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PCOSPCOS Polycystic ovary syndrome is a relatively Polycystic ovary syndrome is a relatively
common clinical disorder that affects 5-10% common clinical disorder that affects 5-10% of women in the reproductive age groupof women in the reproductive age group
PCOS is associated with :PCOS is associated with : Clinical featuresClinical features
BiochemicalBiochemical features features
Ultrasound Ultrasound featuresfeatures
PCOSPCOS-Diagnostic dillema’s--Diagnostic dillema’s-
Clinical features• Menstrual disorder• hirsutism• Acne• obesity• anovulation
Endocrine features• high androgens• high LH• insulin resistance• Hyperinsulinemia
Polycystic ovaries• increased follicle• increased stroma• increased ovarian volume
Ultrasound assessment : Ultrasound assessment : international consensus international consensus
definitiondefinition
1. >=12 follicles of 2-9mm 1. >=12 follicles of 2-9mm in diameter in at least in diameter in at least one ovary or twoone ovary or two 2. Increased ovarian 2. Increased ovarian volume(>=10cm3)volume(>=10cm3) (Balen et al. 2003)(Balen et al. 2003)
EuropeanEuropean
North AmericanNorth American
PCO ovariesPCO ovaries ++ Menstrual disturbanceMenstrual disturbance and/or signs of hyperandrogeand/or signs of hyperandroge
nismnism (hirsutism,acne or alopoecia).(hirsutism,acne or alopoecia).
No hormonal parameters are No hormonal parameters are repaired to make the diagnosirepaired to make the diagnosis.s.
Biochemical evidence of hypeBiochemical evidence of hyperandrogenismrandrogenism
++ Ovarian dysfunction(in the abOvarian dysfunction(in the ab
sence of non classical adrenal sence of non classical adrenal hyperplasia)hyperplasia)
PCO ovariesPCO ovaries not an essential of the diagnonot an essential of the diagno
sis.sis.
RevisedESHRE/ASRM 2003 Consensus RevisedESHRE/ASRM 2003 Consensus on Diagnostic Criteria for PCOSon Diagnostic Criteria for PCOS
Oligo-and /or anovulationOligo-and /or anovulation Clinical and/or biochemical signs of hyClinical and/or biochemical signs of hy
perandrogenismperandrogenism Polycystic ovarian morphologyPolycystic ovarian morphology (exclusive of Congenital adrenal hyper(exclusive of Congenital adrenal hyper
plasia, androgen-secreting tumors, and plasia, androgen-secreting tumors, and Cushing’s syndrome)Cushing’s syndrome)
2 of 3 criteria must be present for diagnosis of PC2 of 3 criteria must be present for diagnosis of PCOSOS
PathophysiologyPathophysiology Primary defects in the hypothalamic-pituiPrimary defects in the hypothalamic-pitui
tary axis and ovarian functiontary axis and ovarian function HyperandrogenemiaHyperandrogenemia LH hypersecretionLH hypersecretion Insulin resistance, and compensatory hypInsulin resistance, and compensatory hyp
erinsulinemiaerinsulinemia A gene or several genes predispose to PCOA gene or several genes predispose to PCO
S susceptibilityS susceptibility Autosomal dominant pattern of inheritanAutosomal dominant pattern of inheritan
cece
Life-time consequences of Life-time consequences of PCOSPCOS
In uterusIn uterus PeripubertPeripubertyy
AdolescencAdolescencee
AdulthoodAdulthood
AgingAging
FetusFetus PCOSPCOS Syndrome XSyndrome X
Adrenal Adrenal androgensandrogens
AnovulationAnovulation DiabetesDiabetes
InsulinInsulin HyperandrogenHyperandrogenismism
HypertensionHypertension
Ovarian Ovarian androgensandrogens
Obesity(50%)Obesity(50%) DyslipidimiaDyslipidimia
LH/FSH ratioLH/FSH ratio CV diseaseCV disease
IntrinsicIntrinsic LH PulsatilityLH Pulsatility B-cell B-cell deficiencydeficiency
ExtrinsicExtrinsic Trand of ObesitTrand of Obesityy
Long term Long term healthhealth
Precocious Precocious pubertypuberty
Reproductive Reproductive disorderdisorder
MetabolicMetabolic
Long term issue in PCOSLong term issue in PCOS Established and handled wellEstablished and handled well Cancer of the uterusCancer of the uterus FertilityFertility Cosmetic concernsCosmetic concerns Established-recognition partially and badly Established-recognition partially and badly
handledhandled DiabetesDiabetes Lipid disorderLipid disorder Unproven-recognition and handling uncertainUnproven-recognition and handling uncertain heart disease heart disease breast cancerbreast cancer
For women who do not wish to For women who do not wish to conceiveconceive
Low dose contraceptive pillsLow dose contraceptive pills restore menstrual regularityrestore menstrual regularity decrease ovarian hormone productiondecrease ovarian hormone production reverse the effects of the excessive andreverse the effects of the excessive and
rogen levelsrogen levels Progesterone: smoke, >35yrsProgesterone: smoke, >35yrs Diane-35: hirsutism or severe acneDiane-35: hirsutism or severe acne
Insulin sensitising agentsInsulin sensitising agents Diet and exercise in lifestyle managemDiet and exercise in lifestyle managem
entent MetforminMetformin Combination therapy: lifestyle and meCombination therapy: lifestyle and me
tformintformin Diazioxide, acarbose, somatostatin, D-Diazioxide, acarbose, somatostatin, D-
chiroinositedchiroinosited
Metformin and PCOSMetformin and PCOS Established efficacyEstablished efficacy - ovulation induction with or without clomife- ovulation induction with or without clomife
nen citratenen citrate - additional benefit to lifestyle change- additional benefit to lifestyle change Promising efficacyPromising efficacy - use in pubertal and teenage years to reduce - use in pubertal and teenage years to reduce
PCOS effectsPCOS effects Logical but unproven useLogical but unproven use - amelioration of long term metabolic proble- amelioration of long term metabolic proble
ms in PCOSms in PCOS Unproven useUnproven use - recurrent miscarriage prevention- recurrent miscarriage prevention
Diet and exercise in Diet and exercise in PCOSPCOS
Many publications on role of dietary manageMany publications on role of dietary management and weight lossment and weight loss
- Little weight loss needed - Little weight loss needed (clark et al. 1995,1998)(clark et al. 1995,1998)
- Effects are due to caloric restriction rather t- Effects are due to caloric restriction rather than han
dietary composition dietary composition (kiddy et al. 1992,Moran et al. 2003)(kiddy et al. 1992,Moran et al. 2003)
- Important of metabolic outcomes such as - Important of metabolic outcomes such as glucose and insulin sensitivity glucose and insulin sensitivity (Kiddy et al. 1992, (Kiddy et al. 1992, Pasquali et al. 1998,2000)Pasquali et al. 1998,2000)
- Group organization superior to individual - Group organization superior to individual motivation motivation (Norman et al. 1999)(Norman et al. 1999)
PCOS and anovulationPCOS and anovulation Anovulation is the major problem faceAnovulation is the major problem face
d by the cliniciand by the clinician
AnovulationAnovulation Surgical approachSurgical approach
Medical Medical approachapproach
Ovulation inductionOvulation induction
Pregnancy +
Gonadotropins
Ovarian responseComplications +/-
Pregnancy +/-
IVF
Clomiphene
Ovulation +
Ovulation -
Ovulation +
Ovarian responseComplications +/-
Pregnancy +/-
Surgical management of Surgical management of PCOSPCOS
L/S removal of ovarian tissue was L/S removal of ovarian tissue was introduced by Palmer in 1967introduced by Palmer in 1967
Multiple ovarian puncture performed Multiple ovarian puncture performed either by diathermy or by laser is either by diathermy or by laser is well known as “ Ovarian drilling”well known as “ Ovarian drilling”
Ovarian drilling Ovarian drilling is a modification ofis a modification of ovarian wedge resectionovarian wedge resection but less invasivebut less invasive
Complication of the Ovalation indComplication of the Ovalation inductionuction
Medical approachMedical approach Ovarian hyperstimulationOvarian hyperstimulation Multiple pregnaciesMultiple pregnacies
Surgical approachSurgical approach Bleeding from the hlolesBleeding from the hloles Adhesion post-opAdhesion post-op Premature ovarian failurePremature ovarian failure
SummarySummary Clinical features associated with PCOS incluClinical features associated with PCOS inclu
de obesity , hirsutism, or acne, cycle abnorde obesity , hirsutism, or acne, cycle abnormality and infertilitymality and infertility
Revised diagnosis: 2 out of 3 criteria includeRevised diagnosis: 2 out of 3 criteria includes oligo/anovulation , hyperandrogenismia als oligo/anovulation , hyperandrogenismia along with PCOong with PCO
Ovulation induction can be applied successfOvulation induction can be applied successfully in the great majority of womenully in the great majority of women
GDM and long-term health consequence sucGDM and long-term health consequence such as high chances for developing type 2 diabh as high chances for developing type 2 diabetes and cardio-vascular disease have gained etes and cardio-vascular disease have gained increasing attention in recent yearsincreasing attention in recent years