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MODERN APPROACH TO PCOS

MODERN APPROACH TO PCOS. J. SERNA MD. PhD. IVI Madrid. Physiology and Diagnosis. What is PCOS? How to Diagnose it? How to Treat it?. High prevalent disease Multiorganic: ovaries, HH, adrenal, fat, skin, pancreas, etc... Different degrees of organ involvement

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MODERN APPROACH TO PCOS

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  1. MODERN APPROACH TO PCOS J. SERNA MD. PhD. IVI Madrid

  2. Physiology and Diagnosis • What is PCOS? • How to Diagnose it? • How to Treat it?

  3. High prevalent disease • Multiorganic: ovaries, HH, adrenal, fat, skin, pancreas, etc... • Different degrees of organ involvement • Main feature: ovarian hyperandrogenism • Multiple phenotypes

  4. Metabolic disorders • IR and Hyperinsulinism • Obesity (male pattern) • Impaired Glucose Tolerance and DM2 • Hyperlypemia PCOS: HETERGENEOUS • Reproductive disorders • Hyperandrogenism • Anovulation: Menstrual disorders, infertility • Polycystic ovaries • Miscarriage • General Health Disorders • Acantosis nigricans • Cardiovascular disease • Endometrial cancer

  5. PCOSDg CRITERIA • Anovulation and/or dysovulation • Clinical and/or Biochemical Hyperandrogenism • Polycystics ovaries • and exclusion of other aetiologies (CAH, • tumours, HPRL, etc) • The Rotterdam ESHRE/ASRM sponsored PCOS consensus workshop group, 2003

  6. Anovulation/dysovulation work-up FSH,LH,PRL,TSH, 17 βE2 PRL PRL N FSH(N /  ) FSH FSH/LH < 1 Estrogens N FSH/LH > 1 Hypoestrogenism Hypo-hypo Amenorrhea WORK-UP hyperPRL PCOS WORK-UP POF Type IV Type II Type I Type III

  7. PCOS • Anovulation and/or dysovulation • Clinical and/or Biochemical Hyperandrogenism • Polycystics ovaries • and exclusion of other aetiologies (CAH, tumours, HPRL, etc) • The Rotterdam ESHRE/ASRM sponsored PCOS consensus workshop group, 2003

  8. Percentage of patients with PCOS and altered biochemical markers N=198

  9. Percentage of patients with PCOS and altered biochemical markers

  10. PCOS DIAGNOSIS • Biochemical hyperandrogenism • Normal boundaries established by laboratories RIA: • 95-97% • Control population? • High variability among normal population (absence of feed-back mechanism) • Diverse androgens: TT,ITL, 17OHP, DHA-S, A4, etc.

  11. PCOS • Anovulation and/or dysovulation • Clinical and/or Biochemical Hyperandrogenism • Polycystics ovaries • and exclusion of other aetiologies (CAH, tumours, HPRL, etc) • The Rotterdam ESHRE/ASRM sponsored PCOS consensus workshop group, 2003

  12. PCOS DIAGNOSIS Polycystic ovary Presence of 12 or more follicles 2-9 mm  and/or ovarian volume higher than 10 mL (one ovary is enough) Non suitable to women on OCP or with a dominant follicle (>10 mm) The Rotterdam ESHRE/ASRMsponsored PCOS consensus workshop group, Hum Reprod 2004,19:41-7

  13. Polycystic ovaries. Pitfalls False positives: 20% normal women False negatives: 30% PCOS US scan cannot make differential diagnosis between multycystic ovaries and polycystics ovaries Time required for measurements

  14. PCOS • Anovulation and/or dysovulation • Clinical and/or Biochemical Hyperandrogenism • Polycystics ovaries • and exclusion of other aetiologies (CAH, tumours, HPRL, etc) • The Rotterdam ESHRE/ASRM sponsored PCOS consensus workshop group, 2003

  15. Dysovulation wo ?? hyperandrogenism Normal cycle and hyperandrogenism ?? PCOS DIAGNOSIS Clinical and/or Biochemical Hyperandrogenism Anov/dysovulation HiperPRL, HA, POF, etc Idiopathic Hirsutism CAH, Tumors • Infertility and miscarriages Exaggerated response to OI • Multiple pregnancy PCO The Rotterdam ESHRE/ASRMsponsored PCOS consensus workshop group, Hum Reprod 2004,19:41-7

  16. Insulin-resistance in PCOS patients 75,3%(n=149) N=198 HOMA (Homeostasis model assesment): Glucose x18,1/Insulin x0,139 (Insulin-resistance: Obese <5,09, Lean <5,48)

  17. Prevalence of Impaired Glucose Tolerance and Diabetes in POCS in two American Studies (New York, Pensylvania y Chicago) and in a Spainish Survey 40 35 31,1 30 % 20 10 8,95 7,5 10 4,47 0 Legro, 1999 Ehrmann, 1999 HSPSC Legro. J Clin Endocrinol Metab 1999. N=244. Ehrmann. Diab Care 1999. N=122 (WHO, 1985) HSPSC N=67 Criteria: WHO, 1999.

  18. Methods for insulin-resistance work-up

  19. Methods for Insulin-Resistance work-up • Gold Standard test IR is euglucemic clamp • . • Due to its complexity, Oral Glucose Tolerance Test or Basal Glucose and Insulin measurements instead • . • OGTT is the main test in the diagnosis of Impaired Glucose Intolerance or Type II Diabetes • Other indexes are less used in clinical routine

  20. IR hyperinsulinism ¿? Hyperandrogenic Anovulation

  21. Diabetes Mellitus IGT IFG or IR And 2 of ≥ 140/90 mmHG Dyslipidaemia Central Obesity Wais:hip ratio BMI Microalbuminuria Central obesity (Waist) Dyslipidaemia TG Dyslipidaemia HDL-C ≥130/85 Fasting glucose >100 mg/dL At least 3 Metabolic Syndrome WHO Adult Treatment Panel

  22. Cardiovasculardisease in women • Near2,5 million women hospitalized each year due to CVD • 1st death cause in women (over the next 14 together) • Half of these deaths are from MCI • Annual cost estimated to be 28,65 billion dolars • Tsang y cols. Risk of caronary heart disease in women: current understanding. Mayo Found Med Educ Research, 2000

  23. Clinical hyperandrogenism • Different prevalence among different populations: ethnicity • Absence of consensus on how to evaluate clinically the hyperandrogenism • Semiquantitative staging methods (Ferriman-Gallwey). Limitations: • Subjective: intra and inter-observer variability • Previous pharmacological or cosmetical treatments • Non validated

  24. Hirsutism Prevalence in Women with SOPQ

  25. Genes in PCOS

  26. TREATMENT

  27. TREAT WHAT?

  28. TREAT WHAT? Imparied Treatment Options Weight/Metabolic Diet/lifestyle Metformin Dysfunctional bleeding Cyclic progesterone OCP Infertility Metformin Clomiphene Letrozole Gonadotropins Ovarian cautery Skin OCP + antiandrogen (spironolactone, flutamide, finasteride) GnRH agonists

  29. Metabolic Syndrome Caloric restriction +/- weight loss ( 6-7 months ) Leptine SHBG IGFBP Insulin Resistance Ovulatory cycles Improve Hirsutism Acanthosis Improvement in Gonadotropins metabolism androgens citochrome P450scc 17-αhidroxilase

  30. Insulin-Sensitizing Agents • α-Glucosidasa Inhibitors • Sulfonilureas • Methiglinidas • Biguanides • Thiazolidindiones

  31. TREAT WHAT? Imparied Treatment Options Weight/Metabolic Diet/lifestyle Metformin Dysfunctional bleeding Cyclic progesterone OCP Infertility Metformin Clomiphene Letrozole Gonadotropins Ovarian cautery Skin OCP + antiandrogen (spironolactone, flutamide, finasteride) GnRH agonists

  32. TREAT WHAT? Imparied Treatment Options Weight/Metabolic Diet/lifestyle Metformin Dysfunctional bleeding Cyclic progesterone OCP Infertility Metformin Clomiphene Letrozole Gonadotropins Ovarian cautery Skin OCP + antiandrogen (spironolactone, flutamide, finasteride) GnRH agonists

  33. Laparoscopic Electrocoagulation Laparoscopic Ovarian Diathermy Several energy sources: Monopolar, LASER (CO2, Argon, KTP, YAG) Mechanism of action • Not well established • Removal of androgen-producing stroma • Total and free testosterone reduction to 40-50% basal levels • LH pulses amplitude decreases • Better prognosis for patients with LH > 10 UI/l before surgery

  34. Year Patients Previous ttm % Ovulation % Spont preg Gjonnaess 1985 58 ---- 72 41 Weise 1991 39 CC, HMG --- 59 Naether 1993 104 CC, HMG 55 34 29.1% had adherence at a 2nd laparoscopy Saravelos 1996 21 CC 76 30 Merchan 1996 74 CC, HMG 88 57 Pelosi 1996 30 CC, HMG 83 70 Total 720 79.7 51.5 LAPAROSCOPIC ELECTORCAUTERY Campo, S. Obst Gyn Surv 1998;53:297-308.

  35. Year Patients Prevıous ttm % Ovulatıon % Spont Preg Daniell (CO2) 1989 85 CC 71 41 Kojima (YAG) 1989 12 CC, HMG 83 58 Gurgan (YAG) 1992 40 CC 70 50 50% had adherence at a 2nd laparoscopy Sinha (YAG) 1993 20 CC, HMG,FSH 100 40 Heylen Argon 1994 44 CC 80 55 Fukaya (YAG) 1995 26 CC, HMG 23 23 Total 322 71.5 43.7 LAPAROSCOPIC LASER VAPORIZATION Campo, S. Obst Gyn Surv 1998;53:297-308.

  36. TREAT WHAT? Imparied Treatment Options Weight/Metabolic Diet/lifestyle Metformin Dysfunctional bleeding Cyclic progesterone OCP Infertility Metformin Clomiphene Letrozole Gonadotropins Ovarian cautery Skin OCP + antiandrogen (spironolactone, flutamide, finasteride) GnRH agonists

  37. Systemic Antiandrogens Spironolactone Finasteride Flutamide OCP GnRH analogs Cutaneous Eflornitine Creams Electrolysis Laser Skin

  38. Thank you

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