pcos polycystic ovary syndrome. continuity clinic objectives know the clinical definition of pcos...
TRANSCRIPT
PCOSPCOSPolycystic Ovary Polycystic Ovary
SyndromeSyndrome
CONTINUITY CLINIC
ObjectivesObjectives
Know the clinical definition of PCOSKnow the clinical definition of PCOS
Know the typical physical and Know the typical physical and laboratory findings associated with laboratory findings associated with PCOSPCOS
Be familiar with the current Be familiar with the current management optionsmanagement options
CONTINUITY CLINIC
DefinitionDefinition
Polycystic ovary syndrome is a Polycystic ovary syndrome is a clinical diagnosisclinical diagnosis
2 or more of the following features:2 or more of the following features: Chronic oligo-ovulation or anovulationChronic oligo-ovulation or anovulation Androgen excessAndrogen excess Polycystic ovariesPolycystic ovaries
CONTINUITY CLINIC
EpidemiologyEpidemiology
Affects 5-10% of women of Affects 5-10% of women of childbearing agechildbearing age
Most common cause of anovulatory Most common cause of anovulatory infertility in developed countriesinfertility in developed countries
Prevalence of the metabolic syndrome Prevalence of the metabolic syndrome is 2-3x higher among women with is 2-3x higher among women with PCOSPCOS
CONTINUITY CLINIC
Theories to Etiology of Theories to Etiology of PCOSPCOS
Genetic predisposition Genetic predisposition Most likely although no gene isolatedMost likely although no gene isolated
Premature adrenarche (<8 y/o)Premature adrenarche (<8 y/o)
Heterozygosity for congenital adrenal Heterozygosity for congenital adrenal hyperplasia (CAH)hyperplasia (CAH)
Intrauterine Growth Retardation (IUGR)Intrauterine Growth Retardation (IUGR)
CONTINUITY CLINIC
PathophysiologyPathophysiology Majority of women with PCOS Majority of women with PCOS
(regardless of weight), have insulin (regardless of weight), have insulin resistanceresistance Association with: type 2 diabetes, Association with: type 2 diabetes,
dyslipidemia, and hypertensiondyslipidemia, and hypertension Effects of hyperinsulinemiaEffects of hyperinsulinemia
Ovaries remain sensitive to insulin (maybe Ovaries remain sensitive to insulin (maybe hypersensitive) hypersensitive) Androgen excess Androgen excess
Inhibits hepatic production of sex hormone binding Inhibits hepatic production of sex hormone binding globulin globulin increases circulating free testosterone increases circulating free testosterone
Impedes ovulationImpedes ovulation
CONTINUITY CLINIC
Nestler J. N Engl J Med 2008;358:47-54
CONTINUITY CLINIC
Pituitary gland
heightened to GnRH
Exaggerated pulsatile
LH release
LH/FSH ratio
elevated
androgens
Cascade Cascade leading to leading to
excess excess androgensandrogens
CONTINUITY CLINIC
Augment pituitary
sensitivity to GnRH
LH
ovaries overproduce
androstenedione and
testosterone
Androgens converted to estrone
and estradiol
Vicious Cycle of PCOS
CYCLE STARTS
CONTINUITY CLINIC
Clinical FindingsClinical Findings
Anovulation Anovulation amenorrhea & infertility amenorrhea & infertility HirsuitismHirsuitism Acne VulgarisAcne Vulgaris Male pattern baldness/thinningMale pattern baldness/thinning Obesity- android-type with Obesity- android-type with waist-hip waist-hip
ratiosratios Cancer- endometrialCancer- endometrial
CONTINUITY CLINIC
Evaluation: Differential Evaluation: Differential DxDx
PregnancyPregnancy PCOPCO HypothyroidismHypothyroidism Ovarian tumorOvarian tumor Pituitary tumorPituitary tumor
CAHCAH Female Athlete Female Athlete
Triad Triad (hypothalamic (hypothalamic amenorrhea)amenorrhea)
Turner’s syndromeTurner’s syndrome Testicular Testicular
FeminizationFeminization
MORE LIKELY LESS LIKELY
Knowing all of this, Knowing all of this, what laboratory what laboratory tests would you tests would you
order for a patient order for a patient you are suspecting you are suspecting
of PCOS?of PCOS?
CONTINUITY CLINIC
Laboratory Tests to Laboratory Tests to Consider in Evaluation Consider in Evaluation
ProcessProcess B-HCGB-HCG ThyroidThyroid LH/FSHLH/FSH Prolactin Prolactin Free/total Free/total
testosteronetestosterone Fasting 17-OPH Fasting 17-OPH
and cortisoland cortisol
Fasting glucoseFasting glucose Fasting Insulin Fasting Insulin
levellevel Fasting Lipid Fasting Lipid
profileprofile Androstenedione Androstenedione DHEASDHEAS KaryotypeKaryotypeRED - those tests most critical to diagnosis of PCOS
GREEN – consider these tests as associated problems with PCOS
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Ultrasound FindingsUltrasound Findings
CONTINUITY CLINIC
Problems associated with high Problems associated with high levels of sex hormones:levels of sex hormones:
Insulin resistanceInsulin resistance
HyperinsulinemiaHyperinsulinemia
DiabetesDiabetes
Cardiovascular Cardiovascular diseasedisease
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Management: Non-Management: Non-medicalmedical
Weight controlWeight control
Low carb dietsLow carb diets
Exercise Exercise reduce weight and CV reduce weight and CV
risk factorsrisk factors Increase insulin Increase insulin
sensitivitysensitivity
CONTINUITY CLINIC
Management: MedicalManagement: Medical OCP’s: OCP’s:
suppress LH suppress LH androgensandrogens SHBG SHBG free testosteronefree testosterone adrenal production of androgenadrenal production of androgen 5alpha-reductase5alpha-reductase
SpironolactoneSpironolactone
Cyclic progestinsCyclic progestins
GnRH agonistsGnRH agonists
CONTINUITY CLINIC
Management: Management: MetforminMetformin
Reduces hyperinsulinemiaReduces hyperinsulinemia Decreases risk factors for CHDDecreases risk factors for CHD Improved weight-lossImproved weight-loss Normalization of circulating Normalization of circulating
androgensandrogens Resumption of normal ovulatory Resumption of normal ovulatory
menses and therefore reversal of menses and therefore reversal of infertilityinfertility
CONTINUITY CLINIC