PANEL DISCUSSIONMANAGEMENT OF

PCOSWOMB to TOMBDr. Sharda Jain

MANAGEMENT OF - WOMB to TOMB

HELD ON 10/10/2014At Wood AppleNEW DELHI

Dr. Sharda Jain

Organized by Delhi Gynaecologist Forum / Sheild H. Care

PANEL DISCUSSIONPCOS

MANAGEMENT OF PCOS WOMB to TOMB

MODERATOR : Sharda Jain PANELISTS : Dr.Chitra setia Dr Puneet Arora Dr. Ila Gupta Dr. Rupam Arora Dr. Archana Sharma Dr. Sangeeta GuptaDermatologists Dr. V.K. UpadhyayDr. S. Kandhari

Stein1935Leventhol

ESHRE /ASRM

IMPORTANCE OF PCOSWomb to Tomb

It is NOT A DISEASE, it is a syndrome with varied presentations

PCOS has a CONTINUUM SPECTRUM starting from the EARLY PREPUBERTAL

YEARS and continuing after Menopause S/S peak through 2nd / 3rd decade of lifeBut Does not become quiescent till her death

Why has journey From Womb To Tomb

• Above average (LFD) or low birth weight for gestational age.

• Premature Adrenarche,• Atypical Sexual Precocity

Birth

Prepubertal

PCOS

PCOSPCOS is condition which can effect• women menstrual cycle, • Fertility • Her appearance (obesity, Acne, Hirsutism)• Hormones / Depression • Has long term health sequelae.(Morbid Co-morbidities)

* Obesity * Dyslipidemia *DM *Hypertension • Acanthosis nigricans , skin Tags • Fatty liver • Sleep apnoea

INSULIN Resistance is the key …….finding

Endometrial Carcinoma

Why has journey From Womb To Tomb

PCOS

4 Sibling

EPIDEMIOLOGYDiagnosis & Incidence

Is the INCIDENCE of PCOS in Adolescents Rising or

has the DIAGNOSIS Improved ?

Q 1.

EPIDEMIOLOGY

Yes, Both things are working • There is a increase in incidence of PCOS in adolescents

• Secondly because diagnosis has improved from NIH-(1990) – TO ROTTERDOM(2004) – TO AES-PCOS SOCIETY DIAG.CRITERIA (2009)

– many more cases are picked –up now

Improvement in Diagnosis of PCOS over the years

NIH (1990) 1. Oligo ovulation2. Hyperandrogenism and / or hyperandrogenemia(with exclusion of related disorders)

ESHRE /ASRM (Rotterdam 2003)

To include TWO OUT OF THREE of the following:1. Oligo – or anovulation 2. Clinical and / or biochemical signs of hyperandrogenism 3. Polycystic ovarian (with exclusion of related disorders)

Improvement in Diagnosis of PCOS over the years

AES – PCOS (2009)1. Hyperandrogenism : hirsutism and / or

hyperandrogenemia and2. Ovarian dysfunction : oligo – anovulation and / or

polycystic ovaries and 3. Exclusion of other androgen excess or related

disorders

PCOS Definition

1990 - 2009

Hyperandrogenism

(Clinical or Biochemical )

Oligo- menorrhea or Oligo-Ovulation

Polycystic Ovaries on USG

NIH (1990) yes yes no

Rotterdam (2003)

yes Yes

2 of the 3 criteria

yes

AE-PCOS Society (2009)

yes Yes

1 of 2 criteria

yes

Diagnosis of Polycystic Ovarian Syndrome

Incidence of adolescent PCOS

IF WE USE STRICTLY NIH criteria = 6-8%Rotterdam criteria = 15-25%In Indian Asian Urban Community– this

number is more & seems to be rising for reasons unknown ??

Prevalence of PCOD In India

30-36% Girls

Indian j pediatr.2012 jan;79suppl 1:s69-73

J pediatr adolesc gynecol.2011 Aug;24(4): 223-7

Near 18-20% (1 in 5) girls going to private schools in Delhi have PCOS (LPS)

OBESE – 50% (over weight , BMI>24 & obese >27)MENSTRUAL PROBLEMS – 60% Delayed Periods Most Common Heavy Menstrual Bleeding – 20%HIRSUTISM – 60-70%ACNE – 30%

DGF Survey of 2 schools 2004 EXPERIENCE

What are the Conditions That May Mimic PCOS ?

Q 2

D/D

OLIGOMENORRHEA•Pregnancy

•Hyperprolactinemia•Thyroid Disease

•Ovarian Insufficiency

DIFFERENTIAL DIAGNOSISof PCOS

HperanrogenismNon – classic CAHCushing syndrome

Androgen – secreting tumors / ovarian hyperthecosis

PCOM Non specific incidental finding has no meaning

• Thyroid disorders • Hyperprolactinemia • Cushing’s syndrome • Late onset congenital adrenal hyperplasia (CAH) \• Basal morning 17-OHP• Ovarian and adrenal tumors DHEAS• WHO I &III –FSH,LH,E2• Syndromes of severe insulin resistance(HAIRAN syn)

Sr.TSH,Sr.PrlSr.TSH,Sr.Prl

Dexa supression testDexa supression test

What are the conditions that may mimic PCOS ?

Any Genetic or Familial Basis ?

Q 3

Any Genetic or Familial Basis ?

• FAMILY Clustering is known :

Risk of PCOS

• 40% - if her sister is having PCOS

• 20% - if her mother suffered from PCOS

• N = 5-10%

GENETIC ETIOLOGY NO LAST WORD AS YET

Genetic & PCOS

AUTOSOMAL DOMINANT pattern ofinheritance

Several genes namely CYP 17CYP11ACYP21,SHBGInsulin receptor

NO CONCLUSIVE

RESULT TILL DATE

Which hormonal/blood tests are done to confirm the diagnosis of

PCOS?

DIAGNOSTICS – BLOOD TESTS

Q4(A)

Testosterone level LH and FSH High LH & low FSH is seen in 60% cases only TSH Prolactin level Fasting glucose level or 2 hr 75 gm OGTT Lipid profile, including total, LDL,HDL 17-hydroxyprogesterone level* *--(Fasting level to r/o CAH)

DIAGNOSTICS – BLOOD TESTS

Which tests should be done before starting insulin sensitizers – fasting / PP blood sugar,

insulin, Glycosylated Hb?

DIAGNOSTICS – BLOOD TESTSbefore METFORMIN

Q4B

• using fasting & 2 hrs blood sugar levels following 75gm glucose load is all that is needed

DIAGNOSTICS – BLOOD TESTS

Insulin Levels are Really Not Needed for diagnosis of PCOS

Category Fasting 2hrs PPNormal <100 mg/dl <140 mg/dlImpaired <100-126 mg/dl > 140 -199NIDDM Over 126 Over 200

Q 4 C. DIAGNOSTICS - USG

How is PCO and PCOM different than PCOS?

USG USG CRITERIA CRITERIA of of POLYCYSTIC OVARIAN MORPHOLOGYPOLYCYSTIC OVARIAN MORPHOLOGY

• Presence of 12 or more follicles in each Presence of 12 or more follicles in each ovary , 2 - 9 mm in diameter and or ovary , 2 - 9 mm in diameter and or increased ovarian volume > 10 ml increased ovarian volume > 10 ml

Or 10 cmOr 10 cm33• Single ovary is sufficientSingle ovary is sufficient to diagnose PCOS to diagnose PCOS • Optimal time for Optimal time for ultrasound (TVS) is D3 – D5 ultrasound (TVS) is D3 – D5

• It is a fact that PCOM ie POLYCYSTIC OVARIAN MORPHOLOGY is present in

20 -35% girls with NORMAL menstrual cycles &

• In Contrast there are patients of TYPICAL PCOS who do not have PCOM on ultrasound.

Q5.PCO, PCOM & PCOS

What are the PHENOTYPES in PCOS & what is there importance ?

Q 6.

Four Different Phenotypes of PCOS are now identified

• TYPE A: hyperandrogenism, chronic anovulation and<

polycystic ovaries.

• TYPE B: hyperandrogenism and chronic anovulation.

• TYPE C : hyperandrogenism and polycystic ovaries

• TYPE D : chronic anovulation and polycystic ovaries

Hyperandrogenemia is the Hallmark of PCOS

Q7 SYMPTOMS

Which are the COMMONEST SYMPTOMS

that women with PCOS present with?

Three Commonest Presentation are• MENSTRUAL DISORDERS when they consult gynaecologists •OBESITY when they consult endrocrinologists•HISUITISM & ACNE when they consult dermatologist

Ans. SYMPTOMS/ Management

current options

Co-operations / Coordination

among specialists is needed

in Adolescents –Management Is Specific To Clinical Symptoms

Acne ObesityHirsutism

Acanthosis Infertility & pregnancy loss

HAIR LOSS

IRREGULAR MENSES

SPECTRUMClinical Manifestation of PCOD

Symptoms & There Frequency in PCOS in Adolescents

Menstrual Cycle disturbance – 70% - Oligomenorrhoea 50% - Amenorrhoea 10% - Abnormal heavy bleeding 10-15% Hyperandrogenism 70% Acne – 30 - 40% Hirsutism 70% Alopecia 10% as seen by Gynaecologits Acanthosis Nigricans 1-3% lean & 20% obeseOBESITY 50- 60 % NORMAL MENSTRUATION 20% * INFERTILITY - 70% * EARLY PREGNANCY LOSS 50-60%

Q 8(A)What is the Pattern of MENSTRUAL

IRREGULARITY in Adolescent PCOS

Q 8(B)Why MENSTRUAL IRREGULARITY in Adolescent PCOS needs treatment ?

DELAYED PERIODS is most common presentation

Other Presentations are:• Withdrawal bleeding only • Absent periods • Heavy menstrual bleeding or• Menometrorrhagia with Anemia

Ans 8(A)What is the Pattern of Menstrual Irregularity in Adolescent PCOS

•20% PCOS have• normal cycles

Obese80%

Lean30%

Ans 8(B)Why MENSTRUAL IRREGULARITY in Adolescent PCOS needs treatment ?

• Menstrual irregularity in adolescent PCOS needs treatment because chronic anovulation increases the risk of developing Endometrial Hyperplasia , which is associated with Endometrial Carcinoma if not monitored.

• In addition , anemia can result from dysfunctional DUB or menorrhagia

Treatment IS Discussed LATER

• It is well accepted that If menstrual

Irregularities persist for 2 years

After Menarche, Then The Risk for PCOS is

Extremely High (70% of Cases)

PCOS remains largely UNDIAGNOSED as irregular menses after menarche for 2 years & acne is commonly

seen in adolescents • Transabdominal ultrasound

resolution has poor sensitivity to diagnose PCOS TVS is recommended

Q-9 COSMETIC CONCERNS

Question to Dermatologist Dr. V. K. UPADHYAY / Dr. S

KANDHARIWHAT ABOUT INCIDENCE OF

ALOPECIA & ACANTHOSIS NIGRICANS IN ADOLESCENTS ?

COSMETIC CONCERNS• Alopecia 10% as seen by Gynaecologists

(Dermatologist feel - Alopecia is not all that uncommon & is around 20%)

HAIR LOSS

Acanthosis

Acanthosis Nigricans 1-3% lean & 20% obese

Is treatment for hirsutism based on Ferring Gallway SCORING?

Q10(A). COSMETIC CONCERNS

HIRSUTISM , ACNE, ALOPECIA

Ferring Gallway SCORING

Ferring Gallway ScaleThis model quantities the extent of hair growth in nine key anatomic sites: the hair growth is graded using a scale from 0 (no terminal hair) to 4 (maximum growth), for a maximum score of 36A score of 8 or more indicates the presence of androgen exces.

However, we do not use it in day to day practice to grade our patients

what all tests are needed to diagnose HYPERANDROGENEMIA?

Q10 (B). COSMETIC CONCERNS

HIRSUTISM , ACNE, ALOPECIA

What All Test Are Needed To Diagnose Hyperandrogenism

(Hirsutism, acne, alopecia)

Free Testosterone & % Free Androgen index have NO ROLE in

diagnosis. It is 10 times costly & is not standard in all labs.

• ANDROSTENADIONE-NO ROLE

BIOCHEMICAL TESTING Total Testosterone& 17 – hydroxyprogesterone level toR/O late onset CAH is all that is needed

NORMAL VALUES OF SERUM ANDROGENS

Testosterone (Total) 20-80 ng/dlDHEAS 100-350 mg/dl17 – hydroxprogesterone(Follicular phase)

30-200 ng /dlOver 800 diagnostic of adult onset CAH

SUDDEN ONSET of these symptoms suggests other D/D

* Cushing’s syndrome * Adrenal or ovarian tumor.

Q10CHirsutism – Virilisation

Does ACNE require systemic treatment or only topical is sufficient?

Q11 COSMETIC CONCERNS

ACNE • Grade 1: Acne are classified

non inflammatory

• Grade 2: Inflammatory

• Grade 3 : Combination of above (Severe)

• Topical Retinoids

•Antimicrobial aqents + •topical ratinoids

TREATMENT MEDICAL ENDOCRINE THERAPY + TOPICAL / ORAL RATINOIDS

Management Topical Retinoids

1. Apply the preparation over the whole affected area and not just spot application

2. Apply the product very miserly as Acne treatments are often irritating and drying

3. Excessive washing of face is to be avoided as it further aggravates the irritation

4. Stop application the moment excessive drying or irritation develops

5. Cream based applications should be preferred as they reduce the concomitant dryness

ACNE GRADE - I

Systemic – Managementis needed for infected or severe acne

• ORAL ANTIBIOTICS – Minocycline, Doxycycline, Azithromycin, CEPHALOSPORINS

• Isotretenoin – 0.5 -1 mg/ Kg body weight. Cumulative dose of 120 – 150 mg /Kg over a period of 6 – 9 months.

• Low dose OCP

Acne / Grade II & III

Hormonal Therapy in Acne

– Recalcitrant acne (severe Acne) – Acne not responding to topical /oral

Isotretenoin – Co- prescribed with Isotretenoin

•OCP •6-9 MONTHS

•Any pill

Acne Treatment – Other Modalities

• Chemical peels• Comedon removal• IPL• Cryotherapy• Microneedling

• Use of steroids

Good Dermatologisthelp is needed.

Gynaecologist can’ttreat on there own

How common is ALOPECIA ? Treatment ?

Q12 COSMETIC CONCERNS

AlopeciaDermatologist feel that it is not all that uncommon

• Diffuse thinning With preservation

of frontal line • Bitemporal

recession CAUSE• Decrease in 5a

reductase -

• in DHT

Incidence in adolescent PCOS

DERMATOLOGIST To Be Care

Guidelines to Gynaecologist on

treatment of

Q 13 COSMETIC CONCERNS

HIRSUTISM

Treatment Hirsutism

IS CHALLENGING

TREATMENT - HIRSUTISM• All combination OCPs are effective• OCPs decrease androgen levels by

suppressing LH and stimulating sex hormone binding globulin (SHBG).

• It takes almost 6 months when decrease growth of hair is noted.

•OCPs with low androgenic Progestins (norgestimate, desogestrel)

may be Most effective for acne and hirsuitism

Hirsutism Treatment• METFORMIN perse are not needed

– To reduce hirsuitism.

– Spironolactone 100mg twice daily (max dose 200 mg/day).

– A full clinical effect may take 6 months or more

– After a periods of time, maintenance dose of 25-50 mg daily.

Anti ANDROGENS (RECEPTOR BLOCKERS)

Any Special Choice of OCPs for hirsutism in PCOS ?

Q 14 B

Q -14 CTOPICAL HAIR GROWTH RETARDANTS

• EFFORNITHINE HYDROCHLORIDE CREAM are effective & take almost 3 months to show effect.

Dosages & Applications • Remove the heir from the affected areas and wait for minimum 5

minutes• Apply a thin layer of hinder cream to the affected areas of the face

and adjacant involved areas under the chin • Rub in thoroughly • The treated area should not be washed for 4 hours • Cosmetics and sunscreens may be applied over the treated areas

after the cream has dried • To be used twice daily at least 8 hours apart • For optimal results, use hinder fo a minimum of 6-12 months along

with other methods of hair removal

Q -14 DGreat TIPS on Solution of Hirsutism

• Temporary Methods – Remove the hair shafts but leave the hair follicle intact.

Example – waxing, shaving, depilatory creams & plucking

The process needs to be repeated indefinitely. Though cheap & effective, are time consuming,

repetitive and often lead to pigmentation and thickening of skin.

OCP & ALDACTONE ARE NEEDED

ELECTROLYSIS IS GOING OUT (Burns / Scarring)LASER THERAPY is not permanent. Repeated sittings may be needed

Q -14 DGreat TIPS on Solution of Hirsutism

OCP & ALDACTONE ARE NEEDED

Which COC is most preferred?

Containing • Levonorgestrel / Desogestrel

• Cyproterone acetate

• Drospirenone

Q -15. CHOICE OF COC

Menstrual Irregularity / Hirsutism / Acne

CHOICE of COC ANY LOW DOSE COC CAN BE GIVEN

• OC’s containing progestins such as NORGESTREL / LEVONORGESTREL / DESOGESTREL are preferable.

•DROSPIRENONE HAS NO ADVANTAGE

• If HIRSUTISM is a problem then Cyproterone Acetate (CPA) is preferred.

Two Types OF OCPs

Desogestrel 0.15 mg + EE 30mcg(novelon) Desogestrel 0.15 mg + EE 20mcg( femilon)

Cyperoterone acetate (EE 30 mcg + C 2 mg - Diane35) Drosperinone- (EE 30 mcg + D 3 mg -Yasmin)

NON ANDROGENIC PROGESTOGENS

ANTIANDROGENS WITH PROGESTATIONAL ACTIVITY

Q 15 BWhat are the

DRAWBACK OF OCP IN PCOS

• Menstrual Problem • Hirsutism

What are the DRAWBACK OF OCP IN PCOS

• Cause salt & water retention making weight loss more difficult.

• In permenarcheal girls with short stature who have open epiphyses, OCPs are contraindicated bcz OCPs contain growth – inhibitory amounts of estrogen

• In Incompletely mature girls - increase risk of post pill amehhnoria

• VTE with OCP is primarily related to dose & duration of estrogen use & progesterone like DROSPERINONE (Twofold increase)

Q15 CCombination OCPs

FOR HOW LONG in adolescents PCOS?

Hirsutims / Menstrual

OCPs FOR HOW LONG ?? in Adolescents PCOS? Hirsutims / Menstrual

By three months the bleeding problems gets stabilized & by six month markedly decrease growth hair is noticed.

As a general rule, OCPs should be continued until the girls is gynaecologcally mature (Five years postmenarcheal) or

has lost substantial amount of excess weight.

Gynaecologists are confused & use it for variable periods but sr. DERMATOLOGISTS feel it should not be discontinued unless girls wants to become pregnant .

DURATION OF TREATMENT with OCP is Controversial

Q16. ETHINYLESTRADIOL – HOW MUCH in

OCP?

What is the patient profile for choosing COCs containing 35, 30, 20 mcg ethinylestradiol ?

Low Dose COC pill is the choice (<35 ug EE is the choice). In adolescent people start with EE 20 ug pill – if BTB – occurs, higher dosage pill is used

ETHINYLESTRADIOL in OCP – HOW MUCH?

Q-17CHOICE OF PROGESTIN in OCP

What is the patient profile for choosing the type of PROGESTERONE in COCs?

Safety of the pill is most important Like venus thromboembolism , mycardial infaction & cancer etc.

CHOICE OF PROGESTIN

SAFETY of OCP is key

• Non Androgenic Progestogens Desogestrel 0.15 mg + EE 30mcg(novelon) , Desogestrel 0.15 mg + EE 20mcg( femilon)

•Antiandrogens with progestational activity • Cyperoterone acetate• (EE 30 mcg + C 2 mg - Diane35)

Drosperinone DVT twofold increase (BMJ)

Noethindrone Norgestril / Levonorgestril Low DVT1st

Gen.

2nd Gen.

DVT?

Drosperinone- (EE 30 mcg + D 3 mg Yasmin)

Q18. CONCERNS WITH COC

Q. What are common complaints with the use of COCs?

* HYPERTENSION * WEIGHT GAIN * ACNE

HYPERTENSION – in few 10 mm rise of BLOOD

PRESSURE may be there which settles once the drug is off

WEIGHT GAIN is not the complication with low dose

COC pills.

ACNE : Infact OCP is the treatment. We preferred pill with

Antiandrogens with progestational activity

CONCERNS WITH COC

Q19. ROLE OF PROGESTIN

in menstrual irregularity

• MICRONIZED PROGESTERONE (100 to 200 mg given orally at bedtime)

• MEDROXPROGESTERONE ACETATE (10mg given orally at bedtime)

can be used for 7 to 10 days out of each month of cycle. SIDE EFFECTS of progestin include * mood symptoms (depression) * Bloating * Breast soreness

Role of Progestin in Menstrual Irregularity

Patients must be informed that oral progestin Prescribed in this manners (i.e. 7 to 10 days each month)

is not a means of contraception

How frequently do you see IR in your PCOS patients?

• Why we are worried ?• Various syndrome with IR• Special signature of IP• Role of metformin

Q20 INSULIN RESISTANCE

?

Ans. In Research situations IR is seen in good 65 to 70% patients among whom 70 to 80% are obese (BMI > 30) & 20 to 25% are normal weight.It is the biggest risk factor for type 2 DM and cardiovascular disease

Ref.http:www.uptodate.com

INSULIN RESISTANCE

You should Know

Insulin Resistance is present Various Clinical Syndrome

• Type 2 diabetes   • Cardiovascular disease   • Essential hypertension   • Polycystic ovary syndrome   • Non-alcoholic fatty liver disease (NASH)   • Certain forms of cancer -

breast,colon,liver,prostate  • Sleep apnea

All are interrelated

• SKIN : Acanthosis nigricans (darkly shaded skin in the flexures of the neck , axilla, or groin – IR/DM)

Significant Findings Insulin Resistance which gynaecologits should always note

Skin tags – IR/DM10 %

Acanthosis nigricans Over 20% obese 5% in lean

Q20(B).INSULIN RESISTANCE

Q. Are insulin sensitizers prescribed to all women with PCOS or only those with insulin resistance?

Gynaecologist are Not Clear and use metformin Left & Right

Both ESHRE & ASRM consensus is that no clear role for insulin sensitizing in management of PCOS except in patients with glucose or type 2 diabetesTherefore, on current evidence - metformin is not a first line treatment of choice in the management of PCOS for any clinical manifestation

Insulin sensitizers like metformin is used in patients with impaired

glucose tolerance patients & not otherwise

INSULIN RESISTANCE

• IMPAIRED Glucose Tolerance / Type 2 Diabetes

– Up to 40% of women with PCOS have impaired glucose tolerance (IGT).

– Risk of IGT and Type 2 Diabetes Mellitus (DM) is increased in both obese and non-obese women with PCOS.

– Retrospective studies have shown 2 to 5 fold increase of type 2 diabetes in women with PCOS.

Importance &Importance &How to Diagnose Insulin Resistance –How to Diagnose Insulin Resistance – Just Do Fasting Glucose & 75 gm 2 hrs oral GTTJust Do Fasting Glucose & 75 gm 2 hrs oral GTT

Q(A) In patients who do not respond to one COC, do you change the COC (consisting of another progestin) or shift them to or add an insulin sensitizer?

Q(B). Metformin / Myoinositol

Q21.Place of INSULIN SENSITIZERS in- YOUR

OPINION?

METFORMIN—PRESENT ROLE• Although there had been widespread enthusiasm to use metformin

left & right – but clinical data no longer support this approach

• Use of metformin in PCOS should be restricted to those patients with glucose intolerance

ESHRE/ASRM-Sponsored PCOS Consensus Workshop *,2007, Thessaloniki, Greece

Dose of Metformin• When metformin is given , therapy is started

with 500 mg daily before the evening meal, with an increase in the dose by 500 mg per week to the effective dose of 1500 to 2000 mg daily , as tolerated .

• The greatest dose (1500 to 2000) often are better tolerated when divided into two daily doses or when given in an extended release form

MYOINOSITOL in PCOS advantage will be known 5 yrs down the line - at

present it is only a concept

2014

Q 22PREGNANCY & PCOS

If the female wishes to conceive, when would you adviseher to stop taking the insulin sensitizers and / or COCs?

COCs need to be stopped, FOLIC ACID started & drugs for ovarian stimulation to be used. CLOMIPHENE CITRATE IS Widely used Simple to use

Minimal side effects Cost effective

PREGNANCY & PCOS

Clomiphene in ANOVULATORY PCOS

• 50-80% will ovulate on CC

• Only 40-50%will conceive

Q 23 What are

INFERTILITY Guidelines ??

FIRST LINEFIRST LINECLOMIPHENE CITRATE

SECOND LINESECOND LINELOD/GONADOTROPINS

THIRD LINETHIRD LINEIVF

The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group March 2–3, 2007, Thessaloniki, Greece. Human Reproduction 2008

RREESSIISSTTAANNCCEE

RREESSIISSTTAANNCCEE

FFAAIILLUURREE

THESSALONIKI CONSENSUS ON INFERTILITY TREATMENT IN PCOS, GREECE 2007

Q (a) Ovulation induction aim (B) First & second line management of infertility in women with PCOS?

(c) Role of LOD (D) Role Luteal phase support(E) OHSS

PCOS & INFERTILITY

Suggested a step by step approach to ovulation induction in women with PCOS

Steps Approach 1 If BMI is elevated - loss at least 5% of current body

weight

2 Ovulation induction with clomiphene citrate 3 Metformin in combination with clomiphene

citrate in CC resistant cases or BMI > 27 ???

4 Gonadotropin Therapy (OHSS / multiple pregnancy)

5 Laparoscopic Ovarian Drilling6 IVF ± Metformin Insulin sensitizer in combination with

gonadotropin therapy to decrease OHSS

Goals of Ovulation induction in IUI / IVF

Minimize Complications & Risk

AIM Ideal Outcome

Singleton live Birth at term

Cycle Cancellation

MultiplePregnancy OHSS

1. First Line Management Clomiphene is drug of Choice

2. In CC Resistant cases metformine has a role

3. 2nd line treatment Lap. Ovarian drilling has a role for women who can’t came for closed follow – up pregnancy role is 50%

4. Gonadotrophines in PCOS have promise, but OHSS & multiple pregnancy, should never before gotten complication

•Tamoxiphene people have just staring using it•Letroz is banned in india•Metformine role dealt

The Truth is that OHSS MUST

BE PREVENTED RATHER than treated

HCG TRIGGER PLAYS THE KEY ROLE

Metformin may be added to CC in women with clomiphene resistance who are older and have visceral obesity (I-A)

SOGC guidelines, 2010

METFORMIN ROLE IN INFERTILITY

Q 24PREGNANCY & PCOS

What is the line of treatment in women with PCOS who have

CONCEIVED NATURALLY ?

• PCOS patients have high chance of miscarriages so they need TLC + micronised vaginal progesterone

• If they have conceived while taking Metformin - it has to be continued for 3 months. This decreases miscarriage rate.• Few caution throughout pregnancy

PREGNANCY & PCOS

Q 25Can we do

LAPAROSCOPIC OVARIAN DRILLING in ADOLESCENTS who do not respond to

OCP

Not Recommended

except for infertility problems

Q26. LONG-TERM COMPLICATIONS

Q. Are the women sensitized to the long- term complications of PCOS?Infertility, Diabetes, Cardiovascular diseases, Cancer…

COUNSELING IS IMPORTANT AT THE FIRST VISIT detailing them of short term & long term

consequences. It helps them in REDUCING WEIGHT, strictly following life style modifications & become

proactive about conception & metabolic disorders timely.

LONG-TERM COMPLICATIONS

Consequences of Polycystic Ovarian disorders

Short Term consequences• Obesity • Infertility• Irregular menses • Abnormal lipid levels/ Hypertension• Hirsutism/acne/androgenic alopecia• Glucose intolerace / acanthosis nigricans• Increase early pregnancy loss / GDMLong – Term consequences • Dibetes mellitus• Endometrial cancer• Cardiovascular disease

The Most Common

Endocrine disorder

In women

Symptoms mayInclude chronically irregular and / or

Absent or delayed periods

Symptoms may include facial hair , central obesity and

acne

Let untreated it may lead to

Heart Disease

Left untreated, it may lead to Uterine cancer

Leading cause of

Infertility

P C O D

Long Term Complications & Consequences

Counseling also helps them to get regular screening / monitor from time to time detect problems early.•Infertility , •Diabetes •Cardiovascular disease, •Endometrial Cancer..

Q27 Counseling

Q28.

CANCER in women & PCOS

Would you like to comment ona) Endometrial Cancer b) Breast cancer in PCOSc) Your Pregnancy Experience

Ans. 28 AEndometrial Cancer in PCOS

• Gynaecologists should not forget that there is 3 fold increase in incidence of endometrial cancer.

• There Should be screening & monitoring for the same from time to time with TVS & EB

Ans. 28 BPCOS & Breast Cancer ??

Limited data exist that Do Not Support theconclusion that women with PCOS are a increased risk for BREAST CANCER.

Q 29

ASSOCIATION IS THERE

NOT THE CAUSATIVE FACTOR

Not included in diag. criteria

OBESITY IN PCOS

OBESITY & PSYCHOSOCIAL HEALTH in WOMAN

1. Poor body image2. Social stigmatisation (‘a laughing

matter’)3. Lower education levels4. Lower rates of marriage5. Lower socio economic levels

Neglected Area

Management of Obesity in general

1st LINE OF MANAGEMENT : Lifestyle changes like

modification of diet , physical activity and daily habits

2nd line of Management : introduction of pharmacotherapy for patients with BMI above 24 with co – morbidities and BMI above 27.5 with no co- morbidity

BARIATRIC SURGERY : may be an option for treatment of morbid obesity (BMI > 32.5) when diet and exercise do not work

1

2

3

Q30ROLE OF VIT – D ?

Vitamin – D Role in PCOS

was suggested by all Panelist

ADD VITAMIN D Too GIVE HER A GIFT FOR LIFE TIME

Q 31Prevention of Endometrial Ca.Monitoring of PCOS patients to preventoccurrence of Endometrial Carcinoma

Guidelines • Frequent TVS• Endometrial Sampling • Progesterone for periods

• TAILOR MADE THERAPY in Adolescent PCOS is our attempt

in this panel discussion

CONCLUSION

RULE OUT Diagnosis:

Pre-Diabetes Fatty Liver

Diabetes type II HyperlipidemiaInsulin Resistance Hypo-ThyroidismMetabolic Syndrome Vitamin-D DeficiencyCancer screening – Endometrial Ca.

CONCLUSION

CONCLUSION

COUNSELING & MONITORING of short & Long term sequalae of

PCOD is the key

More & More PCOS CLUBS should be formed

To shoot Information for teens & young

PCOS patients on its

various aspects

ADDRESS 11 Gagan Vihar, Near Karkari

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WEBSITE : www.lifecarecentre.in

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E-MAIL IDSharda.lifecare@gmail.com

Lifecarecentre21@gmail.cominfo@lifecareivf.com

&

Thank You