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多囊性卵巢 3

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  • Transcript

    • 1. PCOS : P oly C ystic O vary S yndrome By Kimberly Dovin, PGY3 Swedish Family Medicine January 13, 2003
    • 2. PCOS : A Disorder for the Generalist or
    • 3. PCOS: Goals
      • Identify patients with risks for or with Dx of PCOS
      • Assess patients appropriately for PCOS and associated disease states
      • Prescribe therapy to treat complaints and prevent sequelae
    • 4. PCOS: Objectives
      • Define PCOS
      • Understand pathophysiology
      • Form an appropriate differential diagnosis
      • Establish the work-up for PCOS
      • Develop an array of therapies to treat complaints and prevent bad outcomes
    • 5. PCOS: Defined? I
      • ACOG and NIH (1990): hyperandrogenism and chronic anovulation excluding other causes
      • Stein and Levanthal (1935): association of amenorrhea with polycystic ovaries and variably: hirsutism and/or obesity
    • 6. PCOS: Epidemiology
      • Prevalence: 4-6% females
        • Probably same world wide
      • No difference between blacks and whites
      • 75% of women w/ irregularity or infertility
    • 7. PCOS: Signs and Symptoms
      • SYMPTOMS
      • Menstrual irregularity
      • Infertility
      • Hirsutism, acne, etc
      • Obesity
      • SIGNS
      • Hirsutism, acne
      • Obesity
      • Ovarian enlargement
      • Acanthosis nigricans
    • 8. PCOS: Signs and Symptoms II                                                                                                        
    • 9. PCOS: Imaging and Pathology                                                                                                     
    • 10. PCOS: Pathopysiology What we think we know.
      • “ Vicious cycle”
      • Abnormal gonadotropin secretion
        • Excess LH and low, tonic FSH
      • Hypersecretion of androgens
        • Disrupts follicle maturation
        • Substrate for peripheral aromatization
      • Negative feedback on pituitary
        • Decreased FSH secreation
      • Insulin resistance, Elevated insulin levels
    • 11. PCOS: Current theories of pathopysiology Autosomal Dominant Gene Insulin Resistance PCOS GnRH LH A E2 Downstream Signal Defect A=androgens, E2=estradiol
    • 12. “ Could the theory of chaos contribute to the interpretation of pathogenesis of polycystic ovary syndrome?”
    • 13. PCOS: Case 1 - Hx
      • J.D. 31yof
      • Menstrual irregularity,LMP 5 months prior
        • Irregular since menarche
        • Getting longer over time
      • Sexually active and uses condoms
      • 40lb weight gain over past six months
      • Previous U/S w/ ovarian cysts
      • ROS: hair growth on her chin and chest
      • Meds: HCTZ, Effexor, atenolol
    • 14. PCOS: Case 1 - PE
      • BP 126/96, Weight 248lbs
      • Skin: dark hair on chin and chest, moderate to severe acne on face and back
        • no acanthosis nigricans
      • Abd-obese, tender RLQ, no R/G, no abd striae
      • Pelvic exam – nl ext genitalia no clitoromegaly, norm appearing cervix
      • Bimanual: Uterus/adnexa not palpated
      • U/S: Normal appearing ovaries
    • 15. PCOS: Differential Dx
      • Androgen secreting tumor
      • Exogenous androgens
      • Cushing’s syndrome
      • Nonclassical congenital adrenal hyperplasia
      • Acromegaly
      • Genetic defect in insulin metabolism
      • Primary hypothalamic amenorrhea
      • Primary ovarian failure
      • Thyroid dz
      • Prolactin dz
    • 16. PCOS: Case 1 Work-up
      • Total or free testosterone
      • +/- LH and FSH
      • Pelvic U/S
      • Fasting glucose
      • Fasting lipid profile
      • (SHBG, Insulin)
    • 17. PCOS: Work-up (cont’d)
      • TSH
      • Prolactin
      • UHCG
      • +/- 17-hydroxyprogesterone
      • +/- Dexamethasone suppression test
      • +/- DHEA
    • 18. PCOS: Case 1 Treatment
      • Oligomennorhea
        • OCPs, Progestins, insulin-sensitizing agents
      • Hirsutism
        • OCPs, Antiandrogens, ISAs, Eflornithine
        • Mechanical treatments
      • Obesity
        • LIFESTYLE MODIFICATIONS
        • Metformin
    • 19. PCOS: Case 1 Treatment
      • Naturopathic options
        • Flaxseed oil
        • Fish oil
        • D-chiro-inositol
        • Chromimum
        • Urtica Dioica (aka stinging nettle)
        • Saw palmetto
    • 20. Case 1: Outcomes
      • Laboratory analysis: Nl TSH and prolactin, mild elevation of testosterone, LH:FSH 3:1
      • Treatment: Diet and exercise counseling, metformin 850mg bid.
      • Patient reported resumption of menses and thereafter lost to f/u
    • 21. PCOS: Case 2 - Hx
      • R.M. 27yof
      • Desires pregnancy w/o results X 2yrs
      • LMP 2 wks ago/ 3 menses per yr
        • 2 years irregularity,
        • sometimes heavy bleeding
      • Simlar family hx
      • C/o facial hair which she waxes
      • No infertility w/u
    • 22. PCOS: Case 2 – P.E.
      • Weight 247 lbs
      • Skin: Scant facial hair on chin, no acne
      • Abd: obese
      • Pelvic: norm uterus, ovaries not palpated
      • Labs: mild elev prolactin & testosterone, elevated LH
      • Pelvic US WNL
    • 23. PCOS: Infertility
      • WEIGHT LOSS
      • Clomiphene citrate 50-100mg QD +/- dexamethasone
      • Gonadotropins
      • Metformin
      • Ovarian Drilling
    • 24. PCOS: Risks of Pregnancy
      • Gestational Diabetes?
      • Hypertension?
    • 25. PCOS: Case 2 - Outcomes
      • Metformin 500mg bid
        • Menses resumed q28 d X 2
      • Anxious to get pregnant.
        • Advised following BBTemps
        • Timing intercourse.
        • If no result in 3mos start Clomid.
    • 26. PCOS: Case 3 - Hx
      • M.P. 39yof
      • F/u acne face and back
      • C/o hirsutism, “like a beard”
      • Oligomennorhea, q60day cycles
      • G2P2 s/p BTL 14 years ago
      • ROS: weight gain 50lbs in 3-4 years
    • 27. PCOS: Case 3 - P.E.
      • BP 146/92
      • Weight 232lbs, BMI 36.3
      • Skin: Severe acne on face and back, evidence of shaving on face
    • 28. PCOS: Associated Disorders
      • Diabetes
      • Hyperlidpidemia (LDL, Triglycerides)
      • Obesity
      • Hypertension
      • CAD?
        • Incr in Risk Factors, but not mortality
    • 29. PCOS: Associated Disorders
      • Endometrial CA
      • Ovarian CA?
      • +/- Breast CA
      • NO increase in Osteoporosis
      • Eating disorders
      • Psychiatric dz
    • 30. PCOS: Case 3 Follow-up
      • TSH, Prolactin, Free Testosterone, 17-OH progesterone all WNL
      • Fasting glu = 99 LDL = 125
      • Referred to nutrition and prescribed exercise program
        • Pt lost 30lbs over one year, menses more regular, hirsutism and acne slightly improved
        • LDL dropped to 110, BP normalized
    • 31. PCOS: Conclusion
      • PCOS: chronic anovulation/hyperandrogenism
      • Complete a w/u to r/o other causes
      • Advise weight loss and exercise in all patients w/ PCOS
      • Consider medical management
      • Use a Palm memo
    • 32. Bibliography
      • Plycystic Ovary Syndrome. Clinical Management Guidelines. Dec 2002; ACOG Practice Bulletin No. 41.
      • Hunter, H., MD and Sterrett, J, PharmD. Polycystic Ovary Syndrome: It’s Not Just Infertility. AFP. Sept. 1, 2000.
      • Keri Marshall, ND Candidate 2001 Polycystic Ovary Syndrome: Clinical Considerations.
      • Macut D, et al. Cardiovascular risk in adolescent and young adult obese females with polycystic ovary syndrome (PCOS). J Pediatr Endocrinol Metab. 2001;14 Suppl 5:1353-59; discussion 1365.
      • Poretsky, Insulin Resistance and the Polycystic Ovary Syndrome: Mechanism and Implications for Pathogenesis; Endocrine Reviews 20 (4): 535-582.