the polycystic ovary syndrome N Engl J Med, 2014.PMID 25006718
- [4]Kakoly NS, Khomami MB, Joham AE, et al. Ethnicity, obesity and the prevalence of impaired glucose tolerance and type 2 diabetes in PCOS: a systematic review and meta-regression Hum Reprod Update, 2018.PMID 29590375
- [5]Barry JA, Azizia MM, Hardiman PJ Risk of endometrial, ovarian and breast cancer in women with polycystic ovary syndrome: a systematic review and meta-analysis Hum Reprod Update, 2014.PMID 24688118
- [6]Cooney LG, Lee I, Sammel MD, Dokras A High prevalence of moderate and severe depressive and anxiety symptoms in polycystic ovary syndrome: a systematic review and meta-analysis Hum Reprod, 2017.PMID 28333286
- [7]Legro RS, Arslanian SA, Ehrmann DA, et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline J Clin Endocrinol Metab, 2013.PMID 24151290