PCOS and Obesity

DUB is better treated by OCPs

Dr. Ritu Joshi

- Senior consultant Fortis escorts Hospital, Jaipur

- Chairperson Family welfare com. FOGSI (2009-2012)

- Vice President FOGSI 2014

Introduction

One of the most common endocrinopathy.

Unknown etiology.

Prevalence in India of 3.7% to 22.5% with 9.13% to 36% adolescents.

Common symptoms range from-

- menstrual disorders

- Infertility

- Hyperandrogenemia

- Metabolic syndrome.

In India rapid increase in prevalence of PCOS is

associated with morbid conditions such as-

- IR

- Excess body fat

- Adverse body fat patterning

- Hypertriglyceridemia

- Obesity related diseases like diabetes, and

cardiovascular diseases.

Category Specific abnormality

Recommended diagnosis NIH Rotterdam

AE-PCOS

Androgen status

Clinical Hyper-AndrogenismBiochemicalhyperandrogenism

Hirsutism, acne, and Central alopeciaIncreased total bioavailability or free serum testosterone level

XX

XX

X

X

XX

XX

Menstrual History

Oligo- or anovulation

Anovulation frequent (<21 d) or infrequent (>55d) bleeding intervals

Mid luteal progesterone test for anovulatorybleeding in women with regular ovulation

XX X XX

Ovarian appearance

Ovarian size/morphology on ultrasound

PCO morphology presence of 12 follicles of 2-9mm dia and/or ovarian vol >10ml without a cyst or dominant follicle >10mm

X X

Diagnostic criteria for PCOS which has been adapted from Legro et al 2013

Malik, et al.: A Consensus Evidence-based Good Clinical Practice Recommendations

Obesity and PCOS

• Obesity has been linked to abnormal function of

the hypothalamic-pituitary-ovarian axis through

multiple mechanisms that contribute to PCOS.

• Obesity is associated with insulin resistance and

compensatory hyperinsulinemia.

• Insulin serves as co-gonadotropin to stimulate

ovarian androgen production.

• Inputs from adipokines such as leptin are key to

controlling ovulatory function.

Effect of obesity in PCOS

Obesity is associated with increased likelyhood of

metabolic sequelae, like glucose intolerance,

dyslipidemia.

Obesity is associated with anovulation and

hyperandrogenemia.

Obesity and DUB• Hyperandrogenism contributes to ovulatory and menstrual

dysfunction.

• Management of hyperandrogenism focuses on treating its clinical consequences.

• OCPs are the first line management for the treatment of menstrual abnormalities.

• They suppress the gonadotropin release and consequently inhibit ovarian androgen secretion in women with PCOS.

• The estrogen in the OCPs also stimulates hepatic production of sex hormone binding globulin (SHBG), which inturnreduces the free fraction of circulating androgens .

Obese adolescent with PCOS

• OCPs are the first line option-

• They regulate the menstrual cycles.

• Lower the risk of endometrial hyperplasia, acne

and hirsutism.

• Act by regulating the GnRh pulses and suppress

FSH and LH resulting in decreased ovarian

stromal proliferation and reducing ovarian

steroidogenesis and androgen production.

• Mechanism of action of OCPs-

• Estrogen increases the production of SHBG

thereby decreasing the circulating free androgens.

• Reduction in adrenal androgen secretion and

inhibiting peripheral conversion of testosterone to

dihydrotestostrone and binding of

dihydrotesterone to androgen receptors.

• Progestogens counteract the unopposed estrogen

thereby reducing endometrial hyperplasia.

Choice of OCP

• Type of estrogen compound used.Most current

OCPs contain 30-35ug of ethinyl estradiol

combined with a progestin with minimal

androgenic activity.

• Choice of progestin compound used.

• Dosage of estrogen and progestin compounds

in combination.

Existing guidelines

ACOG

RCOG

Endocrine society

PCOS Australian alliance

PCOS guideline-GCPR by Indian fertility society

All suggest use of OCPs as the first line

primary treatment option in menstrual

irregularities.

Oral Contraceptives Pills

• Suppress ovarian androgen

• Increase SHBG

• Regular menstrual cyclicity

• Progestin opposition

• Contraception

Oligomenorrhea

• Combination estrogen-progestin pill first line when fertility is not desired• Decrease in LH secretion and decrease in

androgen production

• Increase in hepatic production of sex-hormone binding globulin

• Decreased bioavailablity of testosterone

• Decreased adrenal androgen secretion

• Regular withdrawal bleeds

• Prevention of endometrial hyperplasia

A comparison of various progestins

Progestin Estro-

genic

Anti-

estrogenic

Andro-

genic

Antiandro-

genic

Antimineralo

-corticoid

Progesterone - - - + +

Older

progestins:

MPA

Norethisterone

Levonorgestrel

-

-

-

-

+

+

+

+

+

-

-

-

-

-

-

Newer

progestins:

Desogestrel

Cyproterone

acetate

-

-

-

-

-

-

-

+

-

-

Drospirenone - - - + +

Advantages

• Best for adolescents.

• In adults who do not wish to conceive

• Best for regulating menstrual cycles.

• Simultaneously also treats acne and hirsutism

when present.