Polycystic Ovarian Syndrome - Obstetrics/Gynecology Case Presentation


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Polycystic Ovarian Syndrome - Obstetrics/Gynecology Case Presentation

  1. 1. Polycystic Ovarian Syndrome Candice E. Reyes, OMS III Obstetrics/Gynecology Arrowhead Regional Medical Center Case-based Presentation
  2. 2. HPI <ul><li>DL is a 25 y/o Caucasian F c/o irregular periods . Her LMP was 5 mo prior and her periods have been irregular since menarche . She notes a 30lb wt gain over the past 6 mo. She is sexually active w/her boyfriend and uses condoms for contraception. She also c/o that she has been breaking out more on her face and back. In addition, she confides that she started to wax the hair on her face and chest because she was embarrassed of it being dark and thick. </li></ul>
  3. 3. Subjective <ul><li>PMHx : Obesity </li></ul><ul><li>FHx : Mother and Father have Type II DM </li></ul><ul><li>SHx : Pt denies any surgical procedures </li></ul><ul><li>SocHx : Pt is a high school teacher. Pt drinks socially - 1-2 drinks/wk. Pt denies use of tobacco products or recreational drugs. She exercises 30min 2-3x/wk. Pt eats a moderately healthy diet. </li></ul><ul><li>Meds : Multivitamin </li></ul><ul><li>Allergies : NKDA </li></ul>
  4. 4. ROS <ul><li>General : Pt states a 30lb wt gain </li></ul><ul><li>Skin : Pt states she has “ breakouts ” on </li></ul><ul><li>her back and face. Pt also states that she </li></ul><ul><li>has a lot of unwanted hair on her face and chest </li></ul><ul><li>HEENT : Pt denies any changes in vision, hearing, smelling. Pt denies lesions. </li></ul><ul><li>Neck : Pt denies lymphadenopathy </li></ul><ul><li>Pulm : Pt denies SOB, coughing, wheezing </li></ul><ul><li>CV : Pt denies chest pain, palpitations, sweating </li></ul><ul><li>GI : Pt denies dyspepsia, nausea, vomitting, constipation, diarrhea </li></ul><ul><li>GU : Pt denies dysuria, polyuria, vaginal pain or itching, dyspareunia </li></ul><ul><li>Neuromuscular : Pt denies muscle weakness or wasting. Pt denies syncope, vertigo, or diplopia </li></ul>
  5. 5. Physical Exam <ul><li>Vitals T 98.7 R 16 P 70 BP 126/96 Pain 0 Ht 5’5’’ Wt 248lbs </li></ul><ul><li>Gen : 25 y/o obese WF in NAD </li></ul><ul><li>Skin : moderate acne on face and back, dark hair on chin and chest, neg acanthosis nigricans </li></ul><ul><li>HEENT : NCAT. Ears clear. Eyes are not icteric and conjunctiva not injected. PERRLA. Nose clear. </li></ul><ul><li>Neck : Supple, no thyroid enlargement </li></ul><ul><li>Lungs : CTAB </li></ul><ul><li>CV : RRR, neg m/c/r/g </li></ul><ul><li>Abd : obese , NTTP, neg R/G, neg striae </li></ul><ul><li>Pelvic : nml ext female genitalia , neg clitoromegaly, moist epithelium, and neg lesions on vagina and cervix, on bimmanual - no masses palpated </li></ul><ul><li>Extremities : pulses 2+ B UE and LE, neg wasting or edema </li></ul>
  6. 7. Ddx <ul><li>Other causes of hyperandrogenism </li></ul><ul><ul><li>Nonclassical congenital adrenal hyperplasia </li></ul></ul><ul><ul><li>Androgen-secreting neoplasms </li></ul></ul><ul><ul><li>Cushing syndrome </li></ul></ul><ul><ul><li>Acromegaly </li></ul></ul><ul><ul><li>Hyperprolactinemia (pituitary adenoma) </li></ul></ul><ul><ul><li>Progestational agents </li></ul></ul><ul><li>Other causes of anovulation </li></ul><ul><ul><li>Extreme exertion </li></ul></ul><ul><ul><li>Rapid weight changes </li></ul></ul><ul><ul><li>Premature ovarian failure </li></ul></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><li>Eating disorder </li></ul></ul>
  7. 8. Making the Diagnosis <ul><li>2003 international consensus panel diagnostic criteria in Rotterdam, Netherlands </li></ul><ul><ul><li>At least 2 of </li></ul></ul><ul><ul><ul><li>Oligo/anovulation (menstrual irregularities) </li></ul></ul></ul><ul><ul><ul><li>Hyperandrogenism </li></ul></ul></ul><ul><ul><ul><li>Polycystic ovaries on Utz </li></ul></ul></ul><ul><li>ACOG Practice Bulletin 108 uses 1990 NIH consensus panel criteria </li></ul><ul><ul><li>Chronic anovulation </li></ul></ul><ul><ul><li>Clinical or biochemical signs of hyperandrogenism </li></ul></ul><ul><ul><li>Other causes excluded </li></ul></ul>
  8. 9. Next step <ul><li>Urine hCG </li></ul><ul><ul><li>R/o pregnancy </li></ul></ul><ul><li>TSH and prolactin levels </li></ul><ul><ul><li>R/o common endocrine causes for amenhorrhea </li></ul></ul><ul><ul><li>Prolactin is nml to mild elev in PCOS </li></ul></ul><ul><li>Hormone levels - testosterone, LH, and FSH </li></ul><ul><ul><li>LH:FSH ratio is >2:1 and testosterone is nml to mod elev in PCOS </li></ul></ul><ul><li>Fasting glucose and fasting lipid </li></ul><ul><ul><li>Metabolic considerations </li></ul></ul>
  9. 10. Results <ul><li>Urine hCG </li></ul><ul><ul><li>Negative </li></ul></ul><ul><li>TSH and prolactin levels </li></ul><ul><ul><li>Nml TSH and prolactin </li></ul></ul><ul><li>Hormone levels - testosterone, LH, and FSH </li></ul><ul><ul><li>LH:FSH 3:1 and testosterone is mildly elevated </li></ul></ul><ul><li>Fasting glucose and fasting lipid </li></ul><ul><ul><li>Fasting glucose 115 </li></ul></ul><ul><ul><li>LDL 130 Total 210 HDL 45 Trig 145 </li></ul></ul>
  10. 11. Still uncertain? <ul><li>Pelvic Utz </li></ul><ul><ul><li>May visualize cysts </li></ul></ul><ul><li>17-hydroxyprogesterone </li></ul><ul><ul><li>Consider congenital adrenal hyperplasia </li></ul></ul><ul><li>Dexamethasone suppression test </li></ul><ul><ul><li>Consider Cushing’s </li></ul></ul><ul><li>DHEA-S </li></ul><ul><ul><li>Consider adrenal tumors </li></ul></ul><ul><li>Insulin-like GF </li></ul><ul><ul><li>Consider acromegaly </li></ul></ul>
  11. 12. Treatment <ul><li>Weight Reduction </li></ul><ul><ul><li>Lifestyle modifications </li></ul></ul><ul><ul><li>Metformin </li></ul></ul><ul><li>Prevent endometrial hyperplasia (patient does not want to get pregnant) </li></ul><ul><ul><li>Progestin therapy, e.g. medroxyprogesterone (Provera) or norethindrone (Norlutin) </li></ul></ul><ul><ul><li>Low-dose OCP </li></ul></ul><ul><ul><ul><li>Advantage - may regulate menstrual cycle and improve androgenic symptoms (hirsutism, acne) </li></ul></ul></ul><ul><ul><li>GnRH analog luprolide (Lupron) IM depot reserved for those who cannot tolerate OCPs </li></ul></ul><ul><ul><ul><li>Long term effects - hypoestrogenemia (hot flushes, bone demineralization, atrophic vaginitis </li></ul></ul></ul>
  12. 13. Follow-up <ul><li>DL just got engaged and will be getting married in a year. She inquires about her ability to get pregnant . Since starting the low-dose OCP , she has had more frequent and regular periods . In addition, her acne and hirsutism have nearly resolved . </li></ul>
  13. 14. What is the treatment now? <ul><li>Ovulation induction </li></ul><ul><ul><li>Clomiphene citrate (Clomid) </li></ul></ul><ul><ul><ul><li>Associated with 75% ovulation rates and 30-40% pregnancy rates </li></ul></ul></ul><ul><ul><li>Human menopausal gonadotropins e.g. follitropin alpha </li></ul></ul><ul><ul><ul><li>Associated with 58-82% pregnancy rates, but risk of ovarian hyperstimulation and multiple pregnancies </li></ul></ul></ul><ul><ul><li>Metformin (Glucophage) improves ovulation and pregnancy rates </li></ul></ul><ul><li>Surgery </li></ul><ul><ul><li>Wedge resection of ovary not used as commonly now that OI agents are available </li></ul></ul><ul><ul><li>Ovarian drilling </li></ul></ul><ul><ul><ul><li>Associated with spontaneous restoration of ovulation, subsequent pregnancy, but postop complications may outweigh benefits </li></ul></ul></ul>
  14. 15. Risks in Pregnancy <ul><li>Miscarriage </li></ul><ul><li>PIH </li></ul><ul><li>GDM </li></ul><ul><li>Premature delivery </li></ul>
  15. 16. Discussion and Questions?
  16. 17. References <ul><li>ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists: number 41, December 2002. Obstet Gynecol. 2002 Dec;100(6):1389-402. </li></ul><ul><li>Legro, Richard S. Clomiphene, Metformin, or Both for Infertility in the Polycystic Ovary Syndrome. N Engl J Med 2007 356: 551-566. </li></ul><ul><li>Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004 Jan;81(1):19-25. </li></ul>