DR.ABHISHEK SINGH PARIHAR M.S (Obs & Gyne) ; FELLOW REPRODUCTIVE MEDICINE CONSULTANT : LIFECARE IVF CENTRE, NEW DELHI ABALONE CLINIC, NOIDA ETERNA IVF CENTER, NEW DELHI MANAGEMENT OF ADOLESCENT PCOS

DEFINITION PCOS is a heterogenous endocrine metabolic disorder characterised by hyperandrogenemia,chronic anovulation,and/or polycystic ovaries Irving F.Stein & Michael L. Leventhal -1935

MAIN FEATURES -Anovulation -POLYCYSTIC OVARIES -Hyperinsulinemia -Hyperandrogenism

Rotterdam consensus Revised 2003 criteria (2 out of 3) 1. Oligo- or anovulation, 2. Clinical and/or biochemical signs of hyperandrogenism, 3. Polycystic ovaries and exclusion of other etiologies (congenital adrenal hyperplasia, androgen-secreting tumors, Cushing’s syndrome)

Exclusion of related disorders CAH-Basal morning 17-OHP,(2-3 ng/ml) WHO I &III –FSH,LH,E2 Hypothyroidism,Hyperprolactenemia-Sr.TSH,Sr.Prl Syndromes of severe insulin resistance(HAIRAN syn) Cushing syndrome-Dexa supression test Androgen secreting tumours /exogenous androgens

PCOS Definition Hyperandro genism (Clinical or Biochemical ) Oligo- menorrhea or Oligo- Ovulation Polycystic Ovaries on USG NIH (1990)yes no Rotterdam (2003) yesYes 2 of the 3 criteria yes AE-PCOS Society (2009) yesYes 1 of 2 criteria yes

Adolescent Period Reproductive Period Menopausal  Menstrual Irregularity Obesity  Cosmetic concerns Acne Hirsutism Hair Loss  Infertility  Early Pregnancy loss  During pregnancy  PIH  GDM  Metabolic Syndrome  Ca Endometrium

Most frequent endocrine problem in adolescent age group In 5-15%women of reproductive age group (12-45 years) Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertility and Sterility Vol. 97, No. 1, January Bart C. J. M. Fauser et.al.

Dietary intervention ( high protien, low carbohydrate, low fat diet more effective) Energy deficit of Kcal/day

Goals – practical,realistic,achievable Small frequent meals More fruits/vegetables/fibre(bran) Decreased sugar/fried food /cola Switch to healthy oils More steamed /grilled cooking

American Diabetes Association recommends minimum of :- 150 minutes/week of moderate to vigrous exercise for individuals with IGT. Should be distributed over 3 days For long term weight reduction – 1 hour/day of exercise is recommended. Ref : Kathleen Metal Clin Obst Gynecol 2007

Find simple ways to add physical activity in daily routine

Role of weight loss Ref : Kathleen M et al Fertility & Sterility % wt. Reduction effective in restoring normal menses and fertility

PCOS can’t be cured but the symptoms can be managed 50 % by just weight control

Fertility and Sterility, Vol. 97, No. 1, January 2012

Overall, the benefits of OCPs outweigh the risks in most patients with PCOS (level B). Women with PCOS are more likely to have contraindications for OCP use than normal women (level C).

There is no evidence for differences in effectiveness and risk among the various progestogens and when used in combination with a 20 versus 30 mg daily dose of estrogen (level B).

PCOS is a major risk factor for developing IGT and Type 2 Diabetes (level A). Obesity (by amplifying insulin resistance) is an exacerbating factor in the development of IGT and T2D in PCOS (level A). The increasing prevalence of obesity in the population suggests that a further increase in diabetes in PCOS is to be expected (level B). Screening for IGT and T2D should be performed by OGTT (75 g, 0- and 2-hour values). There is no utility for measuring insulin in most cases (level C).

Screening should be performed in the following conditions: hyperandrogenism with anovulation, acanthosis nigricans,obesity (BMI >30 kg/m2, or >25 in Asian populations), in women with a family history of T2D or GDM (level C). Metformin may be used for IGT and T2D (level A). Avoid use of other insulin sensitizing agents such as thiazolidinediones (GPP).

Prolonged (>6 months) medical therapy for hirsutism is necessary to document effectiveness (level B) Antiandrogens should not be used without effective contraception (level B) Flutamide is of limited value because of its dose- dependent hepatotoxicity (level B). Drospirenone in the dosage used in some OCPs is not antiandrogenic(level B).

There are moderate quality data to support that women with PCOS have a 2.7-fold (95% confidence interval [CI],1.0–7.3) increased risk for endometrial cancer. (level B). Limited data exist that do not support the conclusion that women with PCOS are at increased risk for ovarian cancer (level B).

Limited data exist that do not support the conclusion that women with PCOS are at increased risk for breast cancer (level B).

CONCLUSION Management of the disease begins by building positive, supportive relationship with adolescent diagnosed with PCOS. Positive relationship helps adolescent to share the signs and symptoms of this chronic disease which can have great impact on one’s body Image and self esteem… Dedicated Adolescent health clinics

Optimization of lifestyle Regular metabolic screening Proactive fertility planning with consideration of planning for conception at an earlier age