1 / 16

Polycystic Ovarian Disorder

Polycystic Ovarian Disorder. Max Brinsmead PhD FRANZCOG April 2013. Criteria for the diagnosis of PCO. Has been controversial… In the US the NIH states that it is: Menstrual abnormalities and anovulation Cinical or biochemical evidence of androgen excess And the exclusion of:

eamon
Download Presentation

Polycystic Ovarian Disorder

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Polycystic Ovarian Disorder Max Brinsmead PhD FRANZCOG April 2013

  2. Criteria for the diagnosis of PCO • Has been controversial… • In the US the NIH states that it is: • Menstrual abnormalities and anovulation • Cinical or biochemical evidence of androgen excess • And the exclusion of: • Prolactin excess, thyroid disorder, congenital adrenal hyperplasia & Cushings syndrome

  3. Criteria for the diagnosis of PCO • In 2003 a European Consensus statement simplified this to… • Any two of the following: • Menstrual abnormalities and anovulation • Cinical or biochemical evidence of androgen excess • Polycystic ovaries on ultrasound • (Transient states e.g. adolescence and simple obesity need to be excluded)

  4. But what is PCO for the practising doctor? • A genetic variant that affects 5 – 10% of the female population • Manifests itself as different problems at different stages of adult life • Can vary in severity from mild to severe • Best regarded as an evolutionary variant that has permitted survival of the species during times of famine • The problem is that there are few famines in the developed world in the 21st century!

  5. Common clinical manifestations of PCO • Obesity • Hirsutism or Acne • Menstrual irregularity • Infertility • Type 2 diabetes • Dyslipidaemia

  6. Other manifestations of PCO • Axillary/Groin Follicular Adenitis • Premature pubarche • Bulimia • Acanthosisnigrans • Recurrent miscarriage • Frontal balding or clitoromegaly • Homosexuality • Cardiovascular disease • Endometrial hyperplasia and cancer

  7. Essential Tests for possible PCO • Ultrasound of pelvis • More than 12 follicles 5 – 10 mm diam in one or both ovaries • NB 20% of cycling women have “polycystic ovaries” • Serum androgens • Must measure free testosterone or equivalent • Fasting glucose, cholesterol & triglycerides • Preferably measure insulin as well • Exclude other causes of the presenting problem • Prolactin, Thyroid function, HydroxyPROG or dexamethasone suppression as clinically indicated

  8. Laboratory Manifestations of PCO • Elevated free testosterone or free androgen index • Hyperinsulinaemia • Elevated LH or raised LH:FSH ratio • Mild chronic hyperoestrinism • Elevated CHOL, LDL or triglycerides • Elevated tissue plasminogen activators • Evidence of low grade chronic inflammation • (Measures of serum leptin correlate with obesity and not PCO)

  9. Management of the PCO Disorder • Will depend on the principal problem… • Hirsutism • Menstrual dysfunction • Infertility • Obesity • Diabetes and or Dyslipidaemia

  10. Management of Hirsutism • Is primarily cosmetic • Shaving • Waxing • Dye or Depilation • Spironolactone • Cyproterone acetate (Androcur) • Combined oral contraceptive • Preferably with cyproterone acetate e.g. Diane • Other measures • Ketoconazole • Flutamide (not available in Australia) • Topical Eflornithine ( “ “ “ “ )

  11. Management of menstrual dysfunction due to PCO Disorder • Diet, exercise and lifestyle changes if obese • Combined oral contraceptive • Use 3rd or 4th generation or cyproterone acetate e.g. Diane • Contraindicated if >35 years AND smoking or morbidly obese • Mirena IUS is a good alternative • Cyclical or continuous progestin • Depot provera • An alternative for those who do not want “the pill” • There may be a role for Metformin • Endometrial resection • Hysterectomy

  12. Management of Infertility due to PCO Disorder • Diet, exercise and lifestyle changes if obese • Is as effective as drugs! • Clomiphene citrate (Clomid) • Metformin • Ovarian drilling • FSH and HCG • IVF and ET

  13. Management of Obesity and Dyslipidaemia with PCO Disorder • Diet, exercise and lifestyle changes • Metformin • A possible role for Glitazones • Sustained release Metformin may improve compliance

  14. So is Metformin the panacea for PCO Disorder? • Results from combined trials: • Decrease androgens by a mean of 20% • Increase ovulation from a mean of 1:5 months to 2:5 months • Decrease BMI by a mean of 4% • So the outcomes are modest

  15. Problems in the use of Metformin for PCO Disorder • There are relatively few large scale and long term studies • Is not as effective as lifestyle changes in RCTs • Nausea and diarrhoea are common • A small risk of hepatoxicity, lactic acidosis and B12 deficiency • May be teratogenic if used in pregnancy

  16. So what is the role of Metformin in PCO Disorder? • To encourage weight loss • Non significant effect in meta analysis of RCT’s • To enhance the effectiveness of Clomid • Non significant effect in meta analysis of RCT’s • Improves egg and embryo quality during IVF • Pregnancy rates doubled and risk of miscarriage reduced • Reduces the risk of OHSS during IVF • 4Xfold reduced risk • May prevent the onset of Type 2 Diabetes • Does reduce the risk of cardiovascular disease when used for Type 2 Diabetes • So the long term use remains controversial

More Related