Get documents about "PCOS Pearls
Document Sample
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
