PCOS/Infertility

Janelle E. Hestin, PharmD

PGY-1 Ambulatory Care Resident
Harrison School of Pharmacy
Auburn University

IRAT/TRAT

1. What is the definition of secondary infertility?

a. Loss of pregnancy during the second trimester
b. Less than 25% likelihood of conception within 1 year
c. Pregnancy has not been attained by either partner in the
current or prior relationships and the couple has been
unsuccessful conceiving after 1 year of unprotected
intercourse
d. Pregnancy was attained in the current or prior relationships,
but the couple has been unsuccessful conceiving after 1 year
of unprotected intercourse

2. The role of FSH in regulating ovulation is:

a. Stimulation of release of mature follicle
b. Preparation of the endometrium for implantation
c. Maturation of the follicle
d. Suppression of GnRH release

3. Which of the following medications induces

ovulation by inhibiting conversion of androgens to
estrogen resulting in increased secretion of LH and
FSH?
a. hCG
b. metformin
c. letrozole
d. clomiphene citrate

4. The role of progesterone in female fertility is:

a. Stimulation of the release of mature follicles
b. Preparation of the endometrium for implantation
c. Maturation of the follicle
d. Suppression of GnRH release

5. For patients with PCOS who wish to become

pregnant, which medication is first-line?
a. Clomiphene citrate
b. Metformin
c. Letrozole
d. hcG

6. The initial dosing regimen for clomiphene citrate is:

a. 50mg PO daily x 5 days
b. 50mg PO BID x 14 days
c. 100mg PO daily x 5 days
d. 150 mg PO BID x 7 days

7. Although clomiphene can be used for 6 cycles,

during which cycle do 75-80% of pregnancies attributed
to clomiphene occur?
a. 3rd
b. 4th
c. 5th
d. 6th

8. Which of the following patient characteristics are

associated with PCOS?
a. Acne and hyperthyroidism
b. Alopecia and hypothyroidism
c. Amenorrhea and acanthosis nigricans
d. Large waist to hip ratio (>0.85) and
dysmenorrhea

9. Which of the following lab results would be present

in a patient with PCOS?
a. Elevated TSH and low T4
b. Low TSH and elevated T4
c. Low serum testosterone
d. High normal LH and normal FSH with a ratio >2

10. OHSS (Ovarian Hyperstimulation Syndrome) is

most common with which fertility treatment?
a. Clomiphene Citrate
b. Glucophage
c. hCG
d. Letrozole

Case Review

Case 1
AB is a 30 yowf who presents to the clinic with complaints of irregular periods. She
states that her periods have been very irregular since puberty, but it hasnt
bothered her until now. She is attempting to use a home ovulation kit in order to
assess the best time to get pregnant, but she is unable to determine her cycle
length because of the irregular nature of her periods. Her current medications
include hydrochlorothiazide 25 mg po qd and atorvastatin 40 mg po QHS.
You gather the following information from the visit:
PE: Thick, dark upper lip hair - states that she has to wax frequently
Acne Severe acne on her face and back, has had since puberty and has tried
several medications/OTC items without success.
Height: 61 inches

Weight: 210 lbs

BMI: 39.7

BP 130/85

Case 1
1. Which lab values would you need to consider when
assessing the possibility of PCOS in this patient?
a. Serum testosterone, LH and FSH, random glucose
level
b. Serum testosterone, LH and FSH, and fasting
glucose level
c. Serum testosterone, serum estradiol, fasting
glucose level
d. Serum testosterone, LH and FSH, progesterone

Differential Diagnosis

Hyperprolactinemia
Prolactin

Hypothyroidism
TSH

Congential Adrenal Hyperplasia

17-hydroxyprogesterone

Case 1
2. Which of the following treatment options would be
the best choice for this patients PCOS? Keep patient
treatment goals in mind and select all that apply.
a.
b.
c.
d.
e.

Metformin
Eflornithine
Lifestyle Changes + clomiphene
Spironolactone
Oral contraceptives

Case 1
3. True or False: If the patient stated that her
symptoms (irregular period, acne, hair growth) started
within the past month rather than at the onset of
puberty, PCOS would still be the suspected cause.
a. True
b. False

Things to Consider
Presentation of PCOS symptoms normally
occur:
At onset of puberty
Following recent weight gain

Case 1
4. Identify the correct statement regarding the
pathophysiology behind PCOS and infertility
a. Low LH inhibits follicle development
b. Low FSH inhibits follicle development
c. Too little estradiol decreases the release of
FSH
d. High progesterone increases the frequency
of menses

Case 2
Patient BC is a 30 yowf. She and her husband have been trying to have a child
for the past year and a half. Her husband has one child from a previous
marriage and she does not have any children of her own. She has had an
irregular period since puberty and has dark patches on her neck and behind the
knees. She presents to the clinic for an evaluation.
PMH: PCOS (x9 years diagnosis), hyperlipidemia, migraine headaches
Vitals: BP 145/90
PE: Dark and thick hair on neck and chinwaxes frequently; dark patches on skin behind
the knees
Height 5 2, Weight 250lbs
SH: Married x 2 years, no children of her own, one stepchild; lost job two years ago and
has struggled to find work since, has issues with income; smoker PPD for almost 2
years (attributes to stress of job loss/financial situation); irregular period since puberty
(age 13)

Case 2
5. After assessing the above information,
would you conclude that the couple is
suffering from infertility? If so, which type?
a. Yes, primary infertility
b. Yes, secondary infertility
c. No, the issue is not infertility

Case 2
6. Before she starts medication, BC is interested in
trying some non-pharmacologic strategies to help her
issue. Which of the following would you suggest for
her? Select all that apply.
a. Management of high blood pressure
b. Weight loss
c. Stress management
d. Smoking cessation

Case 2
BC returns to the clinic 6 months later. She has lost 25
pounds and has quit smoking. She states that despite
her lifestyle changes, she is still having issues getting
pregnant. The physician at the clinic decides to start
her on clomiphene to assist ovulation.

Case 2
7. The physician tells you he remembers that clomiphene helps to
induce ovulation, but cant remember the mechanism. He also cant
remember the normal dose. Before he writes the prescription, what
do you tell him?
a. 1 tablet by mouth daily for 1 month; improves endometrium quality for
better implantation after ovulation
b. 2 tablets by mouth on days 5 9 of cycle to increase LH in order to
induce ovulation
c. 1 tablet by mouth on days 5-9 of cycle for enhancement of follicle
maturation and ovulation
d. 1 tablet by mouth on days 10-15 of cycle for enhancement of follicle
maturation and ovulation

Case 2
8. BC is concerned about the potential side effects of
this new prescription. Which of the following side
effects is most likely to occur with clomiphene use?
a. Anemia
b. Vasomotor symptoms
c. Breakthrough bleeding
d. Weight gain

Case 2
9. BC completed 4 cycles of clomiphene over her past
4 menstrual cycles, but still has not had success in
conceiving. Which of the following is the best next step
in therapy?
a. Continue on clomiphene
b. Switch to metformin
c. Switch to letrozole
d. Add hCG