Pcospcos pcos pcos pcos pcos pcos pcos.pptx

Pcos

1. PCOS

2. PRESENTED BY DR. NIBEDITA RABHA O&G PGT MODERATOR DR. PARESH KALITA MD O&G JOINT DIRECTOR, DHS, BARPETA Cum President, barpeta O&G Society and Dr BHARAT TALUKDAR MD, O&G ASSSISTANT PROFESSOR FAAMCH

3. Polycystic Ovarian Syndrome PCOS or also called as Stein-Leventhal syndrome is the single most common heterogenous and multisystem endocrine abnormality of women in reproductive age group. Most common cause of secondary amenorrhoea Characterised by a combination of menstrual irregularities ,HA, chronic anovulation and polycystic ovaries Frequently associated with insulin resistance and obesity Incidence : World wide incidence is 6-10%

4. National institute of health(NIH) diagnostic criteria for PCOS(1990) It was based on consensus rather than clinical trial evidence Both criterias must be present: Chronic anovulation Clinical and/or biochemical signs of hyperandrogenism and exclusion of other etiologies

5. Rotterdam Criteria for diagnosis of PCOS(2003) In 2003, a concensous workshop on PCOS sponsored by ASRM and ESHRE in Rotterdam stated that any 2 out 3 criteria must be present to be diagnosed as PCOS Menstrual cycle abnormalities ( amenorrhoea/ oligomenorrhoea )(menstrual cycle length upto 35 days) Clinical & or biochemical evidence of Hyperandrogenism(excess androgen activity– mFG >6 and s. testosterone >0.56ng/ml USG appearance of polycystic ovaries : Presence of 12 or more follicles in either ovary measuring 2-9 mm with an ovarian volume of more than 10 mm

6. Any 2/3 criteria are needed to make the diagnosis after the other causes of androgen excess (ex- adrenal tumor and ovarian tumor) are excluded. In adoloscents , all three criteria need to be satisfied as USG features similar to PCOS may be seen normally in this age group. However, ANDROGEN EXCESS AND PCOS SOCIETY IN 2006, TIGHTENED THE CRITERIA and suggested that 3/3 criteria needed for diagnosis of PCOS.

7. Recent updates in ROTTERDEM CRITERIA(2018) International PCOS guideline in 2018 has mentioned threshold follicle numbers per ovary to be greater or more than 12 to diagnose PCOM They introduced this new term PCOM which is also known as POLYCYSTIC OVARIAN MORPHOLOGY. PCOS can be categorized now into 4 phenotypes a/c Rotterdem’s criteria.. Among this phenotype c and d requires presence of PCOM for the diagnosis of PCOS PHENOTYPES HA(HYPERANDROGENISM) ,OD(OVULATORY DYSFUNCTION) and PCOM A HA + OD + PCOM B HA + OD C HA + PCOM D OD + PCOM

8. FIG. TVS SHOWING PERIPHERALLY ARRANGED FOLLICLES IN PCOS (NECKLACE APPERANCE)

9. Irregular menstruation Severe Acne Hirsutism Obesity Acanthosis Nigricans Skin Tags Alopecia Depression Sign and Symptoms of PCOS

10. Screening Recommendations… Only to treat current symptoms is not sufficient in PCOS, but we must try to prevent any long-term morbidity So screening recommendations are an essential part of the management of PCOS.

11. Screening for Type 2 DM and GDM European Society of Endocrinology (ESE) recommends an oral glucose tolerance test (OGTT) in all obese PCOS women and in lean PCOS of > 40 years, with a history of GDM or family history of T2DM On the contrary, the Endocrine Society and ESHRE/ASRM recommend to perform OGTT in all adolescents and adult women with PCOS, due to their high risk in developing IGT and T2DM. Recent international guideline in PCOS recommends an OGTT preconception or early in pregnancy at 24 to 28 week gestation. Neither of the 2 societies recommends HBA1C as screening test.

12. Screening for CVD current international guidelines recommend that all women with PCOS should be screened for individual CVD risk factors Guidelines recommend cigarette smoking assessment, body weight and BMI measurements, blood pressure monitoring, and a complete lipid profile panel The Australian Guideline emphasizes CVD screening recommendations, including blood pressure measurement annually if BMI ≤ 25 kg/m2 or at each visit if BMI ≥ 25 kg/m2 and lipid profile assessment every 2 years if initially normal or every year if initially abnormal

13. Screening for Psychological Wellbeing Guidelines recommend these women should be screened for not only depression and anxiety but also for negative body image, eating disorders, and psychosexual dysfunction If screening is positive, further assessment by health physician and referral to a specialist is recommended. A few studies indicate an increased risk of depression in adolescents also and this group warrants screening.

14. Clinical Management Lifestyle modification Weight reduction Smoking cessation Drug treatments: For women not wanting to conceive at present: DOC: OCPs Regularise the periods Prevents endometrial hyperplasia Also helps with hirsutism

15. Cyclical progestogens: Medroxy progesterone acetate in dose of 10mg twice daily for 5 days or 10 mg once a day for 5 days can regularise periods in women who do not have hirsutism and do not prefer OC pills Oral contraceptives with anti androgen is the drug of choice for adolescent with PCOS with hirsutism and acne Treatment for hirsutism: Oral pill with cyproterone acetate Other drugs like spironolactone, flutamide, finasteride etc can also be helpful

16. Treatment for acne: Oral antibiotics like doxycycline, minocycline are useful For severe cases isotretinoin is used Cosmetic therapy Woman trying to conceive: Drugs to induce ovulation: DOC: Letrozole ( aromatose inhibitor )

17. Management of infertility: Clomiophene citrate is the DOC and first line treatment for all patients of PCOS with infertility In vitro fertilisation in PCOS if all other methods fail To counter insulin resistance: DOC: Metformin Pioglitazone when metformin is not tolerated or resistant

18. Myo-inositol and d- chiro- inositol D chiro inositol is vitamin B8, a post receptor insulin sensitizers and intracellular mediators of insulin action, enhances insulin sensitivity and improves insulin resistance. It is given in dose of 2g twice daily It improves infrequent menstrual bleeding and ovulation in PCOS patients. It also helps in dyslipidemia and weight reduction.

19. [1] 1. European Review for Medical & Pharmaceutical Sciences, 2013, 17:537-540, 2. Ann Nutr Metab (2015) 67 (1): 42-48, 3. Nutrition Reviews, Vol. 56. No. 9, 4. Frontier in Endocrinology, May 2019, Vol. 10, Article 273, 5. Int J. Endocrinology, Vol. 2018, Article ID: 1349868 [2,3] [4,5]

20. Hyperandrogenism & Hyperinsulinemia 1. Plos One, Dec. 2015, 2. Int. J. of Endocrinology, Vol. 2016, 3. Zheng et. al. Medicine (2017) 96:49, 4. Int. J. Obst & Gync . Vol. 101, May 2008, 5. Egypt J. Fertil Steril Vol. 23, N0. 2, Jun 2019, 6. J. of Paed Gync , Vol. 28, Issue 2, Apr. 2015, 7. BMC Women’s Health (2022) 22:79

21. International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2018 OI: Ovulation induction; IUI: Intrauterine insemination; PR: Pregnancy rate; MPA: Medroxyprogesterone acetate; E: Estrogen; P: Progesterone Women of Reproductive Age

22. COC Progesterone Estradiol Levonorgestrel Medroxyprogesterone Acetate Drosperinone Antiandrogenic progestins Cyproterone acetate Dienogest Drospirenone Antiandrogens Ketoconazole Finasteride Spironolactone Insulin-sensitizing drugs letrozole Myo-Inositol Pioglitazone Aromatase inhibitor Other Triptorelin Eflornithine Leuprolide Clomifene Dexamethasone Laproscopic Ovarian Driling Bariatric Surgery Lifestyle Modification Diet Yoga Exercise COC: Combined oral Contraceptives Different Treatment Approaches in Management of PCOS Surgery

23. Surgical intervention: Laproscopic ovarian drilling: Performed by unipolar or bipolar electrocautery Advantages: Ovulation occurs in 80-90% cases with 60-70% pregnancy rate Less invasive Disadvantages: Post operative adhesions Pre mature ovarian failure

24. Referrences Berek and Novak’s Gynecology JB sharma textbook of Gynecology