Adolescent PCOS
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Transcript of Adolescent PCOS
Adolescent
PCOS
Aboubakr Elnashar
Benha university,
Egypt
ABOUBAKR ELNASHAR
CONTENTS
1.DEFINITION
2.PREVALENCE
3.PRESENTATION
4.DIAGNOSIS
5.EVALUATION
6.TREATMENT
CONCLUSION
ABOUBAKR ELNASHAR
1. DEFINITION
Adolescence
From Latin adolescere, meaning to grow up
Transitional stage of physical
and psychological development from puberty to
adulthood
Adolescents
Young people between the ages of 10 and 19 years(WHO)
Adolescent PCOS
Unexplained persistent hyperandrogenic anovulation(American Academy of Pediatrics, 2015).
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2. PREVALENCE
1.8 and 15 %
depending on:
diagnostic criteria
ethnicity [Li et al, 2013].
Increasing
{increasing prevalence of childhood obesity}(Hassan et al, 2007).
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Risk factors
Premature pubarche (before 8 yr old)
Obesity
Family Hx
Ethnicity
more common in – African-American
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Course:
±Progressive course
:full-blown picture of adult PCOS
(evidence is contradictory)(Coviello et al, 2006)
Risk for progress of adolescent to adult PCOS•Persistent irregular cycles 6 y after menarche
• (Venturoli et al, 1987)
•Persistent anovulatory cycles 3y after menarche (Venturoli et al, 1994)
•Increased BMI
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3. PRESENTATION
Menstrual irregularities
Chronic anovulation
Hyperandrogenism
Acne
Hirsutism
Androgenetic alopecia
Hyperandrogenemia
PCO on US
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If assumed pathological:
over diagnosis of PCOS
unnecessary psychological distress of having a diagnosis associated with future subfertility.
If assumed physiological:
under diagnosis of PCOS
more likely to transition to adulthood and suffer the long term consequences of PCOS.
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4. DIAGNOSIS
Specific and very strict criteria:
Sultan and Paris (2006)
Requires 4 of 5:
1. Oligomenorrhoea or amenorrhoea
2. Clinical hyperandrogenism
3. Biochemical hyperandrogenism
4. Hyperinsulinaemia
5. Polycystic ovary morphology
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Carmina (2010)
Requires the presence of all three of the following:
1. Hyperandrogenism:
biochemical or
progressive hirsutism
2. Ovulatory dysfunction
persisting beyond 2 years post-menarche
3. Polycystic ovarian morphology
ovarian volume > 10 mL
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NIH criteria
The preferred diagnostic criteria in adolescents[Hardy, Norman, 2013; Legro et al, 2013].
Androgen Excess Society Criteria
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1. Chronic Anovulation /Oligomenorrhoea
(<6 cycles/year)
For 2 ys since menarche or
Primary amenorrhoea at 17 y
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2. Hyperandrogenism
Acne or hisutism is not criteria for the
diagnosis
•Acne unresponsive to topical treatment : test
for hyperandrogenemia. (Am Academy of Pediatrics, 2015).
•Progressive hirsutism: important sign of
adolescent PCOS (Jeffrey CR, Coffler, 2007).
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3. Hyperandrogenaemia:
Most consistent marker
Extremely important
No established normal ranges. FT ≥ 1.3 ng/dL,(Piltonen et al, 2005)
TT >1 µg/ml (The Rotterdam consensus workshop group, 2004).
Adult cutoffs should be used until
appropriate pubertal levels are defined.(Endocrine Society Clinical Practice , 2013)
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4. US criteria:
increased ovarian volume (>10 cm3).
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AMH:
Elevated: noninvasive screening or diagnostic
test for PCO
No well-defined cutoffs (Pawelczak et al, 2012; Rosenfield et al, 2012).
•>4.5 ng/mL: useful as a substitute for ovarian
morphology when no accurate ovarian US is
available(Dewailly et al, 2011).
6.1ng/mL(Yetim et al, 2016)
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5. EVALUATION1. Cutaneous manifestations
Physical examination should document cutaneous manifestations of PCOS:
Terminal hair growth
Acne
Alopecia,
Acanthosis nigricans
Skin tags (1+++O).(Endocrine Society Clinical Practice, 2013)
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2. Obesity
{Increased adiposity, particularly abdominal, is associated
with hyperandrogenemia and increased metabolic risk }
Screening for increased adiposity, by BMI calculation
measurement of WC(1+++O).
(Endocrine Society Clinical Practice, 2013)
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3. Depression
screening for depression and anxiety by history and, if identified: referral and/or treatment(2++OO).(Endocrine Society Clinical Practice, 2013)
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4. Sleep-disordered breathing/obstructive sleep
apnea (OSA)
screening overweight/obese adolescents for symptoms suggestive of OSA when identified: definitive diagnosis using polysomnography: referred for tt(2++OO).(Endocrine Society Clinical Practice, 2013)
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5. Type 2 diabetes mellitus (T2DM)
OGTT
{they are at high risk for such abnormalities} (1+++O).
HgbA1c:
if unable or unwilling to complete OGTT (2++OO).
Rescreening:
/3–5 y
more frequently if:
central adiposity
substantial weight gain, and/or
symptoms of diabetes develop(2++OO).
(Endocrine Society Clinical Practice, 2013)
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6. Cardiovascular risk
screened for CVD risk factors:
family history
cigarette smoking,
IGT/T2DMhypertension
dyslipidemia
OSAobesity
especially increased abdominal adiposity (1++OO).(Endocrine Society Clinical Practice, 2013)
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6. TREATMENT
Objectives:
symptomatic and prophylactic:
Restoration of body weight
Cycle regulation
Reducing signs of hyperandrogenism
Prevention of long term health hazards.
Infertility
Metabolic syndrome
Obesity
Diabetes
Heart disease.
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Indications
Even in the absence of a definitive diagnosis:
treatment that
alleviate symptoms
decrease the risk for subsequent associated co morbidities (Level B).(Androgen Excess PCOS Society; Pediatric endocrine society, 2015)
Individual PCOS manifestations:
(obesity, hirsutism, irregular menses) should
be treated.(level B)
(ESHRE/ASRM; 2012)
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Lines of therapy
Endocrine Society guidelines (2013):
1. Lifestyle changes (dietary and exercise modification)
2. Followed by either:
OCP {control symptoms of hyperandrogenism} or
Metformin in patients with impaired glucose tolerance or features of metabolic syndrome
[Legro et al, 2013].
± Combine OCP with Met
±Combine Antiandrogen with OCP or Met
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1. Lifestyle therapy:
First-line strategy
Weight loss
Calorie-restricted diets (with no evidence that one type of diet is superior)(2++OO).
Beneficial for both reproductive and metabolic dysfunction.
(Endocrine Society Clinical Practice, 2013)
Why?{obesity during adolescence: an important factor that conditions the evolution of ovarian function(McCartney et al, 2009).wt loss 2-5% testosterone by 21%
resume regular ovulation in 50% womenABOUBAKR ELNASHAR
Exercise
in overweight and obese (2++OO).
{ improves weight lossreduces CV risk factors and diabetes risk}.(Endocrine Society Clinical Practice, 2013)
Avoid alcohol, smoking, psychosocial stressors
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2. Hormonal contraceptives (HCs):
Indications:
First-line management for the
menstrual abnormalities
hirsutism/acne(1++OO).
(Endocrine Society Clinical Practice, 2013)
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Types:
OCP, patch, or vaginal ring(2++OO).
can be used
OCPs either containing or not containing an
antiandrogen(Italian society of endocrinology, 2015)
can be used
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Metabolic effects of COC containing 30ug or less
of EE:
•MildDeterioration of glucose tolerance Worsening of lipid profile
•Should not influence the choice(Italian society of endocrinology, 2015)
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VTE risk is not studied
Odds ratio
1.65 for BMI 25–30 kg/m2
1.84 for BMI 30–35 kg/m2
4.34 for BMI >35 kg/m2
[Murthy, 2010].
Risk is further increased in
CPA or
3rd generation progestins, including
drospirenone[Lenzer, 2011].
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Screening for contraindications
via established criteria(1+++O).
lipid profile and the glucose tolerance should be evaluated before and after 3 months of higher dose OC containing cyproterone acetate(Italian society of endocrinology, 2015)
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BMI:
≤35 kg/m2 with no specific metabolic and/ or CV
abnormalities
Any typeChoice acc to:
preferences of the physician and patientspecific clinical characteristics of the patient.(Italian society of endocrinology, 2015)
≥35 kg/m2 :
COC should be prescribed with caution
≥40 kg/m2:
Not used(RCOG, 2011).
If contraception is needed:
alternative measures, such as progestin-only methods. (Italian society of endocrinology, 2015)
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3. Metformin:
Indications
To treat IGT/metabolic syndrome (2++OO).
long-term resumption of ovulation
especially thos with an inadequate response
to lifestyle intervention.
Commonly used as
first line monotherapy or
in combination with OCPs or
antiandrogen
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Dose:
Lean:
850 mg daily
Overweight and obese:
1.5 to 2.5 g daily.
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Met and COC*:
have comparable therapeutic effectiveness on cycle regularity
and hirsutism.
Met
significant improvement in insulin sensitivity
COC
deterioration of insulin sensitivity*(30 µg EE and150µg desogestrel=Marvelon)
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4. Combined metformin and OC
:
attenuating the adverse metabolic effects of OC
improving body composition
, as compared with OC alone [Glintborg et al, 2014].
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Duration of HC or metformin
Not yet been determined.until the patient is gynecologically mature
(5y postmenarcheal) or
has lost a substantial amount of excess wt. (Rosenfield; 2015)
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5. Anti-androgenic medications
Spironolactone, flutamide, and insulin sensitizing
agents such as pioglitazone
Indication:
when OCP or metformin fail to produce the
clinically desired outcomes [Conway et al, 2014].
±affect bone mass,
short term data: no effect.
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AntiandrogenMetCOClifestylePCOS
+++++++Menstrual Dysfunction
++++++++Hirsutism
++++++++Acne
++++++++Hyperandrogenemia
+++obesity
++++++IGT/2DM
+Psychological
+++: strong evidence
+: some evidence
Morris et al, 2016
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CONCLUSIONS
Diagnosis:
Early and accurate diagnosis is essential for
implementation of appropriate treatment
Criteria for the diagnosis differ from those used
for adult women
Hyperandrogenaemia:
the most consistent marker
Evaluation:
Metabolic
CV risks,
Psychologic
Dermatologic . ABOUBAKR ELNASHAR
Treatment
lifestyle modifications
Hormonal contraceptives
Metformin
Antiandrogen.
Limited data on the best treatment modalities
Should be individualized depending on:
Age
Symptoms
Personal and familial risk factors
Choices.
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Thanks
ABOUBAKR ELNASHAR