1 / 36

POLYCYSTIC OVARIAN SYNDROME (PCOS)

POLYCYSTIC OVARIAN SYNDROME (PCOS). TL KHUMALO 30 AUGUST 2018. Dr TL Khumalo hails from Durban, KwaZulu-Natal, currently practicing as a Specialist Obstetrician and Gynaecologist in Edendale Regional Hospital (Pietermaritzburg )

wilmag
Download Presentation

POLYCYSTIC OVARIAN SYNDROME (PCOS)

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 OVARIANSYNDROME (PCOS) TL KHUMALO 30 AUGUST 2018

  2. Dr TL Khumalo hails from Durban, KwaZulu-Natal, currently practicing as a Specialist Obstetrician and Gynaecologist in Edendale Regional Hospital (Pietermaritzburg) • She obtained her undergraduate degree at the Nelson R. Mandela School of Medicine and obtained her Fellowship in Obstetrics and Gynaecology via the University of KwaZulu-Natal in 2016 • She has keen interests in seeing both Maternal health and the stigmatized Disorders of Sex development improve • She has research interests in Infertility management in low resource settings • Her research interests are in the field of Sexual Reproductive Health

  3. DISCLOSURES • NIL DISCLOSURES

  4. OUTLINE • BACKGROUND • DEFINITION / PREVALENCE • ISSUES RELATED TO PCOS • APPROACH TO MANAGEMENT

  5. SYNDROME Greek Etymology Sun ~ TOGETHER DRAMEIN ~ TO RUN SYNDROME SunDRAMEIN ~ TO RUN TOGETHER

  6. BACKGROUND • 1935 : Stein IF and Leventhal ML designated PCO as a syndrome • ’80s/’90s : Addition of ultrasound criteria • 2003 : Rotterdam Consensus Conference • 2018 : International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2018

  7. BACKGROUND • : International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2018 • Over 3 000 delegates SUPPORT OPTIMAL PATIENT CARE AIMS PROVIDE CLEAR INFORMATION ASSIST CLINICAL DECISION MAKING

  8. BACKGROUND • Ovarian Theca Cells >> Under the control of LH/IGF-1 >> Produces Testosterone >> Granulosa cells convert (Aromatase enzyme) to active Oestradiol • Increasedandrogenproduction • Increased free androgens

  9. PCOS

  10. CONTROVERSIES • Rotterdam criteria is over 10yrs old • Serum AMH is under intense debate • Misnomer of the term poly“cystic” which is referring to aarested follicles not cysts • COCP and the WHO MEC (2015) • Ethics of Distributive Justice

  11. PATHOPHYSIOLOGY

  12. PCOS OA ~ Oligo-Anovulation HA ~ Hyper-androgenism PCOM ~ Polycystic Ovarian Morphology

  13. OA:Oligo-Anovulation • Primary / Secondary Amenorrhoea • Oligomenorrhoea • Less than 8 episodes of menses a year • Cycle length exceeding 35 days (n:21-35) • Complications PCOM diagnosis on US > No longer recommended in the presence OA

  14. OA:Oligo-Anovulation Mx AIM • Balance the steroid hormones (ER/PR) Compete with Oestrogen at receptor level /Hypothalamic level Block conversion to active hormone – Inhibit Aromatase enzyme Anti-androgenic / Anti-oestrogenic action Anti-oestrogenic action

  15. OA:Oligo-Anovulation Mx • Increase SHBG • Suppress of FSH/LH > Negative Feedback on the axis • Reduction in free circulating Androgens • Regulation of menses > Risk reduction of endometrial hyperplasia / EC Low dose COCP

  16. OA:Oligo-Anovulation Mx Low dose COCP • 35mcg Ethinyloestradiol + Cyproterone Acetate not for 1st line in PCOS • Consider combining with Metformin in Adolescents or BMI ≥ 25kg/m² • Regulation of menses > Risk reduction of endometrial hyperplasia / EC

  17. HA: Hyperandrogenism

  18. HA: Hyperandrogenism Biochemical FSH:LH Ratio Testosterone DHEAS AMH Clinical Hirsutism Acne Alopecia Virilisation • Grade the Hirsutism > modified Ferriman-Gallwey score • Mx: Block the peripheral action of hair follicle 5α Reductase > Testosterone to Di-hydrotestosterone therefore blocked

  19. HA: Hyperandrogenism Mx • Grade the Hirsutism > modified Ferriman-Gallwey score (1961) • Rx: Block the peripheral action of hair follicle 5α Reductase > Testosterone to Di-hydrotestosterone therefore blocked • Lifestyle modification • COCP +Drosperinone / Desogestrel / Norgestimate • Anti-androgens : • Spironolactone 50-200mg / day • Cyproterone Acetate 50-100mg (5-15days Induction / Maintenance) • *Ensure adequate contraception / Prevent under virilisation of the male foetus*

  20. HA: Hyperandrogenism Mx • Insulin Lowering / Increase Insulin Sensitisation • Generally off-label / EBM practice • Under the control of LH/IGF-1 : Ovarian Theca Cells produce Testosterone • Adjunctive BMI ≥ 25kg/m² for Ovulation induction • Metformin 500mg tds > Slow release preferred • Reduces Hepatic Glucose production / Lowering Insulin levels • Possible improvement in Ovarian Steroidogenesis

  21. HA: Hyperandrogenism Mx • GnRHa • Blockade of GnRH > Blockade of FSH / LH • Zoladex 3.6mg s/c (3-6 months) • Leuprolide 3.75mg imi (3-6 months) • Add-back therapy if intolerable side-effects • 25-30mcg transdermal Oestradiol • Tibolone is great for oestrogen withdrawal • S/E: Hot flashes, Reduce Bone mineral density, Atrophic vaginitis, FSD

  22. HA: Hyperandrogenism Mx Anti-androgens + COCPs if no control of HA > 6mo

  23. PCOM: Polycystic Morphology

  24. PCOM: Polycystic Morphology • Challenge is not so much the size or volume • US has poor sensitivity in the background of OA /HA • Arrest of Pre-antral follicles • Failure of LH surge • Leading to failure of Ovulation

  25. MULTI-DISCIPLINARY TEAM Gynaecologist Dietician Physician/Endocrinologist Fertility Specialist Support Groups

  26. Mx of PCOS Dietician • Lifestyle modification • Moderate exercise (30 minutes /week) • Target to normalize BMI • Reduction of adipose tissue > Reduces peripheral sites for Androgen production • Higher spontaneous pregnancy rates with lifestyle adjustments

  27. Mx of PCOS Physician/Endocrinologist • Metabolic control • IGT / Insulin Resistance • Risk of Metabolic syndrome secondary to Obesity • Higher incidence of Depressive / Anxiety Disorders

  28. PCOM: Infertility

  29. Mx of PCOS Gynaecologist Fertility Specialist • OVULATION INDUCTION AGENTS • Letrozole • Clomiphene Citrate (CC) 50mg / 100mg /150mg • CC + Metformin

  30. OVULATION INDUCTION • OVULATION INDUCTION AGENTS • Letrozole • Clomiphene Citrate • CC + Metformin • LETROZOLE • Aromatase inhibition • Anti-oestrogenic > Reduction up to 98% in Oestrogen levels • FDA approved for HR+ Breast cancer • Competitively blocks production by binding to the haeme of its CP450 unit • Does not reduce production of mineralo-corticosteroids • 2.5mg/dusual dosage • Doses exceeding 2.5mg/d may cause reduced libido

  31. OVULATION INDUCTION • OVULATION INDUCTION AGENTS • Letrozole • Clomiphene Citrate • CC + Metformin • Clomiphene Citrate • Mechanism of stimulating ovulation remains elusive • Anti-oestrogenic properties • Competes with Oestrogen binding sites • Increase in FSH / LH • Pre-ovulatory LH surge / Corpus luteum maturation • 50mg / 100mg / 150mg • Half-life: 5 – 7 days • Time to peak: 4 – 10 days • Average 7 days

  32. OVULATION INDUCTION • OVULATION INDUCTION AGENTS • Clomiphene Citrate

  33. Mx of PCOS Support Groups www.pcosaa.org #PCOSsupport

  34. Take Home Message

More Related