Polycystic ovary syndrome

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This presentation briefly discuss the polycystic ovary syndrome in terms of pathogenesis, features and management. Then, It moves on to discuss the various guidelines laid down by Endocrine Society in 2013 for the management of patients with polycystic ovary syndrome.

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Polycystic ovary syndrome

  1. 1. Polycystic Ovary Syndrome 28 May 2014 1Presenter : Dr. Jagjit Khosla Presentation : Dr. Jagjit Khosla Junior Resident, Endocrinology, GuruTeg Bahadur Hospital, Delhi
  2. 2. Polycystic Ovary Syndrome • First described by Stein & Leventhal (1935) • Incidence : 5-10% • Leading cause of female infertility • Insulin resistance described later by Burghen (1980) 28 May 2014 2 Polycystic Ovary Amenorrhea ObesityHirsutism Presenter : Dr. Jagjit Khosla
  3. 3. PCOS - Pathophysiology 28 May 2014 3Presenter : Dr. Jagjit Khosla
  4. 4. PCOS – Clinical Features • Hyperandrogenism • Hirsutism • Modified Ferriman Gallwey Score • Acne • Androgenic alopecia • Menstrual Irregularity • Oligomenorrhea (70-75%) • Amenorrhea (20%) • Infertility (30-70%) 28 May 2014 4Presenter : Dr. Jagjit Khosla
  5. 5. PCOS – Clinical Features • Obesity • Insulin resistance • Acanthosis nigricans • Skin tags • Impaired Glucose tolerance • Type 2 DM 28 May 2014 5Presenter : Dr. Jagjit Khosla
  6. 6. PCOS – Evaluation • Biochemical evidence of hyperandrogenism • S. Total testosterone • USG evidence of Polycystic ovary • 12 or more follicles in each ovary measuring 2-9 mm in diameter +/- inc. ovarian volume (>10 mL) [Rotterdam criteria] 28 May 2014 6Presenter : Dr. Jagjit Khosla
  7. 7. PCOS – Evaluation • Exclusion of other differential diagnoses • Hyperprolactinemia, hypothyroidism • Non-Classical Congenital Adrenal Hyperplasia • Ovarian & Adrenal tumors • Cushing’s syndrome, Glucocorticoid resistance • Drugs : Danazol, OCPs 28 May 2014 7Presenter : Dr. Jagjit Khosla
  8. 8. PCOS – Diagnostic criteria NIH (1990) • Menstrual Irregularity • Hyperandrogenism • Exclusion of other etiologies 28 May 2014 8 Rotterdam (2003) • 2 out of 3 required 1. Menstrual Irregularity 2. Hyperandrogenism 3. USG – Polycystic ovary • Exclusion of other etiologies AES (2006) • Menstrual irregularity +/- USG - Polycystic ovary • Hyperandrogenism • Exclusion of other etiologies Presenter : Dr. Jagjit Khosla
  9. 9. PCOS – Management • Lifestyle modifications – • Low calorie diet • Regular brisk walk 25-35 min daily • Hormonal contraceptives – • 1st line T/t of hirsutism, acne and menstrual irregularity • Spironolactone • Added to OCPs if suboptimal results after 6 months 28 May 2014 9 Legro, Richard S., et al. "Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline." Journal of Clinical Endocrinology & Metabolism 98.12 (2013): 4565-4592. Presenter : Dr. Jagjit Khosla
  10. 10. PCOS – Management • Clomiphene citrate – • 1st line t/t for infertility • Insulin sensitizing agents – • Metformin – limited recommendations • Screening patients for long term complications • Endometrial cancer, Mood disorders, OSA, DM, CVD 28 May 2014 10 Legro, Richard S., et al. "Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline." Journal of Clinical Endocrinology & Metabolism 98.12 (2013): 4565-4592. Presenter : Dr. Jagjit Khosla
  11. 11. Spironolactone • Actions • Androgen receptor blockade • Steroid synthesis inhibitor • Aldosterone receptor blockade • Status is PCOS management • 2nd line drug for T/t of hirsutism, acne • If used alone, alternative contraception needed • No endometrial protection 28 May 2014 11Presenter : Dr. Jagjit Khosla
  12. 12. Metformin • Actions • Increase insulin sensitivity • Directly inhibit human theca cell androgen synthesis • Status is PCOS management • Women with PCOS and type 2 DM or IGT • Women who cannot take oral contraceptives • Adjuvant therapy in women undergoing IVF – prevent ovarian hyperstimulation 28 May 2014 12Presenter : Dr. Jagjit Khosla
  13. 13. ES Guidelines for PCOS 2013 • 3 Recommendations Diagnosis of PCOS • 12 Recommendations Associated Comorbidity & Evaluation • 12 Recommendations Treatment of PCOS Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 13
  14. 14. ES Guidelines for PCOS 2013 1 - Diagnosis of PCOS
  15. 15. ES Guidelines for PCOS 2013 1.1 - Diagnosis of PCOS in Adults • Rotterdam (2003) criteria Androgen excess Ovulatory dysfunction Polycystic ovaries (USG) 2 out of 3 + Exclusion of other etiologies Clinical or biochemical Oligo- or anovulation Atleast one ovary with • 12 follicles 2-9mm • Volume > 10mL Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 15
  16. 16. ES Guidelines for PCOS 2013 1.1 - Diagnosis of PCOS in Adults • Rotterdam (2003) criteria • Thyroid disease • Hyperprolactin • Nonclassical congenital adrenal hyperplasia • Cushing’s syndrome • Acromegaly • Androgen secreting tumors • Other causes of amenorrhea Exclusion of other etiologies Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 16
  17. 17. ES Guidelines for PCOS 2013 1.2 - Diagnosis of PCOS in adolescents • Anovulation and Polycystic ovary NOT reliable Androgen excess Persistent oligomenorrhea Exclusion of other etiologies + + Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 17 >2 yrs beyond menarche
  18. 18. ES Guidelines for PCOS 2013 1.3 Diagnosis in perimenopause and menopause • Long term history of oligomenorrhea & hyperandrogenism • Polycystic ovary – less likely Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 18
  19. 19. ES Guidelines for PCOS 2013 2 - Associated comorbidity and Evaluation
  20. 20. ES Guidelines for PCOS 2013 2.1 - Documenting cutaneous menifestations • Hirsutism (Modified Ferriman-Gallwey score) • Acne • Adrogenic alopecia (Ludwig score) • Acanthosis nigricans • Skin tags Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 20
  21. 21. ES Guidelines for PCOS 2013 2.2 - Screening ovulatory status (even in eumenorrheic patients) • ↑ Risk of anovulation and infertility • Menstrual history • Midluteal S. Progesterone 2.3 - Exclude other causes of infertility in couples • Obesity, Male factor infertility, tubal occlusion Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 21
  22. 22. ES Guidelines for PCOS 2013 2.4 - Preconceptual Assessment • ↑ Risk of pregnancy complications (GDM, Preterm delivery, Pre-eclampsia) • BMI, BP, OGTT Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 22
  23. 23. ES Guidelines for PCOS 2013 2.5 - No intervention for prevention of PCOS in offspring of PCOS women • Inconclusive evidence of intrauterine effects Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 23
  24. 24. ES Guidelines for PCOS 2013 2.6 - No routine USG screening for endometrial thickness in PCOS women without abnormal bleeding • Poor diagnostic accuracy Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 24
  25. 25. ES Guidelines for PCOS 2013 2.7 - Screen for increased adiposity • Ass. with Hyperandrogenemia and ↑ Metabolic risk • BMI, Waist circumference Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 25
  26. 26. ES Guidelines for PCOS 2013 2.8 - Screen and manage depression and anxiety 2.9 - Screen and manage Obstructive sleep apnea (OSA) • Polysomnography Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 26
  27. 27. ES Guidelines for PCOS 2013 2.10 - Awareness about possibility of NAFLD and NASH (No screening) Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 27
  28. 28. ES Guidelines for PCOS 2013 2.11 - Screen for IGT and T2DM • OGTT or HbA1c • Re-screening every 3-5 years Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 28
  29. 29. ES Guidelines for PCOS 2013 2.12 - Screen for CVD risk factors At risk • Obesity • Cigarette smoking • Hypertension • Dyslipidemia • Subclinical vascular disease • Impaired glucose tolerance • Family history of premature CVD High risk • Metabolic syndrome • T2DM • Overt vascular or renal disease, CVD • OSA Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 29
  30. 30. ES Guidelines for PCOS 2013 3 - Treatment
  31. 31. ES Guidelines for PCOS 2013 3.1 - Hormonal contraceptives (HC) – First Line management for menstrual abnormalities and hirsutism/acne of PCOS 3.2 - Screen for contraindications of HCs Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 31
  32. 32. ES Guidelines for PCOS 2013 3.3 - Exercise therapy in management of overweight and obesity in PCOS • 30 min moderate to vigorous exercise daily 3.4 - Weight loss strategies for adolescents and those overweight or obese • Calorie-restricted diet Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 32
  33. 33. ES Guidelines for PCOS 2013 3.5 - Metformin NOT first line management for • Cutaneous manifestations • Prevention of pregnancy complications • Obesity Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 33
  34. 34. ES Guidelines for PCOS 2013 3.6 - Metformin to be used in PCOS women if • T2DM or IGT who fail lifestyle modification • Menstrual irregularities present and HCs are contraindicated / not tolerated. Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 34
  35. 35. ES Guidelines for PCOS 2013 3.7 - Clomiphene citrate (or Letrozole) as first line treatment for anovulatory infertility in PCOS 3.8 - Metformin as adjuvant for infertility to prevent Ovarian hyperstimulation syndrome (OHSS) in women with PCOS undergoing IVF Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 35
  36. 36. ES Guidelines for PCOS 2013 3.9 - Insulin sensitizers e.g. inositols or thiazolidinediones use NOT recommended 3.10 - Statins only recommended in PCOS if patient meet current indications for statin therapy. Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 36
  37. 37. ES Guidelines for PCOS 2013 3.11 - Treatment of adolescents • HCs first-line treatment with suspected PCOS • Lifestyle therapy (calorie-restricted diet and exercise) also first-line if overweight/obesity • Metformin use to treat IGT/Metabolic syndrome • Duration not determined Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 37
  38. 38. ES Guidelines for PCOS 2013 3.12 - Start HCs in pre-menarchal girls with hyperandrogenism and advanced pubertal development • ≥ Tanner stage IV breast development Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 38
  39. 39. Summary Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 39 • Follow Rotterdam criteria in adults • Difficult diagnosis in adolescents & perimenopausal/menopausal women Diagnosis of PCOS
  40. 40. Summary Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 40 • Document cutaneous manifestations • Preconceptual assessment to prevent pregnancy complications • Look for other causes of infertility in couple • Screening for anovulation, inc. adiposity, depression, anxiety, OSA, IGT/T2DM, CVD risk factors • No screening needed for endometrial cancer, NAFLD, NASH • No specific intervention to prevent PCOS in offspring Associated comorbidity and evaluation
  41. 41. Summary Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 41 • HCs first line therapy for PCOS in adults, adolescents and pre- menarchal girls with suspected PCOS • Lifestyle modifications first line therapy in obese/overweights • Metformin use recommended only when : • PCOS with T2DM/IGT who fail lifestyle modifications • Menstrual irregularity with contraindication for HCs • Adjuvant therapy to prevent OHSS in PCOS women undergoing IVF • In Adolescents to treat IGT/ Metabolic syndrome Treatment
  42. 42. Summary Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 42 • Clomiphene citrate or Letrozole first line therapy for anovulatory infertility in PCOS • Statins only used if indication for statin therapy present • Insulin sensitizers e.g. inositols & TZDs not recommended in PCOS Treatment
  43. 43. 28 May 2014 Presenter : Dr. Jagjit Khosla 43 Thank you…

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