Polycystic ovary syndrome (PCOS) is characterized by menstrual irregularity, hyperandrogenism, and polycystic ovaries. It affects 5-10% of women of reproductive age. Key features include ovarian dysfunction, hyperandrogenemia, polycystic ovaries on ultrasound, gonadotropin abnormalities, insulin resistance, dyslipidemia, and obesity. Treatment focuses on lifestyle modifications like diet and exercise as well as medications to address symptoms and underlying causes. Women with PCOS have an increased risk of diabetes and cardiovascular disease.
This presentation briefly discuss the polycystic ovary syndrome in terms of pathogenesis, features and management. Then, It moves on to discuss the various guidelines laid down by Endocrine Society in 2013 for the management of patients with polycystic ovary syndrome.
This presentation briefly discuss the polycystic ovary syndrome in terms of pathogenesis, features and management. Then, It moves on to discuss the various guidelines laid down by Endocrine Society in 2013 for the management of patients with polycystic ovary syndrome.
PANEL DISCUSSION
MANAGEMENT OF PCOS - WOMB to TOMB
MODERATOR : Sharda Jain
PANELISTS : Dr.Chitra setia
Dr Puneet Arora
Dr. Ila Gupta
Dr. Rupam Arora
Dr. Archana Sharma
Dr. Sangeeta Gupta
Dermatologists
Dr. V.K. Upadhyay
Dr. S. Kandhari
Treatment of Polycystic Ovary Syndrom (PCOS)Dr JP Singh
An Invented technique to treat the PCOS, Introduced by Dr JP Singh. PCOS is a leading cause of women infertility. Near about 50% women at the age group of 15-30 in Kolkata, (India) are suffering from PCOS. Polycystic ovary syndrome is a Gynecological problem that can affect woman's: Menstrual cycle, Difficulty to be pregnant, Hormonal imbalances, Skin and hair problems. It may be treated through this technique. More details logon: www.brainstup.com
International Guidelines 2018 PCOD Dr Sharda Jain , Dr Jyoti Agarwal Lifecare Centre
International Guidelines 2018 PCOD DIAGNOSTIC ASSESSMENT TOOLS + What we have learnt in last 50 years
OVERVIEW of PCOD
HISTORY
PREVALENCE
ETIOPATHOGENESIS as we understand it.
SYMTOMS & SIGNS
2018 GUIDELINES DIAGNOSTIC criteria, assessment, investigations , monitoring &
short / long term impact of untreated PCOD
Pcos by dr alka mukherjee dr apurva mukherjee nagpur m.s.alka mukherjee
Polycystic ovary syndrome (PCOS) is a highly prevalent endocrine-metabolic disorder that implies various severe consequences to female health, including alarming rates of infertility. Although its exact etiology remains elusive, it is known to feature several hormonal disturbances, including hyperandrogenemia, insulin resistance (IR), and hyperinsulinemia. Insulin appears to disrupt all components of the hypothalamus-hypophysis-ovary axis, and ovarian tissue insulin resistance results in impaired metabolic signaling but intact mitogenic and steroidogenic activity, favoring hyperandrogenemia, which appears to be the main culprit of the clinical picture in PCOS. In turn, androgens may lead back to IR by increasing levels of free fatty acids and modifying muscle tissue composition and functionality, perpetuating this IR-hyperinsulinemia-hyperandrogenemia cycle. Nonobese women with PCOS showcase several differential features, with unique biochemical and hormonal profiles. Nevertheless, lean and obese patients have chronic inflammation mediating the long term cardiometabolic complications and comorbidities observed in women with PCOS, including dyslipidemia, metabolic syndrome, type 2 diabetes mellitus, and cardiovascular disease. Given these severe implications, it is important to thoroughly understand the pathophysiologic interconnections underlying PCOS, in order to provide superior therapeutic strategies and warrant improved quality of life to women with this syndrome.
PANEL DISCUSSION
MANAGEMENT OF PCOS - WOMB to TOMB
MODERATOR : Sharda Jain
PANELISTS : Dr.Chitra setia
Dr Puneet Arora
Dr. Ila Gupta
Dr. Rupam Arora
Dr. Archana Sharma
Dr. Sangeeta Gupta
Dermatologists
Dr. V.K. Upadhyay
Dr. S. Kandhari
Treatment of Polycystic Ovary Syndrom (PCOS)Dr JP Singh
An Invented technique to treat the PCOS, Introduced by Dr JP Singh. PCOS is a leading cause of women infertility. Near about 50% women at the age group of 15-30 in Kolkata, (India) are suffering from PCOS. Polycystic ovary syndrome is a Gynecological problem that can affect woman's: Menstrual cycle, Difficulty to be pregnant, Hormonal imbalances, Skin and hair problems. It may be treated through this technique. More details logon: www.brainstup.com
International Guidelines 2018 PCOD Dr Sharda Jain , Dr Jyoti Agarwal Lifecare Centre
International Guidelines 2018 PCOD DIAGNOSTIC ASSESSMENT TOOLS + What we have learnt in last 50 years
OVERVIEW of PCOD
HISTORY
PREVALENCE
ETIOPATHOGENESIS as we understand it.
SYMTOMS & SIGNS
2018 GUIDELINES DIAGNOSTIC criteria, assessment, investigations , monitoring &
short / long term impact of untreated PCOD
Pcos by dr alka mukherjee dr apurva mukherjee nagpur m.s.alka mukherjee
Polycystic ovary syndrome (PCOS) is a highly prevalent endocrine-metabolic disorder that implies various severe consequences to female health, including alarming rates of infertility. Although its exact etiology remains elusive, it is known to feature several hormonal disturbances, including hyperandrogenemia, insulin resistance (IR), and hyperinsulinemia. Insulin appears to disrupt all components of the hypothalamus-hypophysis-ovary axis, and ovarian tissue insulin resistance results in impaired metabolic signaling but intact mitogenic and steroidogenic activity, favoring hyperandrogenemia, which appears to be the main culprit of the clinical picture in PCOS. In turn, androgens may lead back to IR by increasing levels of free fatty acids and modifying muscle tissue composition and functionality, perpetuating this IR-hyperinsulinemia-hyperandrogenemia cycle. Nonobese women with PCOS showcase several differential features, with unique biochemical and hormonal profiles. Nevertheless, lean and obese patients have chronic inflammation mediating the long term cardiometabolic complications and comorbidities observed in women with PCOS, including dyslipidemia, metabolic syndrome, type 2 diabetes mellitus, and cardiovascular disease. Given these severe implications, it is important to thoroughly understand the pathophysiologic interconnections underlying PCOS, in order to provide superior therapeutic strategies and warrant improved quality of life to women with this syndrome.
Polycystic Ovarian Syndrome: Etiology, Diagnosis and ManagementAparajeya Shanker
Polycystic Ovarian Syndrome is a complex disease, with a constellation of etiology and symptoms. Much of the diagnosis is dependent on the laboratory tests of hormones. This presentation provides a concise and focused approach towards PCOS diagnosis and management.
What is Polycystic Ovarian Syndrome? Hormonal evaluation, diagnosis and treatment and its relation to infertility. How does one manage PCOS in an infertility setting?
Science, practice and evidence are dynamic processes. This is typically vivid when it relates to Polycystic Ovarian Syndrome. PCOS is the commonest hyperandrogenic disorder in women and one of the most common causes of ovulatory infertility. Although polycystic ovaries were first described by the Italian scientist Vallisneri in 1721, it was largely forgotten until the 1930s, and then renamed after its rediscoverers as Stein-Leventhal syndrome. Even then, it still wasn’t until the invention of the ultrasound scanner in the 1980s and consensus of diagnosis in the early 1990s that PCOS was recognized on a wider scale in women of reproductive age. When attempting to diagnose with precision something that is complex, it is important that we first clearly define what it is we are trying to diagnose. PCOS is today seen as a heterogeneous syndrome where a range of symptoms may be present or absent, and may overlap with other conditions, it is perhaps best viewed as a spectrum of symptoms, pathologic findings and laboratory abnormalities. PCOS can be difficult to conceptualize, even for experts, as shown by the fact that there have been several different ways of diagnosing it over the years.
More recently, the fundamental role of hyperandrogenism has been pointed out.
However, PCOS compromises other pathological conditions that strongly modify the phenotype and play a dominant role in the pathophysiology of the disorder, including insulin resistance and hyperinsulinemia, obesity and metabolic disorders, all favoring together with androgen excess, an increased susceptibility to develop type 2 diabetes mellitus (T2DM) and, possibly, cardiovascular diseases. PCOS by itself may also have some genetic component as documented by familial aggregation and recent genetic studies. All the clinical features may however change throughout the lifespan, starting from adolescence to postmenopausal age. Therefore, PCOS should be considered as a lifetime disorder.
I sincerely hope that with the recommended readings attached and lecture, you will be able to strengthen your knowledge, thereby providing evidence-based medicine practice for the management of PCOS in a successful manner to improve and better women’s Health care. The best investment you can make is an investment in yourself. The more you learn, the more you’ll earn (Warren Buffett), so read as much as you can.
Thank You.
Regards: Rafi Rozan
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. INTRODUCTION
Classic syndrome originally described by
Stein and Levanthal in 1935
Hyperandrogenism
Menstrual irregularity
Polycystic ovaries
The most common endocrine disorder in
women of reproductive age (~ 5%-10%)
Syndrome (association of several clinically
recognizable features), not a disease—
multiple potential etiologies with variable
clinical expression
Stein IF, Leventhal ML. 1935.
Dunaif A, et al. 2001
3.
4. NIH Criteria (1990)
(To include all of the following)
Menstrual irregularity due to anovulation or oligo-
ovulation
Evidence of clinical or biochemical
hyperandrogenism
Hirsutism, acne, male pattern baldness
High serum androgen levels
Exclusion of other related disorders
Azziz 2007
6. FEATURES OF PCOS
Ovulatory and menstrual dysfunction
Hyperandrogenemia
Polycystic ovaries
Gonadotropin abnormalities (LH/FSH)
Insulin Resistance and Hyperinsulinemia
Dyslipidemia
Obesity
Type 2 diabetes
Cardiovascular diseases
Mark O. et al 2011
7. OVULATORY AND MENSTRUAL
DYSFUNCTION
75-85% PCOS patients diagnosed with
oligo-amenorrhea or abnormal uterine
bleeding
40% PCOS patients with normal menses
have chronic anovulation
20-50% hyperandrogenic women with
apparent eumenorrhea have chronic
anovulation, may be considered to be
affected by PCOS.
Azziz et al 2009
8. HYPERANDROGENEMIA
Refers to supranormal levels of circulating
endogenous androgens such as:
Total, unbound, or free testosterone (T)
Androstenedione (A4)
Dehydroepiandrosterone (DHEA)
DHEA metabolite DHEA sulphate (DHEAS)
Azziz R, Carmina E, Dewailly D, et
al. 2009
9. … HYPERANDROGENEMIA
T circulates bound to SHBG and albumin and only free
fraction enters into target tissue. Assessment of free T
levels much more sensitive for diagnosis of
hyperandrogenemia. Elevated in ~70% PCOS patients
Only few studies of prospective value available for using
A4 levels as a diagnostic criterion. However, ~10%
patients have elevated A4 levels
~20-30% PCOS patients have elevated DHEAS levels, but
also increased in other hyperandrogenic disorders and
DHEAS levels also decrease with age
Therefore, serum androgen level cannot be used as sole
diagnostic criterion of PCOS
Azziz R, Carmina E, Dewailly D, et
al. 2009
12. HIRSUTISM
Is the presence of terminal hair in a female body in a
male-type pattern, includes hair on 9 body areas:
upper lip, chin, chest, upper back, lower back, upper
and lower abdomen, upper arm and thigh
Method to determine presence of hirsutism uses a
visual score, most common is modified FerrimanGallwey score
0 score represents absence of terminal hair and score
of 4 represents extensive terminal hair growth.
Hirsutism is defined by an mGF score of ≥ 6
However, prevalence of hirsutism varies according to
race and ethnicity of population
DeUgarte et al 2006
13. ACNE AND ANDROGENIC ALOPECIA
Acne affects 15-25% PCOS patients but
unclear whether its prevalence is significantly
increased in these patients over general
population. No single scoring system used,
also varies with ethnicity
Androgenic alopecia or scalp hair loss may
affect 5 – 50% PCOS patients but further
studies are needed to better define this
prevalence
Azziz R, Carmina E, Dewailly D,
et al. 2009
14. POLYCYSTIC OVARIES
3 features used to define PCO:
Ovarian size and volume
Stromal volume
Follicle size and number
Rotterdam criteria defines PCO solely on total follicle
no. : presence of ≥ 12 follicles measuring 2-9 mm in
diameter and/or increased ovarian volume >10 mL in
at least one ovary
Rotterdam definition of PCO cannot be applied to
women taking oral contraceptives as the have
modified ovarian morphology
Azziz R, Carmina E, Dewailly D,
et al. 2009
15. OVARIAN ABNORMALITIES
• Multiple follicles
in peripheral
location
• 80% of women
with PCOS have
classic cysts
ULTRASOUND IMAGE OF
POLYCYSTIC OVARIES
Smith R. 2006
16. GONADOTROPIC ABNORMALITIES
Accelarated GnRH/LH pulse amplitude leads to
increased secretion of LH whereas FSH levels are
normal or even decreased
>75% PCOS patients have a dysregulated
gonadotropin function
Conceptually, increased surge of LH and
increased LH:FSH ratio during the follicular phase
of menstrual cycle has been considered as a
marker of PCOS. However, normal ratio may be
found in obese patients
Goodarzi, Dumesic et al 2011
17. 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
Allahbadia, Merchant, 2010
19. Abnormal steroidogenenesis
Intraovarian androgen excess results in
excessive growth of small ovarian follicles
Follicular maturation is inhibited
Excess androgen causes thecal and stromal
hyperplasia
20. INSULIN RESISTANCE AND
HYPERINSULINEMIA
50-70% women with PCOS have insulin resistance
Defined as a subnormal target tissue response to a
given amount of insulin
Results in Hyperinsulinemia, by the pancreatic islet
cells to maintain normal glucose homeostasis
IR can lead to elevated circulating levels of glucose,
impaired glucose tolerance and eventually diabetes
IR may not always be accompanied by elevated
circulating levels of insulin
Franks S. 1995.
Hopkinson 1998.
22. RELATIONSHIP B/W HYPERINSULINEMA &
HYPERANDROGENISM
If hyperandrogenism caused insulin-resistance,
amelioration of hyperandrogenism would be
expected to improve insulin sensitivity
But antiandrogen therapy has failed to produce
significant improvements in insulin resistance
More support in literature that hyperinsulinemia
causes hyperandrogenism. Recent data suggest
that physiologic insulin levels enhance androgen
production from the granulosa cells of polycystic
ovaries and may act synergistically with LH.
Legro
24. DYSLIPIDEMIA AND OBESITY
Decreased levels of HDL-C
Increased levels of LDL-C
Increased levels of triyglycerides
A great reduction of (HDL) with higher increase
of both triglycerides & total cholesterol, may
make them prone to hypertension as well.
Risk of atherosclerosis & premature
cardiovascular events increases
About 50% PCOS women are obese, it appears
that risk of PCOS increases with obesity
Goodarzi, Dumesic, Azziz, 2011
26. Binding of insulin to its receptor results in autophosphorylation
and tyrosine kinase activation of the receptor which furthers
phosphorylates other downstream mediators [insulin receptor
substrate (IRS) and Src homology domain containing
transforming protein 2 (Shc)].
These mediators then differentially activate various downstream
signaling proteins. Phosphatidylinositol 3-Kinase (PI3K) plays a
major role in glucose transport, glycogenesis and protein
synthesis.
On the other hand, Grb2/SOS (growth factor receptor-bound
receptor 2/ Son of sevenless) complex activates mitogenactivated protein kinase pathway (MAPK) playing a crucial role
in mitogenic response.
Another pathway via inositolglycan generation has been
suggested which may play a vital role in steroidogenesis.
28. ABNORMALITIES OF PCOS OVARY
Increase in CYP17 leads to increased p450c17 enzyme and
hence increased androgen synthesis
Decrease in CYP19 decreases aromatase enzyme activity
and conversion of androgens to E2 (Estradiol) is reduced
Increased 5α-Reductase activity leads to increased
metabolism of ∆4-Androstenedione to 5αAndrostenedione, a competetive inhibitor of aromatase
activity
This loss of aromatase and E2 biosynthesis has been
proposed to involve dysregulation of autocrine and
paracrine signaling within the follicle leading to follicular
arrest
Wickenheisser, McAllister, 2007
30. GENETIC LINK
Familial clustering of PCOS common
1st degree relatives of patients with PCOS
may be at high risk for diabetes and glucose
intolerance
Mothers and sisters of PCOS patients have
higher androgen levels than control subjects
31. INFERTILITY
Intermittent ovulation or anovulation
Inherent ovarian disorder—studies show reduced
rated of conception despite therapy with clomid
32. Treatment
The first step is to help the patient understand that
this chronic disease process can be controlled by
changes in lifestyle.
Lifestyle modification must be emphasized to
include appropriate diets & exercise program is
essential.
Azziz R, Carmina E, Dewailly D, et
al. 2009
33. …Treatment
Metformin may complement the effects of
lifestyle modification, it causes marked
improvement in menstrual pattern & may
improve the response to ovulatory agents.
Clomifene-citrate (competitive inhibitor of
estrogen receptor) is the standard method of
medical ovulation induction in anovulatory
women.
Azziz R, Carmina E, Dewailly D, et
al. 2009
34. …Treatment
Anti-androgens: cyproterone acetate
Spironolactone: alternative anti-androgen.
Low dose of oral contraceptives are effective in
treating acne & hirsutism, minimum of 2 years &
cosmetic measures are needed to achieve good
results.
Azziz R, Carmina E, Dewailly D, et
al. 2009
35. Susceptibility of PCOS patients to cardiovascular
diseases and diabetes
Women with PCOS at ages 20–32 were more likely to
develop incident diabetes by the time they reached 38–
50 years of age
Altered signaling pathways and susceptibility genes
Marker genes for these diseases
Editor's Notes
Clinical Features of PCOS. Hyperandrogenism.
Hyperandrogenemia is a key feature of PCOS, and it may appear as hirsutism, acne, male pattern balding, and/or male distribution of body hair.1
Reference
1. Lobo RA, et al. Ann Intern Med. 2000;132:989-993.
Heritability. Due to the observable trends within families concerning insulin resistance, the question remains whether PCOS has a genetic connection. For instance, first degree relatives inherit B-cell dysfunction (secretory deficits). Franks and colleagues offered the following hypothesis: Linage analysis-syndrome inherited in autosomal recessive fashion; heterogeneous disorder-need to focus on hyperandrogenism to assign phenotype.
Infertility Treatments. Another complicating feature of PCOS is the effects it has on ovulation and fertility. Since there are so many facets to PCOS, there are also multiple options for treating infertility based upon the patient’s characteristics. First line of treatment in overweight patients is weight loss through lifestyle modification. Another cautious approach is administering CC as first line then insulin sensitizer if REGNANCY desired outcome. However, only short-term treatment with sensitizer and although CC has demonstrated benefit it should be limited to three cycles (Gysler et al. Fert Ster 37:161; 1982). The infertility industry has developed multiple treatment protocols to offer women with PCOS. The following slides review two studies demonstrating the published success.