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PCOS- long term management

PCOS- long term management. Dr.Anita mani Gift IVF center , cochin , India. PCOS- L ong T erm M anagement. Dr.Anita mani Gift IVF center , cochin , India. Prevalence 3 to 20 %. 70% undiagnosed. R eproductive S ymptoms of PCOS. Reproductive symptoms Anovulation Subfertility

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PCOS- long term management

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  1. PCOS- long term management Dr.Anita mani Gift IVF center , cochin , India

  2. PCOS- Long Term Management Dr.Anita mani Gift IVF center , cochin , India

  3. Prevalence3 to 20 % 70% undiagnosed

  4. Reproductive Symptoms of PCOS • Reproductive symptoms • Anovulation • Subfertility • Hyperandrogenism

  5. Metabolic sequelae of PCOS • obesity • glucose intolerance • Type 2 Diabetes • Cardiovascular accidents - stroke, MI

  6. Long term management • Life style changes - Diet, weight loss • Screening for cardiovascular risks • Pharmacological intervention • Surgical intervention - Laparoscopy • obstructive sleep apnoea assessment • Psychological assessment and treatment

  7. Multidisciplinary Team Approach clinician, dietitian, exercise specialist, counsellor

  8. Multidisciplinary team approachClinicians - GP, Endocrinologist, Infertility specialistDiabetes specialist, Physician, Cardiologist, Surgeondietician, exercise specialist counsellor, psychologist / psychiatrist

  9. Life style changes - Diet & exercise Life style changes including diet, exercise and weight loss should precede any pharmacological intervention. Even a 5% loss of body weight will reduce insulin resistance and circulating androgens, resulting in spontaneous ovulation and relief of symptoms. Behavior change techniques should target optimal weight. Norman RJ, Davies MJ, Lord J, Moran LJ. The role of lifestyle modification in polycystic ovary syndrome. Trends Endocrinol Metab. 2002;13(6):251-7.

  10. Diet A diet low in saturated fat and high in fibre from predominantly low-glycaemic-index-carbohydrate foods is recommended Marsh K, Brand-Miller J. The optimal diet for women with polycystic ovary syndrome? Br J Nutr. 2005;94(2):154-65.

  11. Exercise Regular exercise (30 minutes of aerobic exercise/day) has been shown to decrease central obesity and increase insulin sensitivity and is therefore strongly recommended. Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344(18):1343-50.

  12. Strategies • motivational interviewing • established behaviour techniques • ways to access support to help with weight loss and exercise • establishing self-monitoring (including pedometer use) • time management techniques • relapse prevention techniques • individual tailoring • engaging social support • setting goals

  13. Screening for cardiovascular risks Women with PCOS should be screened for cardiovascular risk by determination of CVD risk factors (obesity, lack of physical activity, cigarette smoking, family history of type II diabetes, dyslipidaemia, hypertension, impaired glucose tolerance, type II diabetes) They should be strongly warned against smoking. American College of Obstetrics and Gynecology. ACOG Practice Bulletin No. 41: Polycystic Ovary Syndrome. Obstetrics & Gynecology. 2002;100(6):1389-402.

  14. Screening for type II diabetes • Women presenting with PCOS who are overweight (body mass index [BMI] ≥ 25 kg/m2) and women with PCOS who are not overweight (BMI < 25 kg/m2), but who have additional risk factors such as advanced age (> 40 years), personal history of gestational diabetes or family history of type II diabetes, should have a 2-hour post 75 g oral glucose tolerance test performed. • In women with impaired fasting glucose (fasting plasma glucose level from 6.1 mmol/l to 6.9 mmol/l) or impaired glucose tolerance (plasma glucose of 7.8 mmol/l or more but less than 11.1 mmol/l after a 2-hour oral glucose tolerance test), an oral glucose tolerance test should be performed annually.

  15. Protocols for clinicians Protocols should be provided to clinicians, to assess CVD risks considering obesity, physical inactivity, smoking, dyslipidemia, hypertension, glucose intolerance and type II diabetes/family history.

  16. Pharmacological interventions in PCOS Oligo- or amenorrhoea in women with PCOS may predispose to endometrial hyperplasia and later carcinoma. It is good practice to recommend treatment with gestogens to induce a withdrawal bleed at least every 3 to 4 months. Transvaginal ultrasound should be considered in the absence of withdrawal bleeds or abnormal uterine bleeding. In PCOS, an endometrial thickness of less than 7 mm is unlikely to be hyperplasia. A thickened endometrium or an endometrial polyp should prompt consideration of endometrial biopsy and/or hysteroscopy. Hickey M, Higham JM, Fraser I. Progestogens with or without oestrogen for irregular uterine bleeding associated with anovulation. Cochrane Database Syst Rev 2012;(9):CD001895. 61. McCormick BA,Wilburn RD,Thomas MA,Williams DB, Maxwell R,Aubuchon M. Endometrial thickness predicts endometrial hyperplasia in patients with polycystic ovary syndrome. Fertil Steril 2011;95:2625–7.

  17. Subfertility medicines Ovulation inducing agents like clomiphene citrate and gonadotrophin can be used for a limited period of less than 12 months to achieve fertility.

  18. Insulin-sensitizing agents like metformin does not seem to have long-term benefits. Weight reduction drugs reduce hyperandrogenaemia in selected patients with morbid obesity only.

  19. Laparoscopic Ovarian Drilling Laparoscopic ovarian drilling will induce ovulation in 60% of the subjects for 20 years. Gjønnaess H. Ovarian electrocautery in the treatment of women with polycystic ovary syndrome (PCOS). Factors affecting the results. Acta Obstet Gynecol Scand 1994;73:407–12.

  20. Obstructive Sleep Apnea (OSA) Women diagnosed with PCOS should be asked about the symptoms of OSA (snoring, daytime fatigue/somnolence) and offered investigation and treatment if indicated. Fogel RB, Malhotra A, Pillar G, Pittman SD, Dunaif A, White DP. Increased prevalence of obstructive sleep apnea syndrome in obese women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2001;86(3):1175-80. Gopal M, Duntley S, Uhles M, Attarian H. The role of obesity in the increased prevalence of obstructive sleep apnea syndrome in patients with polycystic ovarian syndrome. Sleep Med. 2002;3(5):401-4.

  21. Psychological assessment and intervention Every study of PCOS has shown a higher risk of depression, anxiety and worsened quality of life in this condition. Practitioners must investigate the presence of mental distress and include treatment of this in the management plan. Deeks AA, Gibson-Helm ME, Paul E, Teede HJ. Is having polycystic ovary syndrome a predictor of poor psychological function including anxiety and depression? Hum Reprod. 2011;26(6):1399-407.

  22. Bariatric surgery Bariatric surgery has been shown to be effective in women with PCOS and may be an option for severely obese women with BMI more than 35, in whom long-term diet-based strategies have failed. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724-37. Escobar-Morreale HF, Botella-Carretero JI, Alvarez-Blasco F, Sancho J, San Millan JL. The polycystic ovary syndrome associated with morbid obesity may resolve after weight loss induced by bariatric surgery. J Clin Endocrinol Metab. 2005;90(12):6364-9.

  23. Prevention of PCOS Sequelae • Creating public health awareness on healthy eating and the necessity of regular exercise and including the subjects in the school curriculum is needed. • The government should take steps to bring changes , as there are huge public health implications due to long term sequelae of PCOS. • The significance is not just due to morbidity and mortality , but also the cost involved. Millions are being spent for the treatment of PCOS and its consequences like diabetes, obesity, psychological problems and CVA

  24. “ Why are children obese? May be its because burgers are $0.99 and salads $4.99 ”

  25. “Success is achieved and maintained by those who try and keep trying.” –W.Clement Stone

  26. Make a change! Dr.Anita Mani Infertility surgeon and laparoscopic surgeon

  27. Practical measures Articles in news papers and magazines TV shows Classes to teenage school children by experts Medical conferences to educate doctors, paramedics PCOS awareness associations in every country with regular activities Good blogs by experts Social media postings – targetting next generation possible by face book , instagram, whats up Websites for information Comedy shows , memes with this theme of pcos . Target population likes humour

  28. Target population Mothers- include Healthy eating and exercise part of ANC . Schools - add these in curriculam, add cooking classes Schools – experts can take classes Schools – to reduce sitting hours , increase activities Teenagers – catch them early before it is too late

  29. Target population Infertile women – they are willing to do anything , give them complete care , give information in form of leaflets , put targets for them to achieve wt loss, give options to choose treatment (informed Decision) Counsell them re Future problems . Protocols to GP s , clinicians to screen CVD risks

  30. Finance Unless money is involved, nobody is going to act, so find sponsorers, pharmaceutical companies may help as it will be marketing for them. Companies that sell myo-ionositol, NAC etc will come forward to sponsor meetings

  31. U tube Make something creative , that will go viral, like gangam style Videos (short) on diet , exercise , glycaemic index, medical treatments, complications etc on pcos. We could have recorded and uploaded our talks ! Or take small bits of it .

  32. Governments , Rules Letter to officials with signature from experts, also from pcos patients Repeat several times until they notice. Find pcos patient in higher govt.ranks , and ask for help

  33. Book Write a book for the patients. (not for experts as they already know . Need to get across to patient)All of us can contribute chapters and write in simple language to help PCOS patients. It is practically possible as we all have enough material. Autobiography- living with PCOS.

  34. Camps Doctors can conduct free screening camps in their locality to encourage girls to come forward, for the consultation. We can convince docs , that they will get patients in future , so they will have a motive. We do laparoscopy at reduced rate for Patients yearly once, at our center

  35. conference Bring in live testimonial by patient who went thru the disease, what helped them , who helped them, how much they understood about the disease, what is the expectation from medical fraternity

  36. Review on internet Doctors can get patients to put reviews regarding the experience in internet about the treatment

  37. Research More research into psychological problems in teens and adults with PCOS Try and integrate natural medicines like ayurveda , chinese medicine into research Research on results of Yoga , thai chi etc on PCOS Partners experience of living with PCOS women, QOL. Lesbian population and PCOS incidence

  38. Thank you very much for listening & trying to make a positive change Dr.Anita Mani mom, sister, cousin and doctor of PCOS patients

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