PCOS Made Easy Through Case Discussion Moderator DR. Sharda Jain , DR. raj Bokaria Speaker : Dr. Meenakshi Sharma Dr. Dipti Nabh , Dr. Vandana Gupta

1. Moderator : Dr. Sharda Jain
Dr. Raj Bokaria
Speaker : Dr Dipti Nabh
Dr Meenakshi Sharma
Dr Vandana Gupta
PCOS MADE EASY
(through Case Discussion)
Delhi Gynaecologist Forum’s CME
on PCOS in Delhi

2.  Objective To discuss real-world case-based scenarios to
enable clinicians manage PCOS-related
hyperandrogenism more efficiently

3. Case 1
 17 years old girl presents with irregular infrequent
periods since past 8 months (age of menarche: 12 years)
 Associated complaints of acne not responding to topical
therapy, causing embarrassment
 History of excessive weight gain in past 6 months, with
inability to lose gained weight
 On Examination
• Height: 160.8 cm; Weight: 83 kg
• BMI: 32.1 kg/ m2
• Multiple papules, nodules and comedones present on face

4. Investigations Case 1
• Fasting Blood Sugar- 87
mg/dl [Normal]
• Post Prandial blood sugar -
97 mg/dl
• HbA1C- 5.7% [below 6%]
• Serum LH – 8.7 mIU/ml [5-20
mlU/ml]
• Serum FSH – 5.3 mIU/ml [5-20
mIU/ml]
• Total Testosterone - 97 ng/dl
[14- 76 ng/dl]
• Free Testosterone – 3.6 ng/l
[0.3- 1.0 ng/dl]
• Serum SHBG – 19 [18-144
nmol/L]
• Serum TSH - 2.5 µIU/ml [ 0.3-
5.5 uIU/ml]
Abdominal ultrasound - Normal
appearing uterus, with bilateral normal
ovaries. Specifically, there was no
evidence for polycystic ovaries.
DIAGNOSIS: Polycystic Ovary Syndrome in Adolescent

5.  Question
1
Which criteria will you prefer for diagnosis
of this case?

6. Answer
1. Rotterdam criteria
2. IFS guideline – atleast 1 Biochemical Characteristic in
conjunction with 1 Clinical symptom
(a) Biochemical - BMI
FH of DM, PCOS,
Altered Lipid profile
(b) Clinical - Pubertal deviation
Menstrual irregularity
Hirsutism
Early Acne, Persistent, Sever Acne, Frequent
Relapse in Acne , Acne in facial V area
Acanthosis Nigricans

7.  Question
2
What is the role of Lifestyle modifications in
an adolescent PCOS patient?
What lifestyle changes would you advise?

8. Answer
(A) Role of Lifestyle Modifications - WEIGHT LOSS
Reduces or Reverses Insulin Resistance
Improves Menstrual Irregularity
Normalizes Hyperandrogenism
Improves Metabolic state
Reduces incidence of DM
Improves pregnancy rate
(B) Lifestyle Changes
 Diet – Balanced, Low Fats, Low Carbohydrates, High Protien
 At regular intervals small quantity
 Increase Fiber intake
 Increase Low glycemic index foods
 Decrease refined foods
 Exercise – 150 minutes per week
 Boost metabolism
 Burns calories

9.  Question
3
When should combined hormonal preparations
be started in an adolescent patient?
Which is the progestin of choice? Why?
For how long should CHPs be given to a patient?
* CHPs: Combined Hormonal Pills

10. Answer
3A When should combined hormonal preparations be started in an adolescent
patient?
For management of MI
(a)12 – 16 years. – Low dose COC only for 7 days.
4 cycles per year is the aim.
(b) After 16 – regular low dose COC
 For management Acne / Hirsutism / other cutaneous manifestation s
 (a) Once other Pharmacological options no longer help.
 (b) 2 years post menarche
3B Which is the progestin of choice? Why?
For MI – Drosperinone, Desogestrel
For Acne, Hirsutism – Cyproterone Acetate
These progestins - Have anti androgenic property
Do not alter lipid profile
Decrease SHBG & 5 alpha reeducates.
CV – protective profile
* CHPs: Combined Hormonal Pills

11. Answer
3 C For how long should CHPs be given to a patient?
 Ideal time to stop hormones for hyperandrogenism can
not be established
 Pause treatment for 3 months after one year of
treatment & assess hormonal levels
 Continue treatment till - Patient is gynaecologically
mature i.e. 5 years post menarche.
- Patient has lost substantial amount of
weight
* CHPs: Combined Hormonal Pills

12.  Question
4
What points should be covered during
counselling of an adolescent PCOS patient?

13. Answer
 Reproductive health consequences.
 Cosmetic concerns
 Use of COC is not curative
 Cardiometabolic risk factor survey
 BMI
 BP
 Altered lipid profile
 Deranged glucose metabolism
 Fatty liver
 OSA
 Management & Risk reduction

14. Case 2
 32 years old married female presents with complaints of increased
facial hair and excessive weight gain over past 2 years, causing her to
avoid social interactions
 Associated complaints of dark patches on skin, repeated fungal skin
infections and UTIs, for past 6 months
 Age of menarche: 11 years; G1P1L1; history of Impaired Glucose
Tolerance during pregnancy
 History of Type II diabetes in mother
 Height: 166 cm; Weight: 80 kg; BMI: 28.98 kg/ m2
 Ferriman-Gallwey Score: 12

15. Investigations -Case 2
• Fasting Blood Sugar- 130
mg/dl
• Post Prandial blood sugar -
237 mg/dl
• HbA1C- 7.8 % [below 6%]
• Abdominal ultrasound - Bilateral
enlarged ovaries with multiple
small follicles, ranging from 2-9
mm in size. No dominant follicle
seen.
• Serum LH – 9.7 mIU/ml [5-20
mlU/ml]
• Serum FSH – 8.1 mIU/ml [5-20
mIU/ml]
• Total Testosterone - 93 ng/dl [14-
76 ng/dl]
• Free Testosterone – 7.2 ng/l [0.3 –
1.0 ng/dl]
• SHBG – 22 nmol/ L [18 – 144
nmol/ L]
• Serum TSH - 2.5 µIU/ml [0.3-5.5
uIU/ml]
DIAGNOSIS: Polycystic Ovary Syndrome in Adult

16.  Question
1
What are the most common problems faced
by adult women in the reproductive age-
group who have PCOS?

17. Answer
 Most Common problems in PCOS women
 Obesity
 Infertility
 Menstrual irregularity
 Hirsutism
 Insulin Resistance/ Diabetes
 Metabolic syndrome

18.  Question
2
Which is the progestin of choice for managing
hyperandrogenic manifestations of PCOS?
For how long should CHCs be administered?
Does long CHC use affect the future fertility of such
patients?
* CHPs: Combined Hormonal Pills

19. Answer
 Low Dose CHC 30µg EE with CPA, Drospirenone or
desogesterel is preferred as progestin component
because of antiandrogenic effects of progestins
 CPA showed strongest antiandrogenic activity
Bhattacharya SM, Fertil Steril, 2012
 Drospirenone more beneficial in regularisation of
menstrual cycle and reduction of Hirsuitism score
when compared to desogestrel in Indian conditions
Kriplani A, Contraception, 2010
 Duration of CHC treatment not established but must
pause after 1 year for 3 months in patients high risk
for VTE
 No effect on infertility after long term use of COC- 79-
96% women conceives within one year of cessation of

20.  Question
3
How will you manage this case?

21. Answer
Multidisciplinary management
 Obesity
 Lifestyle modification-diet and exercise
 Menstrual Irregularity
 Low dose CHC with CPA/drospirenone
 Diabetes
 Metformin with OHA or Insulin for euglycemia
 Hirsutism
 Mechanical hair removal methods- Photoepilation/LASER therapy,
Electrolysis
 Topical Eflornithine
 Pharmacological therapy –CHC, with CPA or drospirenone,
 Spironolactone 25-50mg/day or finasteride 5 mg/day can be added as second
line

22. Guideline Recommendations:
Adults with PCOS
Women not intending to conceive: Low-dose CoCs with anti-androgen
progestins (Grade A, EL 1)
CPA is more beneficial in Indian conditions
Direct hair removal methods recommended along with CoCs as first
line (Grade A, EL 1)
No improvement with/ intolerance to CoCs: Spironolactone or Finasteride
recommended (Grade A, EL 2)
Hirsutism in
Adults
Guidelines for management of PCOS-related Hirsutism
Malik et al. Management of Polycystic Ovary Syndrome in India. Fertility Science & Research. Jan-Jun 2014; 1(1): 23-4
Anti-androgen Progestins: Cyproterone acetate, Drospirenone, Desogestrel
CoCs: Combined Oral Contraceptives
• PCOS Certification Modules •

23.  Question
4
What long-term complications can develop
in this patient?
How will you prevent this?

24. Answer
Long term complications in PCOS
 Type 2 Diabetes
 CVD
 Endometrial hyperplasia and cancer
 Obstructive sleep apnea
 Non alcoholic fatty liver disease or nonalcoholic
steatohepatitis
Prevention
 Lifestyle modifications
 Regular screening with OGTT, Lipid profile, BP, BMI-
6mthly for borderline cases and annually for normal
profiles
 Regular screening with TVS for ET, EB for menstrual
irregularity
 Progestin therapy for atleast 3-4 months in a year or

25. Case 3
 Female, 29 years, unable to conceive despite regular unprotected
intercourse for past 3 years
 c/o irregular, usually prolonged menstrual cycles (sometimes once in
2 months), with scanty to heavy bleeds
 Past history of acne, history of diabetes in mother
 On examination
• BMI: 28.5 kg/ m2
• Increased facial hair
• Ferriman Gallway Score - 15

26. Case 3
• Fasting Blood Sugar- 96 mg/dl [Normal]
• Post Prandial blood sugar - 140 mg/dl
• HbA1C- 6.1% [Normal below 6%]
 Trans-vaginal ultrasound -
Multiple hypo-echoic follicles
found in both ovaries [between
0.5 to 0.7 cms], no dominant
follicle noted
• Serum LH – 14.3 mIU/ml [5-20 mlU/ml]
• Serum FSH – 5.6 mIU/ml [5-20 mIU/ml]
• Serum Testosterone - 85 ng/dl [14- 76
ng/dl]
• Serum Prolactin - 12 ng/ml [<25 ng/ml]
• Serum Estradiol - 40 pg/ml [30-400
pg/ml]
• Serum TSH - 2.5 µIU/ml [0.3-5.5
uIU/ml]
DIAGNOSIS: Polycystic Ovary Syndrome related Infertility

27.  Question
1
What additional investigations would you
advise in this patient?

28. Answer
Other investigations to be advised are-
 AMH
 Lipid Profile
 DHEAS
 17OHP
 Basal AFC
 Husband Semen Analysis

29.  Question
2
Is there any role of combined estrogen-progesterone
preparations in management of PCOS-related infertility?
Please specify which preparations should be used?
How long should they be administered?

30. Answer
 COC decreases
 Insulin resistance
 Decreases LH
 Improves ovulation
 COC preparations to be used are
 Ethinyl estradiol 30mcg with antiandrogenic
progesterones – CPA, Drospirenone, Desogestrel
 COC should be administered for 3-4 months
depending on patients age

31.  Question
3
What are the drugs that can be used for
ovulation induction in this patient?
Which will you prefer? Why?

32. PCOS-related Infertility:
Management Algorithm
•
A. Estrogen modulators
•Clomiphene citrate (CC)
•Letrozole
B. CC resistant/failure
•Low-dose gonadotropins
•Glucocorticoids
C. Insulin sensitizers
•Metformin + CC
• Metformin (if BMI ≥30 kg/m2 and prevent
OHSS
•Laparoscopic surgery +gonadotropins (Gn)
•Bariatric surgery if BMI ≥35 kg/m2
First-line
Second-line
Third-line
No improvement
No improvement

33.  Question
4
How will you decide between different
procedures (IUI or IVF)?

34. Answer
 IUI in young patients with no tubal factor
 IVF should be planned earlier in older patients

35.  Question
5
When and in which patients will you advise
surgery?
What are the different surgical methods?
Which one will you prefer?

36. Answer
 When no pregnancy on medical treatment
 Laparoscopic ovarian drilling should be offered to
CC resistant cases
 Bariatric surgery should be offered when BMI
greater than 35 (32.5)

38. Thank you!