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PANEL DISCUSSION MANAGEMENT OF PCOS WOMB to TOMB

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PANEL DISCUSSION
MANAGEMENT OF PCOS - WOMB to TOMB
MODERATOR : Sharda Jain
PANELISTS : Dr.Chitra setia
Dr Puneet Arora
Dr. Ila Gupta
Dr. Rupam Arora
Dr. Archana Sharma
Dr. Sangeeta Gupta
Dermatologists
Dr. V.K. Upadhyay
Dr. S. Kandhari

Published in: Health & Medicine
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PANEL DISCUSSION MANAGEMENT OF PCOS WOMB to TOMB

  1. 1. PANEL DISCUSSION MANAGEMENT OF PCOS WOMB to TOMB Dr. Sharda Jain
  2. 2. MANAGEMENT OF - WOMB to TOMB HELD ON 10/10/2014 At Wood Apple NEW DELHI Dr. Sharda Jain Organized by Delhi Gynaecologist Forum / Sheild H. Care PANEL DISCUSSION PCOS
  3. 3. MANAGEMENT OF PCOS WOMB to TOMB MODERATOR : Sharda Jain PANELISTS : Dr.Chitra setia Dr Puneet Arora Dr. Ila Gupta Dr. Rupam Arora Dr. Archana Sharma Dr. Sangeeta Gupta Dermatologists Dr. V.K. Upadhyay Dr. S. Kandhari
  4. 4. Stein1935Leventhol ESHRE /ASRM
  5. 5. IMPORTANCE OF PCOS Womb to Tomb It is NOT A DISEASE, it is a syndrome with varied presentations PCOS has a CONTINUUM SPECTRUM starting from the EARLY PREPUBERTAL YEARS and continuing after Menopause S/S peak through 2nd / 3rd decade of life But Does not become quiescent till her death
  6. 6. Why has journey From Womb To Tomb • Above average (LFD) or low birth weight for gestational age. • Premature Adrenarche, • Atypical Sexual Precocity Birth Prepubertal PCOS
  7. 7. PCOS PCOS is condition which can effect • women menstrual cycle, • Fertility • Her appearance (obesity, Acne, Hirsutism) • Hormones / Depression • Has long term health sequelae. (Morbid Co-morbidities)
  8. 8. * Obesity * Dyslipidemia *DM *Hypertension • Acanthosis nigricans , skin Tags • Fatty liver • Sleep apnoea INSULIN Resistance is the key …….finding Endometrial Carcinoma Why has journey From Womb To Tomb PCOS 4 Sibling
  9. 9. EPIDEMIOLOGY Diagnosis & Incidence Is the INCIDENCE of PCOS in Adolescents Rising or has the DIAGNOSIS Improved ? Q 1.
  10. 10. EPIDEMIOLOGY Yes, Both things are working • There is a increase in incidence of PCOS in adolescents • Secondly because diagnosis has improved from NIH-(1990) – TO ROTTERDOM(2004) – TO AES- PCOS SOCIETY DIAG.CRITERIA (2009) – many more cases are picked –up now
  11. 11. Improvement in Diagnosis of PCOS over the years NIH (1990) 1. Oligo ovulation 2. Hyperandrogenism and / or hyperandrogenemia (with exclusion of related disorders) ESHRE /ASRM (Rotterdam 2003) To include TWO OUT OF THREE of the following: 1. Oligo – or anovulation 2. Clinical and / or biochemical signs of hyperandrogenism 3. Polycystic ovarian (with exclusion of related disorders)
  12. 12. Improvement in Diagnosis of PCOS over the years AES – PCOS (2009) 1. Hyperandrogenism : hirsutism and / or hyperandrogenemia and 2. Ovarian dysfunction : oligo – anovulation and / or polycystic ovaries and 3. Exclusion of other androgen excess or related disorders
  13. 13. PCOS Definition 1990 - 2009 Hyperandrogenism (Clinical or Biochemical ) Oligo- menorrhea or Oligo-Ovulation Polycystic Ovaries on USG NIH (1990) yes yes no Rotterdam (2003) yes Yes 2 of the 3 criteria yes AE-PCOS Society (2009) yes Yes 1 of 2 criteria yes Diagnosis of Polycystic Ovarian Syndrome
  14. 14. Incidence of adolescent PCOS IF WE USE STRICTLY NIH criteria = 6-8% Rotterdam criteria = 15-25% In Indian Asian Urban Community– this number is more & seems to be rising for reasons unknown ??
  15. 15. Prevalence of PCOD In India 30-36% Girls Indian j pediatr.2012 jan;79suppl 1:s69-73 J pediatr adolesc gynecol.2011 Aug;24(4): 223-7
  16. 16. Near 18-20% (1 in 5) girls going to private schools in Delhi have PCOS (LPS) OBESE – 50% (over weight , BMI>24 & obese >27) MENSTRUAL PROBLEMS – 60% Delayed Periods Most Common Heavy Menstrual Bleeding – 20% HIRSUTISM – 60-70% ACNE – 30% DGF Survey of 2 schools 2004 EXPERIENCE
  17. 17. What are the Conditions That May Mimic PCOS ? Q 2 D/D
  18. 18. OLIGOMENORRHEA •Pregnancy •Hyperprolactinemia •Thyroid Disease •Ovarian Insufficiency DIFFERENTIAL DIAGNOSIS of PCOS Hperanrogenism Non – classic CAH Cushing syndrome Androgen – secreting tumors / ovarian hyperthecosis PCOM Non specific incidental finding has no meaning
  19. 19. • Thyroid disorders • Hyperprolactinemia • Cushing’s syndrome • Late onset congenital adrenal hyperplasia (CAH) • Basal morning 17-OHP • Ovarian and adrenal tumors DHEAS • WHO I &III –FSH,LH,E2 • Syndromes of severe insulin resistance(HAIRAN syn) Sr.TSH,Sr.PrlSr.TSH,Sr.Prl Dexa supression testDexa supression test What are the conditions that may mimic PCOS ?
  20. 20. Any Genetic or Familial Basis ? Q 3
  21. 21. Any Genetic or Familial Basis ? • FAMILY Clustering is known : Risk of PCOS • 40% - if her sister is having PCOS • 20% - if her mother suffered from PCOS • N = 5-10% GENETIC ETIOLOGY NO LAST WORD AS YET
  22. 22. Genetic & PCOS AUTOSOMAL DOMINANT pattern of inheritance Several genes namely CYP 17 CYP11A CYP21, SHBG Insulin receptor NO CONCLUSIVE RESULT TILL DATE
  23. 23. Which hormonal/blood tests are done to confirm the diagnosis of PCOS? DIAGNOSTICS – BLOOD TESTS Q4(A)
  24. 24.  Testosterone level  LH and FSH High LH & low FSH is seen in 60% cases only  TSH  Prolactin level  Fasting glucose level or 2 hr 75 gm OGTT  Lipid profile, including total, LDL,HDL  17-hydroxyprogesterone level* *--(Fasting level to r/o CAH) DIAGNOSTICS – BLOOD TESTS
  25. 25. Which tests should be done before starting insulin sensitizers – fasting / PP blood sugar, insulin, Glycosylated Hb? DIAGNOSTICS – BLOOD TESTS before METFORMIN Q4B
  26. 26. • using fasting & 2 hrs blood sugar levels following 75gm glucose load is all that is needed DIAGNOSTICS – BLOOD TESTS Insulin Levels are Really Not Needed for diagnosis of PCOS Category Fasting 2hrs PP Normal <100 mg/dl <140 mg/dl Impaired <100-126 mg/dl > 140 -199 NIDDM Over 126 Over 200
  27. 27. Q 4 C. DIAGNOSTICS - USG How is PCO and PCOM different than PCOS?
  28. 28. USGUSG CRITERIACRITERIA ofof POLYCYSTIC OVARIAN MORPHOLOGYPOLYCYSTIC OVARIAN MORPHOLOGY • Presence of 12 or more follicles in eachPresence of 12 or more follicles in each ovary , 2 - 9 mm in diameter and orovary , 2 - 9 mm in diameter and or increased ovarian volume > 10 mlincreased ovarian volume > 10 ml Or 10 cmOr 10 cm33 • Single ovary is sufficientSingle ovary is sufficient to diagnose PCOSto diagnose PCOS • Optimal time forOptimal time for ultrasound (TVS) is D3 – D5ultrasound (TVS) is D3 – D5
  29. 29. • It is a fact that PCOM ie POLYCYSTIC OVARIAN MORPHOLOGY is present in 20 -35% girls with NORMAL menstrual cycles & • In Contrast there are patients of TYPICAL PCOS who do not have PCOM on ultrasound. Q5. PCO, PCOM & PCOS
  30. 30. What are the PHENOTYPES in PCOS & what is there importance ? Q 6.
  31. 31. Four Different Phenotypes of PCOS are now identified • TYPE A: hyperandrogenism, chronic anovulation and< polycystic ovaries. • TYPE B: hyperandrogenism and chronic anovulation. • TYPE C : hyperandrogenism and polycystic ovaries • TYPE D : chronic anovulation and polycystic ovaries Hyperandrogenemia is the Hallmark of PCOS
  32. 32. Q7 SYMPTOMS Which are the COMMONEST SYMPTOMS that women with PCOS present with?
  33. 33. Three Commonest Presentation are • MENSTRUAL DISORDERS when they consult gynaecologists •OBESITY when they consult endrocrinologists •HISUITISM & ACNE when they consult dermatologist Ans. SYMPTOMS/ Management current options Co-operations / Coordination among specialists is needed in Adolescents –Management Is Specific To Clinical Symptoms
  34. 34. AcneAcne ObesityObesityHirsutismHirsutism AcanthosisAcanthosis Infertility & pregnancy loss Infertility & pregnancy loss HAIR LOSS HAIR LOSS IRREGULAR MENSES IRREGULAR MENSES SPECTRUM Clinical Manifestation of PCOD
  35. 35. Symptoms & There Frequency in PCOS in Adolescents Menstrual Cycle disturbance – 70% - Oligomenorrhoea 50% - Amenorrhoea 10% - Abnormal heavy bleeding 10-15% Hyperandrogenism 70% Acne – 30 - 40% Hirsutism 70% Alopecia 10% as seen by Gynaecologits Acanthosis Nigricans 1-3% lean & 20% obese OBESITY 50- 60 % NORMAL MENSTRUATION 20% * INFERTILITY - 70% * EARLY PREGNANCY LOSS 50-60%
  36. 36. Q 8(A) What is the Pattern of MENSTRUAL IRREGULARITY in Adolescent PCOS Q 8(B) Why MENSTRUAL IRREGULARITY in Adolescent PCOS needs treatment ?
  37. 37. DELAYED PERIODS is most common presentation Other Presentations are: • Withdrawal bleeding only • Absent periods • Heavy menstrual bleeding or • Menometrorrhagia with Anemia Ans 8(A) What is the Pattern of Menstrual Irregularity in Adolescent PCOS •20% PCOS have • normal cycles Obese 80% Lean 30%
  38. 38. Ans 8(B) Why MENSTRUAL IRREGULARITY in Adolescent PCOS needs treatment ? • Menstrual irregularity in adolescent PCOS needs treatment because chronic anovulation increases the risk of developing Endometrial Hyperplasia , which is associated with Endometrial Carcinoma if not monitored. • In addition , anemia can result from dysfunctional DUB or menorrhagia Treatment IS Discussed LATER
  39. 39. • It is well accepted that If menstrual Irregularities persist for 2 years After Menarche, Then The Risk for PCOS is Extremely High (70% of Cases)
  40. 40. PCOS remains largely UNDIAGNOSED as irregular menses after menarche for 2 years & acne is commonly seen in adolescents • Transabdominal ultrasound resolution has poor sensitivity to diagnose PCOS TVS is recommended
  41. 41. Q-9 COSMETIC CONCERNS Question to Dermatologist Dr. V. K. UPADHYAY / Dr. S KANDHARI WHAT ABOUT INCIDENCE OF ALOPECIA & ACANTHOSIS NIGRICANS IN ADOLESCENTS ?
  42. 42. COSMETIC CONCERNS • Alopecia 10% as seen by Gynaecologists (Dermatologist feel - Alopecia is not all that uncommon & is around 20%) HAIR LOSS HAIR LOSS AcanthosisAcanthosis Acanthosis Nigricans 1-3% lean & 20% obese
  43. 43. Is treatment for hirsutism based on Ferring Gallway SCORING? Q10(A). COSMETIC CONCERNS HIRSUTISM , ACNE, ALOPECIA
  44. 44. Ferring Gallway SCORING
  45. 45. Ferring Gallway Scale This model quantities the extent of hair growth in nine key anatomic sites: the hair growth is graded using a scale from 0 (no terminal hair) to 4 (maximum growth), for a maximum score of 36 A score of 8 or more indicates the presence of androgen exces. However, we do not use it in day to day practice to grade our patients
  46. 46. what all tests are needed to diagnose HYPERANDROGENEMIA? Q10 (B). COSMETIC CONCERNS HIRSUTISM , ACNE, ALOPECIA
  47. 47. What All Test Are Needed To Diagnose Hyperandrogenism (Hirsutism, acne, alopecia) Free Testosterone & % Free Androgen index have NO ROLE in diagnosis. It is 10 times costly & is not standard in all labs. • ANDROSTENADIONE-NO ROLE BIOCHEMICAL TESTING Total Testosterone & 17 – hydroxyprogesterone level to R/O late onset CAH is all that is needed
  48. 48. NORMAL VALUES OF SERUM ANDROGENS Testosterone (Total) 20-80 ng/dl DHEAS 100-350 mg/dl 17 – hydroxprogesterone (Follicular phase) 30-200 ng /dl Over 800 diagnostic of adult onset CAH
  49. 49. SUDDEN ONSET of these symptoms suggests other D/D * Cushing’s syndrome * Adrenal or ovarian tumor. Q10C Hirsutism – Virilisation
  50. 50. Does ACNE require systemic treatment or only topical is sufficient? Q11 COSMETIC CONCERNS
  51. 51. ACNE • Grade 1: Acne are classified non inflammatory • Grade 2: Inflammatory • Grade 3 : Combination of above (Severe) • Topical Retinoids •Antimicrobial aqents + •topical ratinoids TREATMENT MEDICAL ENDOCRINE THERAPY + TOPICAL / ORAL RATINOIDS
  52. 52. Management Topical Retinoids1. Apply the preparation over the whole affected area and not just spot application 2. Apply the product very miserly as Acne treatments are often irritating and drying 3. Excessive washing of face is to be avoided as it further aggravates the irritation 4. Stop application the moment excessive drying or irritation develops 5. Cream based applications should be preferred as they reduce the concomitant dryness ACNE GRADE - I
  53. 53. Systemic – Management is needed for infected or severe acne • ORAL ANTIBIOTICS – Minocycline, Doxycycline, Azithromycin, CEPHALOSPORINS • Isotretenoin – 0.5 -1 mg/ Kg body weight. Cumulative dose of 120 – 150 mg /Kg over a period of 6 – 9 months. • Low dose OCP Acne / Grade II & III
  54. 54. Hormonal Therapy in Acne – Recalcitrant acne (severe Acne) – Acne not responding to topical /oral Isotretenoin – Co- prescribed with Isotretenoin •OCP •6-9 MONTHS •Any pill
  55. 55. Acne Treatment – Other Modalities • Chemical peels • Comedon removal • IPL • Cryotherapy • Microneedling • Use of steroids Good Dermatologist help is needed. Gynaecologist can’t treat on there own
  56. 56. How common is ALOPECIA ? Treatment ? Q12 COSMETIC CONCERNS
  57. 57. Alopecia Dermatologist feel that it is not all that uncommon • Diffuse thinning With preservation of frontal line • Bitemporal recession CAUSE • Decrease in 5a reductase - • in DHT Incidence in adolescent PCOS DERMATOLOGIST To Be Care
  58. 58. Guidelines to Gynaecologist on treatment of Q 13 COSMETIC CONCERNS HIRSUTISM
  59. 59. Treatment Hirsutism IS CHALLENGING
  60. 60. TREATMENT - HIRSUTISM • All combination OCPs are effective • OCPs decrease androgen levels by suppressing LH and stimulating sex hormone binding globulin (SHBG). • It takes almost 6 months when decrease growth of hair is noted. •OCPs with low androgenic Progestins (norgestimate, desogestrel) may be Most effective for acne and hirsuitism
  61. 61. Hirsutism Treatment • METFORMIN perse are not needed – To reduce hirsuitism. – Spironolactone 100mg twice daily (max dose 200 mg/day). – A full clinical effect may take 6 months or more – After a periods of time, maintenance dose of 25-50 mg daily. Anti ANDROGENS (RECEPTOR BLOCKERS)
  62. 62. Any Special Choice of OCPs for hirsutism in PCOS ? Q 14 B
  63. 63. Q -14 C TOPICAL HAIR GROWTH RETARDANTS • EFFORNITHINE HYDROCHLORIDE CREAM are effective & take almost 3 months to show effect. Dosages & Applications • Remove the heir from the affected areas and wait for minimum 5 minutes • Apply a thin layer of hinder cream to the affected areas of the face and adjacant involved areas under the chin • Rub in thoroughly • The treated area should not be washed for 4 hours • Cosmetics and sunscreens may be applied over the treated areas after the cream has dried • To be used twice daily at least 8 hours apart • For optimal results, use hinder fo a minimum of 6-12 months along with other methods of hair removal
  64. 64. Q -14 D Great TIPS on Solution of Hirsutism • Temporary Methods – Remove the hair shafts but leave the hair follicle intact. Example – waxing, shaving, depilatory creams & plucking The process needs to be repeated indefinitely. Though cheap & effective, are time consuming, repetitive and often lead to pigmentation and thickening of skin. OCP & ALDACTONE ARE NEEDED
  65. 65. ELECTROLYSIS IS GOING OUT (Burns / Scarring) LASER THERAPY is not permanent. Repeated sittings may be needed Q -14 D Great TIPS on Solution of Hirsutism OCP & ALDACTONE ARE NEEDED
  66. 66. Which COC is most preferred? Containing • Levonorgestrel / Desogestrel • Cyproterone acetate • Drospirenone Q -15. CHOICE OF COC Menstrual Irregularity / Hirsutism / Acne
  67. 67. CHOICE of COC ANY LOW DOSE COC CAN BE GIVEN • OC’s containing progestins such as NORGESTREL / LEVONORGESTREL / DESOGESTREL are preferable. •DROSPIRENONE HAS NO ADVANTAGE • If HIRSUTISM is a problem then Cyproterone Acetate (CPA) is preferred.
  68. 68. Two Types OF OCPs Desogestrel 0.15 mg + EE 30mcg(novelon) Desogestrel 0.15 mg + EE 20mcg( femilon) Cyperoterone acetate (EE 30 mcg + C 2 mg - Diane35) Drosperinone- (EE 30 mcg + D 3 mg -Yasmin) NON ANDROGENIC PROGESTOGENS ANTIANDROGENS WITH PROGESTATIONAL ACTIVITY
  69. 69. Q 15 B What are the DRAWBACK OF OCP IN PCOS • Menstrual Problem • Hirsutism
  70. 70. What are the DRAWBACK OF OCP IN PCOS • Cause salt & water retention making weight loss more difficult. • In permenarcheal girls with short stature who have open epiphyses, OCPs are contraindicated bcz OCPs contain growth – inhibitory amounts of estrogen • In Incompletely mature girls - increase risk of post pill amehhnoria • VTE with OCP is primarily related to dose & duration of estrogen use & progesterone like DROSPERINONE (Twofold increase)
  71. 71. Q15 C Combination OCPs FOR HOW LONG in adolescents PCOS? Hirsutims / Menstrual
  72. 72. OCPs FOR HOW LONG ?? in Adolescents PCOS? Hirsutims / Menstrual By three months the bleeding problems gets stabilized & by six month markedly decrease growth hair is noticed.
  73. 73. As a general rule, OCPs should be continued until the girls is gynaecologcally mature (Five years postmenarcheal) or has lost substantial amount of excess weight.
  74. 74. Gynaecologists are confused & use it for variable periods but sr. DERMATOLOGISTS feel it should not be discontinued unless girls wants to become pregnant . DURATION OF TREATMENT with OCP is Controversial
  75. 75. Q16. ETHINYLESTRADIOL – HOW MUCH in OCP? What is the patient profile for choosing COCs containing 35, 30, 20 mcg ethinylestradiol ?
  76. 76. Low Dose COC pill is the choice (<35 ug EE is the choice). In adolescent people start with EE 20 ug pill – if BTB – occurs, higher dosage pill is used ETHINYLESTRADIOL in OCP – HOW MUCH?
  77. 77. Q-17 CHOICE OF PROGESTIN in OCP What is the patient profile for choosing the type of PROGESTERONE in COCs?
  78. 78. Safety of the pill is most important Like venus thromboembolism , mycardial infaction & cancer etc. CHOICE OF PROGESTIN
  79. 79. SAFETY of OCP is key • Non Androgenic Progestogens Desogestrel 0.15 mg + EE 30mcg(novelon) , Desogestrel 0.15 mg + EE 20mcg( femilon) •Antiandrogens with progestational activity • Cyperoterone acetate • (EE 30 mcg + C 2 mg - Diane35) Drosperinone DVT twofold increase (BMJ) Noethindrone Norgestril / Levonorgestril Low DVT 1st Gen. 2nd Gen. DVT ? Drosperinone- (EE 30 mcg + D 3 mg Yasmin)
  80. 80. Q18. CONCERNS WITH COC Q. What are common complaints with the use of COCs? * HYPERTENSION * WEIGHT GAIN * ACNE
  81. 81. HYPERTENSION – in few 10 mm rise of BLOOD PRESSURE may be there which settles once the drug is off WEIGHT GAIN is not the complication with low dose COC pills. ACNE : Infact OCP is the treatment. We preferred pill with Antiandrogens with progestational activity CONCERNS WITH COC
  82. 82. Q19. ROLE OF PROGESTIN in menstrual irregularity
  83. 83. • MICRONIZED PROGESTERONE (100 to 200 mg given orally at bedtime) • MEDROXPROGESTERONE ACETATE (10mg given orally at bedtime) can be used for 7 to 10 days out of each month of cycle. SIDE EFFECTS of progestin include * mood symptoms (depression) * Bloating * Breast soreness Role of Progestin in Menstrual Irregularity Patients must be informed that oral progestin Prescribed in this manners (i.e. 7 to 10 days each month) is not a means of contraception
  84. 84. How frequently do you see IR in your PCOS patients? • Why we are worried ? • Various syndrome with IR • Special signature of IP • Role of metformin Q20 INSULIN RESISTANCE ?
  85. 85. Ans. In Research situations IR is seen in good 65 to 70% patients among whom 70 to 80% are obese (BMI > 30) & 20 to 25% are normal weight. It is the biggest risk factor for type 2 DM and cardiovascular disease Ref.http:www.uptodate.com INSULIN RESISTANCE
  86. 86. You should Know Insulin Resistance is present Various Clinical Syndrome • Type 2 diabetes • Cardiovascular disease • Essential hypertension • Polycystic ovary syndrome • Non-alcoholic fatty liver disease (NASH) • Certain forms of cancer - breast,colon,liver,prostate • Sleep apnea All are interrelated
  87. 87. • SKIN : Acanthosis nigricans (darkly shaded skin in the flexures of the neck , axilla, or groin – IR/DM) Significant Findings Insulin Resistance which gynaecologits should always note Skin tags – IR/DM 10 % Acanthosis nigricans Over 20% obese 5% in lean
  88. 88. Q20(B). INSULIN RESISTANCE Q. Are insulin sensitizers prescribed to all women with PCOS or only those with insulin resistance?
  89. 89. Gynaecologist are Not Clear and use metformin Left & Right Both ESHRE & ASRM consensus is that no clear role for insulin sensitizing in management of PCOS except in patients with glucose or type 2 diabetes Therefore, on current evidence - metformin is not a first line treatment of choice in the management of PCOS for any clinical manifestation
  90. 90. Insulin sensitizers like metformin is used in patients with impaired glucose tolerance patients & not otherwise INSULIN RESISTANCE
  91. 91. • IMPAIRED Glucose Tolerance / Type 2 Diabetes – Up to 40% of women with PCOS have impaired glucose tolerance (IGT). – Risk of IGT and Type 2 Diabetes Mellitus (DM) is increased in both obese and non-obese women with PCOS. – Retrospective studies have shown 2 to 5 fold increase of type 2 diabetes in women with PCOS. Importance &Importance & How to Diagnose Insulin Resistance –How to Diagnose Insulin Resistance – Just Do Fasting Glucose & 75 gm 2 hrs oral GTTJust Do Fasting Glucose & 75 gm 2 hrs oral GTT
  92. 92. Q(A) In patients who do not respond to one COC, do you change the COC (consisting of another progestin) or shift them to or add an insulin sensitizer? Q(B). Metformin / Myoinositol Q21. Place of INSULIN SENSITIZERS in- YOUR OPINION?
  93. 93. METFORMIN—PRESENT ROLE • Although there had been widespread enthusiasm to use metformin left & right – but clinical data no longer support this approach • Use of metformin in PCOS should be restricted to those patients with glucose intolerance ESHRE/ASRM-Sponsored PCOS Consensus Workshop *,2007, Thessaloniki, Greece
  94. 94. Dose of Metformin • When metformin is given , therapy is started with 500 mg daily before the evening meal, with an increase in the dose by 500 mg per week to the effective dose of 1500 to 2000 mg daily , as tolerated . • The greatest dose (1500 to 2000) often are better tolerated when divided into two daily doses or when given in an extended release form
  95. 95. MYOINOSITOL in PCOS advantage will be known 5 yrs down the line - at present it is only a concept 2014
  96. 96. Q 22 PREGNANCY & PCOS If the female wishes to conceive, when would you advise her to stop taking the insulin sensitizers and / or COCs?
  97. 97. COCs need to be stopped, FOLIC ACID started & drugs for ovarian stimulation to be used. CLOMIPHENE CITRATE IS Widely used Simple to use Minimal side effects Cost effective PREGNANCY & PCOS
  98. 98. Clomiphene in ANOVULATORY PCOS • 50-80% will ovulate on CC • Only 40-50%will conceive
  99. 99. Q 23 What are INFERTILITY Guidelines ??
  100. 100. FIRST LINEFIRST LINE CLOMIPHENE CITRATE SECOND LINESECOND LINE LOD/GONADOTROPINS THIRD LINETHIRD LINE IVF The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group March 2–3, 2007, Thessaloniki, Greece. Human Reproduction 2008 RR EE SS II SS TT AA NN CC EE RR EE SS II SS TT AA NN CC EE FF AA II LL UU RR EE THESSALONIKI CONSENSUS ON INFERTILITY TREATMENT IN PCOS, GREECE 2007
  101. 101. Q (a) Ovulation induction aim (B) First & second line management of infertility in women with PCOS? (c) Role of LOD (D) Role Luteal phase support (E) OHSS PCOS & INFERTILITY
  102. 102. Suggested a step by step approach to ovulation induction in women with PCOS Steps Approach 1 If BMI is elevated - loss at least 5% of current body weight 2 Ovulation induction with clomiphene citrate 3 Metformin in combination with clomiphene citrate in CC resistant cases or BMI > 27 ??? 4 Gonadotropin Therapy (OHSS / multiple pregnancy) 5 Laparoscopic Ovarian Drilling 6 IVF ± Metformin Insulin sensitizer in combination with gonadotropin therapy to decrease OHSS
  103. 103. Goals of Ovulation induction in IUI / IVF Minimize Complications & Risk AIM Ideal Outcome Singleton live Birth at term Cycle Cancellation Multiple Pregnancy OHSS
  104. 104. 1. First Line Management Clomiphene is drug of Choice 2. In CC Resistant cases metformine has a role 3. 2nd line treatment Lap. Ovarian drilling has a role for women who can’t came for closed follow – up pregnancy role is 50% 4. Gonadotrophines in PCOS have promise, but OHSS & multiple pregnancy, should never before gotten complication •Tamoxiphene people have just staring using it •Letroz is banned in india •Metformine role dealt
  105. 105. The Truth is that OHSS MUST BE PREVENTED RATHER than treated
  106. 106. HCG TRIGGER PLAYS THE KEY ROLE
  107. 107. Metformin may be added to CC in women with clomiphene resistance who are older and have visceral obesity (I- A) SOGC guidelines, 2010 METFORMIN ROLE IN INFERTILITY
  108. 108. Q 24 PREGNANCY & PCOS What is the line of treatment in women with PCOS who have CONCEIVED NATURALLY ?
  109. 109. • PCOS patients have high chance of miscarriages so they need TLC + micronised vaginal progesterone • If they have conceived while taking Metformin - it has to be continued for 3 months. This decreases miscarriage rate. • Few caution throughout pregnancy PREGNANCY & PCOS
  110. 110. Q 25 Can we do LAPAROSCOPIC OVARIAN DRILLING in ADOLESCENTS who do not respond to OCP Not Recommended except for infertility problems
  111. 111. Q26. LONG-TERM COMPLICATIONS Q. Are the women sensitized to the long- term complications of PCOS? Infertility, Diabetes, Cardiovascular diseases, Cancer…
  112. 112. COUNSELING IS IMPORTANT AT THE FIRST VISIT detailing them of short term & long term consequences. It helps them in REDUCING WEIGHT, strictly following life style modifications & become proactive about conception & metabolic disorders timely. LONG-TERM COMPLICATIONS
  113. 113. Consequences of Polycystic Ovarian disorders Short Term consequences • Obesity • Infertility • Irregular menses • Abnormal lipid levels/ Hypertension • Hirsutism/acne/androgenic alopecia • Glucose intolerace / acanthosis nigricans • Increase early pregnancy loss / GDM Long – Term consequences • Dibetes mellitus • Endometrial cancer • Cardiovascular disease
  114. 114. The Most Common Endocrine disorder In women Symptoms may Include chronically irregular and / or Absent or delayed periods Symptoms may include facial hair , central obesity and acne Let untreated it may lead to Heart Disease Left untreated, it may lead to Uterine cancer Leading cause of Infertility P C O D Long Term Complications & Consequences
  115. 115. Counseling also helps them to get regular screening / monitor from time to time detect problems early. •Infertility , •Diabetes •Cardiovascular disease, •Endometrial Cancer.. Q27 Counseling
  116. 116. Q28. CANCER in women & PCOS Would you like to comment on a) Endometrial Cancer b) Breast cancer in PCOS c) Your Pregnancy Experience
  117. 117. Ans. 28 A Endometrial Cancer in PCOS • Gynaecologists should not forget that there is 3 fold increase in incidence of endometrial cancer. • There Should be screening & monitoring for the same from time to time with TVS & EB
  118. 118. Ans. 28 B PCOS & Breast Cancer ?? Limited data exist that Do Not Support the conclusion that women with PCOS are a increased risk for BREAST CANCER.
  119. 119. Q 29 ASSOCIATION IS THERE NOT THE CAUSATIVE FACTOR Not included in diag. criteria OBESITY IN PCOS
  120. 120. OBESITY & PSYCHOSOCIAL HEALTH in WOMAN 1. Poor body image 2. Social stigmatisation (‘a laughing matter’) 3. Lower education levels 4. Lower rates of marriage 5. Lower socio economic levels Neglected Area
  121. 121. Management of Obesity in general 1st LINE OF MANAGEMENT : Lifestyle changes like modification of diet , physical activity and daily habits 2nd line of Management : introduction of pharmacotherapy for patients with BMI above 24 with co – morbidities and BMI above 27.5 with no co- morbidity BARIATRIC SURGERY : may be an option for treatment of morbid obesity (BMI > 32.5) when diet and exercise do not work 1 2 3
  122. 122. Q30 ROLE OF VIT – D ?
  123. 123. Vitamin – D Role in PCOS was suggested by all Panelist
  124. 124. ADD VITAMIN D Too GIVE HER A GIFT FOR LIFE TIME
  125. 125. Q 31 Prevention of Endometrial Ca. Monitoring of PCOS patients to prevent occurrence of Endometrial Carcinoma Guidelines • Frequent TVS • Endometrial Sampling • Progesterone for periods
  126. 126. • TAILOR MADE THERAPY in Adolescent PCOS is our attempt in this panel discussion CONCLUSION
  127. 127. RULE OUT Diagnosis: Pre-Diabetes Fatty Liver Diabetes type II Hyperlipidemia Insulin Resistance Hypo-Thyroidism Metabolic Syndrome Vitamin-D Deficiency Cancer screening – Endometrial Ca. CONCLUSION
  128. 128. CONCLUSION COUNSELING & MONITORING of short & Long term sequalae of PCOD is the key
  129. 129. More & More PCOS CLUBS should be formed To shoot Information for teens & young PCOS patients on its various aspects
  130. 130. www.delhigynaecologistforum.com HEAD OFFICE : 11 Gagan Vihar, Near Karkari Morh Flyover Delhi – 110051 Helpline No : 01122414049 , 8826638849 HEAD OFFICE : 11 Gagan Vihar, Near Karkari Morh Flyover Delhi – 110051 Helpline No : 01122414049 , 8826638849 DR. SHARDA JAIN Sec. Gen. D.G.F. 9650511339 9650588339 DR. URMIL SHARMA President 9810068815 MS. MALTI Admin Officer 8826638849 7533059677

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