Child sexual abuse in Lebanon by liaoqinmei

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									 PCO: Is treatment
   mandatory?
Lebanese Society of Family
     Medicine 2010
                 PCOS
An international consensus defined PCOS as
 having at least two of the following criteria:
 - Reduced or no ovulation.
 - Clinical or biochemical signs of excessive
 secretion of androgens;
 - Polycystic ovaries (the presence of at least
 12 follicles measuring 2 to 9 mm in diameter,
 an ovarian volume of more than 10 ml, or
 both).
       PCOS manifestations
• Infrequent or absent menses, obesity, and
  signs of androgen excess, which include
  acne or seborrhea
• Should be considered in any adolescent
  girl with hirsutism, persistent acne,
  menstrual irregularity, or obesity
• Commonly have insulin resistance,
  elevated serum LH levels
     PCOS- High risk groups
• Women with oligo ovulatory infertility
• Obesity and/or insulin resistance
• Type 1, type 2, or gestational diabetes
  mellitus
• A history of premature adrenarche
• First-degree relatives with PCOS
• Women using antiepileptic drugs : valproic
  acid ?
  PCOS associated morbidities
• Increased risk of
  – Infertility
  – Metabolic syndrome
  – Type 2 diabetes mellitus
  – Probably cardiovascular disease
  – Probably endometrial carcinoma
          PCO and infertility
• Many women having polycystic ovaries
  continue to ovulate
• The high prevalence of this inherited
  condition indicates that it is not an
  absolute cause of infertility
• If the circulating levels of FSH are within
  the normal range the follicles are healthy
   PCOS and Cardiovascular
          disease
• Dyslipidaemia is the most common
  metabolic abnormality found in women
  with PCOS:
  – Elevated triglycerides, small low density
    lipoproteins (LDL) and reduced high density
    lipoprotein (HDL)
  – Increase of LDL size and the type III or type
    IV LDL subclasses: atherogenic LDL
           PCOS and CVD
• Even if young and non-obese, PCOS
  women have a significant increase in
  cardiac size
• Significantly lower left ventricular ejection
  fraction (LVEF) as a measure of systolic
  function, and reduced early atrial mitral
  flow velocity as a measure of diastolic
  function, although all patients have normal
  LVEF overall
           PCOS and CVD
• Hyperinsulinaemia secondary to IR is a
  predictor of coronary artery disease, and
  IR has been proposed as the key factor
  linking hypertension, glucose intolerance,
  obesity, lipid abnormalities and coronary
  heart disease in 'metabolic syndrome ‘
• There are no long-term prospective data
  evaluating end-point morbidity and
  mortality for CVD in PCOS subjects.
Is PCOS treatment mandatory?


• What are treatment options
     PCOS treatment: Weight
           reduction
• In obese women: decreases hirsutism, the
  production of ovarian androgens, and the
  conversion of androstenedione to
  testosterone
• Low-CHO, a high protein/low CHO or a low
  protein/high CHO diets were equally effective
  for weight loss, improvements in menstrual
  cyclicity, insulin resistance, dyslipidemia,
  abdominal fat
• Bariatric surgery
   PCOS treatments: Medical
• There are several treatments for each of
  the symptoms of PCOS; the choice among
  them depends upon the woman's goals.
• Drugs that decrease insulin levels can be
  effective in both obese and normal-weight
  women
          Treatment of PCOS
• When no menstrual period for six or more
  weeks, withdrawal bleeding should be
  induced by administration of 5 to 10 mg of
  medroxyprogesterone acetate daily for 10
  days prior to initiation of oral contraceptive
  treatment
• Patients should be made aware that
  progestin therapy alone will not reduce the
  symptoms of acne or hirsutism, nor will it
  provide contraception
       PCOS and metformin
• Is an alternative therapy that will restore
  ovulatory menses in approximately 50
  percent of women with PCOS
• Begin treatment with 500 mg taken with a
  meal, to reduce gastrointestinal side effects.
• Clinically significant responses are not
  regularly observed at doses less than 1000
  mg daily
• When using extended release tablets, the
  entire daily dose is given at dinner time.

                                   valpic acid
        PCOS and metformin
• Some women do not ovulate during the first
  six months of treatment. Unless cycles are
  regular and ovulatory, one cannot assume
  that the patient has reliable endometrial
  protection. Cyclic progestin is recommended
• A contraceptive (eg, diaphragm, condom)
  should be prescribed for all sexually active
  women not planning pregnancy since
  treatment may induce ovulation
       PCOS and metformin
• Improvement in plasma insulin and insulin
  sensitivity
• Reduction in serum free testosterone
  independent of changes in body weight
  but no significant reduction in hirsutism
• Increase in mean serum HDL cholesterol.
      Treatment for hirsutism
• The main aim is to block or inhibit androgen
  production or action. Can be achieved using
  three groups of drugs:
  – Peripheral androgen blockers (e.g. cyproterone
    acetate, flutamide, or spironolactone) or
    antiandrogens (e.g. finasteride)
  – Insulin-sensitizing agents (e.g. rosiglitazone,
    metformin)
  – Inhibitors of androgen production e.g. oral
    contraceptives, GnRH analogues
         Hirsutism treatment
• No systematic comparative trials, but there
  does not seem to be one agent clearly
  superior to the others.
• Topical eflornithine 11·5% cream
  (Vaniqa®) may be used to inhibit hair
  growth. Eflornithine inhibits ornithine
  decarboxylase (ODC), a key enzyme of
  polyamine synthesis (responsible for cell
  proliferation, migration and differentiation).
       Treatment of hirsutism
• The first-line therapy for treatment of
  hirsutism caused by PCOS is an estrogen-
  progestin contraceptive, as recommended by
  the 2008 Endocrine Society Guidelines. An
  antiandrogen is then added after six months if
  the cosmetic response is suboptimal.
• OCPs given in oligomenorrhea but may
  worsen insulin resistance
• Risk of thrombo embolic diseases
       Treatment of hirsutism
• Typically start with a30 to 35 mcg
  OCP where the progestin has minimal
  androgenicity (such as norethindrone,
  norgestimate, desogestrel, or drospirenone).
• After six months, if the patient is not satisfied
  with the clinical response, add
  Spironolactone 50 to 100 mg twice daily; this
  dose can then be reduced over time as
  needed.
• Other antiandrogens that are effective include
  finasteride and cyproterone acetate
      Treatment of hirsutism
• For women with hirsutism and
  contraindications to oral contraceptives,
  can sometimes use spironolactone alone
• When spironolactone alone is used,
  endometrial protection is also needed.
• Alternative form of contraception is
  essential
      Treatment of hirsutism
• Leuprolide (Lupron Depot) 3.75 mg IM
  monthly until hot flashes appear when
  estrogen-progestin therapy should be
  initiated.
• Increase leuprolide by 50 percent if
  hypoestrogenic state is not achieved by two
  months
• Once a satisfactory dose has been achieved,
  estrogen-progestin therapy should be added
       Treatment of hirsutism
• Reevaluate at regular intervals, and if after
  six months of therapy there has been no
  improvement in hirsutism, serum
  testosterone should be measured to
  determine the extent of ovarian
  suppression.
• Generally not recommended in
  adolescents younger than 16 years of age
        PCO and anovulation
• Initial steps: Weight loss through caloric
  restriction and increased exercise for women
  with a BMI >27
• Initial medical therapy includes metformin or
  clomiphene. Early ovulation induction trials
  reported better results with metformin alone or
  metformin plus clomiphene when compared to
  clomiphene alone
• Metformin may be as effective for restoring
  ovulation, it appears to be less effective for
  fertility
        PCO and anovulation
• A consensus group recommends:
  Clomiphene as the first-line drug for ovulation
  induction in women with PCOS, and
  metformin only in women with glucose
  intolerance

• Approximately 80 percent of women with
  PCOS ovulate in response to
  clomiphene citrate, and approximately 50
  percent conceive
         PCO and ovulation
• Metformin may also modify the ovarian
  response in women with clomiphene-
  resistant PCOS undergoing ovulation
  induction with FSH (without IVF), with
  more orderly follicular growth , and a
  greater likelihood of mono-ovulatory cycles
• Further study is needed to determine the
  role of metformin administration in women
  with PCOS undergoing IVF
          PCO and ovulation
• Miscarriages occurred in 62 to 73 percent of
  pregnancies without metformin and 9 to 36
  percent of pregnancies in the same women
  when metformin was taken
• Although metformin is not FDA approved in
  pregnant women, there is some evidence to
  suggest that its use throughout pregnancy
  may reduce the risk of gestational diabetes
• If medication is needed to treat gestational
  diabetes, insulin is the drug of choice, not an
  oral antihyperglycemic agent
       PCO and anovulation
• Thiazolidinedione therapy may also be
  effective for induction of ovulation.
• We do not suggest the routine use of
  these drugs, as concern has been raised
  about their cardiovascular safety
• Laparoscopic ovarian laser electrocautery
 Is it mandatory to treat PCOS
• Recognizing and treating PCOS are
  important beyond management of the
  presenting symptoms because PCOS
  increases the risk of developing
  endometrial hyperplasia and carcinoma,
  type 2 diabetes mellitus, metabolic
  syndrome, infertility, and possibly
  cardiovascular disease.

								
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