Management of Adolescent PCOD Made Easy ,Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Jyoti Bhaskar Dr. Abhihsek parihar


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  • A prospective study of 254 women with PCOS without known diabetes was compared to a control group without PCOS or diabetes. In the PCOS group (obese and non-obese), the overall prevalence of IGT and type 2 diabetes was 31.1% and 7.5%, respectively. In the control group, the prevalence of IGT and type 2 diabetes was 14% and 0%, respectively .
  • 75% of PCOS women have IR
    Breast cancer patients found to be hyperinsulinemic and best data to support IR association.
    Prostate, colon and liver cancers also more common in obese pts with type 2 DM or pts with increased insulin levels.
    Up to 50% of all pts with essential HTN are IR.
    Metabolic syndrome is defined to capture subset of people with IR at risk for CVD so as to be a practical dx to address CVD risk but IR syndrome may be better way to describe etiology and more studies are looking at IR.
    insulin resistance is not a disease but the description of a physiologic state that greatly increases the chances of an individual developing several closely related abnormalities and associated clinical syndromes.
    PCOS pts may have IR and it is not obesity dependent.
  • Testosterone needed if considering treatment with antiandrogen for hisuitism as levels can then be followed.
    DHEAS not needed.
    Fasting morning 17-hydroxyprogesterone
    Levels > 800 ng/dL (8ng/ml) highly suspicious for late-onset congenital adrenal hyperplasia (CAH)
    Levels between 200-800 ng/dL (2-8ng/ml) unclear
    Levels < 200 ng/dL (2ng/ml) usually no CAH
    A ratio of less than 4.5 of fasting glucose to insulin levels correlates significantly with insulin resistance and has been studied for use as a screening test in obese patients with PCOS. Suggested only in selected patients. Information from Legro RS. Polycystic ovary syndrome: current and future treatment paradigms. Am J Obstet Gynecol 1998;179:S101-8.
  • A ratio of less than 4.5 of fasting glucose to insulin levels correlates significantly with insulin resistance and has been studied for use as a screening test in obese patients with PCOS
  • Increased SHBG leads to decreased free testosterone
    Yasmin (drospirenone/ ethinyl estradiol) contains an anti-androgen roughly equivalent to spironolactone 25mg.
    Orthotricyclen with norgestimate has FDA approval fot the tx of hirsuitism but most experts believe all the 3rd generation ocps to be as efficacious for hirsuitism as they all have less androgenic progestins.
  • All non-FDA approved indications!
    These androgen receptor blockers can be used in combination with ocp in cases when ocp alone is not adequate
    Testosterone levels can be followed to show efficacy with goal < 60.
    It is postulated that topical eflornithine HCl irreversibly inhibits skin ODC (ornithine decarboxylase) activity which slows the rate of hair growth. Marked improvement was seen consistently at 8 weeks after initiation of treatment and continued throughout the 24 weeks of treatment. Hair growth approached pretreatment levels within 8 weeks of treatment withdrawal. Vaniqa has only been studied on the face and adjacent involved areas under the chin of affected individuals. If skin irritation or intolerance develops, direct the patient to temporarily reduce the frequency of application (e.g., once a day). If irritation continues, the patient should discontinue use of the product.Apply a thin layer of Vaniqa to affected areas of the face and adjacent involved areas under the chin and rub in thoroughly. Do not wash treated area for at least 4 hours. Use twice daily at least 8 hours apart or as directed by a physician. IV vaniqa is used to treat sleeping sickness caused by Trypanosoma brucei gambiense.
    Cost $52.90 for 30gm tube.
    Propecia (finasteride), a synthetic 4-azasteroid compound, is a specific inhibitor of steroid Type II 5α-reductase, an intracellular enzyme that converts the androgen testosterone into 5α-dihydrotestosterone (DHT).
    Cost about $54 for 30d supply.
    Flutamide warning-Serum transaminase levels should be measured prior to starting treatment with flutamide. Flutamide is not recommended in patients whose ALT values exceed twice the upper limit of normal. Serum transaminase levels should then be measured monthly for the first 4 months of therapy, and periodically thereafter. Liver function tests also should be obtained at the first signs and symptoms suggestive of liver dysfunction, e.g., nausea, vomiting, abdominal pain, fatigue, anorexia, "flu-like" symptoms, hyperbilirubinuria, jaundice or right upper quadrant tenderness. If at any time, a patient has jaundice, or their ALT rises above 2 times the upper limit of normal, flutamide should be immediately discontinued with close follow-up of liver function tests until resolution. Cost $374 for 3 month supply. In animal studies, flutamide demonstrates potent antiandrogenic effects. It exerts its antiandrogenic action by inhibiting androgen uptake and/or by inhibiting nuclear binding of androgen in target tissues or both. One metabolite of flutamide is 4-nitro-3-flouro-methylaniline. Several toxicities consistent with aniline exposure, including methemoglobinemia, hemolytic anemia and cholestatic jaundice have been observed in both animals and humans after flutamide administration. In patients susceptible to aniline toxicity (e.g., persons with glucose-6-phosphate dehydrogenase deficiency, hemoglobin M disease and smokers), monitoring of methemoglobin levels should be considered. There is a drug interaction with warfarin.
    Spironolactone- competitively binds androgen receptors as well as inhibits alpha-reductase activity.
    Concomitant administration of potassium-sparing diuretics and ACE inhibitors or nonsteroidal anti-inflammatory drugs (NSAIDs), e.g., indomethacin, has been associated with severe hyperkalemia. Cost $82 for 100 tablets of 50 mg.
  • Per Habif:
    Excess facial hair may be plucked, shaved, bleached, wax stripped, or removed by chemical depilatories. These treatments only temporarily alleviate the problem because irritation or plucking rapidly induces the anagen stage and hair-follicle growth.
    Electrolysis and selective photothermolysis with the use of lasers destroy the hair shaft, outer root sheath, bulge, and dermal papilla of the hair follicles. The extent of the destruction determines whether the follicle regenerates. Permanent follicular destruction with an electrical probe that is passed into the follicle is a good option for women with small areas of facial hair.
    There has been an explosive increase in the use of lasers for hair removal since the first lasers were approved in 1996. Currently most devices target melanin in the hair follicle with millisecond-long pulse durations to produce, to some degree, selective photothermolysis of hair follicles. Multiple treatments are necessary. Hair clearance, after repeated treatments, of 30% to 50% is generally reported 6 months after the last treatment. Temporary adverse effects include erythema and perifollicular edema, which are common. Crusting, vesiculation, hypopigmentation, and hyperpigmentation (depending on skin color and other factors) may also occur.
    Great article for further info
    Removal of unwanted facial hair.
    Shenenberger DW - Am Fam Physician - 15-NOV-2002; 66(10): 1907-11
  • There were statistically significant improvements in Ferriman-Galwey scores 12 mos after the end of treatment with spironolactone 100mg/d vs. cyproterone acetate 12.5mg/d first 10 d of cycle and 5mg/d of finasteride as well (Level A) Cyproterone acetate is a 17-hydroxyprogesterone acetate derivative with strong progestagenic properties. Cyproterone acetate acts as an antiandrogen by competing with DHT and testosterone for binding to the androgen receptor. There is also some evidence that cyproterone acetate and ethinyl estradiol in combination can inhibit 5α-reductase activity in skin.[355] Cyproterone acetate is currently not available in the United States but has been used in other countries. The drug is mostly administered in doses of 50 to 100 mg from days 5 through 15 of the treatment cycle. Because of its slow metabolism, it is administered early in the treatment cycle, whereas ethinyl estradiol, when added, is usually used at 50-µg doses between days 5 and 26. This regimen is needed for menstrual control and is usually referred to as the reverse sequential regimen. Cyproterone acetate in doses of 50 to 100 mg/day, combined with ethinyl estradiol at 30 to 35 µg/day, is as effective as the combination of spironolactone, 100 mg/day, and an oral contraceptive in the treatment of hirsutism.[197] In smaller doses (2 mg), cyproterone acetate has been administered as an oral contraceptive in daily combination with 50 or 35 µg of ethinyl estradiol
    Flutamide has risk of hepatic toxicity
    Finasteride prevents conversion of testosterone to active dihydrotestosterone
    Doses spironolactone start 25-50mg/d and increase to 100-200mg/d
    Flutamide start 125mg qd then bid and up to max dose 250mg bid and causes photosensitivity and requires lft monitoring
  • Jared lost weight via diet and exercise – specifically walking – not by eating Subway sandwiches.
  • Enjoy Obesity
  • 10,000 steps a day – This idea is rooted in a Japanese health program from the 60s
  • We’re sitting a lot and it’s really bad for us.
  • Based on statistics from study by University of Texas Southwest Medical Center
  • Like running? Just do it. Not so much? Consider walking.
  • “Why 10,000 Steps a Day Won't Make You Thin,” U.S. News & World Report, May 2014
  • The benefit of walking. Photo by Robert Stribley
  • But how? Some practical ways to get more walking done
  • Wearable devices and step counting
  • Sibutramine (MERIDIA)(a mixed adrenergic/serotonergic drug). , an inhibitor of the reuptake of 5-HT, norepinephrine, and dopamine, is used as an appetite suppressant in the management of obesity
    Orlistat, a gastrointestinal lipase inhibitor used for weight loss, was administered over a 4-year period and resulted in a 37% reduction in the progression of type 2 DM in a group of insulin-resistant obese patients (Torgerson et al., 2004).
  • Management of Adolescent PCOD Made Easy ,Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Jyoti Bhaskar Dr. Abhihsek parihar

    1. 1. Management of Adolescent PCOD Made Easy Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Jyoti Bhaskar Dr. Abhihsek parihar
    2. 2. PCOD & Hyperandrogenism in Adolescents There is Need to Update as Lately it is confusing The Gynaecologists !!
    3. 3. Learning Objectives • Prevalence and onset • Etiology / Pathophysiology • Update on clinical presentation • Update of diagnostic criteria for PCOD. • Short & long term consequences PCOD •Tailor Made Therapy
    4. 4. Importance of PCOD PCOD constitutes a CONTINUUM SPECTRUM starting from the EARLY PREPUBERTAL YEARS and continuing after Menopause S/S peak through 2nd / 3rd decade of life
    5. 5. Diagnosis of Polycystic Ovarian Disease 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) 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
    6. 6. 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 Disease
    7. 7. Prevalence of adolescent PCOD 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 ??
    8. 8. Prevalence of PCOD In India Girls
    9. 9. Experience Near 18-20% girls going to private schools in Delhi have PCOS Obese – 50% Menstrual Problems – 60% Delayed Periods Most Common Heavy Menstrual Bleeding – 20% HIRSUTISM – 60-70% ACNE – 30% DGF Survey of 2 schools 2004
    10. 10. PCOS has a complex & incompletely understood - Etiology • Exact etiology of PCOS is still Unknown – likely due to a steady state of high estrogen, androgens, luteinizing hormone (LH) and insulin levels. • High estrogen levels can cause suppression of pituitary FSH and relative increase in LH. • Increased LH stimulates the ovary, which results in anovulation, multiple cysts and theca cell hyperplasia with excess androgen output. • High insulin levels may also increase the production of testosterone by the ovaries.
    11. 11. Complete Pathophysiology of PCOD
    12. 12. Genetic of PCOS PCOS is a familial disorders with a single autosomal dominant gene defect The current litrature on genetics of PCOS is disappointing, Full of controversies & lack of clear consensus l
    13. 13. VITAMIN D DEFICIENCY IS AN INDEPENDENT PREDICTOR OF Obesity 80% PCOS women are obese PCOS Women with VIT-D deficiency • Higher mean BMI • Hypertension • Hypertriglyceridemia • Lower high-density cholesterol (all p<0.05) Exp Clin Endocrinol Diabetes. 2006 Nov;114(10):577-83.) ACOG
    14. 14. Uploaded in Newer concepts of managing With Myo-Inositol Dr. Jyoti Agarwal Dr. Sharda Jain Dr. Jyoti Bhaskar
    15. 15. DIAGNOSIS
    16. 16. Conforming the diagnosis •History & symptoms •Clinical examination •Biochemical investigation •Ultrasonography 20% normal girls have polycystic ovaries while Polycystic ovaries may not be seen in PCOS girls
    17. 17. History & symptoms • Family History : Risk of PCOS • 40% - if her sister is having PCOS • 20% - if her mother suffered from PCOS
    18. 18. Symptoms & Signs • Hyperandrogenism • Acne • Hirsutism • Metabolic syndrome • Central obesity • Insulin resistance • Glucose intolerance Anovulation & Menstrual irregularities Infertility
    19. 19. Clinical Manifestation of PCOD AAccnnee OObbeessiittyy AAccaannttoossisis HHirirssuuttisismm HAIR LOSS HAIR LOSS IRREGULAR MENSES IRREGULAR MENSES
    20. 20. Common Signs And Symptoms of PCOD AAccnnee HHirirssuuttisismm IRIRRREEGGUULLAARR M MEENNSSEESS OObbeessitityy
    21. 21. Symptoms of PCOD Over weight /Obesity 50-80% Abnormal Uterine Bleeding 30 - 50% Obese patients – Over 50% NON obese - 20 - 25% Around 50-70% PCOS girls Have hirsutism & around 30-35% Girls Have acne
    22. 22. PCOS in Adolescent Menstrual Irregularity • Mestrual problems are present in 80% obese PCOS & 30% with lean PCOS • 20% PCOS have normal cycles •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)
    23. 23. PCOS in Adolescent Pattern of Menstrual Irregularity Delayed periods is most common presentation Other Presentations are: • Withdrawal bleeding only • Absent periods • Heavy menstrual bleeding or • Menometrorrhagia with Anemia
    24. 24. Criteria HMB in PCOS • More then 6 pads/ day • >80 ml per cycles • Ultrasound typical picture - PCO • Increased total testosterone
    25. 25. AAEESS RREECCOOMMMMEENNDDAATTIIOONNSS • PPCCOOSS iiss aa HHYYPPEERRAANNDDRROOGGEENNIICC DDIISSOORRDDEERR • TThhee oovvaarriiaann mmoorrpphhoollooggyy sshhoouulldd bbee ccoonnssiiddeerreedd wwhheenn eessttaabblliisshhiinngg tthhee ddiiaaggnnoossiiss bbeeccaauussee ppoollyyccyyssttiicc oovvaarriieess aarree ffoouunndd iinn tthhee mmaajjoorriittyy,, aalltthhoouugghh nnoott aallll,, wwoommeenn wwiitthh PPCCOOSS
    26. 26. Physical Exam – Significant Findings • SKIN – Acanthosis nigricans (darkly shaded skin in the flexures of the neck , axilla, or groin – IR/DM) Is seen in young girls very frequently Skin tags – IR/DM 1-2 % Acanthosis nigricans NON obese - 10-20% Obese – 50%
    27. 27. Acne – 30% Severe -80% Moderate – 50% Mild - 30%
    28. 28. Alopecia • Less common • Diffuse thinning With preservation of frontal line • Bitemporal recession Cause • Decrease in 5a reductase - in DHT
    29. 29. HIRSUITISM 10% young girls have hirsutism In 60-70% - PCOS is the cause
    30. 30. Insulin Resistance
    31. 31. IInnssuulliinn RReessiissttaannccee • 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.
    32. 32. • PCOS is a major risk factor for developing IG and T2D (level A). • Obesity (by amplifying insulin resistance) is an exacerbating factor in the development of IGT and T2D in PCOS (level A). • The increasing prevalence of obesity in the Population suggests that a further increase in diabetes in PCOS is to be expected (level B). • Screening for IGT and T2D should be performed by OGTT (75 g, 0- and 2-hour values). There is no utility for measuring insulin in most cases (level C).
    33. 33. Insulin Resistance & 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 Because all are interrelated
    34. 34. IInnssuulliinn RReessiissttaannccee • IINNTTEERRPPRREETTAATTIIOONN -NNoorrmmaall ffaassttiinngg→→<<1155 mmiiccrroo IIUU//mmll AAfftteerr 22hhrr PPPP <<3300 mmiiccrroo IIUU//mmll -- IINNSSUULLIINN RREESSIISSTTAANNCCEE lliikkeellyy →→ 110000 --115500 -- IINNSSUULLIINN RREESSIISSTTAANNCCEE →→115511 –– 330000 -- sseevveerree iinnssuulliinn rreessiissttaannccee →→ >> 330000 • FFaassttiinngg gglluuccoossee ttoo ffaassttiinngg iinnssuulliinn rraattiioo iiss nnoo lloonnggeerr rreeccoommmmeennddeedd bbeeccaauussee ooff iittss vvaarriiaabbiilliittyy
    35. 35. • Screening should be performed in the following conditions: hyperandrogenism with anovulation, acanthosis nigricans,obesity (BMI >30 kg/m2, or >25 in Asian populations), in women with a family history of T2D or GDM (level C). • Metformin may be used for IGT and T2 (level A). Avoid use of other insulin sensitizing agents such as thiazolidinediones (GPP).
    36. 36. MMeettaabboolliicc SSyynnddrroommee && PPCCOODD • Insulin resistance , • obesity • atherogenic dyslipidemia , and • hypertension Increase CVD and type 2 DM
    37. 37. PCOS in adolescents may have few special features • Above average or low birth weight for gestational age. • Premature aderenarche, • Atypical sexual precocity • Obesity with acanthosis nigricans PCOS remains largely UNDIAGNOSED as irregular menses after menarche for 2 years & acne is common in adolescents& • Transabdominal ultrasound resolution has poor sensitivity to diagnose PCOS
    38. 38. Obesity
    39. 39. BMI Cutoff for INDIAN -2.5 in each category BMI Cutoff Weight Status Comments <18.5 UNDERWEIGHT Being underweight also puts you at risk for developing many health problems. 18.5 - 23.9 HEALTHY WEIGHT RANGE Your weight is within normal range. You can continue to keep a healthy weight through physical activity and healthy eating. Keep up with the good work! 24 - 26.9 OVERWEIGHT Being overweight can put you at risk for developing many chronic diseases >27 OBESE Obesity increases risks for developing many chronic diseases such as heart disease and diabetes, and decreases overall quality of life.
    40. 40. FAT DISTRIBUTION –CENTRAL OBESITY android, APPLE SHAPE Central Obesity is High Risk For Co-Morbidities / Complications – LOWER BODY OBESITY Gynecoid PEAR SHAPE
    41. 41. Target WAIST Circumference for Indians Sometimes even when BMI is within Normal range, having too much fat around the abdomen (APPLE SHAPE BODY) will still put one at risk for heart disease and diabetes. Below are the target goals for waist circumference measurements. INDIAN WOMEN Equals or less than 80cm (31.5 in)
    42. 42. Lab Diagnosis
    43. 43. Summary of Suggested Lab Test by ACOG  Prolactin level  Testosterone level  LH and FSH  TSH  Fasting glucose level or 2 hr OGTT  Lipid profile, including total, LDL,HDL  17-hydroxyprogesterone level* *--Fasting level to r/o CAH
    44. 44. Bio chemical and Diagnostic Markers of PCOD Accepted everywhere – Elevated androgen (i.e. testosterone > 60 or free testosterone >0.75) levels – Elevated LH:FSH ratio > 2:1 – Increased Insulin levels – Insulin resistance , (Clinical / Lab) Lab diagnosis of insulin resistance is not needed – Ultrasound appearance of PCO
    45. 45. Screening Tests For PCOD ACOG Recommendation • ACOG recommends that all women with a suspected diagnosis of PCOD should be screened with 17-hydroxyprogesterone level to R/O late onset CAH (Level C). • PCOD and late onset CAH are distinguished from each other only by laboratory testing.
    46. 46. A Lab Tests suggested for SUDDEN onset of Hyperandrogenism Test Result Total testosterone level Slightly elevated in PCOS Total testosterone > 200 ng/dL -- suspicious for adrenal or ovarian tumor therefore additional evaluation with pelvic US, CT or MRI indicated Serum DHEAS level Slightly elevated in PCOS DHEAS level > 8 ng/ml -- suspicious for adrenal tumor therefore additional evaluation should include adrenal gland imaging with CT or MRI 24 hour urine cortisol or overnight dexamethasone Urine free cortisol >20 ug/d is suggestive of Cushing’s Syndrome
    47. 47. Hyperandrogenism Hirsutism, acne, alopecia BIOCHEMICAL Testing • Free Testosterone –NO ROLE & 10 times costly • ANDROSTENADIONE-NO ROLE SUDDEN ONSET of these symptoms suggests other D/D * Cushing’s syndrome * Adrenal or ovarian tumor.
    48. 48. Ultrasound Rotterdam Criteria • In one or both ovaries Ovarian volume > 10 ml • 12 follicles, 2-9 mm in diameter • Echo dense stroma Typical “Black Pearl” Necklace
    49. 49. Ultrasound • Ultrasound : during puberty polycystic ovary should be distinguished from multicystic ovaries. • Typical : large size of cyst and thick ovarian stroma is hallmark • Use of the abdominal instead of TVS in teenage virgins decreases ultrasound sensitivity.
    50. 50. EExxcclluussiioonn ooff RReellaatteedd DDiissoorrddeerrss • Thyroid disorders SSrr..TTSSHH,,SSrr..PPrrll • Hyperprolactinemia • Cushing’s syndrome DDeexxaa ssuupprreessssiioonn tteesstt • Late onset congenital adrenal hyperplasia (CAH) • Basal morning 17-OHP,(2-3 ng/ml)) • Ovarian and adrenal tumors DHEAS • WHO I &III –FSH,LH,E2 • Syndromes of severe insulin resistance(HAIRAN syn)
    51. 51. Consequences of Polycystic Ovarian disorders Short Term consequences • Obesity • Infertility • Irregular menses • Abnormal lipid levels • Hirsutism/acne/androgenic alopecia • Glucose intolerace / acanthosis nigricans Long – Term consequences • Dibetes mellitus • Endometrial cancer • Cardiovascular disease
    52. 52. Summary of presentations and Consequences of PCOD in adolescents 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
    53. 53. Cancer & PCOD •There are moderate quality data to support that women with PCOS have a 2.7-fold (95% confidence interval [CI],1.0–7.3) increased ris for ENDOMETRIAL CANCER. (level B). •Limited data exist that do not support the conclusion that women with PCOS are at increased risk for OVARIAN CANCER (level B).
    54. 54. PCOD & Breast Cancer ?? Limited data exist that do not support the conclusion that women with PCOS are a increased risk for BREAST CANCER (level B).
    55. 55. CHALLENGES
    56. 56. It is good to RULE OUT Diagnosis of following before start of Treatment Pre-Diabetes Fatty Liver Diabetes type II Hyperlipidemia Insulin Resistance Hypo-Thyroidism Metabolic Syndrome Vitamin-D Deficiency Diagnostic criteria for various conditions are not discussed here
    57. 57. Challenges of PCOD in Different Age Groups Irregular menaces But the Root Cause is The Same
    58. 58. OBESITY in PCOD & PSYCHOSOCIAL HEALTH of GIRL 1. Poor body image 2. Social stigmatisation (‘a laughing matter’) 3. Lower education levels 4. Lower rates of marriage 5. Lower socio economic levels BIG CHALLENGE
    59. 59. PCOS can’t be cured but the symptoms can be managed 50 % by just WEIGHT CONTROL
    60. 60. Treatment Her concerns are Cosmetic Concerns - Acne - Hirsutism - Hair Loss Obesity •Menstrual Irregularity Team approach is a must for best results Gynaecologist Dermatologist & Endocrinologist
    61. 61. She is just NOT BOTHERED of the Following - Infertility - Early pregnancy loss -During pregnancy - PIH - GDM -Metabolic Syndrome -Ca Endometrium COUNSELLING OF LONG TERM CONSEQUENCES IS VITAL TO NORMALISE HER WEIGHT
    62. 62. Implications of diagnosis & counseling at adolescent age Optimization of lifestyle is better Regular metabolic screening Proactive fertility planning with consideration of planning for conception at an earlier age
    63. 63. Treatment Acne / Hirsutism
    64. 64. Treatment- Acne And Hirsuitism • All combination OCPs effective • OCPs decrease androgen levels by suppressing LH and stimulating sex hormone binding globulin (SHBG). •OCPs with low androgenic progestins (norgestimate, desogestrel) may be Most effective for acne and hirsuitism (Level B)
    65. 65. Hirsuitism Treatment • METFORMIN – Reduces hirsuitism after 12 mos tx (Level A) • ANDROGEN RECEPTOR BLOCKERS – A full clinical effect may take 6 months or more – Spironolactone 25-100mg bid (Level A) – Flutamide 250 mg daily x 12 mos ( Level A) – Cyproterone acetate-ethinylestradiol 50-100mg daily (Level A) Finasteride 1 mg a day (Level C)
    66. 66. Hirsutism • Prolonged (>6 months) medical therapy for hirsutism is necessary to document effectiveness (level B) • Antiandrogens should not be used without effective contraception (level B) • Flutamide is of limited value because of its dose-dependent hepatotoxicity (level B). • Drospirenone in the dosage used in some OCPs is not antiandrogenic(level B).
    67. 67. Treatment of Hirsuitism •Mechanical – Shaving or depilation – Electrolysis – Laser epilation (Level A) • 30-50% reduction at 6 mos after multiple txs •Topical – Ornithine Decarboxylase Inhibitor (Hinder ) • 13.9% cream BID (Level C)
    68. 68. Topical cream • Effornithine hydrochloride Cream 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
    69. 69. Hirsuitism Treatment Few tips by Dermatologist • Combination Therapy to be started 3 months prior to treatment • OCP + antiandrogen may be most effective (Level C)
    70. 70. Few Tips of Solution by Dermatologist • 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, are time consuming, repetitive and often lead to pigmentation and thickening of skin.
    71. 71. Few Tips Of Solution By Dermatologist • Permanent Methods – Destroy the hair follicles. • Electrolysis – Application of electric current via a fine electric probe to individual hair follicle which leads to its destruction. However it is extremely time consuming, painful, needs several sessions and may result in scarring of surrounding skin due to non selective destruction of tissue. • All most given up technique
    72. 72. Few tips of Solution by Dermatologist • Laser Hair Removal a. Laser cause selective destruction of hair follicles. b. Laser do not achieve permanent hair destruction after single treatment. Several sessions between 4 to 8 are needed for significant hair reduction. c. Laser targets melanin which is present only in the anagen state of the hair cycle and younger the hair,more the melanin, better the destruction. d. Resting hairs (Telogen Stage) and grey hairs which do not contain melanin and hence are not effected by laser. e. These resting hairs reach growing stage in 3 to 4 weeks and hence laser needs to be repeated at that interval. To remove this 2nd generation of hairs. This is why many sessions are required.
    73. 73. Classifying Acne A. Non Inflammatory Acne or Comedonal Acne Black Heads White Heads B. Inflammatory Acne Red Papules Pustules Cysts C. Combination of above
    74. 74. Management - Topical 1. 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 moment excessive drying or irritation develops 5. Cream based applications should be preferred as they reduce the concomitant dryness
    75. 75. Management - Systemic • 1. 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 therapy
    76. 76. Management - Systemic • Hormonal therapy – Recalcitrant acne – Acne not responding to oral Isitretenoin – Coprescribed with Isotretenoin – PCOS
    77. 77. Treatment – Other modalities • Chemical peels • Comedon removal • IPL • Cryotherapy • Microneedling • Use of steroids Good Dermatologist help is needed. Dr. V.K. Upadhyay Gynaecologist cant treat on there own
    78. 78. Acne
    79. 79. Obesity in PCOD
    80. 80. Is Obese PCOD Girl at Risk of Infertility Yes an obese girl is about THRICE as likely to be infertile as a normal woman Polotsky AJ, hailper SM skurnick JH, LO JC sternfeld B, santoro N associated of adolescent women’s health across the nation (SWAN) fertility steril 2010;93:2004- 11)
    81. 81. Management in General • Obese patients are advised to lose weight which may be accomplished by one or a combination of following methods - – Diet – Diet & Exercise – Anti-obesity Medicines – BARIATRIC SURGERY
    82. 82. 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
    83. 83. Diet Try to AVOID food which are known to increase blood sugar levels  Reduce intake of refined carbohydrates such as white bread and white rice and saturated fats like coconut oil, animal fat, dairy fat (butter, chees) etc.
    84. 84. Diet Increase intake of  Protein rich food such as meat, sea food, nuts, pulses, dry beans and egg
    85. 85. Why Exercise ? Daily exercise •Decreases insulin resistance •Decreases Occurrence of -- Diabetes -- CV Incidents A 30 minutes daily exercise can improve many symptoms
    86. 86. Weight loss is actually due to REDUCED CALORIES and … Walking.
    87. 87. Cola Drink
    88. 88. You’ve probably heard we should be taking 10,000 Steps a Day < 5000 steps is sedentary
    89. 89. The result - Is obesity We’re sitting A lot And sitting is bad for us SITTING increases Risk of DEATH upto 40%
    90. 90. so if you WORK OUT for 1 hour a day then SIT FOR 6.25 hours you’ve pretty much LOST ALL THE BENEFIT of working out
    91. 91. Solutions? If you enjoy running, by all means, run But if like me, you hate running Consider walking
    92. 92. but it’s about health, not weight Walking alone isn’t a quick ticket to weight loss. Just walking 10,000 steps, you won’t lose a lot of weight. It’s about overall health.
    93. 93. benefits of walking •Walking burns 3-5 times the calories of sitting •Decreased depression – increases neuro-transmitters like serotonin, dopamine and norepinephrine •Improved attention span – people who stop exercising can develop ADHD symptoms •Increased creativity – from a 10-minute walk •Lower blood pressure •Increased self esteem •Improved metabolism •Improved neurogenesis •Reduced risk of Alzheimer's •Reduced risk of diabetes, heart disease, arthritis and more
    94. 94. But how? • Skip an hour of TV and go for a walk • Get off the subway a stop or two early • Take the stairs • Go for a walk on your lunch break • Park your car further away from your destination • Walk while you make all your personal phone calls • Don’t stand still on the escalator • Take the long way home • Get a standing desk* • Ride a cycle to work place • Practice “aimless walking” • Count your steps *some restrictions may apply **not officially walking, but still fun
    95. 95. wearable devices and step counting NOW AVAILABLE IN INDIA
    96. 96. Weight Reduction • Moderate exercise, low calorie (500 kcal/day deficit), low fat & reduced glycemic load improves insulin sensitivity MOA-- Weight Loss ↑SHBG ↓Insulin ↓ Peripheral Aromatization ↓ ↓ of Androgens & ↓ Free E2 & ↓Androgen Estrogens Testosterone
    97. 97. Weight Reduction is must 5-7 % weight loss results in: -Resumption of normal menstruation in 30-60% of cases. -Improvement in endocrine parameters (decreased IR, decreased T, increased SHBG) -Increased spontaneous conception rates. Hence, Cost effective
    98. 98. Treatment of Obesity BMI > 30 Behavioural Counselling Lifestyle Modification – Diet, exercise Pharmacolgical Agents – Orlistat, Sibutramine ???? Bariatric Surgery ????
    99. 99. PHARMACOLOGICAL TREATMENT • SIBUTRAMINE: appetite suppressant, 5- 15mg/day - increase suicide tendency on its way out • ORLISTAT: blocks intestinal absorption of fat, 60-120mg TDS along with meals • To be used along with Diet Restriction & Exercise.
    100. 100. Morbid Obese BMI >35 Indian Over 32.5 BMI • Pharmacological TT NOT to be recommended as a first line in Morbidly obese patients. What To Do Is a BIG Question !! • It is seen diet restriction & Exercise do not decrease weight in cases of morbid Obesity
    101. 101. Bariatric Surgery in adolescent girls ?? • Bariatric Surgery --brings ~ 15–30% weight loss that is sustained in long-term, and significant reductions in healthcare costs and comorbidities (diabetes, hypertension, hyperlipidaemia, sleep apnoea and certain cancers) • Bariatric surgery is considered for patients with a – BMI above 40 kg/m2 (37.5 for indian) – BMI above 35 kg/m2 in the presence of obesity related comorbidities – BMI above 50kg/m2: first-line treatment RRCOG SAC Opinion Paper, March 2010 -2.5 BMI for Indians
    102. 102. Menstrual Irregularity
    103. 103. MENSTRUAL DISORDERS • Weight Stabilisation • Cyclic or continuous OCP/ • Progestins • Metformin
    104. 104. ORAL CONTRACEPTIVE PILLS • Decreases adrenal and ovarian androgen production and increases SHBG. • Reduces hair growth in hirsuite patients with success rate of less than 10% only. • OC’s containing new progestins such as (desogestrel, gestodene, norgestimate, drospirenone) are preferable.
    105. 105. ROLE OF OCP IN Adolescent PCOS • 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- (EE 30 mcg + D 3 mg -Yasmin)
    106. 106. Other Drugs which can be used with OCP
    107. 107. Metformin
    108. 108. Metformin
    109. 109. METFORMIN VERSUS THE COMBINED ORAL CONTRACEPTIVE PILL FOR SYMPTOMS AND RISKS OF Adolescent PCOS. • No evidence of difference in effect between metformin and the OCP on hirsutism and acne. • Metformin was less effective than the OCP in improving menstrual pattern (OR 0.08) • Metformin resulted in a higher incidence of gastrointestinal (OR 7.75), and a lower incidence of non-gastrointestinal (OR 0.11) severe adverse effects. • Metformin was less effective in reducing serum androgen levels, free androgen index. • Metformin was more effective than the OCP in reducing fasting insulin. Cochrane library:2010
    111. 111. TAILOR MADE THERAPY in Adolescent PCOD is our attempt Your comments are needed by SMS / Watsapp 9650588339 Or Facebook
    112. 112. More & More PCOS CLUBS should be formed to shoot Information for teens & young PCOS patients on its various aspects
    113. 113. ADDRESS 11 Gagan Vihar, Near Karkari Morh Flyover, Delhi - 51 CONTACT US 9650588339, 011-22414049, WEBSITE : E-MAIL ID &