Docstoc

PCOS Pearls

Document Sample
PCOS Pearls Powered By Docstoc
					                                                                                                11/4/2010




                                              Historical Context
                                               1935 – Stein-Leventhal Disease
           PCOS “Pearls”                         Seven women
                                                 Amenorrhea, hirsutism,obesity and polycystic
         Jason Hitkari, MD,FRCSC                 ovaries

           Genesis Fertility Centre            How far have we come?
 Clinical Assistant Professor, UBC
                                               Estimate of 5-10% of women
                                               One of the most common hormonal disorders




Who has PCOS?
 33 year old with BMI of 38 and
 amenorrhea and hirsutism

                                                               Pearl # 1
 26 year old with BMI of 20 and hirsutism,
 regular cycles and ovaries that look like:
                                                           Make the Diagnosis



 28 year old with BMI 30 oligomenorrhea and
 an elevated free testosterone level




                                                                                                       1
                                                                             11/4/2010




How Do We Make The Diagnosis?                What “other causes”?
Patients need 2 of 3 of:                      Congenital Adrenal
                                              Hyperplasia
                                                17-0HP blood test
Oligo/Amenorrhea                              Cushing’s Syndrome
Clinical or laboratory evidence                 Clinical signs and AM
  of elevated androgens                         Cortisol
Polycystic ovaries on                         Hyperprolactinemia
  ultrasound                                    Galactorrhea and
                                                elevated prolactin

* BUT, you have to rule out                   Hypothyroidism
   other causes                                 TSH




                                             What do Patients Complain of?
                                              Infertility
                                              Hirsutism/Male pattern
                                              hair loss
                    Pearl #2                  Acne
                                              Irregular Cycles
       Patients will complain of different
           aspects of the syndrome.




                                                                                    2
                                                                                         11/4/2010




                                          Infertility
                                            Not ovulating regularly!

               Pearl #3                   Objective of any fertility
                                           treatment is to get
                                           patients to ovulate.
    You can help treat her infertility!


                                          Weight loss!




                                          Clomiphene Citrate – Practical
Clomiphene Citrate                        Aspects
                                            Anti-estrogen effects on lining of uterus and
                                            cervical mucous
                                            Rate of multiples – 8%
                                            Cost – approx $100/month
                                            May need to bring on a period with Provera

                                          Start at 50 mg, go to 100 mg, and then up to
                                            150 mg.




                                                                                                3
                                                                                                          11/4/2010




 Other Options…..

   FSH injections
                                                                       Pearl #5
   IVF

   Ovarian Drilling                                             Metformin still has a role.




                                                          Kaplan-Meier curves for live birth
 When To Consider Metformin                                    according to treatment
  Patient has impaired glucose tolerance or
  Type II DM
  Patient has PCOS and recurrent pregnancy
  losses
                                                                                                       26.8%
                                                                                                       22.5%
How about hirsutism? OCP better
How about weight loss? Some evidence of 6-14% loss at 3                                                7.2%
  months
How about treating oligomenorrhea – OCP/Progesterone
How about treating infertility?
                                                                                      Legro et al, NEJM, 2007




                                                                                                                 4
                                                                                 11/4/2010




                                      Hirsutism/Acne - Options
                                       Oral Contraceptives
                                        Estrogen increases SHBG and reduces LH
                                        production
                Pearl #6                Progesterone – CAN be anti-androgenic
                                        (ex.Diane-35, Yasmin)
     Most concerns are addressed by
               the OCP.                Anti-androgens
                                        Cyproterone acetate
                                        Spironolactone
                                        Flutamide




What about if NOT trying to
conceive?
 Use the OCP:

  - regulates cycles                                  Pearl # 7
  - reduces hirsutism/acne
  - contraceptive                          Be aware of the long-term health
                                                    implications.




                                                                                        5
                                                                                               11/4/2010




Long Term Health Implications                    Endometrial Cancer – why?
 Endometrial Cancer                                   Persistent stimulation by estrogen
 Hypertension                                         Hyperplasia    cancer
 Dyslipidemia
 Type II DM
 Sleep Apnea
                                                 Women with PCOS should cycle regularly!

                                                      OCP or cyclic progesterone given every three
                                                      months (Provera 10 mg for 10 days)




Type II DM                                       My patient with PCOS has…..
 30-40 % of PCOS patients have impaired          1.    Amenorrhea/oligo-ovulation and wants to
 glucose tolerance                                     conceive    Clomid
 10% will have Type II DM by their fourth        2.    Amenorrhea/oligo-ovulation and DOESN’T
 decade!!                                              want to conceive    OCP
Should be monitored regularly by primary care    3.    Hirsutism   OCP
 physicians                                      4.    Acne     OCP
                                                 5.    Impaired glucose tolerance   Metformin
     OGTT every two years if normal glucose      6.    Recurrent pregnancy loss    Metformin
  tolerance and every year if abnormal glucose
                   tolerance.




                                                                                                      6
                                                                                  11/4/2010




Summary

 Make the diagnosis
 Patients complain of different aspects of the
 syndrome                                        jhitkari@genesis-fertility.com
 You can help treat her infertility
 Metformin has a role in impaired glucose
 tolerance and possibly RPL
 Most concerns are addressed with the OCP
 Be aware of the long-term health implications




                                                                                         7

				
DOCUMENT INFO