1. Polycystic Ovary Syndrome

2. 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

3. 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

4. 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)

5. 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

6. Definition of PCOS should be uniform

7. 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

8. Oligo/anovulation
PCOS

9. 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

12. 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

13. 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

14. Treatment

15. 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

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

17. 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

18. 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)

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

20. 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 +/-

21. 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

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

23. 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

24. Thank you