Pcos p oly c ystic o vary s yndrome
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PCOS : P oly C ystic O vary S yndrome. By Kimberly Dovin, PGY3 Swedish Family Medicine January 13, 2003. or. PCOS : A Disorder for the Generalist. PCOS: Goals. Identify patients with risks for or with Dx of PCOS Assess patients appropriately for PCOS and associated disease states

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Pcos p oly c ystic o vary s yndrome

PCOS:PolyCystic Ovary Syndrome

By Kimberly Dovin, PGY3

Swedish Family Medicine

January 13, 2003


Pcos a disorder for the generalist

or

PCOS:A Disorder for the Generalist


Pcos goals
PCOS: Goals

  • Identify patients with risks for or with Dx of PCOS

  • Assess patients appropriately for PCOS and associated disease states

  • Prescribe therapy to treat complaints and prevent sequelae


Pcos objectives
PCOS: Objectives

  • Define PCOS

  • Understand pathophysiology

  • Form an appropriate differential diagnosis

  • Establish the work-up for PCOS

  • Develop an array of therapies to treat complaints and prevent bad outcomes


Pcos defined i
PCOS: Defined? I

  • ACOG and NIH (1990): hyperandrogenism and chronic anovulation excluding other causes

  • Stein and Levanthal (1935): association of amenorrhea with polycystic ovaries and variably: hirsutism and/or obesity


Pcos epidemiology
PCOS: Epidemiology

  • Prevalence: 4-6% females

    • Probably same world wide

  • No difference between blacks and whites

  • 75% of women w/ irregularity or infertility


Pcos signs and symptoms

SYMPTOMS

Menstrual irregularity

Infertility

Hirsutism, acne, etc

Obesity

SIGNS

Hirsutism, acne

Obesity

Ovarian enlargement

Acanthosis nigricans

PCOS: Signs and Symptoms




Pcos pathopysiology what we think we know
PCOS: PathopysiologyWhat we think we know.

  • “Vicious cycle”

  • Abnormal gonadotropin secretion

    • Excess LH and low, tonic FSH

  • Hypersecretion of androgens

    • Disrupts follicle maturation

    • Substrate for peripheral aromatization

  • Negative feedback on pituitary

    • Decreased FSH secreation

  • Insulin resistance, Elevated insulin levels


Pcos current theories of pathopysiology
PCOS: Current theories of pathopysiology

Autosomal

Dominant Gene

Downstream

Signal Defect

GnRH

E2

LH

Insulin Resistance

PCOS

A

A=androgens, E2=estradiol


“Could the theory of chaos contribute to the interpretation of pathogenesis of polycystic ovary syndrome?”


Pcos case 1 hx
PCOS: Case 1 - Hx interpretation of pathogenesis of polycystic ovary syndrome?”

  • J.D. 31yof

  • Menstrual irregularity,LMP 5 months prior

    • Irregular since menarche

    • Getting longer over time

  • Sexually active and uses condoms

  • 40lb weight gain over past six months

  • Previous U/S w/ ovarian cysts

  • ROS: hair growth on her chin and chest

  • Meds: HCTZ, Effexor, atenolol


Pcos case 1 pe
PCOS: Case 1 - PE interpretation of pathogenesis of polycystic ovary syndrome?”

  • BP 126/96, Weight 248lbs

  • Skin: dark hair on chin and chest, moderate to severe acne on face and back

    • no acanthosis nigricans

  • Abd-obese, tender RLQ, no R/G, no abd striae

  • Pelvic exam – nl ext genitalia no clitoromegaly, norm appearing cervix

  • Bimanual: Uterus/adnexa not palpated

  • U/S: Normal appearing ovaries


Pcos differential dx
PCOS: Differential Dx interpretation of pathogenesis of polycystic ovary syndrome?”

  • Androgen secreting tumor

  • Exogenous androgens

  • Cushing’s syndrome

  • Nonclassical congenital adrenal hyperplasia

  • Acromegaly

  • Genetic defect in insulin metabolism

  • Primary hypothalamic amenorrhea

  • Primary ovarian failure

  • Thyroid dz

  • Prolactin dz


Pcos case 1 work up
PCOS: Case 1 Work-up interpretation of pathogenesis of polycystic ovary syndrome?”

  • Total or free testosterone

  • +/- LH and FSH

  • Pelvic U/S

  • Fasting glucose

  • Fasting lipid profile

  • (SHBG, Insulin)


Pcos work up cont d
PCOS: Work-up (cont’d) interpretation of pathogenesis of polycystic ovary syndrome?”

  • TSH

  • Prolactin

  • UHCG

  • +/- 17-hydroxyprogesterone

  • +/- Dexamethasone suppression test

  • +/- DHEA


Pcos case 1 treatment
PCOS: Case 1 Treatment interpretation of pathogenesis of polycystic ovary syndrome?”

  • Oligomennorhea

    • OCPs, Progestins, insulin-sensitizing agents

  • Hirsutism

    • OCPs, Antiandrogens, ISAs, Eflornithine

    • Mechanical treatments

  • Obesity

    • LIFESTYLE MODIFICATIONS

    • Metformin


Pcos case 1 treatment1
PCOS: Case 1 Treatment interpretation of pathogenesis of polycystic ovary syndrome?”

  • Naturopathic options

    • Flaxseed oil

    • Fish oil

    • D-chiro-inositol

    • Chromimum

    • Urtica Dioica (aka stinging nettle)

    • Saw palmetto


Case 1 outcomes
Case 1: Outcomes interpretation of pathogenesis of polycystic ovary syndrome?”

  • Laboratory analysis: Nl TSH and prolactin, mild elevation of testosterone, LH:FSH 3:1

  • Treatment: Diet and exercise counseling, metformin 850mg bid.

  • Patient reported resumption of menses and thereafter lost to f/u


Pcos case 2 hx
PCOS: Case 2 - Hx interpretation of pathogenesis of polycystic ovary syndrome?”

  • R.M. 27yof

  • Desires pregnancy w/o results X 2yrs

  • LMP 2 wks ago/ 3 menses per yr

    • 2 years irregularity,

    • sometimes heavy bleeding

  • Simlar family hx

  • C/o facial hair which she waxes

  • No infertility w/u


Pcos case 2 p e
PCOS: Case 2 – P.E. interpretation of pathogenesis of polycystic ovary syndrome?”

  • Weight 247 lbs

  • Skin: Scant facial hair on chin, no acne

  • Abd: obese

  • Pelvic: norm uterus, ovaries not palpated

  • Labs: mild elev prolactin & testosterone, elevated LH

  • Pelvic US WNL


Pcos infertility
PCOS: Infertility interpretation of pathogenesis of polycystic ovary syndrome?”

  • WEIGHT LOSS

  • Clomiphene citrate 50-100mg QD +/- dexamethasone

  • Gonadotropins

  • Metformin

  • Ovarian Drilling


Pcos risks of pregnancy
PCOS: Risks of Pregnancy interpretation of pathogenesis of polycystic ovary syndrome?”

  • Gestational Diabetes?

  • Hypertension?


Pcos case 2 outcomes
PCOS: Case 2 - Outcomes interpretation of pathogenesis of polycystic ovary syndrome?”

  • Metformin 500mg bid

    • Menses resumed q28 d X 2

  • Anxious to get pregnant.

    • Advised following BBTemps

    • Timing intercourse.

    • If no result in 3mos start Clomid.


Pcos case 3 hx
PCOS: Case 3 - Hx interpretation of pathogenesis of polycystic ovary syndrome?”

  • M.P. 39yof

  • F/u acne face and back

  • C/o hirsutism, “like a beard”

  • Oligomennorhea, q60day cycles

  • G2P2 s/p BTL 14 years ago

  • ROS: weight gain 50lbs in 3-4 years


Pcos case 3 p e
PCOS: Case 3 - P.E. interpretation of pathogenesis of polycystic ovary syndrome?”

  • BP 146/92

  • Weight 232lbs, BMI 36.3

  • Skin: Severe acne on face and back, evidence of shaving on face


Pcos associated disorders
PCOS: Associated Disorders interpretation of pathogenesis of polycystic ovary syndrome?”

  • Diabetes

  • Hyperlidpidemia (LDL, Triglycerides)

  • Obesity

  • Hypertension

  • CAD?

    • Incr in Risk Factors, but not mortality


Pcos associated disorders1
PCOS: Associated Disorders interpretation of pathogenesis of polycystic ovary syndrome?”

  • Endometrial CA

  • Ovarian CA?

  • +/- Breast CA

  • NO increase in Osteoporosis

  • Eating disorders

  • Psychiatric dz


Pcos case 3 follow up
PCOS: Case 3 Follow-up interpretation of pathogenesis of polycystic ovary syndrome?”

  • TSH, Prolactin, Free Testosterone, 17-OH progesterone all WNL

  • Fasting glu = 99 LDL = 125

  • Referred to nutrition and prescribed exercise program

    • Pt lost 30lbs over one year, menses more regular, hirsutism and acne slightly improved

    • LDL dropped to 110, BP normalized


Pcos conclusion
PCOS: Conclusion interpretation of pathogenesis of polycystic ovary syndrome?”

  • PCOS: chronic anovulation/hyperandrogenism

  • Complete a w/u to r/o other causes

  • Advise weight loss and exercise in all patients w/ PCOS

  • Consider medical management

  • Use a Palm memo


Bibliography
Bibliography interpretation of pathogenesis of polycystic ovary syndrome?”

  • Plycystic Ovary Syndrome. Clinical Management Guidelines. Dec 2002; ACOG Practice Bulletin No. 41.

  • Hunter, H., MD and Sterrett, J, PharmD. Polycystic Ovary Syndrome: It’s Not Just Infertility. AFP. Sept. 1, 2000.

  • Keri Marshall, ND Candidate 2001 Polycystic Ovary Syndrome: Clinical Considerations.

  • Macut D, et al. Cardiovascular risk in adolescent and young adult obese females with polycystic ovary syndrome (PCOS). J Pediatr Endocrinol Metab. 2001;14 Suppl 5:1353-59; discussion 1365.

  • Poretsky, Insulin Resistance and the Polycystic Ovary Syndrome: Mechanism and Implications for Pathogenesis; Endocrine Reviews 20 (4): 535-582.


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