MODERN APPROACH TO PCOS

Presentation Transcript

J. SERNA MD. PhD.

IVI Madrid

Physiology and Diagnosis

What is PCOS?
How to Diagnose it?
How to Treat it?

High prevalent disease

Multiorganic: ovaries, HH, adrenal, fat, skin, pancreas, etc...
Different degrees of organ involvement
Main feature: ovarian hyperandrogenism
Multiple phenotypes

Metabolic disorders

IR and Hyperinsulinism
Obesity (male pattern)
Impaired Glucose Tolerance and DM2
Hyperlypemia

PCOS: HETERGENEOUS

Reproductive disorders
Hyperandrogenism
Anovulation: Menstrual disorders, infertility
Polycystic ovaries
Miscarriage

General Health Disorders
Acantosis nigricans
Cardiovascular disease
Endometrial cancer

PCOSDg CRITERIA

Anovulation and/or dysovulation
Clinical and/or Biochemical Hyperandrogenism
Polycystics ovaries
and exclusion of other aetiologies (CAH,
tumours, HPRL, etc)
The Rotterdam ESHRE/ASRM sponsored PCOS consensus workshop group, 2003

Anovulation/dysovulation work-up

FSH,LH,PRL,TSH, 17 βE2

PRL

PRL N

FSH(N /  )

FSH

FSH/LH < 1

Estrogens N

FSH/LH > 1

Hypoestrogenism

Hypo-hypo Amenorrhea

WORK-UP

hyperPRL

PCOS

WORK-UP POF

Type IV

Type II

Type I

Type III

PCOS

Polycystics ovaries
and exclusion of other aetiologies (CAH, tumours, HPRL, etc)

Percentage of patients with PCOS and altered biochemical markers

N=198

Percentage of patients with PCOS and altered biochemical markers

PCOS DIAGNOSIS

Biochemical hyperandrogenism
Normal boundaries established by laboratories RIA:

95-97%
Control population?

High variability among normal population (absence of feed-back mechanism)
Diverse androgens: TT,ITL, 17OHP, DHA-S, A4, etc.

PCOS

Polycystics ovaries

PCOS DIAGNOSIS

Polycystic ovary

Presence of 12 or more

follicles 2-9 mm 

and/or ovarian volume

higher than 10 mL

(one ovary is enough)

Non suitable to women on OCP or with a dominant follicle (>10 mm)

The Rotterdam ESHRE/ASRMsponsored PCOS consensus workshop group, Hum Reprod 2004,19:41-7

Polycystic ovaries. Pitfalls

False positives: 20% normal women

False negatives: 30% PCOS

US scan cannot make differential diagnosis between multycystic ovaries and polycystics ovaries

Time required for measurements

PCOS

Polycystics ovaries

Dysovulation wo

?? hyperandrogenism

Normal cycle

and hyperandrogenism ??

PCOS DIAGNOSIS

Anov/dysovulation

HiperPRL, HA, POF, etc

Idiopathic Hirsutism

CAH, Tumors

Infertility and miscarriages

Exaggerated response to OI

Multiple pregnancy

PCO

The Rotterdam ESHRE/ASRMsponsored PCOS consensus workshop group, Hum Reprod 2004,19:41-7

Insulin-resistance in PCOS patients

75,3%(n=149)

N=198

HOMA (Homeostasis model assesment): Glucose x18,1/Insulin x0,139 (Insulin-resistance: Obese <5,09, Lean <5,48)

Prevalence of Impaired Glucose Tolerance and Diabetes in POCS in two American Studies (New York, Pensylvania y Chicago) and in a Spainish Survey

40

35

31,1

30

%

20

10

8,95

7,5

10

4,47

0

Legro, 1999

Ehrmann, 1999

HSPSC

Legro. J Clin Endocrinol Metab 1999. N=244.

Ehrmann. Diab Care 1999. N=122 (WHO, 1985)

HSPSC N=67 Criteria: WHO, 1999.

Methods for insulin-resistance work-up

Methods for Insulin-Resistance work-up

Gold Standard test IR is euglucemic clamp
.
Due to its complexity, Oral Glucose Tolerance Test or Basal Glucose and Insulin measurements instead
.
OGTT is the main test in the diagnosis of Impaired Glucose Intolerance or Type II Diabetes

Other indexes are less used in clinical routine

IR

hyperinsulinism

¿?

Hyperandrogenic Anovulation

Diabetes Mellitus

IGT

IFG or IR

And 2 of

≥ 140/90 mmHG

Dyslipidaemia

Central Obesity

Wais:hip ratio

BMI

Microalbuminuria

Central obesity (Waist)

Dyslipidaemia TG

Dyslipidaemia HDL-C

≥130/85

Fasting glucose >100 mg/dL

At least 3

Metabolic Syndrome

WHO

Adult Treatment Panel

Cardiovasculardisease in women

Near2,5 million women hospitalized each year due to CVD
1st death cause in women (over the next 14 together)
Half of these deaths are from MCI
Annual cost estimated to be 28,65 billion dolars
Tsang y cols. Risk of caronary heart disease in women: current understanding. Mayo Found Med Educ Research, 2000