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Presented by:Dr. Zuhayer AhmedHonorary Medical Officer,Dept. of Endocrinology,Dhaka Medical College Hospital,Dhaka
There is no universally accepted definition for PCOS!!
A complex endocrine disorder affecting women of childbearing age characterized by increased androgen production and ovulatorydysfunction.
Commonest cause of anovulatory infertility and hirsutism.
First described by American gynecologists Irving F. Stein, Sr. and Michael L. Leventhal in 1935.
“Syndrome O” Ovarian confusion
Ovulation disruption
Over-nourishment
Overproduction of insulin
20-33% of all reproductive age group have PCO
5-10% of all reproductive age group have PCOS
87% present with oligomenorrhea
26% present with amenorrhea
50% present with infertility
50% with recurrent miscarriage
Exactly Unknown
Genetics:◦ Autosomal Dominant
Environmental Effect
Neuroendorine derangement:◦ Increased LH relative to FSH
Hyperinsulinemia:◦ Defect in insulin action or secretion
Androgen Excess: Most agree that the ovary, rather than
the adrenal is the principal source
Terminal hair in 9 androgen sensitive body areas
Determined by a visual score-◦ Modified Ferriman-Gallwey Score
Different from hypertrichosis
Amenorrhea
Oligomenorrhea
Premenstrual DysphoricSyndrome
Pelvic Pain
Subfertility
NIH (1990) Rotterdam (2003)* AES (2006)
1. MenstrualIrregularity
1. Menstrual Irregularity 1. Menstrual Irregularity+/- USG-PCO
2. Hyperandrgenism 2. Hyperandrogenism 2. Hyperandrogenism
3. Exclusion of other etiologies
3. USG-Polycystic Ovary**
3. Exclusion of other etiologies
*2 out of 3 criteria**Exclusion of other etiologies
Other etiologies to be excluded:◦Hypothyroidism
◦Hyperprolactinemia
◦Non-classical congenital adrenal hyperplasia
◦Cushing Syndrome
◦Acromegaly
◦Androgen secreting tumors
◦Other causes of amenorrhea
Biochemical Evidence:◦ S. Testosterone
◦ LH/FSH ratio
To exclude other etiologies:◦ S. Prolactin
◦ 24 hours urinary free Cortisol
◦OGTT
◦ S. TSH
◦ 17-hydroxyprogesterone
12 or more follicles in each ovary measuring 2-9 mm in diameter +/-increased ovarian volume (>10 ml)
[Rotterdam criteria]
Diet:
◦ Avoid processed & fried foods, simple carbs like rice, potatoes, white sugar & pasta.
◦ Take more complex carbs like oatmeal
◦ Fresh fruits & vegetables, whole grains and lean proteins.
Regular physical exercise:
◦ Brisk walking for at least 30-40 minutes per day
For Hirsutism:◦ Shaving
◦ Bleaching
◦ Waxing
◦ Electrolysis
◦ Laser treatment
For Hirsutism:◦ Eflornithine Cream:
Should be discontinued if no improvement after 4 months of use
Insulin Sensitizers:
◦Metformin
500 mg three times daily
◦ Pioglitazone
Androgen Receptor AntagonistsCyproterone Acetate 2, 50 or 100 mg on days
1-11 of 28-day cycle with Ethinylestradiol 30
microgram on days 1-21
Spironolactone 100-200 mg daily
Flutamide No recommended dose
5- reductase inhibitor:◦ Finasteride: 5 mg daily
Hormonal contraceptives:◦ Combined with Cyproterone acetate◦ Conventional oestrogen containing
contraceptives: Ethinyl estradiol Non-androgenic Progesterone (Desogestrel,
drospirenone)
Reverse Circadian Rhythm:
Prednisolone:
2.5 mg in the morning & 5 mg at night
Suppresses ACTH production
Clomiphene Citrate:
◦ First line therapy for infertility
◦ 50-100 mg daily on days 2-6 of the cycle
◦ Recommended not to use for more than 6 cycles
In one randomized controlled clinical trial, 626 infertile women with PCOS were randomized to receive clomifene, metformin or combination therapy. After 6 months, the live birth rates were 22.5%, 7.2% and 26.8% respectively. Multiple births occurred in 6% of women receiving clomifene and none of those receiving metformin.
“I had all the side effects…dizziness, panic attacks, blurred vision…I was determined to get the thing done. It was awful, but just thought ‘keep going’.”
Jools Oliver
Depression
Anxiety Disorder
Screen for long term complications:
◦ Endometrial cancer
◦ Mood disorders
◦ Obstructive sleep apnea
◦ Diabetes Mellitus
◦ Cardio-vascular disease
Diagnosis:◦ 3 recommendations
Associated Co-morbidities:◦ 12 recommendations
Treatment of PCOS:◦ 12 recommendations
1.3 Diagnosis in perimenopauseand menopause:
Long term history of oligomenorrhea& hyperandrogenism
Polycystic ovary: less likely
Documenting cutaneous manifestations:
◦ Hirsutism (modified Ferriman-Gallwey score)
◦ Acne
◦ Androgenic Alopecia (Ludwig’s score)
◦ Acanthosis nigricans
◦ Skin tags
Screening ovulatory status (even in eumenorrheics):
◦ Increased risk of anovulation and infertility
◦ Menstrual history
◦ Midluteal S. Progesterone
Exclude other causes of infertility:
Obesity
Male factor infertility
Tubal occlusion
Preconceptual assessment:◦ Increased risk of pregnancy complications
(GDM, preterm delivery, pre-eclampsia)
◦ BMI
◦ BP
◦ OGTT
No routine USG screening for endometrial thickness in PCOS: Poor diagnostic accuracy
Screen and manage depression & anxiety
Screen & manage Obstructive Sleep Apnea: Polysomnography
Awareness about possibility of NAFLD and NASH (No screening)
Screen for IGT and T2DM:
◦OGTT or HbA1c
◦ Re-screening every 3-5 years
At Risk High Risk
Obesity
Cigarette smoking
Hypertension
Dyslipidemia
Subclinical vascular disease
Impaired glucose tolerance
Family history of premature CVD
Metabolic syndrome T2DM Overt vascular or
renal disease CVD Obstructive Sleep
Apnea
Hormonal Contraceptives:
◦ First line for menstrual abnormalities and hirsutism/acne of PCOS
◦ Screen for contraindications of HCs
Management of overweight:
◦ Exercise:
30 mins of moderate to vigorous exercise daily
◦Calorie restricted diet
◦Metformin not recommended
Metformin:
◦ NOT first line for cutaneous manifestations, obesity or preventing pregnancy complications
◦ To be used in T2DM or IGT
◦ Menstrual irregularities present and HCs are contraindicated
◦ Adjuvant for infertility to prevent Ovarian hyperstimulation syndrome (OHSS) in women with PCOS undergoing IVF
Insulin sensitizers e.g. inositols or thiazolidinedions NOT recommended
Ovulation inducers:◦Clomiphene citrate
◦ Letrozole
Statins only recommended if indications for statins present
NO TREATMENT DURATION DETERMINED
Vocal of Spice Girl
Has four children
“The Diary of an Honest Mom”
Her struggle against the subfertility
Retaining calories and storing adipose tissue may help in famine!!
The gene responsible would be deleted from the gene pool
Pregnancy issues!! No need for ECP!!
Less likely to develop osteopenia, osteoporosis-less fractures!!