Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to MENOPAUSE & PCO
Similar to MENOPAUSE & PCO (20)
More from Kawita Bapat
More from Kawita Bapat (20)
Recently uploaded
Recently uploaded (20)
MENOPAUSE & PCO
- 9. TREAT YOUR AS Patients Queen The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. DR KAWITA BAPAT
- 13. History • Originally described by Stein and Leventhal in 1935, first known as the “Stein-Leventhal syndrome” DR KAWITA BAPAT
- 14. Hyper Andro genism Menstrual Irregularity Polycystic ovaries Central Adiposity DR KAWITA BAPAT Classic syndrome originally described by Stein and Levanthal • Syndrome, not a disease—multiple potential etiologies with variable clinical expression
- 15. Diagnostic criteria based on the modified consensus of National Institutes of Health Major Chronic anovulation Clinical signs of hyperandrogenism Other etiologies excluded • • – DR KAWITA BAPAT
- 16. Diagnostic criteria based on the modified consensus of National Institutes of Health Minor Insulin resistance Perimenarchal onset of hirsutism and obesity Elevated LH : FSH ratio Intermittent anovulation associated with hyperandrogenemia (free testosterone, DHEAS). DR KAWITA BAPAT
- 17. Polycystic ovaries (>12 peripheral follicles or increased ovarian volume >10cm3) Oligo- or anovulation Clinical and/or biochemical signs of hyper androgenism And exclusion of other etiologies such 1. Hypothyroidism, 2. Hyperprolactinemia 3. Congenital Adrenal Hyperplasia, 4. Cushing Syndrome, 5. Androgen Secreting Tumors • 1 Rotterdam criteria • 2 • 3 • 4
- 18. AE-PCOS SOCIETY 2006 Hyperandrogenism- hirsutism and/ or hyperandrogenemia Ovarian dysfunction- oligo-anovulation and/ or polycystic ovaries Exclusion of other androgen excess or related disorders DR KAWITA BAPAT
- 19. Abnormal Pituitary Function— Altered Negative Feedback Loop • Increased GnRH from hypothalamus • Excessive LH secretion relative to FSH by pituitary gland • LH stimulates ovarian thecal cells-- androgen production • Ineffective suppression of the LH pulse frequency • by estradiol and progesterone • Androgen excess increases LH by blocking the hypothalamic inhibitory feedback of progesterone DR KAWITA BAPAT
- 20. Abnormal steroidogenenesis • Follicular maturation is inhibited • Excess androgen causes thecal and stromal hyperplasia • Intraovarian androgen excess results in excessive growth of small ovarian follicles DR KAWITA BAPAT
- 21. HYPERANDROGENISM important Hirsu/sm, acne, male paAern balding, alopecia Elevated Serum Androgen Levels Free testosterone levels most sensi/ve Increased Muscle Mass, Deepening Voice, Clitormegaly
- 22. Insulin resistance • Favors anovulation, 1. androgen excess, 2. reduced SHBG • Metabolic syndrome • Abdominal obesity DR KAWITA BAPAT
- 23. Insulin Resistance: Associated Conditions Insulin Resistance Type 2 diabetes Hypertension Impaired Glucose tolerance Obesity (central) Polycystic ovary diseaseHyperuricemia Acanthosis Nigricans Decreased Fibrinolytic Activity Dyslipidemia Atherosclerosis DR KAWITA BAPAT
- 24. Clinical Presentation of Women with PCOS Adolescent Period Reproductive Period Menopausal ♣ Menstrual Irregularity ♣Cosmetic concerns ♣ Acne ♣ Hirsutism ♣ Hair Loss ♣ Infertility ♣ Early Pregnancy loss ♣ During pregnancy ♣ PIH ♣ GDM ♣ Metabolic Syndrome ♣ Ca Endometrium ObesityDR KAWITA BAPAT
- 25. MENSTRUAL DYSFUNCTION Delayed menarche deficient progesterone secretion Chronic estrogen stimulation No Progesterone For Differentiation Intermittent Breakthrough Bleeding Dysfunctional Uterine Bleeding Increased risk for endometrial hyperplasia Endometrial CA DR KAWITA BAPAT
- 26. • Elevated CRP and heart disease • Advanced atherosclerosis 4 • Metabolic syndrome—43% of PCOS pa/ents • (2 fold higher than age-‐matched popula/on) 3 • Sleep apnea • Nonalcoholic steatohepa//s 2 ASSOCIATED MEDICAL CONDITIONS • Increased risk of developing Type 2 Diabetes • Low HDL and high triglycerides 1 DR KAWITA BAPAT
- 27. PCOS & Metabolic Syndrome Metabolic Syndrome: • • Cluster of Cardiovascular risk factors related to Insulin Resistance: - Obesity - Hyperinsulinemia - Hypertension - Atherogenic Dyslipidemia - Atherosclerosis - Hyperglycemia Major Risk Factors: - Physical inactivity - Atherogenic diet - Adiposity / abdominal obesity DR KAWITA BAPAT
- 28. Blood pressure 130/ 85 mm Hg HDL cholesterol: <50 mg/dL Triglycerides >150 mg/dL . Waist circumference >88 cm (>35 inch) . ATP III Clinical Iden/fica/on of the Metabolic Syndrome 2 3 Fasting glucose >110 mg/dL*New ADA guidelines increases risk for Metabolic Syndrome •Presence of any 2 of 5 criteria required 1 4 5 DR KAWITA BAPAT
- 29. Trouble In Diagnosis • With PCOS when women already reached menopause it is not possible to diagnose Because • The Cardinal Features Disappear. • Menses Cease • Testosterone Levels May No Longer Be Higher DR KAWITA BAPAT
- 30. Trouble In Diagnosis • Although Less Conven/onal Measures • Androgen Excess • Levels Remain Higher 1. Free Androgen Index 2. Human Chorionic Gonadotropin-‐ s/mulated Androstenedione 3. 17-‐hydroxyprogesterone DR KAWITA BAPAT
- 31. Trouble In Diagnosis • PCO Morphology Persists Into Menopause • Hypo Echoic Structures On Ultrasound • In Postmenopausal Women With PCOS Correspond 1. Inclusion Cysts 2. Vascular Structures Rather Than Follicles Pathology Studies Do Not Demonstrate Secondary Follicles In Postmenopausal Ovaries DR KAWITA BAPAT
- 32. Trouble in diagnosis • When women with PCOS had reached menopause • no difference in 1. fas/ng insulin levels 2. HOMA of insulin resistance 3. glucose levels • prevalence of hypertension higher • triglyceride levels increased DR KAWITA BAPAT
- 33. MENOPAUSAL TRANSITION DYSLIPIDEMIA WITH AGE SPECIFIC INCREASE IN LDL 01 METABOLIC ABNORMALITIES IN WOMEN WITH PCOS ALSO WORSEN WITH AGE. 02 • WAIST CIRCUMFERENCE • CHOLESTEROL • TRIGLYCERIDE LEVELS INCREASE IN • AS THEY REACH 40 TO 50 YEARS 03 BMI INCREASED IN SOME 04 All women experience Increasing insulin resistance Abdominal adiposity along with chronic inflamma/on
- 34. PHENOTYPE Recommenda/on Of The Na/onal Ins/tutes Of Health (NIH) Evidence-‐based Methodology 01 02 03 04 (Phenotype A) ● (Phenotype B) ●(Phenotype C) ● (Phenotype D) Androgen excess + ovulatory dysfunc/on + polycys/c ovarian morphology Androgen excess + ovulatory dysfunc/on Androgen excess + polycys/c ovarian morphology Ovulatory dysfunc/on + polycys/c ovarian morphology in menopausal women is difficult to define. DR KAWITA BAPAT
- 35. Hyperandrogenism • Persists Ager The Menopausal Transi/on. • Con/nue To Manifest The Metabolic Altera/ons Such As – Insulin Resistance – Which Makes Them More Suscep/ble To Type 2 Diabetes Mellitus. DR KAWITA BAPAT
- 37. Insulin Resistance Cardiovascular Risk Obstructive Sleep Apnea Malignancy Risk Management Long-term Issues 01 02 03 04
- 38. Diet and Exercise • 4-12 weeks of dietary restriction. obese, endocrine-metabolic parameters markedly improve – SHBG levels rise • Decrease – Serum insulin. – IGF-1 levels – free testosterone levels fall by 2-fold. • • • • Moran LJ, Pasquali R, et all Treatment of obesity in polycystic ovary syndrome: a position statement of the Androgen Excess and Polycystic Ovary Syndrome Society. Fertil Steril. Dec 3 2008; DR KAWITA BAPAT
- 39. Diet and Exercise A moderate amount of daily exercise 1. Increases of levels of IGF-1 binding protein 2. Decreases IGF-1 levels by 20%. lifestyle management as the primary therapy in overweight and obese women with PCOS for the treatment of metabolic complications. • • • • Moran LJ, Pasquali R, et all Treatment of obesity in polycystic ovary syndrome: a position statement of the Androgen Excess and Polycystic Ovary Syndrome Society. Fertil Steril. Dec 3 2008; DR KAWITA BAPAT
- 40. Management: Long-Term Issues • Obstructive Sleep Apnea – – – • 30-fold increased risk of OSA, not explained by obesity alone. • Insulin resistance strongest predictor of OSA (not BMI, age, testosterone) • Consider polysomnography if at risk DR KAWITA BAPAT
- 41. Management: Long-Term Issues • Risk for malignancy – – – • 3 fold increased risk endometrial carcinoma in PCOS • Increased risk of ovarian and breast cancer • Warrants regular screening, low threshold for endometrial biopsy DR KAWITA BAPAT
- 42. Thank you DR KAWITA BAPAT
- 43. Thank you DR KAWITA BAPAT
- 44. DR KAWITA BAPAT