Management of the Commonest Endocrine disorder in females Miss Bini Ajay

Cases  25 year old with BMI 35, with history of infrequent periods, facial hair  30year old, normal BMI with irregular periods and unable to conceive for 3 years

PCOS Definition Pathophysiology Management Long term consequences Summary

Stein & Levanthal in % PCOS,20% PCO Heritable disorder 30%of PCOS- normal periods, 85-90% of oligomenorrhoea,30-40 % of amenorrhoea 70%- hyperandrogenism 50-70%- insulin resistance, 30-40% -IGTT, % - type II 40% - subfertility 42-73%-miscarriages 35%- depression Facts

Pathophysiology

Pathophysiology Insulin Resistance Hyperinsulinemia Stimulates Hypothalamus Stimulates adrenal gland Stimulates ovaries Suppresses Liver – less SHBG- Increased Androgen

Diagnosis Rotterdam Criteria - 12 or more follicle <10mm - Oligoovulation /anovulation - hyperandrogenism

PCOS

Biochemicaltests Biochemical tests - TFT/ Prolactin - Free androgen & SHBG - Androgen secreting tumours/ CAH(17OHprogesterone) - LH:FSH > 2:1 - AMH - GTT(fasting insulin) - Lipid profile

Treatment Exercise,weight loss(5%) Oral contraceptive pill- Dianette, Yasmin Spironolactone,Finasteride Isotretinoin Laser, electrolysis

Vaniqa Eflornithine Monohydrate chloride Blocks the action of ornithine decarboxylase in skin Twice daily 4 months

Metformin Decreases androgens Use insulin Reduces cholesterol Improves metabolism Increases ovulation If pregnant can continue Metformin

Inositol Myo-inositol- carbohydrate essential for insulin modulation Increases action of insulin –improves insulin sensitivity Reduces cholesterol and BP Reduces androgen Increases ovulation-69.5%

Laparoscopicdrilling Laparoscopic drilling Drills into the outer capsule Decreases testosterone Increase FSH

Long termEffects Long term Effects Diabetes, cardio and cerebrovascular disease-lipid profile, BP, HbA1c Endometrial cancer –hyperplasia Obstructive Sleep Apnoea- obese, insulin resistance – CPAP Psychological –Depression, sexual difficulties, eating disorder

PCOS and Trigycerides Obesity and high insulin – promotes high triglycerides- increases VLDL Insulin resistance – reduced clearance of VLDL and chylomicrons Hepatic content of triglycerides is high larger VLDL particles are produced- metabolised to small, dense LDL particles- poorly cleared and atherogenic Statins improve hyperandrogenemia

PCOS and hypertension Increased endothelin_1 levels Increased aldosterone concentrations Czech-22% Dutch-28% Coronary artery calcium (CAC scores) and carotid intima –media thickness (CIMT)- subclinical atherosclerosis- stroke,MI

Endometrialhyperplasia Endometrial hyperplasia Endometrial cancer Withdrawl bleed -3-4months TVS- ET-7mm

PCOS and Pregnancy Gestational diabetes- GTT at 16 and 28weeks Preeclampsia Preterm birth Perinatal mortality Multiple pregnancy

Summary PCOS is a common endocrine and metabolic disorder with long term consequences