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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 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

slide12

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

pcos case 1 hx
PCOS: Case 1 - Hx
  • 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
  • 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
  • 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
  • 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)
  • TSH
  • Prolactin
  • UHCG
  • +/- 17-hydroxyprogesterone
  • +/- Dexamethasone suppression test
  • +/- DHEA
pcos case 1 treatment
PCOS: Case 1 Treatment
  • 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
  • Naturopathic options
    • Flaxseed oil
    • Fish oil
    • D-chiro-inositol
    • Chromimum
    • Urtica Dioica (aka stinging nettle)
    • Saw palmetto
case 1 outcomes
Case 1: Outcomes
  • 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
  • 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.
  • 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
  • WEIGHT LOSS
  • Clomiphene citrate 50-100mg QD +/- dexamethasone
  • Gonadotropins
  • Metformin
  • Ovarian Drilling
pcos risks of pregnancy
PCOS: Risks of Pregnancy
  • Gestational Diabetes?
  • Hypertension?
pcos case 2 outcomes
PCOS: Case 2 - Outcomes
  • 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
  • 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.
  • 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
  • Diabetes
  • Hyperlidpidemia (LDL, Triglycerides)
  • Obesity
  • Hypertension
  • CAD?
    • Incr in Risk Factors, but not mortality
pcos associated disorders1
PCOS: Associated Disorders
  • Endometrial CA
  • Ovarian CA?
  • +/- Breast CA
  • NO increase in Osteoporosis
  • Eating disorders
  • Psychiatric dz
pcos case 3 follow up
PCOS: Case 3 Follow-up
  • 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
  • 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
  • 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.