Pcos

PCOS

1. Case presentation Fadhila Al- Busaidi family medicine R4

2. Case F 22 yrs old lady, unmarried, c/o irregular period since 2 yrs. Her period comes every 2-3 months. normal flow , no inter-menstrual bleeding She gained 20kg in the past 18 months.

3. Case: O/E: Obese lady, BMI 30 BP: 125/80 . HR: 75 Grade II acne over her face. Mild fine hair growth , face . Thyroid: normal. Systemic examination normal.

4. Outline: Epidemiology and pathophysiology. Clinical manifestation. Diagnosis. Management.

5. E pidemiology: PCOS is the most common endocrinopathy among reproductive-aged women in the United States, affecting approximately 7% of female patients. Azziz R, Woods KS, Reyna R, Key TJ, Knochenhauer ES, Yildiz BO. The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab . 2004;89(6):2745-2749.

6. Pathophysiology: H as been linked to altered ( LH) action, insulin resistance, and a possible predisposition to hyperandrogenism . One theory maintains that underlying insulin resistance exacerbates hyperandrogenism by: suppressing synthesis of sex hormone–binding globulin and increasing adrenal and ovarian synthesis of androgens, thereby increasing androgen levels. These androgens then lead to irregular menses and physical manifestations of hyperandrogenism

7. Clinical manifestation:

8. Diagnosis: Rotterdam criteria: Diagnosis requires the presence of at least two of the following three findings: H yperandrogenism , O vulatory dysfunction, P olycystic ovaries. ] AAFP and RCOG [

9. Diagnosis: Diagnosis can generally be accomplished with a careful history, physical examination, and basic laboratory testing, without the need for ultrasonography or other imaging. ] AAFP [

10. Common Comorbidities PCOS is associated with metabolic syndrome . About one-half of women with PCOS are obese . Increase risk of cardiovascular disease. Fourfold increase in the risk of T2DM. I ncreased prevalence of nonalcoholic fatty liver disease, sleep apnea, and dyslipidemia in patients with PCOS, even when BMI is controlled. I ncreased risk of mood disorders among patients with PCOS

11. PCOS the American College of Obstetricians and Gynecologists recommend that clinicians evaluate: blood pressure at every visit, lipid levels at the time of diagnosis, screen for T2DM with GTT regardless of a patient’s BMI. Patients should have repeat diabetes screening every 3-5years , or more often if other indications for screening are present.

12. How to approach pt with PCOS

13. Remember: There is no need to order laboratory testing for these conditions if the patient does not have suggestive physical findings .

14. LH/FSH ratio ? N ot necessary A ratio >2 generally indicates PCOS, but there are no exact cutoff values because many different assays are used . The FSH level is more helpful in ruling out ovarian failure.

15. Adolescent and PCOS Anovulation is common after menarche, so it is reasonable to delay workup for PCOS in adolescents until they have been oligomenorrheic for at least two years. If an adolescent is evaluated for PCOS, it has been suggested that she meet all three of the Rotterdam criteria before being diagnosed with the condition.

16. Treatment: Treatment should be individualized based on the patient’s presentation and desire for pregnancy.

17. Anovulation and infertility Lifestyle modification and weight reduction reduce insulin resistance and can significantly improve ovulation . Lifestyle modification considered as first-line therapy for women who are overweight . AAFP

18. Anovulation and infertility clomiphene citrate (50–100 mg ). S uccessful in inducing ovulation in 75–80% of women. Needs Ultrasound monitoring to minimise the 10% risk of multiple pregnancy, and to ensure that ovulation is taking place ] NICE [

19. Anovulation and infertility The Endocrine Society recommends clomiphene or letrozole ( Femara ) for ovulation induction. AAFP Recent studies suggest that letrozole is associated with higher live-birth rates and ovulation rates compared with clomiphene in patients with PCOS. Legro RS, Brzyski RG, Diamond MP, et al.; NICHD Reproductive Medicine Network. Letrozole versus clomiphene for infertility in the polycystic ovary syndrome [published correction appears in N Engl J Med . 2014; 317(15):1465]. N Engl J Med . 2014;371(2):119-129.

20. Metformin and F ertility The impact of metformin on fertility is controversial; although it was once believed to improve infertility, a 2012 Cochrane review concluded that it does not. AAFP Metformin alone may improve the rate of ovulation, but results of a large RCT shows that metformin will result in a live birth rate of only 7%. In the same RCT, metformin added to clomiphene conferred no additional benefit in terms of live birth rate compared with clomiphene alone. NICE

21. Irregular period: In a patient not seeking pregnancy, hormonal contraception i s the initial medication for treatment of irregular menses and hyperandrogenism manifesting as acne or hirsutism . N o superiority of one oral contraceptive over another in treating PCOS. Prevention of endometrial hyperplasia from chronic anovulation may be accomplished by progesterone derivatives .

22. Irregular period: Small studies have shown that metformin can restore regular menses in up to 50% to 70% of women with PCOS, but oral contraceptives have been shown to be superior to metformin for regulating menses and lowering androgen levels Romualdi D, De Cicco S, Tagliaferri V, Proto C, Lanzone A, Guido M. The metabolic status modulates the effect of metformin on the antimullerian hormone-androgens-insulin interplay in obese women with polycystic ovary syndrome. J Clin Endocrinol Metab . 2011;96(5):E821-E824.

23. Hirsutism : According to a 2015 Cochrane review, the most effective first-line therapy for mild hirsutism is oral contraceptives . Spironolactone , 100 mg daily, and flutamide , 250 mg twice daily, are safe for patient use, but the evidence for their effectiveness is minimal . E lectrolysis , or lasers and intense pulsed light.

24. Acne: Hormonal contraceptives are first-line medications for treating acne associated with PCOS, in conjunction with standard topical acne therapy (e.g., retinoids , antibiotics, benzoyl peroxide) or as monotherapy . Antiandrogens , spironolactone can be added as second-line medications .

25. When to refer: Serum testosterone >5 nmol /l (to exclude other causes of androgen excess, e.g. tumours , late onset congenital adrenal hyperplasia, Cushing's syndrome) Infertility Rapid onset of hirsutism (to exclude androgen secreting tumours ) Glucose intolerance/diabetes Amenorrhoea of more than 6 months—for pelvic ultrasound scan to exclude endometrial hyperplasia Refractory symptoms NICE

26. Take home messages: All women diagnosed with PCOS should be screened for metabolic abnormalities (T2DM, dyslipidemia, hypertension), regardless of BMI. All women with suspected PCOS should be screened for thyroid disease, hyperprolactinemia , and nonclassical congenital adrenal hyperplasia.

27. References: AAFP July 2016. NICE September 2012. RCOG June 2015.