Polycystic Ovary Syndrome-Emam

8/3/2019 Polycystic Ovary Syndrome-Emam

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BY

Mohammad EmamProf. OB& GYN

Mansoura Faculty of Medicine

Mansoura integrated fertility center (MIFC)

EGYPT

Polycystic Ovary Syndrome In

The Era Of Metabolic Syndrome


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Syndrome X =IRMetabolic Syndrome ( MS) =

Is a cluster of metabolicdisorders, with a

subnormal biologicalresponse to insulinoccurring mainly invisceral obesity.

The more components of the syndrome ,

the greater the risks .


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ooGlucoseGlucoseV. ObesityV. Obesity

qq HDLHDL--CC

oo BPBP

oo TGTG

Glucose u 6.1mmol/L

Waist Circumference

bu 102cm

cu 88cm

HDL-C

b1.0 mmols/L

c 1.3 mmols/L

BP u130/u85 mmHg

Triglycerides u 1.7mmol/L

Diagnostic Criteria forDiagnostic Criteria forMetabolic SyndromeMetabolic Syndrome

Diagnosis is made when 3 or more

of these risk criteria are met


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Two of the following three features are present,

after exclusion of other etiologies :

(i) Oligomenorrhoea and or Anovulation

(ii) Hyperandrogenism and/or hyperandrogenemia.

(iii) Polycystic ovaries (sonar).

Definition PCOSDefinition PCOS

( Rotterdam( Rotterdam 20032003))


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Phenotypes (Rotterdam)Phenotypes (Rotterdam)

PCOS WITH PCO .PCO + HYPERANDROGENISM + ANOVULATION.

PCO + Hyperandrogenism.

PCO + Anovulation.

PCOS WITHOUT PCO .Hyperandrogenism + Anovulation.

PCO WITHOUT PCOS.( Isolated PCO = Asymptomatic PCO ).


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What is The significance of PCO in PCOS??What is The significance of PCO in PCOS??

The presence of PCO

usually correlateswith the presence of

insulin resistance(Richard J 2002).


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Prevalence Of MS In PCOS

MS is present in 2/3 of thePCOS (2-fold higher than

women in the generalpopulation).


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Pitfalls Rotterdam Definition

1. doubts still exist regarding borderlinegroups of patients ,such as hirsute

ovulatory Normoandrogenic women

with PCO???.

2. Neglect role of IR


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PCOS + IR (70 % ).

PCOS without IR (Legro etal 2004).

Phenotypes Of PCOSAccording to IR


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1) IR Phenotype of PCOS

Abdominal obesity ( Minority may be lean)

Acanthosis Nigericans.

Hirsutism. Resistance to CC,


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2) PCOS Without IR

Lean.

Euinsulinemic/Euglycemic

Enhanced OvarianSensitivity to insulin(although no hyperinsulinemia).


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RATIONALE

MSIs associated with medical and psychosocial co-

morbidities that are both immediate and long-term

( PCOS Is one of these co-morbidities ).

PCOS:

PCOS is now recognized as an importantmetabolic and reproductive disorder .

So, Overlap and vicious circle can be present

between PCOS and MS.


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Co-morbidities With IR


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Objective

To illustrate the link between two current

,intimate and hidden epidemics , MS and

PCOS .

To pinpoint the role of gynecologists

regarding the management ofPCOS in the

era of MS.


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Link between MS & PCOS

PCOSPCOSMSMS

IRIR


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The Central Player

( Insulin Resistance & Vicious circle )

Genetics

AgingPregnancy Drugs Lifestyle

obesity

HyperinsulinemiaIncreased lipid storage

Altered lipoprotein &

cholesterol metabolismAltered steroid

hormone metabolism

PCOS

Insulin

Resistance


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The high ovarianresponse to insulin.

Opposed by the wholebody resistance.

IR : The central paradox


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Genetic Of (MS) & PCOS

There is evidence for linkage

of the hyperandrogenemiaphenotype with an allele of amarker locus on chromosome

19, in the region ofthe geneencoding the insulin receptor.


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E E

F F

Insulina

Types of insulin resistanceTypes of insulin resistance

Type B

Type A

Type C

Autoantibodies

to insulin receptorsGenetic defectof insulin receptor

(Kahn syndrome)

Defect of tyrozine

kinase

tyrozine kinase


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How IR Can Be Confirmed ??

Fasting glucose / insulin < 4.5

Fasting insulin > 24 uU / ml

One hour insulin post OGTT-75 gm > 150

uU/ml


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Targets for ttt

IR None IR

Causative ttt

( Insulin sensitizers)

Symptomatic ttt + Insulin

sensitizers ( prevent

Hyperandrogenism IRVicious circle ) :

Acne.

Hirsutism.

INFERTILITYT

PCOS


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Causative

ttt

Life- style modifications:

Diet modificationWeight loss

Exercise

Psychosocial support.

Cessation smoking.

Improve IR ( Metformin)


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Proposed Approach for ttt of Anovulation In PCOS

Baseline evaluation ( Semenogram , HSG , Midluteal p)

Life style modification ( Exercise , Wt loss , Prohibit smoking

Metformin 500mg / day x first week , then 500 bd on week 2 ,then 500 tds from week 3 till 6-12 month . ( Ensure liver and

renal functions prior ttt )

Not pregnant addCC for 6 cycles

Pregnant: continueMetformin first

trimesterNot pregnant , consider GN ,

OVDrilling , IUI , I

VFOR ICSI


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The advantages of Metformin over drilling

continue beyond conception:

It reduces the miscarriage rate.

Decreases the development of

gestational diabetes.


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Indications OfD

rilling

Regressed behind.Failure of :

Change of life style.

Insulin sensitizing agents.CC +/- HMG.


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Role Of Metformin In None IR( PCOS)

Prevents starting vicious circle of hyperandrogenemia -IR.

Improve spontaneous and CC-induced ovulation.

Improve follicular maturation in IVF cycles.

The continuation in the first trimester appearsto reduce the risk of abortion

( Metformin = FDA group B ).


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Conclusions

We are facing two current

intimate epidemics ( MS &PCOS ) which affect a large scale

of population and also affecttheir reproductive future.


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Gynecologists should categorize any case of PCOS,depending on :

1. Rotterdam criteria.

2.IR or not

Conclusions


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conclusionsInsulin sensitizers are the milestone in ttt of PCOS :

whether as a causative therapy in( IR) sub phenotype.

OR AS

A prohibitor of the starting

Hyperandrogenemia- IR vicious circle

in (none IR) sub phenotype

Conclusions


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We are inAt The Endneed for an applicable

integrated classification ofPCOS to satisfy different

specialists at the same

time!!!!


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Email. [email protected]

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Polycystic Ovary Syndrome-Emam