Polycystic Ovary Syndrome

PCOS Polycystic ovary syndrome is a relatively common clinical disorder that affects 5-10% of women in the reproductive age group PCOS is associated with : Clinical features Biochemical features Ultrasound features

PCOS -Diagnostic dillema’s- Endocrine features high androgens high LH insulin resistance Hyperinsulinemia Clinical features Menstrual disorder hirsutism Acne obesity anovulation Polycystic ovaries increased follicle increased stroma increased ovarian volume

Ultrasound assessment : international consensus definition 1. >=12 follicles of 2-9mm in diameter in at least one ovary or two 2. Increased ovarian volume(>=10cm3) (Balen et al. 2003)

European North American PCO ovaries + Menstrual disturbance and/or signs of hyperandrogenism (hirsutism,acne or alopoecia). No hormonal parameters are repaired to make the diagnosis. Biochemical evidence of hyperandrogenism Ovarian dysfunction(in the absence of non classical adrenal hyperplasia) not an essential of the diagnosis. European North American

Definition of PCOS should be uniform

RevisedESHRE/ASRM 2003 Consensus on Diagnostic Criteria for PCOS Oligo-and /or anovulation Clinical and/or biochemical signs of hyperandrogenism Polycystic ovarian morphology (exclusive of Congenital adrenal hyperplasia, androgen-secreting tumors, and Cushing’s syndrome) 2 of 3 criteria must be present for diagnosis of PCOS

Oligo/anovulation PCOS

Pathophysiology Primary defects in the hypothalamic-pituitary axis and ovarian function Hyperandrogenemia LH hypersecretion Insulin resistance, and compensatory hyperinsulinemia A gene or several genes predispose to PCOS susceptibility Autosomal dominant pattern of inheritance

Life-time consequences of PCOS In uterus Peripuberty Adolescence Adulthood Aging Fetus PCOS Syndrome X Adrenal androgens Anovulation Diabetes Insulin Hyperandrogenism Hypertension Ovarian androgens Obesity(50%) Dyslipidimia LH/FSH ratio CV disease Intrinsic LH Pulsatility B-cell deficiency Extrinsic Trand of Obesity Long term health Precocious puberty Reproductive disorder Metabolic

Long term issue in PCOS Established and handled well Cancer of the uterus Fertility Cosmetic concerns Established-recognition partially and badly handled Diabetes Lipid disorder Unproven-recognition and handling uncertain heart disease breast cancer

Treatment

For women who do not wish to conceive Low dose contraceptive pills restore menstrual regularity decrease ovarian hormone production reverse the effects of the excessive androgen levels Progesterone: smoke, >35yrs Diane-35: hirsutism or severe acne

Insulin sensitising agents Diet and exercise in lifestyle management Metformin Combination therapy: lifestyle and metformin Diazioxide, acarbose, somatostatin, D-chiroinosited

Metformin and PCOS Established efficacy - ovulation induction with or without clomifenen citrate - additional benefit to lifestyle change Promising efficacy - use in pubertal and teenage years to reduce PCOS effects Logical but unproven use - amelioration of long term metabolic problems in PCOS Unproven use - recurrent miscarriage prevention

Diet and exercise in PCOS Many publications on role of dietary management and weight loss - Little weight loss needed (clark et al. 1995,1998) - Effects are due to caloric restriction rather than dietary composition (kiddy et al. 1992,Moran et al. 2003) - Important of metabolic outcomes such as glucose and insulin sensitivity (Kiddy et al. 1992, Pasquali et al. 1998,2000) - Group organization superior to individual motivation (Norman et al. 1999)

PCOS and anovulation Anovulation is the major problem faced by the clinician Anovulation Medical approach Surgical approach

Conventional ovulation induction treatment algorithm Clomiphene Ovulation + Pregnancy + Ovulation - Gonadotropins Conventional ovulation induction treatment algorithm Ovarian response Complications +/- Pregnancy +/- Ovulation + IVF Ovarian response Complications +/- Pregnancy +/-

Surgical management of PCOS L/S removal of ovarian tissue was introduced by Palmer in 1967 Multiple ovarian puncture performed either by diathermy or by laser is well known as “ Ovarian drilling” Ovarian drilling is a modification of ovarian wedge resection but less invasive

Complication of the Ovalation induction Medical approach Ovarian hyperstimulation Multiple pregnacies Surgical approach Bleeding from the hloles Adhesion post-op Premature ovarian failure

Summary Clinical features associated with PCOS include obesity , hirsutism, or acne, cycle abnormality and infertility Revised diagnosis: 2 out of 3 criteria includes oligo/anovulation , hyperandrogenismia along with PCO Ovulation induction can be applied successfully in the great majority of women GDM and long-term health consequence such as high chances for developing type 2 diabetes and cardio-vascular disease have gained increasing attention in recent years

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