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Year 5 Medicine . Polycystic Ovary Syndrome and Hirsutism. Stella Milsom. Overview. diagnosis of PCOS-new Rotterham Consensus symptoms of PCOS future health risks associated with PCOS relevant investigation of woman with likely symptoms management of hirsutism related to PCOS.

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year 5 medicine

Year 5 Medicine

Polycystic Ovary Syndrome and Hirsutism

Stella Milsom

overview
Overview
  • diagnosis of PCOS-new Rotterham Consensus
  • symptoms of PCOS
  • future health risks associated with PCOS
  • relevant investigation of woman with likely symptoms
  • management of hirsutism related to PCOS
what is polycystic ovary syndrome
What is polycystic ovary syndrome?
  • syndrome of ovarian hyperandrogenisation
  • associated symptoms of androgen excess
  • anovulation leads to menstrual irregularity
  • most common gynaecological condition affecting women of childbearing age
  • also associated with the metabolic syndrome
pathogenesis of pcos
Pathogenesis of PCOS

LH  insulin/IGF1  cytochrome P450



 ovarian androgen production

disturbed folliculogenesis

obesity

diagnosis of polycystic ovary syndrome
Diagnosis of polycystic ovary syndrome

symptoms of androgen excess

  • irregular menses
  • acne, hirsutism

biochemical androgen excess

  •  total / free testosterone,  androstenedione,  LH

pelvic ultrasound

  • 1 or both ovaries enlarged, >12 peripheral follicles
anovulation in pcos

Anovulation in PCOS

presents as:

absence of periods

infrequent periods ( > 35 day cycle)

dysfunctional uterine bleeding

occasionally regular periods

risk of endometrial cancer

biochemistry in pcos
Biochemistry in PCOS

Raised LH or LH:FSH ratio

One or more androgen levels raised

testosterone

androstendione

DHEAS

polycystic ovaries
Normal ovaries

volume < 8 cm3

scattered follicles

Polycystic Ovaries

Generally >8cm3

peripheral distribution of follicles

increased stroma

Polycystic Ovaries
2004 consensus pcos definition
2004 Consensus PCOS Definition

2 out of the following 3 features

anovulation

clinical and/or biochemical evidence of androgen excess

polycystic ovaries on ultrasound:

1 or more ovaries ≥10mls in size and ≥12 follicles

Human Reproduction, 2004

slide15

PCOS

  • PCOS is also associated with a characteristic metabolic syndrome that includes:
    • insulin resistance
    • dyslipidemia
    • hypertension
  • These features are linked with increased risks of type 2 diabetes and possibility of premature cardiovascular disease
metabolic a bnormalities in pcos due to i nsulin r esistance
Metabolic abnormalities in PCOS due to insulin resistance
  • impaired GTT 40%
  • Diabetes – 5x more likely than weight matched controls OGTT vs FG
  • gestational diabetes increased risk
  • dyslipidemia ¯HDL LDL TG

 potential cardiovascular risk

slide17

Associations of PCO with clinical conditions

PCO present in

  • 75% cases of anovulatory infertility (Adams 1986, Hull 1987)
  • 87% cases of oligomenorrhoea (Adams 1986)
  • 80% cases of hirsutism and regular menses

(Adams 1986, Hull 1987)

  • 83% women presenting with acne to dermatology clinic

(Bunker 1989)

  • 30-40% women with amenorrhoea (Adams 1986)
what tests are useful
What tests are useful?
  • androgens, FSH, LH, estradiol
  • prolactin, thyroid function, pregnancy test (causes of secondary amenorrhea)
  • ultrasound pelvis
what tests are useful19
What tests are useful?

remember to exclude secondary causes of PCOS

  • androgen secreting tumour
  • acromegaly
  • non classical CAH
management of pcos
Management of PCOS
  • symptom orientated
  • long term risk reduction
management of pcos current symptoms
Management of PCOS- Current Symptoms
  • determine which predominates-infertility or androgen excess
  • then consider antiandrogen versus ovulation induction therapy
  • consider state of endometrium
  • first line medical management from diagnosis to reproduction most likely be OCP
hirsutism and pcos

Hirsutism and PCOS

defined as coarse terminal hair in a male distribution

do not confuse with lanugo hair

assessed by the Ferriman-Galwey score

does not always correlate with androgen levels

management of androgen excess symptoms in pcos
Management of androgen excess symptoms in PCOS

symptoms include:

hirsutism

acne

androgenic alopecia

management of androgen excess symptoms in pcos24
Management of androgen excess symptoms in PCOS

First line treatment for mild hirsutism

weight loss and exercise

oral contraceptive (Estelle and Yasmin)

metformin

effect of lifestyle in hirsute pcos
Effect of lifestyle in hirsute PCOS
  • weight gain causes an increase in insulin resistance and androgen production in PCOS women
  • antiandrogen therapy is less efficacious
  • modest weight loss and increase in exercise e.g. 5-10% weight loss will often improve hirsutism by reducing androgen production
ocp and hirsutism
OCP and hirsutism
  • first line treatment for hirsutes (manages endometrium and contraception also)
  • synthetic E2 suppresses gonadotropin driven androgen production
  • increase in SHBG decreases bioavailable T to hair follicle
  • addition of low dose CPA (Estelle) provides antiandrogenic progesterone
metformin and hirsutism
Metformin and hirsutism

useful alternative to OCP in woman with hirsutism who also desiresfertility

common to have gut side effects

commence slowly, work up to 1500mg/day

moniter with liver and renal function ( occasional hepatotoxicity, theoretical risk of lactic acidosis)

metformin and hirsutism28
Metformin and hirsutism

In both lean and overweight women with PCO

  • improves insulin sensitivity and lipids
  • decreases hyperandrogenism
  • increases frequency of ovulation (40-70%) compared to placebo
management of androgen excess symptoms in pcos29
Management of androgen excess symptoms in PCOS

Treatment of more severe hirsutism (refer)

OCP plus additional antiandrogen therapy:

spironolactone 200mg/day

cyproterone in reverse sequential regime (specialist)

flutamide 250mg/day (specialist)

finasteride unfunded and less effective

for the future: vaniqa cream (ornithine decarboxylase inhibitor)

combination antiandrogen therapy
Combination antiandrogen therapy
  • use in conjunction with OCP
  • specialist prescription
  • require monitoring (liver function)
  • used in more severe hirsutism or unresponsive women
  • course up to 36 months
  • require contraception
  • 6 months before effect but may improve up to 2 years after initiating therapy (50% reduction in FG score)
management of pcos longer term
Management of PCOS-longer term
  • consider OCP, metformin, progestins, antiandrogens, ovulation induction, lipid lowering agents, antihypertensives as necessary
  • surveillance for diabetes, hypertension and dyslipidemia especially if positive family history and overweight
  • monitor endometrium
  • active weight loss and exercise programme