2014 gynaecology refresher for general practitioners
TRANSCRIPT
Learning objectives
• Perform the appropriate investigations in women where there is a clinical suspicion of PCOS
• Diagnose PCOS
• Counsel about PCOS and the associated short and long term medical issues
• Discuss treatment options
• Composition of the PCOS team
What do we know about PCOS?
• Common: 5-12 % of reproductive female population
• Unknown etiology - Autosomal dominant
• PCOS expressed shortly after menarche
• PCOS persists for most of the reproductive life
• The phenotypes are variable according to weight
• Short and long term consequences
PCOS is the commonest endocrine disorder in women
• 90 % of women with oligomenorrhea
• 40 % of amenorrheic women (exclud. pregnancy)
Amongst women with PCOS:
70% are hirsute
50% are obese
30% have acne
10% have alopecia
Definition?
Rotterdam 2004: Diagnosis 2 out of 3
• Polycystic ovaries on ultrasound
• Clinical or biochemical evidence of excess androgens
• Oligo-anovulation
But also exclusion of differential diagnosis
Polycystic Ovaries
Better at D3-D5 of the menstrual cycle, TVS
• more than 12 (25) follicules and 2-9 mm in size (USS machine dependant)
• Uni/bilateral
• Volume of the ovary 10 ml or more
Clinical or biochemical evidence of excess androgens
Clinical
Hirsutism – Acne - Alopecia
Or Biochemical:
Free testosterone- Free Androgen index
(20% difference with laboratory values= endocrinologist)
Oligo-anovulation
• Oligo/amenorrhea
• Practically, less than 9 periods in 12 months or no period in 3 months or more
• Cycle lasting more than 35 or less than 21 days
Differential diagnosis
• Hypothyroid
• Hyperprolactinemia
• Androgen secreting tumours (adrenals, ovaries)
• Exogenous androgens
• Cushing's syndrome
• Congenital Adrenal Hyperplasia (17-OH progesterone)
Mode of presentation
Self-referral (family, friend, google…)
Abnormal periods
Subfertility (real or fear of)
Acne/hirsutism/alopecia
Incidental findings on USS or blood tests
Early onset type 2 diabetes
Depression/anxiety/sexual dysfunction/eating disorders/body image issues
What tests should I ask?
• Pregnancy test
• USS- TVS ovaries
• TFT
• Prolactin
• Free Testosterone (screening test)
• If Testosterone is above 5 – consider DHEA-S, 17 hydroxyprogesterone (CAH), 24h urine cortisol (Cushing) and speak to an endocrino
Multidisciplinary approach: The team PCOS
The GP is the team Leader Gynaecologist (period regulation, fertility, prevention of endometrial hyperplasia) Dermatologist Endocrinologist Psychologist Dietitian Exercise physiologist Bariatric surgeon Physician Sleep specialist
Treatment
• No cure for PCOS
• Targeted against symptoms and concerns
• Prevention and early detection of long term complications
Short term medical issues
• Hair and acne
• Fertility
• Irregular periods
• Depression
• Excessive weight gain
• Sleep apnea
Hirsutism/acne/alopecia
Cosmetic:
Gel/cream to reduce pore blocking
Shaving
Waxing
Laser or electrolysis (dermatologists)
Eflornithine (takes up to 8 weeks- lifetime)
Hirsutism/acne/alopecia
Medical:
1- To reduce the amount of androgens circulating in the body • COC –Metformin to reduce insulin resistance 2- To reduce the action of androgens • Spironolactone- Cyproterone acetate- finasteride-
isotretinoin- minoxidil NB: specialist drugs- fetal abnormalities- side effects profile)
Fertility
• Weight loss (5-10%) in obese PCOS improves ovulation
• Clomiphene- 1st line ovulation in 80% - 50% conceive (multiple birth, ?increased risk of ovarian cancer?)
• FSH – will induce ovulation in remaining 80%
• Ovarian drilling as effective as FSH ovulation
• Metformin in insulin resistant patient (better when coupled with clomiphene)
• Aromatase inhibitor (letrozole)
• ART
Irregular periods
• Low dose COC in the absence of fertility desire and after assessment of risk factor for DVT/PE
They act by stopping the ovarian production of androgens and by increasing SHBG which binds to free testosterone
• Weight loss
• Metformin?
Weight loss
For all with BMI above 25 Improves ovulation Regulates menstrual cycle Reduces insulin resistance by 50% Improves Spontaneous pregnancy rate Reduction in miscarriage rate Improves self-esteem Reduce risk factors for metabolic disease
Other problems
Emotional well-being
Reassurance- information- support group- psychologist
Sleep apnea
Weight loss- CPAP
Long term concern
• Prevention of endometrial cancer
• Impaired glucose tolerance/diabetes
• Cardiovascular risk
Long term concern:
Prevention of endometrial cancer
• COC
• Progesterone – medroxyprogesterone 10 mg for 7-10 days every 3 months to achieve a withdrawal bleed
• IUS
• Weight loss
Long term concern
Screening for type 2 diabetes
GTT every second year
And yearly if additional high risk factors: (age, gender, ethnicity, smoking, raised BMI, use of antypertensives)
So in real life: EVERY YEAR
Long term concern Cardiometabolic risk
• Smoking cessation advice
• Hypertension (yearly)
• Dyslipidemia (check every 2 years)
• Lifestyle changes (diet/excercise/behavourial interventions)
PCOS and pregnancy
Miscarriage
GDM (early GTT + repeat at 28/40)
Hypertension/preeclampsia
Increased intervention at birth
Quizz
1- How long would you wait to assess the androgen status of woen taking the COC before testing them (1-3-6 months?)
2- How long would you wait after menarche before using “irregular periods” as part of your diagnosis criteria (1-2-3 years?)
Quizz
3- Who is the care coordinator of women with PCOS? (GP-Gynae-endocrinologist)
4- What is the first line test to assess androgen levels? (free testosterone –SHBG- DHEA-S)
5- What is the first line drug to assist fertility?
(metformin, Clomiphene, FSH)
Quizz
6- How do you manage an incidental report of an ultrasound report of PCO? (label the patient PCOS- reassess the patient- refer to the gynecologist)
7- What is the percentage of women with PCOS?
(5- 10- 20)
8- Metformin is teratogenic (T/F)
Quizz
9- The majority of teenagers have PCOS (T/F)
10- PCOS is a transient disease (T/F)
11- The PCOS Australian Alliance document is the reference for assessment and management of PCOS in Australia (T/F)