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Polycystic Ovarian Syndrome (PCOS)

Polycystic Ovarian Syndrome (PCOS). ACP Regional Meeting October 20, 2007. Patricia S. Wu, MD, FACE, FRCP Associate Clinical Professor of Medicine University of California San Diego Division of Endocrinology Kaiser Permanente San Diego. Diagnosis of PCOS. NIH criteria (1990)

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Polycystic Ovarian Syndrome (PCOS)

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  1. Polycystic Ovarian Syndrome (PCOS) ACP Regional Meeting October 20, 2007 Patricia S. Wu, MD, FACE, FRCP Associate Clinical Professor of Medicine University of California San Diego Division of Endocrinology Kaiser Permanente San Diego

  2. Diagnosis of PCOS NIH criteria (1990) Chronic oligo- / anovulation AND Hyperandrogenism Rotterdam criteria (2003) 2 of 3 Chronic oligo- / anovulation Hyperandrogenism Polycystic Ovary Morphology

  3. Oligo- / Anovulation • Irregular menses, peri-menarchal onset • < 9 menses / yr; cycle length varies > 2d ßHCG, prolactin, LH, FSH • Hyperandrogenism • Hirsutism, acne, androgenic alopecia • Gradual onset, stable, chronic Testosterone, Androstendione, SHBG • Ovarian morphology • Helpful for diagnosis if only one criteria present • Evaluate endometrial thickness Ovarian Ultra-Sound Scan (Optional) • Insulin Resistance / Metabolic risk • Acanthosis nigricans • W:H, waist >88cm, OSA Fasting lipids, Glucose tolerance (2h pp BG or OGTT)

  4. Differential diagnosis • Drugs – exogenous androgens, valproic acid • Pregnancy • Hyperprolactinemia • Non classical Congenital Adrenal Hyperplasia • Cushing’s syndrome • Virilizing adrenal or ovarian tumor • Simple obesity

  5. Management of Hyperandrogenism • Combination therapies >> Monotherapy • May take up to 6 months for response (except cosmetic treatments) • Use only if no plan to conceive OCP Norgestimate / Desogestrel / Drospirenone as progestin Anti-androgens Spironolactone 100mg/d, cyproterone acetate (n/a) finasteride 5mg/d (not FDA approved) Cosmetic bleaching, waxing, shaving, electrolysis, laser Vaniqa Cream (eflornithine HCl) Insulin sensitizers Metformin; Thiazolidindiones (Actos, Avandia)

  6. Reproductive Issues • Endometrial Protection in anovulatory cycles • OCP; Medroxyprogesterone 5 or 10mg x 14 days • EMB if no menses >1 yr • US to assess endometrial thickness • Contraception • use barrier contraceptive if not on OCP • Infertility • Weight loss -  risk of pregnancy morbidity • Ovulation induction: • Clomiphene Citrate, Aromatase Inhibitors (n/a), exogenous gonadotrophins, GnRH • Metformin; TZD • ART

  7. Role of Insulin Sensitizers in PCOS: Metformin & TZD • Metformin – most available data • 6m Metformin  50% regular menses • Metformin+Clomiphene >>Clomiphene for ovulation induction • Pregnancy category B drug •  Ovarian hyperstimulation in gonadotrophin therapy • Improves outcome of IVF •  early pregnancy loss,  GDM • TZD • ovulation, T, SHBG • Pregnancy category C • Both may improve metabolic indices, DM

  8. Metabolic Risks Reduction •  HTN, dyslipidemia (HDL, LDL,  TG) insulin resistance, obesity, increased W:H ratio • 30-50% obese PCOS IGT or DM • Weight Loss 5-10% improves symptoms • Lifestyle Intervention • Metformin or TZD only approved for IGT or DM • Aggressive management of HTN and dyslipidemia • Smoking cessation • Evaluation of Obstructive Sleep Apnea

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