PCOS PDF

PCOS Dr Nadia Muhaidat  Polycystic ovary syndrome (PCOS) is a significant public health issue with reproductive, metabolic and psychological features. PCOS is one of the most common Background conditions in reproductive aged women...

PCOS Dr Nadia Muhaidat  Polycystic ovary syndrome (PCOS) is a significant public health issue with reproductive, metabolic and psychological features. PCOS is one of the most common Background conditions in reproductive aged women affecting 8-13% of reproductive-aged women with a higher prevalence in certain ethnicities Up to 70% of affected women are undiagnosed  Two of the following three criteria are required: Oligo/anovulation Hyperandrogenism clinical (hirsutism or less commonly male pattern alopecia) or Rotterdam biochemical (raised FAI or free testosterone) Criteria Polycystic ovaries on ultrasound Other aetiologies must be excluded such as congenital adrenal hyperplasia, androgen secreting tumours, Cushing syndrome, thyroid dysfunction and hyperprolactinaemia  > Hirsutism and male pattern balding consistent with hyperandrogenism, acne - Irregular or absent menstrual cycles Presentation > C Subfertility or infertility Psychological symptoms - anxiety, depression, - psychosexual dysfunction, eating disorders - - Metabolic features obesity, dyslipidaemia, diabetes - - Phenotypes National Institutes of Health (NIH) evidence-based methodology workshop of PCOS 2012 phenotypes: Phenotype A: Androgen excess + ovulatory dysfunction + polycystic ovarian morphology Phenotype B: Androgen excess + ovulatory dysfunction Phenotype C: Androgen excess + polycystic ovarian morphology Phenotype D: Ovulatory dysfunction + polycystic ovarian morphology Oligo/anovulation > 1 to < 3 years post menarche: < 21 or > 45 days - normal in the first year post > 3 years post menarche to menarche as part of the perimenopause: < 21 or > 35 # pubertal transition days or < 8 cycles per year - - - Primary amenorrhea by age E Irregular menstrual cycles3 are defined as: 15 or > 3 years post thelarche (breast > 1 year post menarche > 90 days for any one cycle- development) - - Ovulatory dysfunction can still occur with regular cycles and if anovulation needs to be confirmed serum progesterone levels can be measured. Hyperandrogenism Hirsutism: difficult to assess as most women treat this. Acne Male pattern alopecia Biochemical hyperandrogenaemia If free testosterone is significantly raised or there is evidence of rapid virilisation, further investigations are required to exclude late onset congenital adrenal hyperplasia and virilising tumours  polycystic ovaries on ultrasound are diagnosed when& - 12 small antral follicles are seen in per ovary measuring 2 to 9 mm in diameter or an ovary that has a - volume of greater than 10 mL. A single ovary meeting either or both of these - - - - definitions is sufficient for the diagnosis of polycystic ovaries. - Ovarian A unilateral polycystic ovary is rare but still clinically significant. Morphology Ultrasound is not reliable in the diagnosis of polycystic ovaries in adolescent and young women. Up to 70% of young women may have polycystic ovaries on ultrasound Ultrasound should not be used to diagnose PCOS within 8 years of menarche. This Photo by Unknown Author is licensed under CC BY  Management of PCOS requires identification and management of current symptoms, attention to fertility and emotional concerns, as well as preventive activities to minimise the risk of future associated health problems. Management Lifestyle modification Medical treatment Surgical treatment Ovulation induction/Assisted reproduction techniques  Higher prevalence of PCOS in women who are overweight and obese Lifestyle Women with PCOS have a higher rate of weight gain than those without PCOS about 1 2 kg/year. Modification Even a small amount of weight loss (5%) can help restore menstrual cycle regularity and ovulation, assist mental wellbeing, halve the risk of diabetes in high risk groups and help prevent future cardiometabolic risk. Lifestyle Modification HEALTHY DIET WITH CALORIC BEHAVIOUR CHANGE SUPPORT AND RESTRICTION EXERCISE TO AID IN WEIGHT LOSS AND PREVENTION OF FUTURE WEIGHT GAIN.  Irregular menstrual cycles The combined oral contraceptive pill (COCP) is effective in achieving Cmenstrual cycle regularity and also > provides contraception if this is required. The 35 microgram ethinyloestradiol plus cyproterone acetate preparations Medical should not be considered first line in PCOS as per general population Treatment guidelines, due to adverse effects including venous thromboembolic risks. In women with oligo/amenorrhoea, intermittent progestin every 3 months may be used to induce a withdrawal bleed and protect the endometrium from hyperplasia.  Hirsutism The choice of options depends on patient preference, impact on wellbeing and access and affordability. The best treatment for localised hirsutism is cosmetic therapy (eg. laser and electrolysis) by an experienced operator, but expense and access may be barriers to Medical this treatment for some women. Treatment of local facial hair may be augmented in the Treatment short term by topical eflornithine, but this is also costly. Generalised hirsutism may benefit from a combined medical and cosmetic approach.The COCP is first line medical therapy with no clear evidence to support the benefit of any particular COCP. Metformin may also provide some benefit. Surgical Treatment surface ofovary Laparoscopic ovarian drilling -no injury on the - tissue avarian Aggressive  Polycystic ovary syndrome is the most common cause of anovulatory infertility. Lifestyle modification: In women aged less than 35 years with a BMI >25 kg/m2 and no other cause of infertility, an intensive lifestyle program addressing weight loss, without any pharmacological treatment Subfertility for the first 6 months. If lifestyle measures are unsuccessful, then consider referral to a fertility specialist. Referral should be initiated early for women aged more than 35 years and in couples with additional factors contributing to infertility.  1st line: Letrozole superior to clomiphene citrate Ovulation 2nd line: gonadotrophins If the above are unsuccessful or if induction in there are other factors contributing to infertility such as endometriosis or PCOS male factors, in vitro fertilisation or intra-cytoplasmic sperm injection is recommended. Laparoscopic ovarian drilling  Assess cigarette smoking and discuss quitting - Weight monitoring and management - Cardiovascular Lipid profile monitoring every 2 years if initially normal Risk - and every year if abnormal and/or overweight or obese. Modification Measure blood pressure annually if BMI 25 kg/m2 - - - => Assess for prediabetes with oGTT  Proven to be beneficial in patients with impaired glucose tolerance/insulin resistance - - Metformin in addition to lifestyle modification, could be recommended in adult women with PCOS, for the treatment of weight, hormonal and metabolic outcomes. -Can be used as an adjunct to COCP for cycle regulation Metformin Can be used as an adjunct to oral or parenteral OI agents Er Good safety profile - - Side effects may be significant THE END