多囊性卵巢 3

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  • 多囊性卵巢 3

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

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