Polycystic Ovary Syndrome (PCOS) (1).pptx

nursing, microbiology and parasitology

1. •A 28 year old nulliparous women comes to see you because of infrequent period every (8-10) weeks. On examination her BMI 36 Kg\m2 with evidence of hirsutism. What is the most likely diagnosis ?and ddx ? •Polycystic ovarian syndrome

2. PCOS Definition: PCOS is a syndrome of ovarian dysfunction along with the cardinal features of hyperandrogenism and polycystic ovary morphology Prevalence: PCOS is the most common endocrine disorder in women, it affects around 5-10% of women of reproductive age. The prevalence of PCO seen on U/S is much higher-around 25%

3. •Causes • Genetic •environmental factors •Risk factors •Obesity •not enough exercise family history

4. Clinical Features Presenting features usually range from no symptoms to those of menstrual irregularities, hirsutism, obesity, acne & infertility. Clinical features of PCOS: — Oligomenorroea / amenorrhoea : This occurs in up to 65-75% of PCOS patients & is predominantly related to chronic anovulation. —Hirsutism: Occur in 30-70% of women. —Subfertility: In up to 75%. —Obesity: 40% are clinically obese. —Recurrent miscarriage: Seen in 50-60% of women with more than 3 early pregnancy losses. —Acanthosis nigricans : Occur in around 2% of women with PCOS. Are areas of increased skin pigmentations that are velvety in texture seen in axilla & other flexures. —Others: Acne & female androgenic alopecia. —Asymptomatic: With polycystic ovaries on ultrasound.

5. How you approach to the diagnosis and how you exclude other causes?? DAGNOSIS OF PCOS ( ROTTERDAM CRITERIA 2003 )( Two of three criteria needed )

6. How you manage her ? —Lifestyle modifications are considered first-line treatment for women with PCOS. —Include the following: —Diet —Exercise —Weight loss Smoking cessation

7. How you manage her ? Amenorrhea treatment —Women with PCOS tend to be anovulatory but with normal or high estrogen levels. —Without treatment there is theoretical risk of unopposed oestrogen & endometrial cancer. Also, oligomenorrhoea with infrequent but heavy bleeds for this reason Cyclical Progesterone induce regular menstruation and to protect endometrium. —e.g. MPA- 10mg daily for 10 days. —Alternative treatment is oral contraceptive pill. Metformin- an oral biguanide , a drug that increases insulin sensitivity & there is a clear evidence that it improves menstrual cyclicity & ovulation in PCOS. It is less effective than clomiphene for ovulation induction and does not improve pregnancy outcome

8. Hirsutism —Treatment aimed at reducing testosterone levels, this will not restore the hair to its pre-PCOS pattern but will slow the rate of hair growth. The treatment options include the following: 1. Cyproterone acetate: A potent progestational , anti-androgen that competitively inhibits the androgen receptor. 2. Yasmin: Contain progestagen , drosperinone , that has an anti-androgen effect through: —Inhibition of ovarian androgen production. —Blockage of androgen receptors. —RCTs compared two OCPs containing either drosperinone or cyproterone acetate & showed them to be similarly effective. 3. Metformin: As an insulin sensitizing agent. It improves parameters of insulin resistance, hyperandrogenaemia,anovulation and acne in PCOS. 4. Local treatment: —Mechanical depilation —Electrolysis Eflornithine hydrochloride 13.9% cream ( Vaniqua ™) is believed to block ODC & threby slow the differentiation of the cell within the hair follicles.

9. Infertility treatment 1.Reduction of body weight by 5-10% of body weight may restore ovulation. 2.clomiphene citrate(first line treatment) or metformin1 or a combination of both.Anti-estrogen treatment e.g. clomiphene (50 mg/day for day 2-6 of the cycle is the usual starting dose .U/S monitoring is recommended specially in the first cycle .In woman who do not respond to initial dose ,then the dose is increased in 50 mg increment in subsequent cycles to a maximum of 150 mg/day .Usually a maximum of 6 treatment cycles will be offered.Ø Women prescribed metformin should be informed of the side effects associated with its use(such as nausea, vomiting and other gastrointestinal disturbances)

10. resistant to clomifene citrate, consider one of the following Second-line treatments 3. laparoscopic ovarian drilling orcombined treatment with clomifene citrate and metformin if not already offered as first-line treatment orGonadotrophins. 4. hCG is used to trigger ovulation when adequate response is achieved .S.E.  multiple pregnancy & ovulation hyperstimulation syndrome ,so close monitoring is indicated Third line treatment (ART(IUI,IVF) if above failed

11. LONG-TERM SEQUELAE OF PCOS —PCOS predisposes to Type 2 Diabetes mellitus & cardiovascular disease in latter life. — Women with PCOS, particularly if they are overweight are at increased risk of impaired glucose tolerance,Type 2 Diabetes and metabolic syndrome. —Several studies show that morbidity from CVD is increased in women with PCOS.— It is also well recognised that oligomenorrhea or amenorrhea in women with PCOS may pre-dispose to endometrial hyperplasia and carcinoma. Persistant high oestrogen may lead to hyperplastic changes of the endometrium, which in turn can lead to malignant change (endometrial carcinoma). Almost every study of PCOS has shown a higher risk of depression, anxiety and worsened quality of life in this condition.

12. . A student is discussing PCOS with their professor. The professor states that all of the following are causes of anovulation as seen with PCOS expect: a. Increased ovarian androgen production b. Disorders of LH/FSH release c. Increase of SHBG production d. Insulin resistance

13. 2. Which of the following symptoms would you expect to see in a patient with PCOS? Select all that apply a. Obesity b. Anorexia c. Oligomenorrhea d. Hyperandrogenism e. Polymenorrhea f. Heavy menstrual bleeding

14. 3. Which of the following methods is how a diagnosis of PCOS is confirmed? a. Ultrasound b. Thorough clinical exam c. CBC d. Serum androgen, LH, and FSH levels

15. 4. As a patient with PCOS ages, she is at an increased risk for which of the following? a. Type 1 diabetes b. Ovarian cancer c. Uterine cancer d. Anorexi

16. 5. Which of the following would not be considered a first-line treatment for polycystic ovarian syndrome? a. Using insulin to maintain blood glucose levels under 150 b. Encouraging lifestyle modifications c. A regular daily exercise regime d. A consultation for a dietitian for weight loss management