PCOS
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Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders in women of reproductive age, affecting 5-10% of women. It is characterized by hyperandrogenism, chronic anovulation, and polycystic ovaries. PCOS increases the risk of metabolic syndrome, diabetes, cardiovascular disease, and endometrial cancer. Treatment involves lifestyle modifications like weight loss and exercise. Pharmacological treatments include combined oral contraceptives to regulate menstrual cycles and metformin to reduce insulin resistance. PCOS management may involve specialists like gynecologists, endocrinologists, and dietitians.
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PCOS
- 2. Dermatologist Disorder of hair growth, Acne Fertility problem Menstrual dysfunctionGynecologist Obesity problem Risk of DM II Risk of CVS disorderInternist General practitioner ? PREVALANCE: 5-10% IN 20-40 YR FEMALES
- 3. • 1st described by Irving Stein and Michael Leventhal (1935) as a triad of amenorrhea, obesity and hirsutism • One of the most common endocrine disorders occurring in women
- 4. Definition of PCOS ESHRE (European Society for Human Reproduction) & ASRM (American Society of Reproductive Medicine) 2003 2 of the 3 elements: – Hyperandrogenism (clinical or biochemical) – Chronic anovulation – Polycystic ovaries (with exclusion of other etiologies)
- 5. OTHER ETIOLOGIES • Hypothyroidism • Hyperprolactinemia • Nonclassic congenital adrenal hyperplasia • Cushing’s syndrome • Androgen-secreting neoplasm • Acromegaly • Drugs-related (androgens, valproic acid, cyclosporine, or other drugs).
- 6. PATHOGENESIS
- 7. Genetic Predisposition Aging Pregnancy Drugs Lifestyle Insulin Resistance Hyperinsulinemia Altered Fat Metabolism Altered Steroid Hormone Metabolism PCOS: Acne, hirsutism, Hyperandrogenism, infertility Adapted from Cristello F et al, Gynecological Endocrinology, 2005. Android Obesity ↑ Lipid Storage
- 11. Hirsutism (excessive growth of thick, dark terminal hair in women where hair growth is normally absent) Modified Ferriman-Gallwey scoring system 0-36 Mild <4 Moderate 4-7 Severe ≥8 1.Upper Lip 2.Chin 3.Chest 4.Upper Back 5.Lower Back 6.Upper Abdomen 7.Upper Arm 8.Forearm 9.Thigh /Leg
- 12. • HAIR-AN Syndrome HyperAndrogenism Insulin Resistance Acanthosis Nigricans • SAHA Syndrome Seborrhea Acne Hirsutism Alopecia
- 13. OBESITY • 60% • 10% - undiagnosed diabetes • 35% - impaired glucose tolerance
- 14. Menstrual irregularity Normal cycle 21-35 days Oligomenorrhea - Cycles consistently more than 35 days Less than 10 periods per year
- 15. Reproductive age Obesity Menstrual irregularity Infertility Pregnancy related complication
- 16. Infertility • >75% of women with anovulatory infertility •Follicular arrest – Impaired selection of dominant follicle Ovulation PCOS No ovulation Infrequent ovulation
- 17. Pregnancy Complications • Spontaneous Abortions • Impaired Glucose Tolerance • Gestational diabetes • Hypertension • Small for Gestational Age
- 19. Increased risk very likely • Lipid abnormalities – lower HDL – higher total chol, LDL, TG • risk of Type 2 diabetes • • risk of endometrial carcinoma – Unopposed estrogen on endometrium
- 20. Increased risk possible • Hypertension • Cardiovascular disease
- 21. Increased risk unlikely • Ovarian cancer • Breast cancer
- 22. Long Term risks
- 23. OBSTRUCTIVE Sleep Apnea • Increased risk • Fasting plasma insulin levels and glucose-to-insulin ratios strongest predictors
- 24. The Metabolic Syndrome and PCOS • 43-46% NCEPATP III Hypertension Current antihypertensive therapy and/or BP>130/85mmHg Dyslipidemia Plasma Triglyceride level >150mg/dl and/or HDL level <50 mg/dl Obesity Waist Circumference >88cm Glucose Fasting Blood Glucose level >110mg/dl Requirements for Diagnosis Any 3 of the above disorders
- 25. Body Image and Quality of Life Obesity and infertility cause the greatest degree o stress • Anorexia nervosa • Bulimia • Pelvic pain • Depression • Psychosexual dysfunction
- 26. DIAGNOSIS
- 27. ULTRASOUND (POLYCYSTIC OVARY) ESHRE/ASRM at least one ovary with ≥ 12 follicles of 2–9mm (between day 2-5 of cycle) or ovarian volume > 10mL in the absence of a cyst or dominant follicle > 10 mm
- 28. LAB INVESTIGATION • LH: FSH ratio • DHEAS • Free Testosterone
- 29. Diagnostic tests for exclusion • Thyroid function test • Serum Prolactin • 17- alpha OH Progesterone (CAH)
- 30. Screening test repeat at 6 months for borderline risk and two year for normal profiles Lipid profile Fasting glucose / OGTT
- 31. Other • Insulin resistance (IR) – Fasting insulin >25 µIU/ml – Fasting glucose: insulin < 4.5 indicate IR in adult obese PCOS <7 useful index of IR in adolescents Test for IR not necessary to diagnose PCOS or to select any treatment
- 33. Adolescents • Menstrual irregularity persists beyond two years of menarche • Minimal diagnosis of PCOS Include 5 tests 1. Serum total testosterone (cut off 60 ng/dL) 2. OGTT (at zero and two hours after 75 g glucose load) 3. Serum 17– hydroxy progesterone (assessed at 8 am) 4. Serum TSH 5. Serum prolactin levels • Serum LH, FSH and cortisol as indicated
- 34. MANAGEMENT
- 35. Types of Physicians/Ancillary Professionals Involved with PCOS General Practitioner Fertility/Reproductive Specialist Dermatologist Dietician Endocrinologist Obstetrician/Gynecologist Pediatrician Cardiologist Pulmonologist Neurologist Oncologist Surgeon(Bariatric Surgery) Psychiatrist Radiologist Internist Gastroenterologist
- 36. Non-pharmacological interventions LIFESTYLE MODIFICATION WEIGHT LOSS EXCERSICE BALANCED DIET
- 37. PHARMACOLOGICAL MANAGEMENT • COMBINED ORAL CONTRACEPTIVES • INSULIN SENSITISERS – METFORMIN
- 38. • inducing withdrawal bleed every 3 to 4 months with progestogens - reduce the risk • hyperinsulinemia is the primary cause of endometrial hyperplasia - use of insulin sensitizers can reduce the hyperplasia
- 39. withdrawal bleed every 3 to 4 months reduce the risk of endometrial cancer hyperinsulinemia is the primary cause of endometrial hyperplasia insulin sensitizers can reduce the hyperplasia
- 40. COMBINED ORAL CONTRACEPTIVES first-line agents in women not willing to conceive Menstrual irregularities Hirsutism Acne (androgenic/refractory/nodulocystic)
- 41. • Anti-androgenic progestins Cyproterone acetate (CPA) Drospirenone Desogestrel • 6-12 cycles
- 42. US FDA 2012 • OCPs containing drospironone associated with 3 times higher risk of VTE compared with COCs containing levonorgestrel (Mala N, Mala D, Loette ) • Assess risk of VTE before starting drospironone containing COC • Do not use if history of thromboembolism (in family or self)
- 43. METFORMIN • Mechanism - Inhibits hepatic glucose production. Reduces insulin resistance and secretion Directly inhibits ovarian steroidogenesis Reduces T, free T, A4, DHEAS, LH, Waist to hip ratio, BMI, BP Increases FSH, SHBG • Use – IGT IR DM • 1500mg-2500mg/day, at least 3 months.
- 44. Adolescents • lifestyle modification - first-line therapy • Low dose COCs (with or without anti-androgenic progestins drospirenone and desogestrel) for the management of MI • metformin is second-line therapy with a wait period of 2 years post- menarche in children • In adolescents with hyperandrogenism, if glucose intolerance is not established by OGTT, metformin should not be started • Menstrual regularity: 4 cycles/year in adolescents of 12-16 years
- 45. Hirsutism • Manual hair removal • Laser • Eflornithine (locally acting antiandrogens) • Spironolactone • Finasteride
- 46. acne Topical applications first-line treatment e.g. • Benzoyl peroxide • Topical retinoids • Topical antibiotics
- 47. Infertility • Ovulation induction • Ovarian drilling • IVF
- 48. Pregnancy • Preconceptional care - explain the risks - screen for markers of obesity, hypertension and IR - RPL - serum homocysteine • Do not to use metformin therapy during pregnancy until specific evidence on beneficial effects is demonstrated
- 49. Obesity • Antiobesity drugs • Bariatric surgery • Nutritional therapy • Exercise programmes
- 50. Thank You