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Endocrine
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Endocrine

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Questions and Answers

What is a potential consequence of prolonged undetected Type 2 Diabetes Mellitus (T2DM)?

  • Increased physical activity
  • Enhanced glucose tolerance
  • Neuro or cardiovascular abnormalities (correct)
  • Improved immune function

    • Which sign is NOT associated with immune system dysfunction in the context of T2DM?

  • Chronic skin infections
  • Acanthosis nigricans
  • Eruptive xanthomas (correct)
  • Chronic yeast infections

    • Why should individuals with prediabetes be screened more frequently for diabetes?

  • To provide immediate insulin therapy
  • To ensure regular fasting tests are performed
  • To increase efforts for diabetes prevention (correct)
  • To reduce potential costs of treatment

    • Which of the following is NOT a risk factor for Type 2 Diabetes Mellitus screening?

    <p>High HDL cholesterol levels</p> Signup and view all the answers

    What is a characteristic measurement for diagnosing T2DM?

    <p>Random glucose measurement with symptoms</p> Signup and view all the answers

    At what age should routine screening for Type 2 Diabetes begin?

    <p>45 years old</p> Signup and view all the answers

    Which testing method is preferred over blood glucose for its accuracy?

    <p>Plasma/Serum glucose</p> Signup and view all the answers

    Which symtomatic condition is closely associated with Type 2 Diabetes due to high sugar levels?

    <p>Acanthosis nigricans</p> Signup and view all the answers

    What is the primary genetic cause of the most common form of monogenic diabetes?

    <p>GCK mutation</p> Signup and view all the answers

    What differentiates Maturity Onset Diabetes of the Young (MODY) from Type 1 Diabetes Mellitus (T1DM)?

    <p>Lack of autoantibodies</p> Signup and view all the answers

    What is the typical age of onset for MODY?

    <p>25 years or younger</p> Signup and view all the answers

    What is the most common complication associated with HNF mutation in MODY?

    <p>Microvascular and macrovascular complications</p> Signup and view all the answers

    Which of the following is a characteristic of GCK mutations in MODY?

    <p>Mild asymptomatic stable fasting hyperglycemia</p> Signup and view all the answers

    What type of inheritance is typically associated with MODY?

    <p>Autosomal dominant</p> Signup and view all the answers

    What is often included in the monitoring of patients with diabetes related issues?

    <p>Quarterly to yearly visits</p> Signup and view all the answers

    What is the common risk factor for individuals with HNF mutations?

    <p>Increased risk of vascular complications</p> Signup and view all the answers

    What is the primary mechanism of action for lorcaserin?

    <p>Promotion of satiety through serotonin agonist activity</p> Signup and view all the answers

    Which appetite suppressant is classified as a Schedule IV drug in the US?

    <p>Phentermine + topiramate</p> Signup and view all the answers

    What is a possible serious side effect of using naltrexone + bupropion?

    <p>Suicidal thoughts</p> Signup and view all the answers

    What is the recommended BMI for considering bariatric surgery?

    <p>≥35 with comorbidities</p> Signup and view all the answers

    What is the average weight loss associated with the use of RESHAPE gastric balloons in short-term trials?

    <p>7.2 kg</p> Signup and view all the answers

    Which of the following is a potential complication after bariatric surgery?

    <p>Gallbladder disease</p> Signup and view all the answers

    Which of the following medications is associated with a 5% body weight loss?

    <p>Lorcaserin (Belviq)</p> Signup and view all the answers

    What type of adverse effects are commonly reported with liraglutide?

    <p>Nausea, vomiting, diarrhea</p> Signup and view all the answers

    How much weight loss is typically seen with the combination of naltrexone and bupropion?

    <p>2-4%</p> Signup and view all the answers

    Which of the following obesity-related outcomes is NOT mentioned in the information?

    <p>Hepatic failure</p> Signup and view all the answers

    What is the primary symptom associated with androgen-secreting tumors?

    <p>Virilization</p> Signup and view all the answers

    Which of the following conditions is least likely to be associated with hirsutism?

    <p>Hypothyroidism</p> Signup and view all the answers

    In the context of hirsutism, what does an elevated level of DHEAS usually indicate?

    <p>Adrenal carcinoma</p> Signup and view all the answers

    What is the common diagnostic criterion for diagnosing polycystic ovarian syndrome?

    <p>Oligo- or anovulation</p> Signup and view all the answers

    Which drug is considered effective for blocking androgen response in hirsutism?

    <p>Spironolactone</p> Signup and view all the answers

    What hormonal measurement indicates a possible 21-hydroxylase deficiency in congenital adrenal hyperplasia?

    <p>17-hydroxyprogesterone &gt; 800</p> Signup and view all the answers

    Which of the following is a common metabolic risk factor for women with polycystic ovarian syndrome?

    <p>Insulin resistance</p> Signup and view all the answers

    Which imaging study is primarily used to check for the presence of polycystic ovaries?

    <p>Transvaginal ultrasound</p> Signup and view all the answers

    What does the presence of acanthosis nigricans suggest in the context of hirsutism?

    <p>Insulin resistance</p> Signup and view all the answers

    In hirsutism diagnostic evaluation, what would indicate idiopathic hirsutism?

    <p>Total testosterone = Normal</p> Signup and view all the answers

    Which treatment is NOT recommended for managing hirsutism in pregnant women?

    <p>Spironolactone</p> Signup and view all the answers

    What condition is typically diagnosed using the Rotterdam criteria?

    <p>Polycystic ovarian syndrome</p> Signup and view all the answers

    Which of the following conditions can result in elevated prolactin levels?

    <p>All of the above</p> Signup and view all the answers

    What is the key ultrasound finding for diagnosing PCOS?

    <p>Ovarian volume greater than 10 cm³ or ≥ 12 follicles of 2-9 mm</p> Signup and view all the answers

    Which method is primarily used to confirm ovulation?

    <p>Basal body temperature charting</p> Signup and view all the answers

    What is the first-line treatment for PCOS in patients without pregnancy intent?

    <p>Combined hormonal oral contraceptives</p> Signup and view all the answers

    Which treatment is NOT typically recommended for managing hirsutism in PCOS?

    <p>Insulin therapy</p> Signup and view all the answers

    What does the presence of insulin resistance and hyperinsulinemia in PCOS increase the risk of?

    <p>Type 2 diabetes mellitus</p> Signup and view all the answers

    Which of the following treatments for PCOS has no effect on hirsutism, acne, or infertility?

    <p>Medroxyprogesterone</p> Signup and view all the answers

    What should be monitored in patients with PCOS due to their increased cardiovascular disease risk?

    <p>Blood pressure, BMI, and waist circumference</p> Signup and view all the answers

    If a patient with PCOS desires pregnancy, which is considered the first-line treatment for ovarian stimulation?

    <p>Clomiphene citrate</p> Signup and view all the answers

    What is a significant cause of Type 2 Diabetes Mellitus (T2DM)?

    <p>Genetic predisposition coupled with environmental influences</p> Signup and view all the answers

    Which of the following is a classic symptom associated with T2DM?

    <p>Frequent urination</p> Signup and view all the answers

    What is the primary characteristic of Latent Autoimmune Diabetes in Adults (LADA)?

    <p>Development of insulin dependency over time</p> Signup and view all the answers

    What is a common lab diagnostic test for T2DM?

    <p>Random plasma glucose (RPG)</p> Signup and view all the answers

    Which demographic group is reported to have the highest prevalence of T2DM in the US?

    <p>American-Indian and Alaskan populations</p> Signup and view all the answers

    What is the gold standard treatment approach for T2DM?

    <p>Diet and exercise, followed by Metformin</p> Signup and view all the answers

    Which of the following is NOT a microvascular complication of diabetes?

    <p>Coronary artery disease</p> Signup and view all the answers

    Which of the following best describes the pathophysiology of T2DM?

    <p>Decreased glucose uptake by cells due to insulin resistance</p> Signup and view all the answers

    What is the main characteristic of GCK mutations in MODY?

    <p>Leads to asymptomatic stable fasting hyperglycemia</p> Signup and view all the answers

    How is MODY typically inherited?

    <p>Autosomal dominant</p> Signup and view all the answers

    What is a common treatment option for hyperglycemia associated with HNF mutations?

    <p>Sulfonylureas</p> Signup and view all the answers

    What age is typically associated with the onset of MODY?

    <p>25 years or younger</p> Signup and view all the answers

    Which gene mutation is most commonly linked to MODY?

    <p>GCK</p> Signup and view all the answers

    What distinguishes MODY from Type 1 Diabetes Mellitus (T1DM)?

    <p>Presence of autoantibodies</p> Signup and view all the answers

    Which complication is associated with HNF mutations in MODY?

    <p>Microvascular and macrovascular complications</p> Signup and view all the answers

    What is a critical aspect of monitoring for patients with diabetes-related distress?

    <p>Screening for psychosocial problems</p> Signup and view all the answers

    What does an A1C level of 6.5% or higher indicate?

    <p>Type 2 Diabetes Mellitus</p> Signup and view all the answers

    Which method is commonly used to confirm a diagnosis of Type 2 Diabetes Mellitus in asymptomatic patients?

    <p>Fasting plasma glucose (FPG) test</p> Signup and view all the answers

    What is the primary risk associated with elevated levels of glycosylated hemoglobin (HgbA1c)?

    <p>Increased risk of microvascular complications</p> Signup and view all the answers

    What dietary strategy is often recommended to improve cardiac risk factors associated with Type 2 Diabetes Mellitus?

    <p>Decrease carbohydrate intake by 5-10%</p> Signup and view all the answers

    Which of the following is a primary test method for diagnosing diabetic ketoacidosis (DKA)?

    <p>Blood evaluation for ketones</p> Signup and view all the answers

    For an Oral Glucose Tolerance Test (OGTT), what is the standard glucose dose given to the patient?

    <p>75g of glucose in 300 mL of water</p> Signup and view all the answers

    Which condition would make HbA1c testing inappropriate for diagnosing diabetes?

    <p>High prevalence of hemoglobinopathies</p> Signup and view all the answers

    What is the primary initial treatment recommended for managing Type 2 Diabetes Mellitus?

    <p>Diet and exercise</p> Signup and view all the answers

    What is the primary cause of hirsutism in women of reproductive age?

    <p>Polycystic ovary syndrome (PCOS)</p> Signup and view all the answers

    Which androgen is primarily produced by the ovaries and is significant in the development of hirsutism?

    <p>Testosterone</p> Signup and view all the answers

    What percentage of American women are estimated to have hirsutism?

    <p>20%</p> Signup and view all the answers

    What is a common manifestation of excessive androgens in females?

    <p>Thinning scalp hair</p> Signup and view all the answers

    Which of the following conditions is characterized by excess androgens with no cortisol deficiency?

    <p>Nonclassical adrenal hyperplasia</p> Signup and view all the answers

    What is a rapid virilization symptom linked to excessive adrenal androgens?

    <p>Clitoromegaly</p> Signup and view all the answers

    What is the main reason that androgens are associated with hair growth on sensitive body areas?

    <p>They lengthen the anagen phase</p> Signup and view all the answers

    What is the effect of stopping daily consumption of a 16 oz soda on weight loss?

    <p>20 lbs weight loss per year</p> Signup and view all the answers

    What condition is most commonly linked to excess testosterone levels in women?

    <p>Androgen-secreting tumor</p> Signup and view all the answers

    Which of the following is a symptom of Cushing syndrome commonly seen in patients with hirsutism?

    <p>Abdominal striae</p> Signup and view all the answers

    What is the most common endocrine disorder in reproductive-age women?

    <p>Polycystic Ovarian Syndrome (PCOS)</p> Signup and view all the answers

    In the differential diagnosis of hirsutism, which condition would likely present with an elevated level of DHEA-S?

    <p>Androgen-secreting tumor</p> Signup and view all the answers

    Which of the following treatments is an androgen antagonist recommended for hirsutism management?

    <p>Spironolactone</p> Signup and view all the answers

    What is a characteristic finding of idiopathic hirsutism during diagnostic evaluation?

    <p>Normal testosterone levels</p> Signup and view all the answers

    What imaging study is essential for confirming polycystic ovarian morphology in suspected PCOS?

    <p>Transvaginal ultrasound</p> Signup and view all the answers

    What is the potential risk factor for a woman to develop PCOS, particularly before the age of 8?

    <p>Premature Adrenarche</p> Signup and view all the answers

    Which of the following biochemical markers is important for ruling out congenital adrenal hyperplasia in patients suspected of having PCOS?

    <p>17-hydroxyprogesterone</p> Signup and view all the answers

    Which symptoms are commonly linked to a diagnosis of PCOS?

    <p>Hirsutism and oligomenorrhea</p> Signup and view all the answers

    Which underlying cause should be addressed in the management of hirsutism?

    <p>Treating the underlying condition, such as tumor removal</p> Signup and view all the answers

    What is considered a common metabolic risk associated with PCOS?

    <p>Type 2 Diabetes Mellitus (T2DM)</p> Signup and view all the answers

    What finding on ultrasound is indicative of polycystic ovaries?

    <p>Multiple small follicles on one or both ovaries</p> Signup and view all the answers

    What hormonal changes during pregnancy primarily contribute to insulin resistance?

    <p>Secretion of diabetogenic hormones from the placenta</p> Signup and view all the answers

    Which factor increases the risk of developing gestational diabetes mellitus (GDM)?

    <p>Obesity and advanced maternal age</p> Signup and view all the answers

    What is the recommended screening timeline for gestational diabetes in pregnant women?

    <p>24 to 28 weeks of pregnancy</p> Signup and view all the answers

    What is a potential consequence of gestational diabetes for the infant?

    <p>Large for gestational age infant (LGA)</p> Signup and view all the answers

    What is the consequence of maternal insulin resistance during pregnancy?

    <p>Hyperglycemia requiring increased insulin needs</p> Signup and view all the answers

    What is the primary genetic defect associated with Maturity Onset Diabetes of the Young (MODY)?

    <p>Defects in pancreatic beta cell function</p> Signup and view all the answers

    What characterizes GCK mutation in MODY?

    <p>No treatment required</p> Signup and view all the answers

    At what age is the onset of MODY generally observed?

    <p>≤ 25 years</p> Signup and view all the answers

    Which of the following is a common manifestation of HNF mutations in MODY?

    <p>Progressive pancreatic beta cell dysfunction</p> Signup and view all the answers

    Which form of diabetes is most common among monogenic diabetes cases?

    <p>Maturity Onset Diabetes of the Young</p> Signup and view all the answers

    What is an important consideration when monitoring patients with diabetes-related issues?

    <p>Quarterly to yearly visits for complications</p> Signup and view all the answers

    What type of inheritance pattern is associated with MODY?

    <p>Autosomal dominant</p> Signup and view all the answers

    Which psychosocial factor should be routinely screened in patients with diabetes?

    <p>Diabetes-related distress</p> Signup and view all the answers

    What type of therapy are patients with MODY3 initially responsive to?

    <p>Sulfonylurea therapy</p> Signup and view all the answers

    What characteristic suggests a diagnosis of MODY rather than T1DM?

    <p>Strong family history of diabetes</p> Signup and view all the answers

    Which of the following conditions is commonly associated with MODY?

    <p>Renal cysts</p> Signup and view all the answers

    What is a significant indicator of endogenous insulin production?

    <p>Increased C-peptide levels</p> Signup and view all the answers

    Which test is least useful in distinguishing MODY from Type 2 Diabetes Mellitus (T2DM)?

    <p>Fasting blood glucose test</p> Signup and view all the answers

    Which of the following is NOT a typical feature of Latent Autoimmune Diabetes in Adults (LADA)?

    <p>Obesity</p> Signup and view all the answers

    For which patients should genetic testing for MODY be considered?

    <p>Patients with a strong family history and onset before age 35</p> Signup and view all the answers

    What is the primary treatment strategy for Latent Autoimmune Diabetes in Adults (LADA)?

    <p>Insulin replacement therapy</p> Signup and view all the answers

    Which statement about MODY is accurate?

    <p>MODY can exhibit strong familial patterns of inheritance.</p> Signup and view all the answers

    Which test should be avoided when testing for autoantibodies if the patient has received insulin therapy for two weeks?

    <p>Insulin Autoantibodies</p> Signup and view all the answers

    What is the first-line treatment option for hyperandrogenism in non-pregnancy patients diagnosed with PCOS?

    <p>Combined hormonal OCPs</p> Signup and view all the answers

    Which ultrasound finding is indicative of polycystic ovarian morphology?

    <p>≥ 12 follicles in either ovary 2-9mm diameter</p> Signup and view all the answers

    What does the absence of a biphasic pattern on a basal body temperature chart indicate?

    <p>Anovulation</p> Signup and view all the answers

    In women with PCOS desiring pregnancy, which medication is considered first-line for ovarian stimulation?

    <p>Letrozole</p> Signup and view all the answers

    Which of the following screenings is NOT recommended for assessing fatty liver in PCOS?

    <p>Ultrasound</p> Signup and view all the answers

    Which treatment for hirsutism may be added if there is no improvement after 6-12 months on low-dose combination OCPs?

    <p>Spironolactone</p> Signup and view all the answers

    What is a significant risk associated with insulin resistance and hyperinsulinemia in women with PCOS?

    <p>Increased risk for endometrial cancer</p> Signup and view all the answers

    Which of the following screening methods is primarily used for assessing cardiovascular disease risk in women with PCOS?

    <p>Fasting lipid profile</p> Signup and view all the answers

    What is the primary mechanism of action for phentermine plus topiramate in weight loss?

    <p>Amphetamine + anticonvulsant</p> Signup and view all the answers

    Which side effect is associated with the use of lorcaserin (Belviq)?

    <p>Possible breast tumors</p> Signup and view all the answers

    What weight loss percentage is typically associated with the use of liraglutide (Saxenda, Victoza)?

    <p>3-4%</p> Signup and view all the answers

    Which of the following conditions is an obesity-related co-morbidity that makes patients eligible for bariatric surgery?

    <p>Hypertension</p> Signup and view all the answers

    What is the average weight loss seen with the RESHAPE gastric balloon device in short-term studies?

    <p>7.2 kg</p> Signup and view all the answers

    Which potential complication is associated with bariatric surgery?

    <p>Nutritional deficiencies</p> Signup and view all the answers

    Which of the following appetite suppressants has the highest risk of addiction?

    <p>Phentermine + topiramate</p> Signup and view all the answers

    What is the mortality risk associated with bariatric surgery typically noted during the postoperative period?

    <p>1% risk</p> Signup and view all the answers

    What potential psychiatric issue is a known side effect of using naltrexone plus bupropion?

    <p>Possible suicide</p> Signup and view all the answers

    What is the main mechanism through which liraglutide helps in weight management?

    <p>Promoting satiety</p> Signup and view all the answers

    Which of the following is a contraindication for prescribing Metformin?

    <p>Liver disease</p> Signup and view all the answers

    What is the primary mechanism of action of Metformin in the management of Type 2 Diabetes Mellitus?

    <p>Decrease hepatic glucose production</p> Signup and view all the answers

    Which lifestyle intervention is recommended alongside pharmacotherapy for managing Type 2 Diabetes?

    <p>DASH diet</p> Signup and view all the answers

    At which age is statin therapy recommended for patients with diabetes, regardless of CVD risk factors?

    <p>40 years old</p> Signup and view all the answers

    How frequently should HbA1c levels be tested in patients with diabetes who are stable in their management?

    <p>2-4 times a year</p> Signup and view all the answers

    Which of the following statements about the effects of Metformin on obesity is accurate?

    <p>It aids in weight loss in obese patients.</p> Signup and view all the answers

    What monitoring is essential for patients with diabetes to prevent potential complications?

    <p>Annual kidney disease testing</p> Signup and view all the answers

    Which of the following best describes diabetic dyslipidemia?

    <p>Elevated LDL cholesterol and triglycerides</p> Signup and view all the answers

    What BMI range is considered healthy according to the standard classification?

    <p>18.5 - 24.99</p> Signup and view all the answers

    Which obesity-related condition is NOT typically associated with centripetal obesity?

    <p>Cirrhosis</p> Signup and view all the answers

    What percentage of American adults is classified as obese?

    <p>42.4%</p> Signup and view all the answers

    Which factor does NOT influence obesity according to recent epidemiology data?

    <p>Secondary obesity causes</p> Signup and view all the answers

    What is a common misconception regarding individuals with a BMI in the healthy range?

    <p>Some may experience health issues despite their BMI.</p> Signup and view all the answers

    Which of the following is NOT a component of obesity patient evaluation?

    <p>Genetic testing</p> Signup and view all the answers

    What is the primary health risk associated with upper body obesity?

    <p>Greater health risk compared to lower body obesity</p> Signup and view all the answers

    Which symptom is a sign of secondary obesity related to hypothyroidism?

    <p>Cold intolerance</p> Signup and view all the answers

    What ultrasound finding is indicative of polycystic ovarian morphology?

    <p>≥ 12 follicles in either ovary 2-9mm diameter</p> Signup and view all the answers

    Which treatment option is considered first-line for managing hirsutism in PCOS?

    <p>Low-dose combination OCPs</p> Signup and view all the answers

    What is a significant risk associated with anovulation in patients with PCOS?

    <p>Unopposed estrogen leading to endometrial cancer</p> Signup and view all the answers

    In patients with PCOS who desire pregnancy, what is the predicted live birth rate with Clomiphene treatment?

    <p>20-40%</p> Signup and view all the answers

    Which factor is NOT typically monitored for cardiovascular disease risk in patients with PCOS?

    <p>Liver function tests</p> Signup and view all the answers

    What imaging technique is used to confirm ovarian morphology in women with normal menstrual cycles and hyperandrogenism?

    <p>Transvaginal ultrasound</p> Signup and view all the answers

    Which is the recommended second-line treatment for improving menstrual function in PCOS?

    <p>Metformin</p> Signup and view all the answers

    What is the effect of spironolactone on hirsutism alone when not used with contraception?

    <p>It does not impact hirsutism treatment</p> Signup and view all the answers

    What is the most common cause of hirsutism in women of reproductive age?

    <p>Polycystic ovary syndrome (PCOS)</p> Signup and view all the answers

    What percentage of American women are estimated to experience hirsutism?

    <p>20%</p> Signup and view all the answers

    Which androgen is primarily produced by the ovaries and contributes to hirsutism?

    <p>Testosterone</p> Signup and view all the answers

    What is a key characteristic of idiopathic hirsutism?

    <p>Normal androgen concentrations</p> Signup and view all the answers

    Which of the following groups of women typically has the least body hair?

    <p>East Asian women</p> Signup and view all the answers

    What could indicate sudden virilization in a female patient?

    <p>New onset of masculine traits</p> Signup and view all the answers

    Which condition is associated with excess androgens and may include symptoms like clitoromegaly?

    <p>Nonclassical adrenal hyperplasia</p> Signup and view all the answers

    What significant outcome occurs in approximately 50% of patients who undergo Roux-en-Y gastric bypass after five years?

    <p>Weight regain</p> Signup and view all the answers

    Which appetite suppressant has a mechanism of action involving serotonin agonist activity?

    <p>Lorcaserin (Belviq)</p> Signup and view all the answers

    What is the primary concern associated with the use of liraglutide?

    <p>Thyroid tumors</p> Signup and view all the answers

    Which bariatric surgery has a 1% risk of mortality in the postoperative period?

    <p>Roux-en-Y gastric bypass</p> Signup and view all the answers

    Which medication combination is indicated to achieve a 2-4% weight loss?

    <p>Naltrexone + bupropion</p> Signup and view all the answers

    What is a common adverse effect reported with the use of bariatric surgery?

    <p>Nausea and vomiting</p> Signup and view all the answers

    What weight loss percentage is typically expected from the combination of phentermine and topiramate?

    <p>5-10%</p> Signup and view all the answers

    Which of the following obesity-related outcomes does NOT indicate a direct physiological complication?

    <p>Psychosocial disability</p> Signup and view all the answers

    Which condition is a contraindication for intraluminal gastric balloon placement?

    <p>History of eating disorders</p> Signup and view all the answers

    Which appetite suppressant has a risk of psychiatric problems as a side effect?

    <p>Lorcaserin (Belviq)</p> Signup and view all the answers

    What is a significant risk factor for increased mortality post-bariatric surgery?

    <p>Severe obesity (BMI ≥40)</p> Signup and view all the answers

    What is the BMI range considered healthy?

    <p>18.5 – 24.99</p> Signup and view all the answers

    What type of obesity is associated with a higher health risk compared to lower body obesity?

    <p>Centripetal obesity</p> Signup and view all the answers

    Which of the following conditions is NOT a consequence of obesity?

    <p>Chronic fatigue syndrome</p> Signup and view all the answers

    How many American adults are categorized as obese?

    <p>42.4%</p> Signup and view all the answers

    What factor contributes significantly to the increasing prevalence of obesity among American adults over the past three decades?

    <p>Genetic influences</p> Signup and view all the answers

    What does a waist circumference greater than 40 inches in men and 35 inches in women indicate?

    <p>Centripetal obesity</p> Signup and view all the answers

    Which of the following is NOT part of the obesity patient evaluation process?

    <p>Psychological assessment</p> Signup and view all the answers

    What underlying conditions account for less than 1% of obesity cases?

    <p>Hypothyroidism and Cushing syndrome</p> Signup and view all the answers

    What body measurement indicates increased centripetal fat distribution in men?

    <p>Waist circumference greater than 40 inches</p> Signup and view all the answers

    Which sign is associated with significant insulin resistance?

    <p>Acanthosis nigricans</p> Signup and view all the answers

    What is one reason individuals with Type 2 Diabetes Mellitus (T2DM) should be screened?

    <p>To detect asymptomatic cases that may have complications</p> Signup and view all the answers

    Which category is NOT part of the glucose tolerance test results for diagnosing diabetes?

    <p>Hyperglycemia due to stress</p> Signup and view all the answers

    Which groups are considered at risk for Type 2 Diabetes Mellitus screening?

    <p>Overweight or obese individuals with sedentary lifestyles</p> Signup and view all the answers

    What is the significance of testing women with a history of gestational diabetes?

    <p>They should be tested every 3 years after gestation</p> Signup and view all the answers

    Which condition may indicate chronic inflammation due to immune system dysfunction in T2DM?

    <p>Chronic skin infections</p> Signup and view all the answers

    Which diagnostic criterion is NOT used specifically for diagnosing Type 2 Diabetes Mellitus?

    <p>Abnormal triglyceride levels</p> Signup and view all the answers

    What percentage of American women are reported to have hirsutism?

    <p>20%</p> Signup and view all the answers

    Which androgen primarily originates from the ovaries?

    <p>Testosterone</p> Signup and view all the answers

    What is the major cause of hirsutism in women of reproductive age?

    <p>Polycystic Ovary Syndrome (PCOS)</p> Signup and view all the answers

    Which ethnic background is associated with the lowest incidence of body hair in women?

    <p>East Asian</p> Signup and view all the answers

    Which of the following conditions can lead to excess androgen levels resulting in hirsutism?

    <p>Nonclassical adrenal hyperplasia</p> Signup and view all the answers

    What is the typical weight loss associated with stopping daily consumption of a 16 oz soda?

    <p>20 lbs per year</p> Signup and view all the answers

    What is the common manifestation of Nonclassical Adrenal Hyperplasia in females during puberty?

    <p>Menstrual irregularities and hirsutism</p> Signup and view all the answers

    What physiological effect do androgens have on hair follicles?

    <p>They promote longer growth phases</p> Signup and view all the answers

    What does an A1C level of 6.5% indicate regarding Type 2 Diabetes Mellitus?

    <p>Diabetes</p> Signup and view all the answers

    Which population might not be suitable for using HgbA1c as an indicator for glucose levels?

    <p>Individuals with hemoglobinopathies</p> Signup and view all the answers

    What method is commonly recommended for confirming a Type 2 Diabetes diagnosis if there are no symptoms of hyperglycemia?

    <p>Two confirmatory tests on the same day</p> Signup and view all the answers

    During an oral glucose tolerance test, how much glucose is recommended for consumption?

    <p>75g</p> Signup and view all the answers

    What is the first-line treatment approach for individuals diagnosed with Type 2 Diabetes Mellitus?

    <p>Implement a low-carb diet and increase physical activity</p> Signup and view all the answers

    What is a limitation of urine tests in diagnosing conditions like diabetic ketoacidosis (DKA)?

    <p>They do not detect beta-hydroxybutyric acid</p> Signup and view all the answers

    Which dietary modification is associated with improved cardiac risk factors in Type 2 Diabetes management?

    <p>Decrease carbohydrate intake</p> Signup and view all the answers

    What is the impact of glycosylated hemoglobin (HgbA1c) levels on predicting microvascular complications?

    <p>Increased levels predict higher risk</p> Signup and view all the answers

    Which of the following complications is associated with gestational diabetes?

    <p>Neonatal cardiomyopathy</p> Signup and view all the answers

    What is the primary goal in the management of gestational diabetes before giving birth?

    <p>Achieving euglycemia</p> Signup and view all the answers

    Which factor is NOT a risk factor for developing gestational diabetes?

    <p>Maintaining a healthy pre-pregnancy BMI</p> Signup and view all the answers

    Which long-term consequence is highly associated with gestational diabetes?

    <p>Increased risk of Type 2 diabetes</p> Signup and view all the answers

    Which of the following criteria is used to diagnose gestational diabetes through a 3-hour oral glucose tolerance test?

    <p>At least 2 abnormal values</p> Signup and view all the answers

    In patients with gestational diabetes, hypoglycemia can occur due to:

    <p>Inadequate caloric intake</p> Signup and view all the answers

    What maternal condition is associated with the highest risk for developing kidney-related complications due to gestational diabetes?

    <p>Gestational hypertension</p> Signup and view all the answers

    Which of these conditions has the most direct link to metabolic syndrome in the context of diabetes?

    <p>Polycystic ovary syndrome</p> Signup and view all the answers

    Which of the following is NOT a recognized sign of neonatal morbidity associated with gestational diabetes?

    <p>Infantile eczema</p> Signup and view all the answers

    What finding on screening would classify a patient as having gestational diabetes?

    <p>1-hour glucose level &gt;140 mg/dL</p> Signup and view all the answers

    Which statement accurately reflects the relationship between BMI and health risks?

    <p>BMI does not distinguish between muscle and fat composition.</p> Signup and view all the answers

    What is a common consequence of centripetal obesity?

    <p>Higher likelihood of developing diabetes.</p> Signup and view all the answers

    Which factor significantly contributes to the prevalence of obesity in adults?

    <p>Genetic predisposition.</p> Signup and view all the answers

    What should be assessed to evaluate a patient's readiness for lifestyle changes related to obesity management?

    <p>The level of motivation to change.</p> Signup and view all the answers

    Which of the following health conditions is NOT typically associated with obesity?

    <p>Asthma.</p> Signup and view all the answers

    How is upper body obesity characterized in relation to health risks?

    <p>It increases the risk of certain chronic conditions.</p> Signup and view all the answers

    What percentage of American adults are classified as obese?

    <p>42.4%</p> Signup and view all the answers

    Which health condition is considered secondary obesity?

    <p>Hypothyroidism.</p> Signup and view all the answers

    What is the most common gastrointestinal manifestation of autonomic neuropathy?

    <p>Constipation</p> Signup and view all the answers

    Which factors contribute to the development of Hyperglycemia Hyperosmolar State (HHS)?

    <p>Insufficient insulin despite its presence</p> Signup and view all the answers

    What laboratory finding is indicative of a Nonketotic Hyperosmolar State?

    <p>Serum osmolality &gt; 320</p> Signup and view all the answers

    What is a key symptom that distinguishes Hyperglycemia Hyperosmolar State from diabetic ketoacidosis?

    <p>Kussmaul respirations</p> Signup and view all the answers

    What should be included as part of the management plan for a patient with Type 2 Diabetes Mellitus?

    <p>A written plan involving medications, diet, and exercise</p> Signup and view all the answers

    What cardiovascular symptom commonly develops in patients with autonomic neuropathy?

    <p>Persistent sinus tachycardia</p> Signup and view all the answers

    What is the primary approach to obesity treatment if no underlying condition is identified?

    <p>Diet and exercise</p> Signup and view all the answers

    What is the recommended weight loss goal over a 6-month period for effective obesity management?

    <p>10% of total body weight</p> Signup and view all the answers

    During the assessment of a patient with T2DM, which urinary-related symptom is likely to arise from autonomic neuropathy?

    <p>Bladder neuropathy with incomplete emptying</p> Signup and view all the answers

    What consequence may arise from the treatment of gastroparesis in diabetic patients?

    <p>Improved glucose control with dietary changes and prokinetic agents</p> Signup and view all the answers

    Which of the following dietary guidelines is appropriate for women aiming for weight loss?

    <p>1200-1700 kcal/day</p> Signup and view all the answers

    Which lab tests are essential for evaluating obesity-related conditions?

    <p>TSH, free T4, fasting lipid panel, and fasting glucose</p> Signup and view all the answers

    What type of exercise is recommended as part of the obesity treatment plan?

    <p>Combined moderate and vigorous physical activity</p> Signup and view all the answers

    Which of the following behavioral therapy strategies is effective in obesity management?

    <p>Cognitive restructuring and self-monitoring techniques</p> Signup and view all the answers

    In the context of pharmacological treatment for obesity, which would be indicated?

    <p>BMI ≥30 kg/m² or BMI ≥27 kg/m² with obesity-related disease</p> Signup and view all the answers

    What is a potential weight loss benefit of a low-carb, high-protein diet within the first 6 months?

    <p>Significant weight loss</p> Signup and view all the answers

    What testosterone level is typically observed in patients with androgen-secreting tumors?

    <p>Greater than 700 ng/dL</p> Signup and view all the answers

    Which condition is characterized by elevated DHEAS levels, indicating adrenal carcinoma?

    <p>Androgen-secreting tumor</p> Signup and view all the answers

    What is one of the signs of congenital adrenal hyperplasia (CAH)?

    <p>Menstrual abnormalities</p> Signup and view all the answers

    Which of the following treatments is specifically indicated to block androgen response in hirsutism?

    <p>Spironolactone</p> Signup and view all the answers

    In PCOS, which of the following is a sufficient criterion for diagnosis based on the Rotterdam criteria?

    <p>Polycystic ovaries on ultrasound</p> Signup and view all the answers

    What metabolic risk is associated with PCOS due to high rates of insulin resistance?

    <p>Type 2 Diabetes Mellitus</p> Signup and view all the answers

    What is the primary characteristic differentiating ovarian hyperthecosis from PCOS?

    <p>Temporal onset of hirsutism</p> Signup and view all the answers

    Which condition can lead to elevated prolactin levels?

    <p>Pituitary adenoma</p> Signup and view all the answers

    Which treatment option is contraindicated in pregnancy when managing hirsutism?

    <p>Finasteride</p> Signup and view all the answers

    What imaging study is essential for evaluating suspected androgen-secreting tumors?

    <p>Computed Tomography (CT) of the abdomen</p> Signup and view all the answers

    What endocrine dysfunction would be indicated by delayed menarche and amenorrhea?

    <p>Hypothalamic dysfunction</p> Signup and view all the answers

    What condition is characterized by regular menstruation but the presence of mild to moderate hirsutism?

    <p>Idiopathic hirsutism</p> Signup and view all the answers

    Which condition typically shows a higher prevalence of hirsutism in older women?

    <p>Ovarian hyperthecosis</p> Signup and view all the answers

    Which test should be performed to rule out congenital adrenal hyperplasia?

    <p>Serum 17-hydroxyprogesterone</p> Signup and view all the answers

    What is the mechanism of action for lorcaserin in promoting weight loss?

    <p>Serotonin agonist activity</p> Signup and view all the answers

    Which of the following is a common adverse effect associated with the use of liraglutide?

    <p>Tachycardia</p> Signup and view all the answers

    Bariatric surgery may be considered for patients with a BMI of at least what value?

    <p>40</p> Signup and view all the answers

    Phentermine combined with topiramate may lead to what potential side effect?

    <p>Addictive potential</p> Signup and view all the answers

    What is the expected average weight loss associated with the use of ORBERA gastric balloons in short-term trials?

    <p>8.8 kg</p> Signup and view all the answers

    Among the following, which obesity-related outcome has the highest association with increased mortality risk?

    <p>Thromboembolic disorders</p> Signup and view all the answers

    Which appetite suppressant has shown to potentially increase the risk of breast tumors?

    <p>Lorcaserin (Belviq)</p> Signup and view all the answers

    What common complication can arise from bariatric surgery?

    <p>Blood clots</p> Signup and view all the answers

    What serious side effect may result from the use of naltrexone + bupropion?

    <p>Suicidal thoughts</p> Signup and view all the answers

    Which of the following bariatric procedures involves placing a device endoscopically?

    <p>Intraluminal gastric balloon</p> Signup and view all the answers

    Study Notes

    Urination & Thirst

    • Prolonged undetected/untreated diabetes can lead to neurological or cardiovascular abnormalities.
    • Chronic skin and yeast infections indicate immune system dysfunction.
    • Increased centripetal fat distribution is a sign of diabetes, with waist circumference greater than 40 inches for men and 35 inches for women.
    • Acanthosis nigricans, a darkening of the skin in skin folds with associated skin tags, indicates significant insulin resistance.
    • Eruptive xanthomas are a consequence of hyperchylomicronemia, characterized by increased triglycerides.

    Diabetes Screening

    • Many people with Type 2 Diabetes are asymptomatic and unaware of their condition.
    • Early intervention in Type 2 Diabetes leads to superior outcomes.
    • Screening for Type 2 Diabetes is essential to prevent complications and progression.
    • People with prediabetes should increase efforts towards diabetes prevention.
    • Screening is cost-effective.

    Type 2 Diabetes (T2DM) Screening Guidelines

    • Overweight or obese individuals with one or more risk factors should be screened.
      • Family history of diabetes, ethnicity (African American, Latino, Asian, etc.), hypertension, low HDL or high triglycerides, PCOS, acanthosis nigricans, history of heart disease, physical inactivity, insulin resistance (e.g., severe obesity)
    • Individuals previously diagnosed with high blood sugar (IFG, IGT, A1C 5.7-6.4%) should be screened annually.
    • Women with a history of gestational diabetes should be screened every three years.
    • Everyone should begin screening at age 45, every three years.
    • People with HIV should be screened regularly.

    T2DM Diagnostic Evaluation

    • Glucose tolerance can be classified into three categories: normal glucose homeostasis, impaired glucose homeostasis, and diabetes mellitus.
    • Diagnosis of T2DM in non-pregnant patients is based on any of four abnormalities:
      • Elevated fasting plasma glucose (FPG)
      • Random elevated glucose with symptoms
      • Elevated HgB A1C
      • Abnormal oral glucose tolerance test (OGTT)
    • Plasma/serum glucose is a more accurate measure of glucose concentration than blood glucose because it avoids interference from red blood cell concentration (Hct).

    Monogenic Diabetes (MODY)

    • Single gene disorders resulting in genetic defects of pancreatic beta cell function.
    • Genes involved control pancreatic beta cell development, function, and regulation. Mutations in these genes cause impaired glucose sensing and insulin secretion with minimal or no defect in insulin.
    • Non-insulin requiring diabetes (typically), although some forms of MODY may require insulin.
    • Most common form of monogenic diabetes, accounting for 2-5% of diabetes cases.
    • Age of onset is typically ≤25 years old, with a lack of autoantibodies (differentiating MODY from Type 1 Diabetes).
    • Autosomal dominant inheritance, with multiple gene abnormalities on different chromosomes.
    • Most common causes are GCK (glucokinase) and HNF (hepatocyte nuclear factor) mutations.
      • GCK Mutation:
        • Causes mild asymptomatic stable fasting hyperglycemia.
        • Glucose sensor molecules are defective, requiring higher plasma glucose levels to stimulate insulin secretion.
        • Resulting hyperglycemia is often stable and mild, not associated with the vascular complications common in other types of diabetes.
        • No treatment required.
      • HNF Mutation:
        • Causes progressive pancreatic beta cell dysfunction and hyperglycemia, which can lead to microvascular complications.
        • Can be well controlled with a sulfonylurea.
        • Hepatocyte Nuclear Factor 4-alpha (MODY1): Patients are at risk for hyperglycemia-associated microvascular and macrovascular complications of diabetes.
        • Hepatocyte Nuclear Factor-1 (MODY3): Most common form, especially among Europeans.

    Obesity

    • Obesity is a major public health concern, characterized by excessive body fat accumulation.
    • Obesity is associated with a range of health complications, including hypertension, hyperlipidemia, type 2 diabetes, osteoarthritis, psychosocial disability, increased cancer risk, thromboembolic disorders, digestive tract diseases, and skin disorders.

    Obesity Treatment Options

    • Lifestyle Modification:
      • Dietary Changes:
        • Calorie restriction, focus on fruits vegetables, whole grains, lean protein.
        • Limiting sugar, processed foods, saturated and trans fats.
      • Exercise:
        • Regular physical activity is crucial for weight loss and overall health.
        • Aim for at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity per week.
    • Medications:
      • Orlistat (Xenical, Alli):
        • MOA: Inhibits absorption of dietary fat, leading to reduced calorie intake.
        • Side Effects: GI distress (diarrhea, cramping, flatulence).
        • Low-fat diet reduces symptoms, motivating patients to maintain their diet.
      • Appetite Suppressants (Anorexiants):
        • Lorcaserin (Belviq) (10 mg PO BID):
          • 5% body weight loss.
          • MOA: Promotes satiety through serotonin agonist activity.
          • Side Effects: Possible breast tumors, valvular heart disease, psychiatric problems.
        • Phentermine + Topiramate:
          • 5-10% weight loss.
          • MOA: Amphetamine + anticonvulsant.
          • Side Effects: Addictive potential, hypertension, tachycardia.
          • Distribution in the US is restricted (Class IV drug).
        • Naltrexone + Bupropion:
          • 2-4% weight loss.
          • MOA: Opioid antagonist + NE-dopamine reuptake inhibitor.
          • Side Effects: Possible suicide, seizures, hypertension, tachycardia.
        • Liraglutide (Saxenda, Victoza):
          • 3-4% weight loss.
          • MOA: Injectable glucagon-like peptide-1 receptor agonist (regulates appetite and caloric intake).
          • Concerns: Thyroid tumors, pancreatitis, gallbladder disease, renal impairment, tachycardia, suicidal thoughts.
          • Side Effects: Nausea, vomiting, diarrhea, constipation, hypoglycemia.
    • Bariatric Surgery:
      • Considered for patients with:
        • Severe obesity (BMI ≥ 40)
        • Moderate obesity (BMI ≥ 35) associated with serious medical conditions/co-morbidities.
        • Obesity co-morbidities: joint disease, obstructive sleep apnea (OSA), diabetes, hypertension, GERD.
      • Surgical procedures include:
        • Roux-en-Y gastric bypass
        • Gastric banding
        • Sleeve gastrectomy
        • Intraluminal gastric balloon
          • Intraluminal gastric balloon devices are placed in the stomach endoscopically.
          • Two devices approved: RESHAPE (consists of two silicone balloons connected to a central silicone shaft) and ORBERA (single-balloon device).
          • Mean weight loss of 7.2 kg and 8.8 kg, respectively, was seen in short-term pivotal trials.
          • Both systems are approved only for ≤ 6 months of use in adults with a BMI of 30-40.
          • Adverse Effects: Nausea, vomiting, abdominal pain.
      • Complications: infection, hernia, nutritional deficiencies, neuropathy, blood clots.
      • Mortality: 1% risk postoperatively, with higher rates within the first year after surgery.
      • Multidisciplinary approach: diet, exercise, behavior modification, social support, pre-meal planning.

    Hirsutism

    • Excessive hair growth in women, often in male-pattern distribution, can be a symptom of various endocrine disorders.
    • Hirsutism can range from mild to severe, with varying symptoms and underlying causes.
    • Possible causes of Hirsutism include:
      • Polycystic Ovarian Syndrome (PCOS): The most common endocrine disorder in reproductive-age women, accounting for 90% of hyperandrogenism.
      • Ovarian Hyperthecosis: A nonmalignant ovarian disorder with increased testosterone production from luteinized thecal cells.
      • Androgen-secreting tumors: usually occur later in life and progress rapidly compared to PCOS, accounting for approximately 5% of ovarian tumors.
      • Uncommon causes:
        • Hyperprolactinemia (pituitary adenoma)
        • Acromegaly (pituitary adenoma)
        • Hypothyroidism
        • Severe insulin resistance
        • Drugs: Androgenic medications (e.g., testosterone, DHEA), Danazol

    Hirsutism Clinical Presentation

    • Mild to moderate hirsutism: Regular menses, no clear cause. Consider idiopathic hirsutism.
    • Hirsutism with acne, male pattern hair loss, acanthosis nigricans, obesity, and/or oligomenorrhea.
    • Increased prolactin (PRL): Galactorrhea (milk production), vision changes, infertility, oligo/amenorrhea (irregular or absent menstrual cycles).
    • Congenital Adrenal Hyperplasia (CAH): Menstrual abnormalities, virilization (development of male characteristics in females), increased DHEA/DHEA-S/androstenedione.
    • Androgen-secreting tumor: Older age, rapid progression, virilization.
    • Ovarian hyperthecosis: Older age, intense slow-progressing hirsutism.

    Hirsutism Diagnostic Evaluation

    • Idiopathic Hirsutism:
      • Total testosterone: Normal
    • Polycystic Ovarian Syndrome (PCOS):
      • Total testosterone: Usually elevated.
      • Transvaginal Ultrasound (TVUS): Necessary for evaluation.
    • Androgen-secreting Tumor:
      • Total testosterone: Elevated ≥2x normal values.
      • DHEAS (primarily adrenal origin) and androstenedione (primarily ovarian origin): Required for assessment.
      • Pelvic ultrasound: Recommended.
      • CT of the abdomen and pelvis.
    • Ovarian Hyperthecosis:
      • Total testosterone: Elevated.
      • TVUS.
    • DHEAS:
      • Elevated DHEAS suggests adrenal carcinoma.

    Hirsutism Treatment

    • Treat underlying causes:
      • Remove tumor.
      • Block androgen production: Oral contraceptive pills suppress GnRH, LH, and FSH, reducing ovarian androgens.
    • Block androgen response:
      • Spironolactone (androgen antagonist): Recommended.
      • Finasteride: Inhibits 5-alpha-reductase type 2, an enzyme that converts testosterone to dihydrotestosterone (DHT). Concerns exist regarding inadvertent use during pregnancy.
      • Flutamide: Non-steroidal androgen receptor antagonist, primarily used for prostate cancer but sometimes used off-label.
      • Antiandrogens are contraindicated during pregnancy.
    • Block hair growth: Vaniqa (eflornithine) cream retards hair growth.
    • Hair removal:
      • Depilatory creams (e.g., Nair)
      • Electrolysis, laser ablation
      • Manual removal (plucking)

    Hirsutism Urgent Considerations

    • Rapid virilization: Evaluate for a tumor.
      • Adrenal gland CT.
      • Ovarian transvaginal ultrasound.

    Polycystic Ovarian Syndrome (PCOS)

    • The most common endocrine disorder in reproductive-age women, affecting 5- 10%.
    • Accounts for 90% of hyperandrogenism in women.
    • Prevalence does not vary across different regions of the world.
    • Causes menstrual irregularity and androgen excess.
    • Symptoms: Hirsutism, irregular menses, polycystic ovarian morphology on transvaginal ultrasound.

    PCOS Etiology

    • Unknown etiology: Multiple systems involved; the primary defect is unclear.
    • Theories:
      • Hypothalamic-pituitary axis defect → Increased amplitude and frequency of LH pulses → Increased gonadal androgens.
      • Intrinsic ovarian defect → Androgen overproduction and anovulation (lack of ovulation).
      • Defects in insulin sensitivity = Insulin resistance → Hyperinsulinemia.
    • Pathophysiology: Not well understood; multiple mechanisms are possible.

    PCOS Risk Factors

    • Family history: PCOS is inherited as a common complex disorder with multiple genes involved.
    • Premature adrenarche: Before age 8 in girls.

    PCOS Signs/Symptoms

    • Menstrual Dysfunction: Delayed menarche, oligomenorrhea (irregular flow), amenorrhea (no menses for 3+ months).
    • Hyperandrogenism: Hirsutism, acne, male pattern hair loss; most women with PCOS have elevated androgens.
    • Hirsutism
    • Polycystic Ovaries: Seen on TVUS.
    • Metabolic/Cardiovascular Risks:
      • 40-85% of patients with PCOS are overweight or obese.
      • Insulin resistance, Type 2 diabetes, coronary artery disease (CAD), sleep apnea, nonalcoholic fatty liver disease.
    • Mood: Linked to depression, anxiety, impaired quality of life, and eating disorders.
    • Additional Symptoms: Hirsutism (60%), Acne (20%), Scalp hair loss (5%), Oligomenorrhea (< 6-8 menses per year), Amenorrhea (no menses), Irregular menses, weight gain, infertility.
    • Physical Examination Findings: Hirsutism, acne, alopecia (hair loss), possible hypertension, acanthosis nigricans, sweating, oily skin.

    PCOS Differential Diagnosis

    • Congenital Adrenal Hyperplasia (CAH) = 21-hydroxylase deficiency: Most common cause of CAH, resulting in a missing enzyme that leads to overproduction of adrenal hormones.
    • Thyroid Dysfunction
    • Hyperprolactinemia
    • Cushing Syndrome (rare)
    • Androgen-secreting neoplasm

    PCOS Diagnostic Evaluation

    • Rotterdam Criteria (Preferred): Two out of three required.

      • Oligo- and/or anovulation
      • Clinical and/or biochemical signs of hyperandrogenism
      • Polycystic ovaries (by ultrasound)

    • Diagnosis is confirmed after excluding other conditions: thyroid disease, nonclassic congenital adrenal hyperplasia (NCCAH), hyperprolactinemia, androgen-secreting tumors.

    • Serum total testosterone:

      • Measure if evidence of androgen excess.
      • Upper limit of normal for women is 45-60.
      • Levels > 150 require evaluation for an ovarian or adrenal androgen-secreting tumor or ovarian hyperthecosis.

    • DHEAS:

      • Not suggested for every patient.
      • Measure for symptoms of severe hyperandrogenism.
      • Can be extremely elevated in patients with adrenal carcinoma.

    • Androstenedione: Its role in the evaluation of PCOS is unclear; mixed results have been reported.

    • Serum 17-hydroxyprogesterone:

      • Morning level in the early follicular phase is measured to rule out congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

      • 800 indicates adrenal hyperplasia.

    • FSH and estradiol: High in premature ovarian insufficiency (also have low estradiol).

    • TSH: Check for thyroid abnormalities (can also cause irregular menses/ovulation).

    • Increased prolactin: Pituitary adenoma causes irregular menses, ovulation, and galactorrhea.

    • Cushing syndrome: If suspected, perform a 24-hour urine cortisol or dexamethasone test. Shared symptoms include: oligomenorrhea, hirsutism, obesity, hypertension, striae (stretch marks), muscle weakness.

    • Transvaginal Ultrasound (TVUS): Used to check for polycystic ovarian morphology (PCOM).

      • Not all suspected PCOS patients need an ultrasound.
      • If oligomenorrhea and hyperandrogenism are present, PCOS can be diagnosed without an ultrasound.
      • TVUS is used in hyperandrogenic women with normal menstrual cycles to check for PCOM.

    • Pelvic ultrasound:

      • ≥ 12 follicles in either ovary measuring 2-9 mm in diameter OR Ovarian volume > 10 cm3

    • Basal body temperature chart:

      • Absence of a biphasic pattern indicates anovulation.
      • Rarely used now.

    • Other considerations:

      • Blood pressure (BP), BMI, waist circumference (CVD risk)
      • Fasting lipid profile
      • 2-hour OGTT (oral glucose tolerance test) or fasting glucose and hgbA1C (hemoglobin A1C)
      • Screen for OSA (obstructive sleep apnea)
      • Liver enzymes (US is not recommended for screening for fatty liver)
      • Screen for depression and anxiety disorders.

      PCOS Treatment

    • Obese patients: Weight loss and exercise can reverse metabolic issues and induce ovulation.

    • Non-pregnancy patients:

    • First-line: Combined hormonal oral contraceptive pills (OCPs) for hyperandrogenism and menstrual irregularities.

    • Alternatives: Intermittent or continuous progestin therapy or hormonal intrauterine device (IUD) for endometrial protection.

    • Metformin: Second-line, improves menstrual function but has no effect on hirsutism, acne, or infertility: Used for glucose issues.

    • Medroxyprogesterone (Provera) (10 mg q.d. PO for the first 10 days of each month): Only initiates and regulates menses but does not inhibit androgen excess.

    • Low-dose combination OCPs: - Use low-androgenic activity progestins. - Regulates menses and may decrease androgens while preventing pregnancy.

    • Patients who desire pregnancy:

      • Ovulation stimulation:
        • Letrozole (first-line)
        • Clomiphene
        • Increased risk of twins with ovarian stimulation.

    • Hirsutism:

      • Low-dose combination OCPs for 6-12 months
      • If not improved, add spironolactone 25 mg PO tid (only use with contraception).
      • Topical eflornithine (Vaniqa) cream applied to the face BID for 6 months.
      • Electrolysis/laser therapy as needed (PRN).

    PCOS Prognosis

    • Insulin resistance and hyperinsulinemia increase the risk of Type 2 diabetes.
    • Anovulation causes unopposed estrogen, which increases the risk of endometrial cancer.
    • Pregnancy desired: 20-40% live birth rate with clomiphene treatment.

    Type II Diabetes Mellitus

    • Type 2 Diabetes Mellitus (T2DM) is characterized by progressive loss of beta cell insulin secretion with varying degrees of tissue insensitivity to insulin.
    • T2DM is the most common type of diabetes, accounting for over 90-95% of all diabetes cases in the US.
    • T2DM is a very expensive disease, costing $327 billion per year in 2017.
    • T2DM is associated with increased risk of microvascular complications (retinopathy, neuropathy, nephropathy) and macrovascular complications (coronary artery disease, peripheral arterial disease, stroke).

    T2DM Pathophysiology

    • Insulin facilitates the movement of glucose from blood into cells for energy use, transporting glucose to the liver and muscles for energy utilization and storing glucose in fat tissue.
    • T2DM patients produce insulin, but often not enough for the body’s needs, and may struggle to use produced insulin effectively.
    • Insulin levels are sufficient to prevent ketoacidosis but not hyperglycemia.

    T2DM Etiology

    • T2DM is caused by a combination of genetic and environmental factors.
    • Genetics play a significant role, with a high heritability (30-70%) and over 60 genetic variants.
    • Environmental factors play a significant role, with obesity being the highest absolute risk factor.
    • Other environmental factors include reduced activity, age, poor diet, and prior gestational diabetes.

    T2DM Epidemiology

    • The highest prevalence of T2DM in the US is among American-Indian and Alaskan populations.
    • The highest prevalence of T2DM globally is in China.
    • T2DM has a higher prevalence in certain Pacific islands and the Middle East, and an intermediate prevalence in countries like India and the US.
    • T2DM has peak incidence in minority groups over 45 years of age (slightly younger than white onset).
    • Males are slightly more likely to have T2DM than females.

    T2DM Clinical Presentation

    • T2DM is often asymptomatic, with an insidious onset.
    • Patients are often overweight or obese.
    • Patients may experience increased thirst, frequent urination, increased hunger, weight loss, blurred vision, fatigue, slow-healing sores, and frequent infections.

    T2DM Diagnostic Evaluation

    • Laboratory diagnostics include clinical evaluation, fasting plasma glucose (FPG), random plasma glucose (RPG), HbA1c, C-peptide, and insulin levels.
    • HbA1c is a measure of average blood glucose over the prior 6-12 weeks.
    • FPG and HbA1c are preferred for diagnosis due to convenience.

    T2DM Treatment

    • The treatment goals for T2DM are to eliminate hyperglycemic symptoms, reduce/eliminate long-term microvascular/macrovascular complications, and allow patients to achieve as normal a lifestyle as possible.
    • The first-line treatment involves diet and exercise (plus metformin).
    • Psychosocial counseling is essential for patients with T2DM.

    Monogenic Diabetes (Maturity-Onset Diabetes of the Young - MODY)

    • MODY is a single gene disorder characterized by genetic defects of pancreatic beta cell function.
    • MODY is a non-insulin-requiring diabetes, but some forms may require insulin.
    • The age of onset for MODY is typically under 25 years of age.
    • MODY is an autosomal dominant disorder with multiple gene abnormalities on different chromosomes.

    Polycystic Ovarian Syndrome (PCOS)

    • PCOS is the most common endocrine disorder in women of reproductive age, affecting 5–10%.
    • PCOS causes menstrual irregularity and androgen excess.
    • PCOS does not have a clear cause, but multiple systems are likely involved.
    • PCOS symptoms include hirsutism, irregular menses, and polycystic ovarian morphology on transvaginal ultrasound.

    PCOS Etiology

    • The etiology of PCOS is unknown, but several theories exist, including:
      • Hypothalamic-pituitary axis defect leading to increased amplitude and frequency of LH pulses, resulting in increased gonadal androgens.
      • Intrinsic ovarian defect leading to androgen overproduction and anovulation.
      • Defects in insulin sensitivity, causing insulin resistance and hyperinsulinemia.

    PCOS Risk Factors

    • PCOS is inherited as a common complex disorder with multiple genes involved.
    • Premature adrenarche (before age 8 in girls) is a risk factor for PCOS.

    PCOS Signs & Symptoms

    • Menstrual dysfunction: Delayed menarche, oligomenorrhea, amenorrhea.
    • Hyperandrogenism: Hirsutism, acne, male pattern hair loss, elevated androgens.
    • Polycystic ovaries: Seen on transvaginal ultrasound.
    • Metabolic/Cardiovascular risks: Overweight/obesity, insulin resistance, T2DM, CAD, sleep apnea, nonalcoholic fatty liver disease.
    • Mood: Linked to depression, anxiety, impaired quality of life, eating disorders.

    PCOS Differential Diagnosis

    • Congenital adrenal hyperplasia (CAH) - 21 hydroxylase deficiency.
    • Thyroid dysfunction.
    • Hyperprolactinemia.
    • Cushing syndrome.
    • Androgen-secreting neoplasm.

    PCOS Diagnostic Evaluation

    • Rotterdam Criteria: 2 of 3 required:
      • Oligo- and/or anovulation.
      • Clinical and/or biochemical signs of hyperandrogenism.
      • Polycystic ovaries (by ultrasound).
    • Serum total testosterone: Measured if evidence of androgen excess.
    • DHEAS: Measured for symptoms of severe hyperandrogenism.
    • Androstenedione: Role unclear in PCOS evaluation.
    • Serum 17-hydroxyprogesterone: Measured in the early follicular phase to rule out CAH due to 21-hydroxylase deficiency.
    • FSH & estradiol: High in premature ovarian insufficiency.
    • TSH: Check for thyroid abnormalities.
    • Prolactin: Elevated prolactin levels may indicate a pituitary adenoma.
    • Cushing syndrome: If suspected, perform a 24-hour urine cortisol or dexamethasone test.
    • Transvaginal ultrasound (TVUS): Used to check for polycystic ovarian morphology (PCOM).

    Hirsutism

    • Hirsutism is excessive male pattern hair growth in women of reproductive age.
    • Hirsutism affects 5-10% of females of reproductive age.
    • PCOS is the most common cause of hirsutism.
    • Hirsutism can occur with virilization, which is characterized by male pattern alopecia, voice deepening, increased muscle bulk, and clitoromegaly.

    Hirsutism Etiology

    • Hirsutism can be idiopathic or caused by various factors, including:
      • Nonclassical adrenal hyperplasia.
      • Females with virilization or severe hyperandrogenemia.
      • Uncommon causes: hyperprolactinemia, acromegaly, hypothyroidism, severe insulin resistance, medications.

    Hirsutism Clinical Presentation

    • Mild-moderate hirsutism with regular menses and no clear cause can indicate idiopathic hirsutism.
    • Hirsutism with acne, male pattern alopecia, acanthosis nigricans, obesity, and/or oligomenorrhea may indicate PCOS, CAH, or other conditions.

    Hirsutism Diagnostic Evaluation

    • Idiopathic hirsutism: Total testosterone is usually normal.
    • PCOS: Total testosterone is usually elevated.
    • Androgen-secreting tumor: Total testosterone is elevated ≥ 2x normal values.

    Hirsutism Treatment

    • Treatment involves addressing the underlying cause, blocking the androgen response, blocking hair growth, and hair removal.

    Hirsutism Urgent Considerations

    • Rapid virilization necessitates evaluation for tumors, including an adrenal gland CT and an ovarian transvaginal ultrasound.

    Diabetes Mellitus

    • Type 1 Diabetes Mellitus (T1DM) is an autoimmune disease characterized by the destruction of pancreatic beta cells, leading to absolute insulin deficiency.
    • Type 2 Diabetes Mellitus (T2DM) is a metabolic disorder characterized by insulin resistance and a progressive decline in beta cell function, leading to hyperglycemia.
    • Gestational Diabetes (GDM) is a condition that develops during pregnancy characterized by insulin resistance brought on by the hormonal changes in pregnancy.
    • Latent Autoimmune Diabetes in Adults (LADA) is a slowly progressing form of autoimmune diabetes where the body slowly destroys beta cells resulting in a gradual decline in insulin production.
    • Monogenic Diabetes (Maturity Onset Diabetes of the Young (MODY)) is a rare form of diabetes caused by a single gene mutation affecting beta cell function.

    Type 1 Diabetes Mellitus (T1DM)

    • T1DM typically presents in childhood or adolescence, but can occur at any age.
    • T1DM is often characterized by rapid weight loss, polyuria, polydipsia, and polyphagia.
    • T1DM requires lifelong insulin therapy to control blood glucose levels.

    Type 2 Diabetes Mellitus (T2DM)

    • T2DM is the most common type of diabetes, accounting for 90-95% of all cases.
    • T2DM is often associated with obesity, family history, and physical inactivity.
    • T2DM can be managed through lifestyle modifications (weight loss, exercise, and healthy diet), oral medications, and sometimes insulin therapy.

    Gestational Diabetes (GDM)

    • GDM typically develops in the second or third trimester of pregnancy.
    • GDM is often a temporary condition that resolves after delivery.
    • GDM can increase the risk of complications for both the mother and the baby, including macrosomia (large for gestational age), shoulder dystocia, and birth defects.

    Latent Autoimmune Diabetes in Adults (LADA)

    • LADA is a slowly progressing form of autoimmune diabetes, often mimicking type 2 diabetes.
    • LADA can initially be managed with oral medications, but it eventually requires insulin therapy.

    Monogenic Diabetes (Maturity Onset Diabetes of the Young (MODY))

    • MODY is caused by a single gene mutation that disrupts beta cell function.
    • MODY is often diagnosed in younger adults and can sometimes be managed with oral medications.

    MODY Subtypes

    • Glucokinase (GCK) mutation : This subtype causes mild asymptomatic stable fasting hyperglycemia. Treatment is generally not required.
    • Hepatocyte nuclear factor mutations: These subtypes can lead to more severe hyperglycemia and potential complications. Treatment may include sulfonylureas or insulin therapy.

    Management of Diabetes Mellitus

    • Blood Glucose Monitoring: Essential for monitoring blood sugar levels and adjusting treatment plans.
    • Psychosocial Counseling: Can help address mental health concerns associated with diabetes, such as depression, anxiety, and eating disorders.
    • Regular Follow-Up and Monitoring: Important for early detection and management of complications.

    Polycystic Ovary Syndrome (PCOS)

    • PCOS is a hormonal disorder that affects women of reproductive age.
    • PCOS is characterized by irregular periods, excess androgen (male hormones), and multiple cysts on the ovaries.

    Diagnosis of PCOS

    • Diagnosis of PCOS is typically made based on clinical presentation and imaging studies.
    • Pelvic Ultrasound: Used to confirm the presence of multiple cysts on the ovaries.
    • Other Diagnostic Tests:
      • Blood pressure, BMI, and waist circumference to assess cardiovascular risk.
      • Fasting lipid profile to assess cholesterol levels.
      • Two-hour oral glucose tolerance test (OGTT) or fasting glucose and HbA1c to assess diabetes risk.
      • Screening for obstructive sleep apnea (OSA).
      • Liver enzymes to assess liver function.
      • Screening for depression and anxiety disorders.

    Treatment for PCOS

    • Weight Loss and Exercise: Can improve metabolic issues and induce ovulation in obese patients.
    • Medications:
    • Combined hormonal oral contraceptives (OCPs): First-line treatment for hyperandrogenism and menstrual irregularities.
    • Metformin: Second-line treatment that can improve menstrual function and manage glucose issues.
    • Other Medications: Spironolactone, eflornithine (Vaniqa) cream, and electrolysis/laser therapy for hirsutism.
    • Ovarian Stimulation: Used for patients who desire pregnancy.
    • Lifestyle Modifications: Multidisciplinary approach: Diet, exercise, behavior modification, social support, pre-meal planning

    Prognosis for PCOS

    • PCOS can increase the risk of developing type 2 diabetes, endometrial cancer, and infertility.
    • Treatment options can improve ovulation and fertility, but success rates vary.
    • Long-term complications:
      • Cardiovascular disease: due to insulin resistance, hyperlipidemia, and hypertension.
      • Type 2 diabetes: due to insulin resistance.
      • Endometrial cancer: due to unopposed estrogen.
      • Infertility: due to anovulation.
      • Metabolic syndrome: a cluster of conditions including obesity, insulin resistance, high blood pressure, and high cholesterol.
      • Mental health issues: such as depression, anxiety, and eating disorders.

    HDL (Good Cholesterol)

    • Exercise is crucial for improving HDL levels. Aim for at least 150 minutes of moderate aerobic activity per week, spread over 3 or more days with no gaps of more than 2 days.
    • Metformin (Glucophage) is the first-line treatment for type 2 diabetes (T2DM). Start pharmacotherapy at diagnosis, do not wait to see if lifestyle changes are sufficient.
      • Mechanism of action: Metformin, a biguanide, works by reducing hepatic glucose production, decreasing intestinal glucose absorption, and increasing insulin sensitivity through enhanced peripheral glucose uptake and utilization.
      • Benefits: Metformin reduces HbA1c by 1-2%, lowers triglycerides in obese patients, promotes weight loss, carries a low risk of hypoglycemia, and is associated with reduced micro and macrovascular complications with long-term use.
      • Dosage: 2000 mg orally per day
      • Side Effects: Gastrointestinal upset
      • Contraindications:
        • Alcohol use, liver disease, unstable congestive heart failure (risk of lactic acidosis)
        • Severe renal impairment (eGFR < 30, elevated creatinine), diabetic ketoacidosis (DKA)
    • Lifestyle therapy for improving HDL:
      • Weight loss (if needed)
      • DASH diet (low sodium, high potassium)
      • Alcohol moderation
      • Increased physical activity
    • Pharmacotherapy for improving HDL:
      • Include an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB)
      • Multiple drug therapy is often required.

    Cholesterol Monitoring in T2DM

    • Statin therapy is recommended for all individuals with T2DM above the age of 40, regardless of the presence or absence of cardiovascular disease (CVD) risk factors.
    • Diabetic dyslipidemia is a characteristic of insulin resistance syndrome.
    • Circulating lipoprotein levels are dependent on insulin, similar to glucose.

    Guidelines for Ongoing Comprehensive Care for Individuals with T2DM

    • Establish an individualized glycemic goal and treatment plan.
    • Self-monitor blood glucose regularly, based on individual needs, using fingersticks or continuous monitoring.
    • Test HbA1c 2-4 times per year.
    • Manage diabetes with lifestyle changes:
      • Diabetes education and support
      • Nutrition therapy
      • Physical activity
      • Mental health support (for depression and anxiety)
    • Detect, prevent, or manage diabetes-related complications:
      • Annual or biannual eye exams
      • Foot exams 1-2 times per year by a provider, daily by the patient
      • Annual neuropathy exams
      • Annual kidney disease testing.

    Obesity

    • BMI (Body Mass Index) does not distinguish between muscle and fat.
    • BMI of 18.5 - 24.99 is considered healthy.
      • However, some individuals may be healthy with other BMI ranges, and some individuals may be unhealthy within this range.
    • Obesity increases the risk of:
      • Hypertension
      • Diabetes
      • Dyslipidemia
      • Obstructive sleep apnea
      • Nonalcoholic fatty liver disease
      • Certain malignancies
    • Centripetal obesity (waist circumference greater than 40 inches for men and 35 inches for women) leads to:
      • Increased risk of diabetes
      • Increased risk of stroke
      • Increased risk of coronary artery disease
      • Increased risk of early death
    • Upper body obesity (abdomen and flanks) poses a greater health risk compared to lower body obesity (buttocks and thighs).

    Obesity Epidemiology

    • Prevalence of obesity in American adults:
      • 30.7% overweight
      • 42.4% obese
      • 9.2% severely obese
      • 60% of individuals with obesity have metabolic syndrome
      • 40-70% of obesity is attributed to genetic influences
      • Less than 1% of obesity is secondary obesity (due to conditions like hypothyroidism or Cushing's syndrome)
    • Increased prevalence of obesity over the past 3 decades, particularly in individuals aged 20-60 (peaking at age 60 and slightly declining thereafter).

    Obesity Patient Evaluation

    • 1. Focused History:
      • Factors contributing to the patient's obesity
      • Impact of obesity on the patient's health
      • Patient's level of risk from obesity
      • Patient's challenges in managing weight
      • Patient's goals and expectations
      • Patient's motivation to begin a weight management program
      • Type of support the patient needs
    • 2. Physical Exam: Determine the degree and type of obesity.
    • 3. Assessment of Co-morbid Conditions.
    • 4. Determination of Fitness Level.
    • 5. Assessment of the Patient's Readiness to Adopt Lifestyle Changes.
    • History and Physical Exam:
      • Family history of obesity: If absent, search for other contributing factors.
      • History of weight gain: Recent versus chronic weight gain.
      • Diet and exercise routine: Sedentary, active, or athletic lifestyle.
      • Degree and distribution of body fat: Increased health risks associated with centripetal obesity.
      • Signs of secondary obesity:
        • Cushing's syndrome: Round face, buffalo hump, striae
        • Hypothyroidism: Depression, fatigue, constipation, cold intolerance, etc.

    Obesity Treatments

    • Lifestyle Modifications:
      • Dietary Changes:
        • Calorie Restriction: Reduced calorie intake is a cornerstone of weight management. It is essential to create a substantial calorie deficit.
        • Healthy Food Choices: Focus on nutrient-rich foods, prioritizing fruits, vegetables, whole grains, lean protein sources, and healthy fats. Limit processed foods, sugary drinks, and excessive saturated and trans fats.
        • Portion Control: Become aware of portion sizes and practice mindful eating. Utilize smaller plates, avoid second helpings, and prioritize satiating foods.
        • Meal Frequency: Eating several smaller meals throughout the day can help boost metabolism and regulate blood sugar levels.
        • Fluids: Staying hydrated is important, particularly water. Other fluids like unsweetened tea and black coffee can be included.
      • Physical Activity: Regular exercise plays a vital role in promoting weight loss and overall health.
        • Types of Exercise: A combination of aerobic and resistance training is recommended.
        • Frequency: Aim for at least 150 minutes of moderate-intensity aerobic activity (brisk walking, cycling, swimming) per week, spread over 3 or more days with no gaps larger than 2 days. Resistance training (weightlifting or bodyweight exercises) should be performed 2-3 times per week.
        • Intensity: Start gradually and progress gradually. Find an appropriate intensity level based on your fitness level and capabilities.
      • Behavioral Therapy: Cognitive-behavioral therapy (CBT) can be helpful in addressing unhealthy eating patterns and behaviors that contribute to weight gain.
    • Medications:
      • Orlistat (Xenical, Alli):
        • Mechanism of Action: Orlistat inhibits fat absorption in the gastrointestinal tract.
        • Side Effects: Can cause gastrointestinal distress (diarrhea, cramping, flatulence).
        • Management Tip: A low-fat diet can help minimize side effects and motivate patients to adhere to dietary recommendations.
      • Appetite Suppressants (Anorexiants):
        • Lorcaserin (Belviq) (10 mg orally twice daily):
          • Mechanism of Action: Lorcaserin promotes satiety through serotonin agonist activity.
          • Weight Loss: May result in approximately a 5% body weight loss.
          • Side Effects: Possible breast tumors, valvular heart disease, psychiatric problems.
        • Phentermine + Topiramate:
          • Mechanism of Action: Combination of amphetamine and anticonvulsant.
          • Weight Loss: 5-10% body weight loss.
          • Side Effects: Addictive potential, hypertension, tachycardia.
          • Distribution in US: Restricted due to its classification as a Class IV drug.
        • Naltrexone + Bupropion:
          • Mechanism of Action: Opioid antagonist and norepinephrine-dopamine reuptake inhibitor.
          • Weight Loss: 2-4% body weight loss.
          • Side Effects: Potential for suicide, seizures, hypertension, tachycardia.
        • Liraglutide (Saxenda, Victoza):
          • Mechanism of Action: Injectable glucagon-like peptide-1 receptor agonist (regulates appetite and caloric intake).
          • Weight Loss: 3-4% body weight loss.
          • Concerns: Thyroid tumors, pancreatitis, gallbladder disease, renal impairment, tachycardia, suicidal thoughts.
          • Side Effects: Nausea, vomiting, diarrhea, constipation, hypoglycemia.
    • Bariatric Surgery:
      • Considerations for Surgery:
        • Severe Obesity: Body mass index (BMI) greater than or equal to 40.
        • Moderate Obesity: BMI greater than or equal to 35, in conjunction with serious medical conditions or co-morbidities (e.g., joint disease, obstructive sleep apnea, diabetes, hypertension, GERD).
      • Surgical Procedures:
        • Roux-en-Y Gastric Bypass:
        • Gastric Banding:
        • Sleeve Gastrectomy:
        • Intraluminal Gastric Balloon: Balloon devices placed endoscopically into the stomach.
          • Approved Devices: RESHAPE (two silicone balloons attached to a central silicone shaft), ORBERA (single-balloon device).
            • Mean Weight Loss: 7.2 kg (RESHAPE) and 8.8 kg (ORBERA) in short-term pivotal trials.
            • Approval: Both devices are approved for use for 6 months or less in adults with a BMI of 30-40.
          • Adverse Effects: Nausea, vomiting, abdominal pain.
      • Complications: Infection, hernia, nutritional deficiencies, neuropathy, blood clots.
      • Mortality: 1% risk in the postoperative period, higher rate within the first year after surgery.
      • Multidisciplinary Approach: Diet, exercise, behavior modification, social support, pre-meal planning.

    Obesity Outcomes and Prognosis

    • Health Complications:
      • Hypertension and hyperlipidemia
      • Coronary artery disease
      • Type 2 diabetes
      • Degenerative joint disease
      • Psychosocial disability
      • Increased risk of cancer (colon, rectum, prostate, uterus, biliary tract, breast, ovary)
      • Thromboembolic disorders (myocardial infarction, stroke, pulmonary embolism)
      • Digestive tract diseases (gallstones, reflux esophagitis)
      • Skin disorders (hidradenitis suppurativa, striae, acanthosis nigricans, delayed wound healing, infections)
    • Weight Loss Outcomes:
      • Approximately 20% of individuals lose 20 pounds and maintain that loss for over two years.
      • Approximately 5% of individuals lose 40 pounds and maintain that loss for over two years.
    • Weight Loss Strategies:
      • Very Low-Calorie Diets: Can result in a weight loss of 2 pounds per week (duration varies).
      • Elimination of Sugary Drinks: Stopping daily consumption of 16 ounces of soda can lead to a weight loss of 20 pounds per year (diet soda can result in weight gain or loss).
      • Orlistat (Xenical, Alli): 4-8 pounds of weight loss over two years.
      • Roux-en-Y Gastric Bypass: 50% of initial body weight loss, with an average of 50% weight regain by 5 years.

    Hirsutism

    • Hirsutism is excessive male-pattern hair growth in women of reproductive age.
    • Prevalence: Affects 5-10% of females of reproductive age.
    • Most common cause: Polycystic ovary syndrome (PCOS)
    • Hirsutism Epidemiology:
      • Prevalence: 20% of American women experience hirsutism.
      • Androgen Excess: 80% of women with androgen excess (not all) have hirsutism.
      • Ethnic Variation:
        • East Asian and Native American women tend to have less body hair.
        • Southern European women (Mediterranean) often have more body hair.
    • Hirsutism and Virilization:
      • Virilization: Presence of male-pattern hair loss, voice deepening, increased muscle bulk, and clitoromegaly.
      • Cause: Moderate to severe androgen excess.
    • Hirsutism Etiology:
      • Idiopathic Hirsutism:
        • Women with hirsutism, normal androgen concentrations, and no menstrual irregularities.
        • No identifiable cause for the hirsutism.
      • Androgen Hair Follicle Sensitivity:
        • Hirsutism results from the interplay of circulating serum androgens, hair follicle sensitivity to these androgens, and local growth factors.
        • Key Androgens: Testosterone (primarily from ovaries), Dehydroepiandrosterone sulfate (DHEAS) (from adrenal glands), Androstenedione (from adrenal or ovarian sources).
        • Hair Growth:
          • Hair growth on the scalp, eyebrows, and eyelashes occurs without the influence of androgens.
          • Androgens stimulate hair growth in other body regions (face, arms, legs, trunk).
          • Androgens lead to larger follicles, thicker hair, and a longer growth (anagen) phase.
          • Excess androgens in women promote hair growth in sensitive areas (lip, chin, back).
          • Scalp hair loss occurs due to a shorter growth (anagen) phase in androgen excess.
      • Nonclassical Adrenal Hyperplasia:
        • Characterized by excess androgens (observed in congenital adrenal hyperplasia).
        • Usually recognized at birth or early infancy.
        • Nonclassical form (primary 21-hydroxylase deficiency) presents as:
          • Hirsutism, menstrual irregularities, or primary amenorrhea at puberty.
          • No cortisol deficiency.
      • Females with Virilization or Severe Hyperandrogenemia:
        • Rapid Virilization: Sudden onset of masculine traits in women, frequently caused by excessive adrenal androgens.
        • Common Causes: Androgen-secreting tumors (ovarian, adrenal) or ovarian hyperthecosis.
          • Ovarian Hyperthecosis: Hyperplasia of thecal cells in the ovaries leads to excessive testosterone, resulting in hirsutism and virilization.

    Polycystic Ovary Syndrome (PCOS)

    • PCOS is a common hormonal disorder affecting women of reproductive age.
    • Characteristics:
      • Ovarian Cysts: Multiple small cysts develop on the ovaries.
      • Hormonal Imbalances: Increased levels of androgens (male hormones) and insulin resistance (difficulty using insulin to regulate blood sugar).
      • Other Features: Irregular periods, acne, excess hair growth (hirsutism), weight gain, difficulty conceiving.
    • Diagnosis:
      • Rotterdam Criteria: Requires at least two of the following:
        • Oligomenorrhea or Irregular Menstrual Cycles: Infrequent or irregular periods, or absence of menstruation.
        • Clinical and/or Biochemical Signs of Hyperandrogenism:
          • Clinical: Hirsutism, acne, or alopecia (hair loss).
          • Biochemical: Elevated testosterone levels.
        • Polycystic Ovaries: Multiple follicles in the ovaries on ultrasound.
    • PCOS Testing:
      • Pelvic Ultrasound:
        • Diagnosis:
          • At least twelve follicles in either ovary, measuring 2-9 millimeters in diameter, or an ovarian volume greater than 10 cubic centimeters.
      • Basal Body Temperature Chart:
        • Purpose: To detect the absence of a biphasic pattern, indicating anovulation (lack of ovulation).
        • Current Use: Rarely used in clinical practice.
      • Other Considerations:
        • Blood Pressure, BMI, and Waist Circumference: Indicators of cardiovascular disease risk.
        • Fasting Lipid Profile: Assesses cholesterol levels.
        • 2-hour Oral Glucose Tolerance Test (OGTT) or Fasting Glucose and HbA1c: Detects glucose issues.
        • Screen for Obstructive Sleep Apnea (OSA):
        • Liver Enzymes: (Ultrasound not recommended for screening fatty liver).
        • Screen for Depression and Anxiety Disorders:

    PCOS Treatment

    • Obesity:
      • Weight loss and exercise can reverse metabolic issues and induce ovulation.
    • Non-pregnancy Patients:
      • First-Line Treatment:
        • Combined Hormonal Oral Contraceptives (OCPs): For hyperandrogenism (excess androgens) and menstrual irregularities.
      • Alternatives:
        • Intermittent or Continuous Progestin Therapy: For endometrial protection (lining of uterus)
        • Hormonal Intrauterine Device (IUD): For endometrial protection.
      • Metformin:
        • Mechanism of Action: Improves insulin sensitivity.
        • Benefits: May improve menstrual function, but does not typically impact hirsutism, acne, or infertility.
        • Use: Considered second-line therapy for glucose issues.
      • Medroxyprogesterone (Provera) (10 mg orally daily for the first 10 days of each month):
        • Purpose: Initiates and regulates menses.
        • Limitation: Does not inhibit androgen excess.
      • Low-Dose Combination OCPs:
        • Progestins: Use progestins with low androgenic activity.
        • Benefits: Regulates menses and may decrease androgens while preventing pregnancy.
    • Patients Desiring Pregnancy:
      • Ovary Stimulation:
        • Letrozole: First-line treatment.
        • Clomiphene: Another ovulation-inducing medication.
        • Increased Risk: Increased risk of twins with ovary stimulation.
    • Hirsutism Treatment:
      • Low-Dose Combination OCPs: For 6-12 months.
      • Spironolactone (25 mg orally three times daily):
        • Additional Treatment: If OCPs do not sufficiently improve hirsutism.
        • Contraceptive Requirement: Must be used in conjunction with contraception.
      • Topical Eflornithine (Vaniqa) Cream: Applied to the face twice daily for 6 months.
      • Electrolysis or Laser Therapy: As needed.

    PCOS Prognosis

    • Insulin Resistance and Hyperinsulinemia: Increased risk of developing type 2 diabetes.
    • Anovulation: Lack of ovulation can lead to unopposed estrogen, increasing the risk of endometrial cancer.
    • Pregnancy: A live birth rate of 20-40% with clomiphene treatment.

    Urination & Thirst

    • Prolonged undetected/untreated urinary or cardiovascular abnormalities can signify a health concern.
    • Chronic skin infections and yeast infections can indicate immune system dysfunction.
    • Increased centripetal fat distribution is a sign of metabolic abnormalities:
      • Men: Waist circumference greater than 40 inches.
      • Women: Waist circumference greater than 35 inches.
    • Acanthosis nigricans (darkening of skin with folds and skin tags) is associated with significant insulin resistance.
    • Eruptive xanthomas are associated with hyperchylomicronemia (increased triglycerides).

    T2DM Screening & Diagnosis

    • Many individuals with T2DM are asymptomatic and unaware of the condition.
    • Screening for T2DM is crucial to prevent complications and progression of the disease.
    • Early intervention leads to superior outcomes.
    • Diagnosis of prediabetes warrants increased efforts for diabetes prevention.
    • Cost-effectiveness justifies screening.
    • Recommended screening for T2DM:
      • Individuals overweight or obese, with at least one risk factor: family history of diabetes, certain ethnicities (African American, Latino, Asian), hypertension, low HDL or high triglycerides, PCOS or acanthosis nigricans, history of heart disease, physical inactivity, insulin resistance (severe obesity).
      • Yearly screening for those previously diagnosed with high blood sugar (IFG, IGT, A1C 5.7-6.4%).
      • Every three years for women with past gestational diabetes.
      • Starting at age 45, every three years for everyone.
      • Screening for individuals with HIV.
    • Three broad categories for glucose tolerance: normal glucose homeostasis, impaired glucose homeostasis, and diabetes mellitus.
    • T2DM diagnosis in non-pregnant individuals is based on any one of four abnormalities:
      • Elevated fasting plasma glucose (FPG).
      • Random elevated glucose with symptoms.
      • Elevated HbA1c.
      • Abnormal oral glucose tolerance test (OGTT).
    • Plasma/serum glucose is a more accurate measure of glucose concentration in body tissues compared to blood glucose, as it avoids interference from red blood cell concentration (hematocrit).
    • Concentration of glucose in plasma/serum is typically 10-15% higher than in whole blood.
    • Glycosylated Hb (HbA1c):
      • Glucose irreversibly attaches to the beta chain of HbA.
      • HbA1c levels reflect average blood glucose over the prior 6-12 weeks.
      • More heavily influenced by glucose levels in the prior four weeks.
      • Increased HbA1c predicts the risk of microvascular complications.
      • Not suitable for populations with a high prevalence of hemoglobinopathies or conditions with increased red cell turnover.
    • Oral glucose tolerance test (OGTT)
      • Consume 150-200 g of carbohydrates per day for three days preceding the test.
      • Nothing by mouth (NPO) past midnight prior to the test day.
      • Perform the test in the morning to avoid diurnal variation in glucose tolerance.
      • Administer 75 g of glucose in 300 mL of water orally, consumed within five minutes.
      • Obtain plasma glucose levels at 0 hours (fasting) and 2 hours.
      • Most commonly used in pregnancy.
    • Urine Tests:
      • Urine glucose: Urine dipstick for glucose detects >100 mg/dL of glucose.
      • Urine & blood ketones: Urine dipstick aids in early detection of ketoacidosis, but does not detect beta-hydroxybutyric acid (the primary ketone in DKA). It cannot confirm DKA, but can estimation ketonuria; blood evaluation required to assess for significant ketones.
    • T2DM diagnosis confirmation:
      • If there is no clear symptomatic hyperglycemia, confirm the diagnosis by repeating the same test on a different day or performing two confirmatory tests on the same day.
      • Preferred tests due to convenience: fasting plasma glucose (FPG) and HbA1c.

    T2DM Treatment

    • Treatment goals: eliminate hyperglycemia symptoms, reduce/eliminate long-term micro/macrovascular complications of DM, and enable the patient to achieve as normal a lifestyle as possible.
    • First-line treatment: Diet and exercise (plus metformin).
      • 5-10% weight loss is associated with significant improvement in cardiac risk factors.
      • Diet: Decreased carbohydrate intake to promote decreased triglycerides and increased HDL.

    Gestational Diabetes

    • High glucose levels can cause polyhydramnios (increased amniotic fluid).
    • Increased risk of stillbirth with GDM and suboptimal glucose control.

    Gestational Diabetes Complications

    • Maternal complications:
      • Maternal hypoglycemia, diabetic coma, ketoacidosis.
      • Maternal cardiac, renal, ophthalmic, and peripheral vascular injuries.
    • Neonatal morbidity:
      • Increased risk of hypoglycemia, hyperbilirubinemia, hypocalcemia, hypomagnesemia, polycythemia, respiratory distress, and/or cardiomyopathy.
      • Delayed pulmonary, hepatic, and neurologic organ maturity.
      • Congenital defects: heart, neural tube, renal.
      • Abnormal fetal heart rate patterns.
      • Intrauterine fetal growth retardation and intrauterine fetal distress.
    • Maternal infection.

    Gestational Diabetes Long-Term Consequences

    • GDM is a strong marker for maternal development of T2DM, including diabetes-related vascular disease.
    • GDM increases the offspring's risk of developing obesity, impaired glucose tolerance, and diabetes.

    Gestational Diabetes Risk Factors

    • Personal history of impaired glucose tolerance, HbA1c > 5.7.
    • Family history of diabetes, especially first-degree relatives.
    • Pre-pregnancy BMI > 30, weight gain in early adulthood, between pregnancies, or between 18 and 24 weeks of pregnancy.
    • Older maternal age > 40.

    Gestational Diabetes Screening

    • Obtain HbA1c as part of prenatal laboratory studies at the initial visit. Manage as diabetic if > 6.5%.
    • Targeted screening at 24-28 weeks gestational age with an oral one-hour glucose tolerance test (OGCT).
      • 50-g 1-hr oral glucose challenge test (OGCT) without prior oral intake restrictions (50 g for screening, 100 g for diagnosis).
      • 1-hr serum glucose > 140 mg/dL is abnormal and requires a 3-hr OGTT.
      • 1-hr serum glucose > 200 mg/dL is indicative of GDM, and the 3-hr OGTT is not performed.
    • 3-hr OGTT (if the screening is abnormal, after an overnight fast).
      • Fasting blood sugar (FBS) obtained prior to the start of the test.
      • 100 g oral glucose load.
      • Two or more abnormal values indicate GDM.

    Gestational Diabetes Management

    • Team approach: Patient, obstetrician, maternal-fetal medicine specialist, nutritionist.
    • Goal: Euglycemia.
      • FBS < 95 mg/dL.
      • 1-hr postprandial < 140 mg/dL.
      • 2-hr postprandial < 120 mg/dL.

    Metabolic Syndrome

    • Insulin resistance and hyperglycemia are treated with Metformin, Pioglitazone, and Rosiglitazone.
    • Dyslipidemia is treated with Statins and other lipid-lowering drugs.
    • Hypertension is treated with lifestyle modification and antihypertensive medications.
    • Low-dose aspirin (81 mg orally daily) may be considered: weigh the risk of bleeding against the potential benefit.
    • Metabolic syndrome increases the risk of a pro-thrombotic and pro-inflammatory state, making individuals more susceptible to atherosclerosis and cardiovascular events.
    • Clinical implications of metabolic syndrome:
      • Fatty liver disease (steatosis, fibrosis, and cirrhosis).
      • Hepatocellular carcinoma and intrahepatic cholangiocarcinoma.
      • Chronic kidney disease (CKD = GFR < 60 mL/min per 1.73 m2).
      • Polycystic ovary syndrome.
      • Male hypogonadism.
      • Sleep-disordered breathing, including obstructive sleep apnea (OSA).
      • Hyperuricemia and gout.
      • Increased risk of cognitive decline and dementia.

    Obesity

    • BMI: A measure of excess adipose tissue; weight (kg)/height (m)2.
    • BMI Classifications:
      • 18.5-24.9 = Normal.
      • 25-29.9 = Overweight.
      • 30-34.9 = Class I obesity.
      • 35-39.9 = Class II obesity.

      • 40 = Extreme obesity.

    • BMI does not differentiate between muscle and fat.
    • A BMI range of 18.5-24.99 is generally considered healthy, but individual health can vary outside this range.
    • Increased risk associated with obesity:
      • Hypertension.
      • Diabetes.
      • Dyslipidemia.
      • Obstructive sleep apnea.
      • Nonalcoholic fatty liver disease.
      • Some malignancies.
    • Centripetal obesity (waist circumference > 40 inches in men, > 35 inches in women) leads to increased risk of diabetes, stroke, coronary artery disease, and early death.
    • Upper body obesity (abdomen and flanks) poses greater health risks than lower body obesity (buttocks and thighs).

    Obesity Epidemiology

    • American adults:
      • 30.7% are overweight.
      • 42.4% are obese, including severe obesity.
      • 60% of individuals with obesity suffer from metabolic syndrome.
      • 40-70% of obesity is attributed to genetic influences.
      • Less than 1% experience secondary obesity (hypothyroidism, Cushing's syndrome).
    • Prevalence has increased over the past three decades, especially among those aged 20-60 years (peaks at 60, then slightly declines).

    Obesity Patient Evaluation

    • Focused History:
      • Factors contributing to the patient's obesity.
      • How obesity affects the patient's health.
      • The patient's level of risk from obesity.
      • The patient's difficulties in managing weight.
      • The patient's goals and expectations.
      • The patient's motivation to start a weight management program.
      • The type of assistance the patient requires.
    • Physical exam to determine the degree and type of obesity.
    • Assessment of comorbid conditions.
    • Determination of fitness level.
    • Assessment of the patient's readiness to adopt lifestyle changes.
    • History and Physical:
      • Family history of obesity (if negative, look for extraneous causes).
      • Weight gain history over time (recent vs. chronic).
      • Diet and exercise routine (sedentary vs. active vs. athletic).
      • Degree and distribution of body fat (increased health risks with centripetal obesity).
      • Signs of secondary obesity:
        • Cushing's syndrome (round face, buffalo hump, striae).
        • Hypothyroidism (depression, fatigue, constipation, cold intolerance, etc.).

    Hirsutism

    • Excessive male-pattern hair growth in women of reproductive age.
    • Affects 5-10% of females of reproductive age.
    • The most common cause is polycystic ovary syndrome (PCOS).

    Hirsutism Epidemiology

    • 20% of American women experience hirsutism.
    • 80% of women with androgen excess exhibit hirsutism (but not all women with hirsutism have excess androgens).
    • The extent of terminal hair growth varies by ethnic background:
      • East Asian and Native American women: Less body hair.
      • Southern European women (Mediterranean): More body hair.
    • Hirsutism can sometimes occur with virilization:
      • Male pattern alopecia, voice deepening, increased muscle bulk, clitoromegaly.
      • Virilization represents moderate to severe androgen excess.

    Hirsutism Etiology

    • Idiopathic Hirsutism:
      • Females with hirsutism, normal androgen concentrations, no menstrual irregularities, and no identifiable cause.
    • Hirsutism results from the interaction of circulating serum androgens, hair follicle sensitivity to those androgens, and local growth factors.
    • Key androgens:
      • Testosterone: Primarily from the ovaries.
      • Dehydroepiandrosterone sulfate (DHEAS): From the adrenal glands.
      • Androstenedione: From adrenal or ovarian sources.
    • Hair growth on the scalp, eyebrows, and eyelashes does not require androgens.
    • Androgens increase hair growth in other body areas (face, arms, legs, trunk).
      • Androgens lead to larger follicles, thicker hair, and a longer growth (anagen) phase.
      • Excess androgens in females cause hair growth in sensitive areas (lip, chin, back).
      • Scalp hair loss occurs due to a shorter growth (anagen) phase in androgen excess.
    • Nonclassical Adrenal Hyperplasia:
      • Characterized by excess androgens (seen in congenital adrenal hyperplasia).
      • Usually recognized at birth or early infancy.
      • The nonclassical form (primary 21-hydroxylase deficiency) presents as:
        • Females with hirsutism at puberty, menstrual irregularities, or primary amenorrhea.
        • No cortisol deficiency.
    • Females with Virilization or Severe Hyperandrogenemia:
      • Rapid virilization: Sudden onset of masculine traits in females, often from excess adrenal androgens.
      • Common causes: Androgen-secreting tumors (ovarian, adrenal) or ovarian hyperthecosis.
        • Ovarian hyperthecosis: Thecal cell hyperplasia in ovaries leads to excess testosterone, causing hirsutism and virilization.

    Autonomic Neuropathy

    • Generalized - ataxia, gait instability
    • Gastrointestinal - constipation (most common manifestation), dysphagia, abdominal pain, nausea, vomiting, diarrhea, fecal incontinence, gastroparesis
      • Gastroparesis may lead to poor glucose control.
      • Treatment includes diet changes and prokinetic agents (erythromycin, cisapride, domperidone).
      • Anti-emetics can be used for treatment.
      • Metoclopramide is used for severe cases only.
    • Cardiovascular - persistent sinus tachycardia, orthostasis, exercise intolerance
    • Genitourinary - Bladder neuropathy (poor urinary stream/straining, feeling of incomplete emptying, recurrent UTIs, pyelonephritis, incontinence), erectile dysfunction, retrograde ejaculation
    • Sudomotor Neuropathy - Heavy sweating of the upper body and anhidrosis (lack of sweat) of the lower body, gustatory sweating

    Hyperosmolar Hyperglycemic State (HHS)

    • Second most common form of hyperglycemic coma and a serious acute complication
    • It is a severe hyperglycemia in the absence of significant ketoacidosis.
    • There is hyperosmolality and dehydration leading to altered mental status.
    • Etiology: type 2 diabetes mellitus (T2DM) plus illness with fluid intake, but no ketoacidosis.
    • Pathophysiology: Decreased insulin -> Increase in counterregulatory hormones -> Decreased glucose utilization and increased gluconeogenesis -> Hyperglycemia -> Osmotic diuresis -> Dehydration -> Limited access to water, so the body holds onto water -> Hyperosmolar state
    • Signs/Symptoms: Develops over weeks to days, polyuria (+/- polydipsia), weight loss, weakness, tachycardia, hypotension, dry skin and mucous membranes, poor skin turgor, altered mental status without Kussmaul respirations

    Nonketotic Hyperosmolar State

    • Diagnosis: Plasma glucose > 600, serum osmolality > 320 (normal = 280-290), profound dehydration up to an average of 9 liters.
    • Blood urea nitrogen (BUN)/creatinine is elevated due to dehydration -> poor perfusion.
    • There is no significant acidosis (serum pH > 7.3, bicarbonate concentration > 15, small ketonuria and absent-to-low ketonemia).
    • May have some ketosis due to lack of eating.
    • Treatment: Rehydration, correction of hyperglycemia, treatment of underlying illness. May require insulin.

    Type 2 Diabetes Mellitus Wrap-Up

    • Every patient with T2DM needs:
      • Multidisciplinary team working with both the patient and the patient’s family.
      • A written plan that encompasses medications, diet/exercise, and goal setting.
      • Medications (with adequate refills). Most patients with T2DM are on multiple medications.
      • Education on using devices to calculate whether individuals are overweight or underweight.

    Body Mass Index (BMI)

    • BMI does not distinguish between muscle and fat.
    • BMI 18.5 – 24.99 = considered to be healthy.
    • Some people are healthy with other BMIs.
    • Some people are unhealthy in this BMI range.

    Obesity

    • Increased risk of:
      • Hypertension
      • Diabetes
      • Dyslipidemia
      • Obstructive sleep apnea
      • Nonalcoholic fatty liver disease
      • Some malignancies
    • Centripetal obesity (>40 inches in men, >35 inches in women) leads to an increased risk of diabetes mellitus, stroke, coronary artery disease, and early death.
    • Upper body obesity (abdominal and flank) = greater health risk vs. lower body (buttocks and thighs) obesity.

    Obesity Epidemiology

    • American adults:
      • 30.7% = overweight
      • 42.4% = obese
      • 9.2% = severe obesity
      • 60% with obesity have metabolic syndrome
      • 40-70% of obesity = genetic influences
      • < 1% = secondary obesity (hypothyroidism, Cushing syndrome)
    • Increased prevalence over the last 3 decades, especially with ages 20-60 years old (peaks at 60 then slightly declines).

    Obesity Patient Evaluation

    • Focused history:
      • History considerations:
        • What factors contribute to the patient’s obesity?
        • How is the obesity affecting the patient’s health?
        • What is the patient’s level of risk from obesity?
        • What does the patient find difficult about managing weight?
        • What are the patient’s goals and expectations?
        • Is the patient motivated to begin a weight management program?
        • What kind of help does the patient need?
    • Physical exam to determine the degree and type of obesity
    • Assessment of comorbid conditions
    • Determination of fitness level
    • Assessment of the patient’s readiness to adopt lifestyle changes

    Obesity History and Physical Examination

    • Family history of obesity. If negative, search for extraneous causes.
    • Weight gain history:
      • Recent vs. chronic.
    • Diet and exercise routine:
      • Sedentary vs. active vs. athletic.
    • Degree and distribution of body fat: Increased health risks with centripetal obesity.
    • Signs of secondary obesity:
      • Cushing syndrome - round face, buffalo hump, striae.
      • Hypothyroidism - depression, fatigue, constipation, cold intolerance, etc.

    Obesity Diagnostic Evaluation

    • Measurements:
      • Blood pressure.
      • Weight and height -> Calculate BMI.
      • Waist circumference.
    • Labs:
      • Thyroid-stimulating hormone (TSH) and Free T4.
      • Fasting lipid panel.
      • Fasting glucose.

    Obesity Differential Diagnosis

    • Increased caloric intake (life changes).
    • Fluid retention (heart failure, cirrhosis, renal failure).
    • Hypothyroidism.
    • Diabetes mellitus (type 2).
    • Drugs (antipsychotics, antidepressants, corticosteroids).
    • Insulinoma.
    • Binge eating disorder.

    Obesity Treatment

    • Primary approach (if no underlying condition): Diet and exercise.
    • Goal: Decrease in 10% body weight over 6 months or 1-2 pounds per week.
    • Reassess treatment plan after 6 months.

    Obesity Diet

    • General guidelines for weight loss:
      • Aim for a 500-750 kcal/day deficit from habitual diet.
      • For women: Consume 1200-1700 kcal/day.
      • For men: Consume 1500-1800 kcal/day.
      • Caloric intake should be adjusted based on the individual’s body weight.
    • No single diet is proven superior for long-term weight loss (>1 year). Mediterranean diet may reduce atherosclerotic cardiovascular disease (ASCVD) risk.
    • Low-carb, high-protein diets show increased weight loss at 6 months.

    Obesity Exercise

    • Best approach - Combine diet and exercise for effective long-term weight loss.
      • Exercise alone is usually not enough for maintaining weight loss beyond 1 year.
    • Physical Activity Guidelines:
      • 150 minutes of moderate-intensity or 75 minutes of vigorous activity per week performed for at least 10 minutes and spread throughout the week.
    • Simple activities: Brisk walking, using stairs, housework, and sports.
      • Pedometers or accelerometers can be used to track steps and activity.
      • Step counts are highly correlated with overall activity level.

    Obesity Adjunctive Behavioral Therapy

    • Cognitive behavioral therapy (CBT) strategies to help change and reinforce new dietary and physical activity behaviors.
    • Self-monitoring techniques (e.g., journaling, weighing, and measuring food and activity), stress management, stimulus control (e.g., using smaller plates, not eating in front of the television or in the car), social support, problem-solving, and cognitive restructuring to help patients develop more positive and realistic thoughts about themselves.

    Obesity Adjunctive Pharmacological Treatment

    • Considered for patients with:
      • BMI ≥ 30 kg/m2.
      • BMI ≥ 27 kg/m2 with concomitant obesity-related disease and when dietary and physical activity therapy has not been successful.
    • Gastrointestinal (GI) fat blockers - Orlistat (Xenical, Alli) (120 mg PO TID with meals).
      • 5% body weight loss.
      • Mechanism of action (MOA): Decreases fat absorption in the gastrointestinal tract (GIT).
      • Side effects: May cause GI distress (diarrhea, cramping, flatulence).
        • Low fat diet reduces symptoms, which can motivate the patient to stay on diet.
    • Appetite suppressants (anorexiants):
      • Lorcaserin (Belviq) (10 mg PO BID):
        • 5% body weight loss.
        • MOA: May promote satiety through serotonin agonist activity.
        • Side effects: Possible breast tumors, valvular heart disease, psychiatric problems.
      • Phentermine + topiramate:
        • 5-10% weight loss.
        • MOA: Amphetamine + anticonvulsant.
        • Side effects: Addictive potential, hypertension, tachycardia.
        • Distribution in the US is restricted (class IV drug).
      • Naltrexone + bupropion:
        • 2-4% weight loss.
        • MOA: Opioid antagonist + norepinephrine-dopamine reuptake inhibitor.
        • Side effects: Possible suicide, seizures, hypertension, tachycardia.
      • Liraglutide (Saxenda, Victoza):
        • 3-4% weight loss.
        • MOA: Injectable glucagon-like peptide-1 receptor agonist (regulates appetite and caloric intake).
        • Concerns include: Thyroid tumors, pancreatitis, gallbladder disease, renal impairment, tachycardia, suicidal thoughts.
        • Side effects: Nausea, vomiting, diarrhea, constipation, hypoglycemia.

    Obesity Bariatric Surgery

    • Considered for patients with:
      • Severe obesity (BMI ≥ 40).
      • Moderate obesity (BMI ≥ 35) associated with serious medical conditions/comorbidities.
        • Obesity comorbidities: Joint disease, obstructive sleep apnea, diabetes mellitus, hypertension, gastroesophageal reflux disease (GERD).
    • Surgical procedures include: Roux-en-Y gastric bypass, gastric banding, sleeve gastrectomy, intraluminal gastric balloon.
      • Intraluminal gastric balloon: Gastric balloon devices placed in the stomach endoscopically.
        • Two devices approved - RESHAPE (consists of two silicone balloons attached to a central silicone shaft) and ORBERA (single-balloon device).
          • Mean weight loss of 7.2 kg and 8.8 kg, respectively, was seen for these devices in short-term pivotal trials.
          • Both systems are approved only for ≤ 6 months of use in adults with a BMI of 30–40.
        • Adverse effects: Nausea, vomiting, abdominal pain.
    • Complications: Infection, hernia, nutritional deficiencies, neuropathy, blood clots.
    • Mortality: 1% risk in the postoperative period, higher rate within the first year after surgery.
    • Multidisciplinary approach: Diet, exercise, behavioral modification, social support, pre-meal planning.

    Obesity Outcomes and Prognosis

    • Hypertension and hyperlipidemia.
    • Coronary artery disease.
    • Type 2 diabetes mellitus.
    • Degenerative joint disease.
    • Psychosocial disability.
    • Increased cancers (colon, rectum, prostate, uterus, biliary tract, breast, ovary).
    • Thromboembolic disorders (myocardial infarction, stroke, pulmonary embolism).
    • Digestive tract diseases (gallstones, reflux esophagitis).
    • Skin disorders (hidradenitis suppurativa, striae, acanthosis nigricans, delayed wound healing, infections).
    • 20% lose 20 pounds.

    Hirsutism

    • Excessive hair growth in women in male-pattern distribution (face, chest, abdomen, back).
    • It is a common symptom of androgen excess.
    • Most common causes include:
      • Polycystic ovary syndrome (PCOS).
      • Idiopathic hirsutism.
      • Ovarian hyperthecosis.
      • Androgen-secreting tumors.
      • Nonclassic congenital adrenal hyperplasia (NCCAH).
      • Other less common causes.

    Ovarian Hyperthecosis

    • Nonmalignant ovarian disorder with increased testosterone from luteinized thecal cells.
    • Testosterone levels are often greater than 700, meaning markedly increased.
    • It is unclear if it is a distinct disorder or part of PCOS.
    • Mostly affects postmenopausal women but can occur in premenopausal women.

    Androgen-Secreting Tumors

    • Usually occurs later in life and progresses rapidly compared to PCOS.
    • Approximately 5% of ovarian tumors.
    • Identified by pathology (biopsy/surgery) or transvaginal ultrasound (TVUS).
    • Most females have testosterone levels >150-200 and present with virilization.
    • Rare cause of androgen excess.
    • Adenomas secrete testosterone.
    • Carcinomas secrete dehydroepiandrosterone (DHEA), DHEA sulfate (DHEAS), and cortisol.
    • Symptoms: Androgen excess, Cushing syndrome.
    • Elevated DHEAS suggests adrenal carcinoma.

    Uncommon Causes of Hirsutism

    • Hyperprolactinemia (pituitary adenoma).
    • Acromegaly (pituitary adenoma).
    • Hypothyroidism.
    • Severe insulin resistance.
    • Drugs: Androgen therapy (testosterone, DHEA), danazol (used to treat endometriosis).

    Hirsutism Clinical Presentation

    • Mild to moderate hirsutism:
      • Regular menses, no clear cause -> Idiopathic hirsutism.
    • Hirsutism with:
      • Acne, male pattern alopecia, acanthosis nigricans, obesity, and/or oligomenorrhea -> Think PCOS.
      • Increased cortisol and/or androgens.
    • Increased prolactin (PRL): Galactorrhea, vision changes, infertility, oligo/amenorrhea.
    • Congenital adrenal hyperplasia (CAH): Menstrual abnormalities, virilization, increased DHEA/DHEAS/androstenedione.
    • Androgen-secreting tumor: Older age, rapid progression, virilization.
    • Ovarian hyperthecosis: Older age, intense slow-progressing hirsutism.

    Hirsutism Diagnostic Evaluation

    • Idiopathic hirsutism:
      • Total testosterone = Normal.
    • Polycystic ovary syndrome (PCOS):
      • Total testosterone = usually elevated.
      • Transvaginal US (TVUS).
    • Androgen-secreting tumor:
      • Total testosterone = elevated ≥ 2x normal values.
      • Get DHEAS (primarily adrenal origin) and androstenedione (primarily ovarian origin).
      • Pelvic ultrasound.
      • Computed tomography (CT) of abdomen and pelvis.

    Hirsutism Treatment

    • Treat underlying cause: Remove tumor, block androgen production (Oral contraceptive pills suppress gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) = decreased ovarian androgens).
    • Block androgen response:
      • Spironolactone (androgen antagonist, recommended).
      • Finasteride (inhibits 5-alpha-reductase type 2 - enzyme that converts testosterone to dihydrotestosterone (DHT), concerns about its use inadvertently in pregnancy).
      • Flutamide (non-steroidal androgen receptor antagonist, prostate cancer drug used off label).
      • Antiandrogens contraindicated in pregnancy.
    • Block hair growth: Vaniqa (retards hair growth).
    • Hair removal:
      • Depilatory creams (Nair).
      • Electrolysis, laser ablation.
      • Manual (plucking).

    Hirsutism Urgent Considerations

    • Rapid virilization:
      • Evaluate for tumor.
      • Adrenal gland CT.
      • Ovarian TVUS.

    Polycystic Ovarian Syndrome (PCOS)

    • Most common endocrine disorder in reproductive-age women (5-10%).
    • 90% of hyperandrogenism in women.
    • Prevalence does NOT vary across different regions of the world.
    • Causes menstrual irregularity and androgen excess.
    • Symptoms: Hirsutism, irregular menses, polycystic ovarian morphology on transvaginal ultrasound.

    PCOS Etiology

    • Unknown etiology: Multiple systems involved, primary defect unclear.
    • Theories:
      • Hypothalamic-pituitary axis defect -> Increased amplitude and frequency of luteinizing hormone (LH) pulses -> Increased gonadal androgens.
      • Intrinsic ovarian defect -> Androgen overproduction and anovulation.
      • Defects in insulin sensitivity = insulin resistance -> hyperinsulinemia.
    • Pathophysiology: Not well understood, multiple mechanisms possible.

    PCOS Risk Factors

    • Family history (FHx): PCOS inherited as a common complex disorder (multiple genes involved).
    • Premature adrenarche (before age 8 in girls).

    PCOS Signs/Symptoms

    • Menstrual dysfunction: Delayed menarche, oligomenorrhea (irregular flow), amenorrhea (no menses for 3+ months).
    • Hyperandrogenism: Hirsutism, acne, male pattern hair loss, most have elevated androgens.
    • Hirsutism.
    • Polycystic ovaries: Seen on TVUS.
    • Metabolic/cardiovascular risks:
      • 40-85% are overweight/obese.
      • Insulin resistance, type 2 diabetes mellitus, coronary artery disease, sleep apnea, nonalcoholic fatty liver disease.
    • Mood: Linked to depression, anxiety, impaired quality of life, eating disorders.
    • Symptoms:
      • Hirsutism 60%.
      • Acne 20%.
      • Scalp hair loss 5%.
      • Oligomenorrhea (< 6-8 menses/year).
      • Amenorrhea (no menses).
      • Irregular menses.
      • Weight gain.
      • Infertility.
    • Physical examination:
      • Hirsutism.
      • Acne.
      • Alopecia.
      • Possible hypertension.
      • Acanthosis nigricans.
      • Sweating.
      • Oily skin.

    PCOS Differential Diagnosis

    • Congenital adrenal hyperplasia (CAH) = 21 hydroxylase deficiency - most common cause of congenital adrenal hyperplasia, missing enzyme -> overproduction of adrenal hormones.
    • Thyroid dysfunction.
    • Hyperprolactinemia.
    • Cushing syndrome (rare).
    • Androgen-secreting neoplasm.

    PCOS Diagnostic Evaluation

    • Rotterdam Criteria (Preferred) - 2 of 3 Required -
      • Oligo- and/or anovulation.
      • Clinical and/or biochemical signs of hyperandrogenism.
      • Polycystic ovaries (by ultrasound).
      • Diagnosis confirmed after excluding other conditions (thyroid disease, nonclassic congenital adrenal hyperplasia (NCCAH), hyperprolactinemia, androgen-secreting tumors).
    • Serum total testosterone:
      • Measure if evidence of androgen excess.
      • Upper limit of normal for women is 45-60.
      • Levels > 150 require evaluation for ovarian or adrenal androgen-secreting tumor or ovarian hyperthecosis.
    • DHEAS - not suggested for everyone:
      • Measure for symptoms of severe hyperandrogenism.
      • Can be extremely elevated in patients with adrenal carcinoma.
    • Androstenedione: Role unclear in evaluation of PCOS (mixed results).
    • Serum 17-hydroxyprogesterone:
      • Measure morning level in early follicular phase to rule out congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

      • 800 = adrenal hyperplasia.

    • Follicle-stimulating hormone (FSH) and estradiol: High in premature ovarian insufficiency (also have low estradiol).
    • Thyroid-stimulating hormone (TSH): Check for thyroid abnormalities (also cause irregular menses/ovulation).
    • Increased prolactin: Pituitary adenoma causes irregular menses, ovulation, galactorrhea.
    • Cushing syndrome: If suspected, perform 24-hour urine cortisol or dexamethasone test.
      • Shared symptoms include: Oligomenorrhea, hirsutism, obesity, hypertension, striae, muscle weakness.
    • Transvaginal ultrasound (TVUS): Used to check for polycystic ovarian morphology (PCOM).
      • Not all suspected PCOS patients need ultrasound.

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