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Introduction. Heterogenous problemCommonest hormonal disturbanceOvarian expression of metabolic syndromeLong term consequences - strategies to screenStein Leventhal syndrome. ASRM/ ESHRE. Rotterdam: May 2003Two of three: Oligomenorrhoea
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1. PCOS Dr. Mridula A Benjamin
Dept of Obs and Gyn
RIPAS Hospital, Brunei
2. Introduction Heterogenous problem
Commonest hormonal disturbance
Ovarian expression of metabolic syndrome
Long term consequences - strategies to screen
Stein Leventhal syndrome
3. ASRM/ ESHRE Rotterdam: May 2003
Two of three: Oligomenorrhoea & or anovulation
Hyperandrogenism; Clinical/biochemical
PCO on USG; 12 or more, 2-9mm,10cm3
Single PCO
The follicle distribution & increase in stromal echogenecity & volume should be omitted
Chronic anovulation & hyperandrogenism in absence of other endocrine disorders
January issue of Fertility & Sterility J, 2004
4. Ultrasound Polycystic ovaries
Bilateral
Multiple cysts
Cyst diam <2-9mm
Stroma increased
8. Gross appearance of ovaries Enlarged bilaterally and have a smooth thickened avascular capsule
On cut section, subcapsular follicles in various stages of atresia are seen
Microscopically luteinizing theca cells are seen
16. Prevalence PCO on ultrasound - 20%-33%
Oligomenorrhea - 4 – 21 %
Oligomenorrhea + hyperandrogenism - 3.5 – 9 %
17. Pathogenesis (etiology?) Hypersecretion of adrenal androgens?
Hypersecretion of ovarian androgens?
A genetic disorder with an autosomal dominant mode of inheritance?
A multifactorial genetic disorder?
20. Obesity and insulin resistance Diminished biological response to insulin
In both obese and non obese
In 40%
More in obese and oligomenorrhoeic
Euglycaemia at expense of hyperinsulinaemia
Obesity more of central -35-60%
22. Presentation
Amenorrhea-
Oligomenorrhea
Infertility
Hirsutism
Obesity
Acne Vulgaris
Asymptomatic
24. Laboratory studies Increased androgen levels in blood (testosterone and androstendione)
Increased LH, exaggerated surge
Increased fasting insulin
Increased prolactin
Increased estradiol and estrone levels
Decreased SHBG levels
25. Long term risks in PCOS
Definite
Type 2 diabetes(15%), IGT( 18-20%)
Dyslipidemia (Hypercholesterolemia with diminished HDL2 and increased LDL)
Endometrial cancer (OR 3.1 95% CI 1.1 -7.3)
26. Possible
Hypertension
Cardiovascular disease
Gestational diabetes mellitus
Pregnancy-induced hypertension
Ovarian cancer
Unlikely
Breast cancer
Long term consequences
27. Management Symptom oriented
Diet & exercise
Wt. loss
Improves both symptoms & endocrine profile
BMI >30kg/ m2
Keep CHO content down, avoid fatty food
Obesity clinics
28. Contd Menstrual irregularities
OCP- Yasmin, Dianette
ET >10mm(oligo), >15mm(amen)-Withdrawal bleed
Fails - Endometrial sampling
31. Mx of Hirsutism
Cosmetic
Medical- 6-7 months
Cyproterone acetate+ EE, Spironolactone
Reliable contraception
Flutamide & Finasteride - Rare
32. Reproductive Endocrinologist S.testosterone > 5nmol/L
Rapid onset hirsutism
IGT/ Type2 DM
Refractory symptoms
Amen. > 6 months
Subfertility
33. Guidelines (RCOG, May 2003) 1-Patients presenting with PCOS particularly if they are obese, should be offered measurement of fasting blood glucose and urine analysis for glycosuria. Abnormal results should be investigated by a glucose tolerance test
Such patients are at increased risk of developing type II diabetes (Evidence level IIb[C]) 2- Women diagnosed as having PCOS before pregnancy should be screened for gestational diabetes in early pregnancy
Refer to specialized obstetric diabetic service if abnormalities detected (evidence level IIb[B])
34. Guidelines (RCOG, May 2003) 3-Measurement of fasting cholesterol, lipids and triglycerides should be offered to patients with PCOS, since early detection of abnormal levels might encourage improvement in diet and exercise (Evidence level III[C])
4- Olig- and amenorrhoeic women with PCOS may develop endometrial hyperplasia and later carcinoma. It is good practice to recommend treatment with progestogens to induce withdrawal bleed at least every 3-4 months (Evidence level IIa[B])
35. Guidelines (RCOG, May 2003) 5- Evidence has accumulated demonstrating safety and efficacy of insulin-sensitizing agents in the management of short-term complications of PCOS, particularly anovulation. Long-term use of these agents for avoidance of metabolic complications of PCOS cannot as yet be recommended (Evidence level IV[B]) 6- No clear consensus regarding regular screening of women with PCOS for later development of diabetes and dyslipidemia
Obese women with strong family history of cardiac disease or diabetes should be assessed regularly in a general practice or hospital outpatient setting. Local protocols should be developed and adapted (Evidence level IV[C])
36. Guidelines (RCOG, May 2003) Young women diagnosed with PCOS should be informed of the possible long-term risks to health that are associated with their condition. They should be advised regarding weight and exercise (Evidence level III[C])