Management of the Commonest Endocrine disorder in females

Miss Bini Ajay

CasesCases

25 year old with BMI 35, with history ofinfrequent periods, facial hair

30year old, normal BMI with irregular periods and unable to conceive for 3 years

PCOS

•Definition•Pathophysiology•Management•Long term consequences•Summary

• Stein & Levanthal in 1935• 5-10% PCOS,20% PCO• Heritable disorder• 30%of PCOS- normal periods, 85-90% of oligomenorrhoea,30-40 % of amenorrhoea• 70%- hyperandrogenism• 50-70%- insulin resistance, 30-40% -IGTT, 7.5-10% -type II• 40% - subfertility• 42-73%-miscarriages• 35%- depression

Facts

PathophysiologyPathophysiology

PathophysiologyPathophysiology

Insulin Resistance

Hyperinsulinemia Stimulates Hypothalamus Stimulates adrenal gland Stimulates ovaries Suppresses Liver – less SHBG- Increased Androgen

DiagnosisDiagnosis

Rotterdam Criteria - 12 or more follicle <10mm

- Oligoovulation /anovulation

- hyperandrogenism

PCOSPCOS

BiochemicalBiochemical teststests

-TFT/ Prolactin

- Free androgen & SHBG

- Androgen secreting tumours/ CAH(17OHprogesterone)

- LH:FSH > 2:1

- AMH

- GTT(fasting insulin)

- Lipid profile

TreatmentTreatment

• Exercise ,weight loss(5%)• Oral contraceptive pill- Dianette, Yasmin• Spironolactone ,Finasteride• Isotretinoin• Laser, electrolysis

VaniqaVaniqa

• Eflornithine Monohydrate chloride

• Blocks the action of ornithine decarboxylase in skin

• Twice daily • 4 months

MetforminMetformin

• Decreases androgens• Use insulin• Reduces cholesterol• Improves metabolism• Increases ovulation• If pregnant can continue Metformin

InositolInositol• Myo-inositol- carbohydrate essential for insulin

modulation• Increases action of insulin –improves insulin

sensitivity• Reduces cholesterol and BP• Reduces androgen • Increases ovulation-69.5%

LaparoscopicLaparoscopic drillingdrilling

• Drills into the outer capsule• Decreases testosterone• Increase FSH

Long termLong term EffectsEffects

• Diabetes, cardio and cerebrovascular disease-lipid profile, BP, HbA1c

• Endometrial cancer –hyperplasia

• Obstructive Sleep Apnoea- obese, insulin resistance –CPAP

• Psychological –Depression , sexual difficulties, eating disorder

PCOS and TrigyceridesPCOS and Trigycerides• Obesity and high insulin – promotes high triglycerides-

increases VLDL• Insulin resistance – reduced clearance of VLDL and

chylomicrons• Hepatic content of triglycerides is high larger VLDL

particles are produced- metabolised to small, dense LDL particles- poorly cleared and atherogenic

• Statins improve hyperandrogenemia

PCOS and hypertensionPCOS and hypertension• Increased endothelin_1 levels• Increased aldosterone concentrations• Czech-22% Dutch-28%• Coronary artery calcium (CAC scores) and

carotid intima –media thickness (CIMT)- subclinical atherosclerosis- stroke ,MI

EndometrialEndometrial hyperplasiahyperplasia

• Endometrial cancer• Withdrawl bleed -3-4months• TVS- ET-7mm

PCOS and PregnancyPCOS and Pregnancy

• Gestational diabetes- GTT at 16 and 28weeks• Preeclampsia• Preterm birth• Perinatal mortality• Multiple pregnancy

SummarySummary• PCOS is a common endocrine and metabolic disorder

with long term consequences