Polycystic Ovarian Syndrome Dr Louise Knowles 12/12/16 PCOS;

Polycystic Ovarian Syndrome Dr Louise Knowles 12/12/16 PCOS;

Polycystic Ovarian Syndrome Dr Louise Knowles 12/12/16 PCOS; points to cover today Diagnosis Clinical Features; presentation and long term consequences Hormonal Disturbances

Subtypes PCOS Investigations Management. PCOS Originally described 1935 by Stein and Leventhal. Redefined 2003 by American and

European Societies reproductive medicine Patient likely to present with menstrual disturbance, acne, hirsutism, infertility. PCOS; genetics Heterogenous; familial clustering. Autosomal dominant inheritance, variable penetrance in females; 50% chance of

offspring being affected Phenotype manifests itself via raised androgen levels secreted by ovarian theca cells. Severity seems to be determined by factors such as obesity PCOS Statistics

Incidence: 15-25% UK Women 50% UK Asian Women South Asian women present at younger age and often have more severe symptoms USS assessment 20-30% Caucasian women have PCO

5-15% Caucasian women have PCOS Polycystic ovaries not necessary to make diagnosis of PCOS Ultrasound assessment of the polycystic ovary: international consensus 12 or more follicle

measuring 2-9mm and/or Increased ovarian volume (>10cm3) ASRM Consensus 2003 Diagnostic Criteria Two out of three criteria required 1.Anovulation or oligo-anovulation

2.Hyperandrogenism Clinical (hitsuitism, acne) Biochemical (raised testosterone) 3.Polycystic ovaries(12 or more follicles,29mm diameter) Diagnostic criteria Other causes of menstrual disturbance

and hyperandrogenism must be excluded. Hyperandrogenism Alopecia Hirsuitism Acne

Differential Diagnoses Cushings Adrenal/Ovarian tumours ( virilisation) Congenital adrenal hyperplasia Menopause/Ovarian failure Exogenous- anabolic steroid, testosterone medication Hypothalamic/pituitary disorders

Long Term Consequences Metabolic syndrome, with increased risk type 2 diabetes, hyperlipidaemia Fertility problems Psychological distress Endometrial cancer Increase risk sleep apnoea

Endocrinology Normal function of the pituitary and ovary Hormonal abnormalities underlying PCOS PCOS; the hormones In women with PCOS, the theca cells of the ovary produce excess androgens,

which may be due to hyperinsulinaemia or increased serum levels of luteinizing hormone (LH) Weight gain Insulin Resistance

Insulin Inhibits SHBG Testosterone Androgenic Effects

Acne Hirsuitism Irreg periods Infertility Fat storage PCOS; the hormones Insulin resistancehyperinsulinaemia as a

key factor in PCOS for many women Insulin and LH lead to androgen production from theca cells. androgen leads to follicular arrest and anovulation Subtypes of PCOS

LH Driven Insulin Driven LH Driven Slim High LH High Impaired GTT

(10%) Responds to ovarian diathermy Insulin Driven XS Centripetal fat Acanthosis Nigricans Longer inter-menstrual

interval Investigations; PCOS LH; or normal FSH often normal. Total testosterone; normal or slightly raised ( if >5 nmol/l exclude androgen secreting tumours)

Free testosterone may be SHBG normal or Free androgen index normal or Investigations Free androgen index FAI FAI =Total testosteronex100/SHBG Or; Free Testosterone.

Investigations for diff. diagnosis TSH Prolactin

17-hydroxyprogesterone ( CAH) DHEA-S and FAI ( androgen secreting tumours) 24 hr urinary cortisol ( Cushings) Investigations PCOS In addition to hormone profile; need to check Lipid profile

LFTs if high BMI HBa1C/GTT ( fasting glucose not sensitive enough) Other Menstrual Irregularities FSH + LH + E

Other Menstrual Iregularities FSH + LH + E Ovarian failure/ menopause Other Menstrual Iregularities FSH + LH + E

Ovarian failure/ menopause FSH + LH + E Other Menstrual Iregularities FSH + LH + E Ovarian failure/ menopause

FSH + LH + E Hypothalamic/pituitary Underweight Overexercise Chronic Illness

Management Aims: Managing symptoms Reducing long term consequences Management Weight management/ psychological support Hair removal.

Oligo/amenorrhoea Infertility Weight Management Aim: 5-10% wt loss (can achieve 30% loss of visceral fat) Empower the patient Be kind

Discuss long term health Depression in 70% Oligo/amenorrhoea Need to bleed every 3-4m to avoid unopposed oestrogen, increased risk endometrial cancer. Endometrial protection will be provided by

desogestrel/implant/ Mirena. Consider COCP COCP

Oestrogens increase SHBG Dianette Yasmin Any cocp will help prevent androgenic effects and give regular bleed enabling endometrial protection Fertility, when BMI>30

Clomiphene citrate Ovarian drilling( useful in LH driven PCOS) Ovulation induction IVF Weight loss alone may be enough. Goal weight

5-10% weight loss reduces visceral fat by 30%..... Beware of pregnancy Impact on insulin levels Give realistic goals; eg 1kg per week. Orlistat Bariatric surgery. What about metformin?

Ineffective for hyperandrogenism Ineffective for anovulation Use for IGT( & continue if conceives?)

May be used to reduce risk of ovarian hyperstimulation in IVF May be used in sec care in treatment infertility (Nice 2013)? Hirsutism Eflornithine ( Vaniqua); 4m trial.....55 per tube!! Can be prescribed as NHS drug in

PCOS/hirsutism (Spironolactone) Laser treatment Pregnancy and PCOS Gestational diabetes( OR 3.6)Do GTT at 24-28w Increased risk hypertension, preclampsia.

Increased risk preterm birth/ small for dates infants. Increased risk PCOS in offspring 14% will have a major pregnancy related complication West Yorkshire! South Asian women resident in Yorkshire

with anovular PCOS; Present younger Develop oligomenorrhoea younger Have more T2DM in families Have more acanthosis nigricans & hirsutism Have higher insulin resistance.

PCO and the future Increasing incidence Needs holistic approach Primary care pivotal role with support specialists; gynaecology, dietician, counsellors, beauticians. Patient support groups

www.verity-pcos.org.uk www.soulcysters.com American Useful references Polycstic Ovary Syndrome; Nice CKS Feb 2013 RCOG Green Top guideline No 33; Long Term Consequences of PCOS (2014)

Hirsutism; Nice CKS Dec 2014 https://www.womens-health-concern.org have an excellent fact sheet for patients.

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