What advice will you give a 34-year-old, well-educated woman with PCOS about (a)
her fertility (6 marks) and (b) the wider health implications of her condition?
(14 marks)
Common mistakes
● Discussing:
● Infertility in PCOS
● Irregular periods, and how to manage them
● Acne and hirsutism, and how to manage them
● Ovulation induction in women with PCOS
● The patient did not present with specific symptoms (so do not state that this will
depend on her symptoms)
● Do not advise on contraception and other related problems
A good answer will include some or all of these points
(a) What advice will you give a 34-year-old, well-educated woman with PCOS about her
fertility? (6 marks)
● Periods – vary from normal to irregular and amenorrhoea
● Anovulation – may struggle to become pregnant; if oligomenorrhoea – may take long to
become pregnant
● May require assistance for induction of ovulation – medical/surgical
● Increased risk of miscarriage
● Increased risk of gestational diabetes and, if obese, related complications
(b) What advice will you give a 34-year-old, well-educated woman with PCOS about the
wider implications of her condition? (14 marks)
● Insulin resistance, resulting in impaired glucose tolerance and diabetes mellitus
● Need to be aware of early symptoms of diabetes mellitus and make regular check-ups
with GP and check urine
● Ischaemic heart disease due to abnormal cholesterol metabolism:
● General health advice – adequate and regular exercise
● Dietary – aim to reduce cholesterol levels
● Early warning signs of heart disease/attacks
● Hypertension – increased risk:
● Regular blood pressure check
● Persistent headaches need to be checked
● Malignancies:
● Endometrial carcinoma:
● Menstrual disorders – educate on the relevance of this as a symptom of
cancer/hyperplasia:
● Perimenopausal irregular vaginal bleeding
● Postmenopausal bleeding
● Breast cancer:
● Inconclusive evidence; however, obesity, hyperandrogenism and infertility are
risk factors for breast cancer. Syndrome per se may not be associated with an
increase but watchful vigilance is required
● Regular breast examination and mammography
● Ovarian cancer:
● Most likely to be related to ovulation-induction drugs rather than the condition
per se
● Those who have had infertility treatment must be followed up with a high index
of suspicion since symptoms of ovarian cancer are vague and non-specific
● Excessive weight gain:
● Dietary control
● Regular exercises
Sample answer
(a) What advice will you give a 34-year-old, well-educated woman with PCOS about her
fertility? (6 marks)
She may conceive spontaneously but because of oligomenorrhoea/amenorrhoea, this may take
longer, if it happens at all. Even if she did conceive, there is an increased risk of spontaneous
miscarriages, especially in the first trimester. Ovulation induction with different agents,
including weight loss and laparoscopic drilling of the ovaries, will significantly improve her
fertility. Although the ovulation rate with most of the regimens is high, pregnancy rates are
much lower and she will be at an increased risk of multiple pregnancies and ovarian hyperstimulation syndrome. During pregnancy, she is at risk of developing gestational diabetes and,
if obese, the complications thereof.
(b) What advice will you give a 34-year-old, well-educated woman with PCOS about the
wider implications of her condition? (14 marks)
She is at increased risk of cardiovascular disorders. These include hypertension and ischaemic
heart disease. Abnormal cholesterol metabolism is responsible for this increased risk.
Therefore, the advice for the patient will relate to early warning signs of hypertension and
ischaemic heart disease. These include headaches, easy fatigability, shortness of breath and
precordial chest pain. It is important that she reduces cholesterol in her diet and visits her GP
regularly. Her GP must be informed of these increased health risks and monitor the patient’s
blood pressure and cholesterol levels and examine her cardiovascular system regularly.
She is also at an increased risk of developing insulin resistance. This is due to hyperandrogenism and insulin-like growth factors in PCOS. She must therefore be educated on the early
symptoms of diabetes mellitus, such as polyuria, polydypsia and polyphagia. In addition, she
must attend her GP clinic regularly for urine testing and occasional blood-glucose estimation.
An important complication of PCOS is the development of endometrial cancer. In educating this patient, it is important to be extremely sensitive and cautious as she could become
unnecessarily alarmed. Irregular periods are a recognised symptom of PCOS and may also be
a presentation for endometrial cancer; PCOS is one condition in which endometrial cancer
may occur before menopause. Therefore, it is important for the patient to visit her GP if any
unusual vaginal bleeding occurs and ultrasound scans should be performed and endometrial
biopsies taken. Early referral for hysteroscopic assessment of the endometrium would be
highly recommended to her GP.
Obesity is an important consequence of this condition. Appropriate dietary and exercise
advice should be offered whether or not she is obese. Weight loss will not only reduce the risk
of the other wider health issues, such as hypertension and endometrial cancer, but will also
reduce the risks of diabetes.
Finally, the advice this patient will be given will need to be reinforced by information she
receives from her GP and from information leaflets about the wider health implications of this
common endocrine condition
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