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PCOS : P oly C ystic O vary S yndrome

PCOS : P oly C ystic O vary S yndrome. By Kimberly Dovin, PGY3 Swedish Family Medicine January 13, 2003. or. PCOS : A Disorder for the Generalist. PCOS: Goals. Identify patients with risks for or with Dx of PCOS Assess patients appropriately for PCOS and associated disease states

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PCOS : P oly C ystic O vary S yndrome

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  1. PCOS:PolyCystic Ovary Syndrome By Kimberly Dovin, PGY3 Swedish Family Medicine January 13, 2003

  2. or PCOS:A Disorder for the Generalist

  3. PCOS: Goals • Identify patients with risks for or with Dx of PCOS • Assess patients appropriately for PCOS and associated disease states • Prescribe therapy to treat complaints and prevent sequelae

  4. PCOS: Objectives • Define PCOS • Understand pathophysiology • Form an appropriate differential diagnosis • Establish the work-up for PCOS • Develop an array of therapies to treat complaints and prevent bad outcomes

  5. PCOS: Defined? I • ACOG and NIH (1990): hyperandrogenism and chronic anovulation excluding other causes • Stein and Levanthal (1935): association of amenorrhea with polycystic ovaries and variably: hirsutism and/or obesity

  6. PCOS: Epidemiology • Prevalence: 4-6% females • Probably same world wide • No difference between blacks and whites • 75% of women w/ irregularity or infertility

  7. SYMPTOMS Menstrual irregularity Infertility Hirsutism, acne, etc Obesity SIGNS Hirsutism, acne Obesity Ovarian enlargement Acanthosis nigricans PCOS: Signs and Symptoms

  8. PCOS: Signs and Symptoms II

  9. PCOS: Imaging and Pathology

  10. PCOS: PathopysiologyWhat we think we know. • “Vicious cycle” • Abnormal gonadotropin secretion • Excess LH and low, tonic FSH • Hypersecretion of androgens • Disrupts follicle maturation • Substrate for peripheral aromatization • Negative feedback on pituitary • Decreased FSH secreation • Insulin resistance, Elevated insulin levels

  11. PCOS: Current theories of pathopysiology Autosomal Dominant Gene Downstream Signal Defect GnRH E2 LH Insulin Resistance PCOS A A=androgens, E2=estradiol

  12. “Could the theory of chaos contribute to the interpretation of pathogenesis of polycystic ovary syndrome?”

  13. PCOS: Case 1 - Hx • J.D. 31yof • Menstrual irregularity,LMP 5 months prior • Irregular since menarche • Getting longer over time • Sexually active and uses condoms • 40lb weight gain over past six months • Previous U/S w/ ovarian cysts • ROS: hair growth on her chin and chest • Meds: HCTZ, Effexor, atenolol

  14. PCOS: Case 1 - PE • BP 126/96, Weight 248lbs • Skin: dark hair on chin and chest, moderate to severe acne on face and back • no acanthosis nigricans • Abd-obese, tender RLQ, no R/G, no abd striae • Pelvic exam – nl ext genitalia no clitoromegaly, norm appearing cervix • Bimanual: Uterus/adnexa not palpated • U/S: Normal appearing ovaries

  15. PCOS: Differential Dx • Androgen secreting tumor • Exogenous androgens • Cushing’s syndrome • Nonclassical congenital adrenal hyperplasia • Acromegaly • Genetic defect in insulin metabolism • Primary hypothalamic amenorrhea • Primary ovarian failure • Thyroid dz • Prolactin dz

  16. PCOS: Case 1 Work-up • Total or free testosterone • +/- LH and FSH • Pelvic U/S • Fasting glucose • Fasting lipid profile • (SHBG, Insulin)

  17. PCOS: Work-up (cont’d) • TSH • Prolactin • UHCG • +/- 17-hydroxyprogesterone • +/- Dexamethasone suppression test • +/- DHEA

  18. PCOS: Case 1 Treatment • Oligomennorhea • OCPs, Progestins, insulin-sensitizing agents • Hirsutism • OCPs, Antiandrogens, ISAs, Eflornithine • Mechanical treatments • Obesity • LIFESTYLE MODIFICATIONS • Metformin

  19. PCOS: Case 1 Treatment • Naturopathic options • Flaxseed oil • Fish oil • D-chiro-inositol • Chromimum • Urtica Dioica (aka stinging nettle) • Saw palmetto

  20. Case 1: Outcomes • Laboratory analysis: Nl TSH and prolactin, mild elevation of testosterone, LH:FSH 3:1 • Treatment: Diet and exercise counseling, metformin 850mg bid. • Patient reported resumption of menses and thereafter lost to f/u

  21. PCOS: Case 2 - Hx • R.M. 27yof • Desires pregnancy w/o results X 2yrs • LMP 2 wks ago/ 3 menses per yr • 2 years irregularity, • sometimes heavy bleeding • Simlar family hx • C/o facial hair which she waxes • No infertility w/u

  22. PCOS: Case 2 – P.E. • Weight 247 lbs • Skin: Scant facial hair on chin, no acne • Abd: obese • Pelvic: norm uterus, ovaries not palpated • Labs: mild elev prolactin & testosterone, elevated LH • Pelvic US WNL

  23. PCOS: Infertility • WEIGHT LOSS • Clomiphene citrate 50-100mg QD +/- dexamethasone • Gonadotropins • Metformin • Ovarian Drilling

  24. PCOS: Risks of Pregnancy • Gestational Diabetes? • Hypertension?

  25. PCOS: Case 2 - Outcomes • Metformin 500mg bid • Menses resumed q28 d X 2 • Anxious to get pregnant. • Advised following BBTemps • Timing intercourse. • If no result in 3mos start Clomid.

  26. PCOS: Case 3 - Hx • M.P. 39yof • F/u acne face and back • C/o hirsutism, “like a beard” • Oligomennorhea, q60day cycles • G2P2 s/p BTL 14 years ago • ROS: weight gain 50lbs in 3-4 years

  27. PCOS: Case 3 - P.E. • BP 146/92 • Weight 232lbs, BMI 36.3 • Skin: Severe acne on face and back, evidence of shaving on face

  28. PCOS: Associated Disorders • Diabetes • Hyperlidpidemia (LDL, Triglycerides) • Obesity • Hypertension • CAD? • Incr in Risk Factors, but not mortality

  29. PCOS: Associated Disorders • Endometrial CA • Ovarian CA? • +/- Breast CA • NO increase in Osteoporosis • Eating disorders • Psychiatric dz

  30. PCOS: Case 3 Follow-up • TSH, Prolactin, Free Testosterone, 17-OH progesterone all WNL • Fasting glu = 99 LDL = 125 • Referred to nutrition and prescribed exercise program • Pt lost 30lbs over one year, menses more regular, hirsutism and acne slightly improved • LDL dropped to 110, BP normalized

  31. PCOS: Conclusion • PCOS: chronic anovulation/hyperandrogenism • Complete a w/u to r/o other causes • Advise weight loss and exercise in all patients w/ PCOS • Consider medical management • Use a Palm memo

  32. Bibliography • Plycystic Ovary Syndrome. Clinical Management Guidelines. Dec 2002; ACOG Practice Bulletin No. 41. • Hunter, H., MD and Sterrett, J, PharmD. Polycystic Ovary Syndrome: It’s Not Just Infertility. AFP. Sept. 1, 2000. • Keri Marshall, ND Candidate 2001 Polycystic Ovary Syndrome: Clinical Considerations. • Macut D, et al. Cardiovascular risk in adolescent and young adult obese females with polycystic ovary syndrome (PCOS). J Pediatr Endocrinol Metab. 2001;14 Suppl 5:1353-59; discussion 1365. • Poretsky, Insulin Resistance and the Polycystic Ovary Syndrome: Mechanism and Implications for Pathogenesis; Endocrine Reviews 20 (4): 535-582.

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