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PCOS, Endometriosis and Pelvic Pain


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PCOS, Endometriosis and Pelvic Pain

  1. 1. Thomas Lemon School of Medicine Cardiff University ©All rights reserved. 2012.
  2. 2. Aims PCOS Endometriosis Pelvic Pain -Classification -Symptoms -Causes -Pathogenesis -Treatment -Prognosis -Summary -Aetiology -Features -Diagnosis -Treatment -Summary -Classification -Causes -Treatment -Summary
  3. 3. • Polycystic ovary syndrome (PCOS) is one of the most common female endocrine disorders. • PCOS is a complex, heterogeneous disorder of uncertain aetiology, but strong evidence it can largely be classified as a genetic disease • PCOS produces symptoms in approximately 5% to 10% of women of reproductive age (12–45 years old). • It is thought to be one of the leading causes of female subfertility and the most frequent endocrine problem in women of reproductive age. PCOS-What is it?
  4. 4. PCOS- Who has it?
  5. 5. Anovulation Resulting in irregular menstruation, amenorrhea, ovulation- related infertility, and polycystic ovaries. Excessive amounts or effects of androgenic hormones Resulting in acne and hirsutism Insulin resistance Often associated with obesity, Type 2 diabetes, and high cholesterol levels. PCOS-Features
  6. 6. Symptom Frequency Oligomenorrea 29-52% Amenorrea 19-51% Hirsutism 64-69% Obesity 35-41% Acne 27-35% Alopecia 3-6% Acanthosis nigricans <1-3% Infertility 20-74% Elevated Serum LH 40-51% Elevated testosterone 29-50% PCOS -Symptoms
  7. 7. European Society of Human Reproduction and Embryology (ESHRE) in Rotterdam indicated PCOS to be present if any 2 out of 3 criteria are met 1.oligoovulation and/or anovulation 2.excess androgen activity 3.polycystic ovaries (by gynaecologic ultrasound) In 2006, the Androgen Excess & PCOS Society suggested a tightening of the diagnostic criteria to all of: 1.excess androgen activity 2.oligoovulation/anovulation and/or polycystic ovaries 3.other entities are excluded that would cause excess androgen activity PCOS-Diagnosis
  8. 8. Other causes of irregular or absent menstruation and hirsutism…. -hypothyroidism -congenital adrenal hyperplasia (21-hydroxylase deficiency) -Cushing's syndrome -hyperprolactinameia, androgen secreting neoplasms, and other pituitary or adrenal disorders -PCOS has been reported in other insulin-resistant situations such as acromegaly PCOS-Differential Diagnosis
  9. 9. The genetic component is autosomal dominant fashion with high genetic penetrance but variable expressivity in females The genetic variant(s) can be inherited from either the father or the mother, and can be passed along to both sons (asymptomatic carriers or symptoms such as early baldness and/or excessive hair) and daughters, who will show signs of PCOS The allele appears to manifest itself via heightened androgen levels secreted by ovarian follicle theca cells from women with the allele The exact gene affected has not yet been identified The clinical severity of PCOS symptoms determined by factors such as obesity. PCOS aetiology
  10. 10. Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of male hormones (androgens), particularly testosterone, by either one or a combination of the following (almost certainly combined with genetic susceptibility) the release of excessive LH by the anterior pituitary gland through high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries are sensitive to this stimulus Alternatively or as well, reduced levels of sex-hormone binding globulin can result in increased free androgens ‘Cysts" are actually immature follicles, not cysts The follicles have developed from primordial follicles, but the development has stopped ("arrested") at an early antral stage due to the disturbed ovarian function.The follicles may be oriented along the ovarian periphery, appearing as a 'string of pearls' on ultrasound examination. Women with PCOS have higher GnRH, which in turn results in an increase in LH/FSH ratio in women with PCOS. A majority of patients with PCOS have insulin resistance and/or are obese. Hyperinsulinemia increases GnRH pulse frequency, LH over FSH dominance, increased ovarian androgen production, decreased follicular maturation, and decreased SHBG binding; all these steps contribute to the development of PCOS. PCOS Pathogenesis
  11. 11. In many cases PCOS is characterised by a complex positive feedback loop of insulin resistance and hyperandrogenism. In most cases it can not be determined which (if any) of those two should be regarded causative. Adipose tissue possesses aromatase, an enzyme that converts androstenedione to estrone and testosterone to oestradiol.The excess of adipose tissue in obese patients creates the paradox of having both excess androgens (which are responsible for hirsutism and virilizattion) and oestrogens (which inhibits FSH via negative feedback). PCOS Pathogenesis ctd
  12. 12. Medical treatment of PCOS is tailored to the patient's goals. Broadly, these may be considered under four categories: 1. Lowering of insulin levels 2. Restoration of fertility 3. Treatment of hirsutism or acne 4. Restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer PCOS-Management
  13. 13. Women with PCOS are at risk for the following: -Endometrial hyperplasia and endometrial cancer -Insulin resistance/Type II diabetes -High blood pressure, particularly if obese and/or during pregnancy -Depression -Dyslipidemia -Cardiovascular disease -Weight gain -Miscarriage -Sleep apnoea -Non-alcoholic fatty liver disease -Acanthosis nigricans (patches of darkened skin under the arms, in the groin area, on the back of the neck) -Autoimmune thyroiditis PCOS-Prognosis
  14. 14. • Presumed to be genetic aetiology • Complicated pathogenesis, due to increased action of oestrogen • Common • Serious complications – fertility issues • Easy spot signs, hirsutism, obesity etc • Treatment is available • Failure to treat increases risk of many other diseases PCOS -Summary
  15. 15. Endometriosis
  16. 16. • Condition in which the endometrium is found outside the uterine cavity • Most commonly found in the Pouch of Douglas, umbilicus and in scars after gynae operations • Endometriosis within the myometrium is called adenomysosis Endometriosis
  17. 17. • Retrograde menstruation leading to implantation • Implantation of fragments at operation • Change of peritoneal mesothelial cells to endometrial cells Endometriosis-Aetiology
  18. 18. Common in Europe Uncommon in negroes COMMON IN NULLIPAROUS WOMEN Pelvic pain Dysmenorrhea Menorrhagia Frequent periods Dysparenuia Infertility Pelvic pressure symptoms Uterine retroversion Thickening of the utero-sacral ligaments Nodules of the Pouch of Douglas Ovarian enlargements and cysts Endometriosis- Features
  19. 19. Medical -continuous progestogen -continuous danazol (anti gonadotrophic agent) Surgical - diathermy of endometriomata - excision of endometriomata Endometriosis- Management
  20. 20. • Endometrium where it shouldn’t be • Endometrioma is large enough to be classified a tumour and is called chocolate cyst • Oestrogen dependent • No pathognomonic symptoms but pain, mass and infertility common symptoms • Treatment- Laser, Diathermy, Excision Endometriosis-Summary
  21. 21. Pelvic Pain
  22. 22. • Acute • Chronic Pelvic Pain- Classification
  23. 23. • Associated with pregnancy (ectopic or abortion) • Ovarian cysts complication (torsion, corpus luteum rupture) • Dysmenorrhea • Infections and Inflammations (+++ gonorrhoea) • Fibroid complications (red degeneration of pregnancy) • Non gynae causes e.g. appendicitis Acute pelvic Pain
  24. 24. • Infections (Chronic Inflammatory Pelvic Disease) • Endometriosis • Pelvic tumours • Non gynae causes Chronic Pelvic Pain
  25. 25. Approach to women with pelvic pain…
  26. 26. • Acute or Chronic helps to define aetiology and enable bespoke and suitable management • Any Chronic cause can present acutely but unlikely vice versa Pelvic pain - Summary
  27. 27. CASE
  28. 28. History -21 year old female referred to dermatologist complaining of facial hair growth. Her skin has become more greasy lately. -Menarche was 13, her period has been erratic with intermentstrual interval ranging 3 days to 3 months. -She lives alone, smoke 20 cigarettes a day and drinks about 20 units a week. CASE
  29. 29. O/E BMI 31 Greasy facial skin Otherwise normal FSH 1U/l LOW LH 32U/l HI Oestradiol 284nmol/24hr HI Testosterone 8.2nmol/l HI
  30. 30. DDx?
  31. 31. DDx of hirsutism 1.Constitutional 2.Drugs – Cyclosporin, Minoxidil 3. Cushings syndrome 4.CAH 5.Androgen secreting tumours 6. Hypothyroidism Which two of these are the rarest causes?
  32. 32. Cushings and Androgen Secreting Tumours both under 1% of cases
  33. 33. Stein- Leventhal syndrome (aka PCOS) Why? Patient has hirsutism and 2rdy amenorrhea due to polycystic ovaries Diagnosis?
  34. 34. Thank you