dr.abhishek singh parihar m.s (obs & gyne) ; fellow reproductive medicine consultant : lifecare...

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

DEFINITIONPCOS 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 consensusRevised 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 disordersCAH-Basal morning 17-OHP,(2-3 ng/ml)WHO I &III –FSH,LH,E2Hypothyroidism,Hyperprolactenemia-

Sr.TSH,Sr.PrlSyndromes of severe insulin

resistance(HAIRAN syn)Cushing syndrome-Dexa supression testAndrogen secreting tumours /exogenous

androgens

PCOS Definition

1990 - 2009

Hyperandrogenism

(Clinical or

Biochemical )

Oligo- menorrhea

or

Oligo-Ovulation

Polycystic Ovaries on USG

NIH (1990) yes yes no

Rotterdam (2003)

yes Yes

2 of the 3 criteria

yes

AE-PCOS Society (2009)

yes Yes

1 of 2 criteria

yes

Adolescent Period

Reproductive Period

Menopausal

Menstrual Irregularity•ObesityCosmetic 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 2012. Bart C. J. M. Fauser et.al.

Dietary intervention ( high protien, low carbohydrate , low fat diet more effective)

Energy deficit of 500-1000 Kcal/day

Goals – practical,realistic,achievable Small frequent mealsMore fruits/vegetables/fibre(bran)Decreased sugar/fried food /cola Switch to healthy oilsMore 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 2007Ref : Kathleen Metal Clin Obst Gynecol 2007

Find simple ways to add physical activity in daily routine

Role of weight lossRole of weight loss

Ref : Kathleen M et al Fertility & Sterility 2004Ref : Kathleen M et al Fertility & Sterility 2004

5-7% 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).

CONCLUSIONManagement 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