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
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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