whs pr symposium: obesity, reproduction and pcos
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8/10/2019 WHS PR Symposium: Obesity, Reproduction and PCOS
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Obesity, Reproduction andPolycystic OvarianSyndrome (PCOS)
Nabal Jose Bracero, M.D., F.A.C.O.G.Reproductive Endocrinolog and !n"ertilit
Assistant #ro"essor
Depart$ent o" Obstetrics and Gnecolog%niversit o" #uerto Rico &c'ool o" Medicine
Medical Director
GENE& "ertilit institute
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Pre-Q1:A patient it! PCOS s!ould !ave an endometrial biopsy per"ormed:
a# $early even i" s!e is !avin% re%ularit!draal menstrual cycles, eit!er due to
ovulation or !ormonal t!erapyb# &" s!e is !avin% "eer t!an ' cycles a year
c# &" s!e is over ' years o" a%e it! re%ularovulatory cycles
d# &" an ultrasound reveals !er endometrium tobe mm in t!ic*ness
e# At least once i" s!e is over + years o" a%eindependent o" !er menstrual cycles
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Pre-Q:
Overei%!t patients it! PCOS s!ould be evaluated "or type &&diabetes mellitus typically usin%:
a# '-!our %lucose tolerance test
b# .astin% blood su%ar
c# .astin% blood su%ar to insulin ratio
d# -!our %lucose tolerance test usin%
%rams o" %lucose solution
e# 1-!our test usin% %rams o" %lucosesolution
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Obesity/Reproduction/PCOS
Repro-duction Obesity
PCOS
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Obesity and Reproduction
( Obesity is de0ned as 2& 3'
( &n t!e 4nited States, t!ere as a 5increase in pre-pre%nancy Obesity "rom
166+ to '#( .astest %roin% !ealt! problem in t!e 4#S#
) '15 o" non-7ispanic !ite omen
) '85 o" 7ispanic omen
) +65 o" non-7ispanic blac* omen
( Associated it! si%ni0cant medical problemsand adverse reproductive outcomes
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Adverse &mpact o" Obesity on
7ealt!
( 9ype && iabetes
( 7ypertension
( Coronary 7eart disease
( yslipidemia
( Sleep apnea
(Increase in
uterine/ovarian/colon/breast ca
( AR;SS 7& ?&9A> S&
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2enstrual isturbances
( &ncreasin% 2& and truncal obesitycorrelates it! menstrual irre%ularities
( Close to 5 o" obese omen !ave
menstrual cycle disturbances( Obesity, menstrual disorders, and
increased aist-to-!ip ratio are t!e mostcommon "eatures o" PCOS
( 7oever, not all omen it! PCOS areobese and not all obese omen !ave PCOS#
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&n"ertility
( 2ay be primarily related to ovulatorydys"unction as opposed to pure !i%! 2&
( RR "or anovulatory in"ertility is 1#' "or
2& +-'1 and # "or 2& 3'1#
( Ovulatory "unction improves a"ter ei%!tloss#
( Conversely, "ecundity don by +5 "oreac! 2& unit above a 2& o" 6 inovulatory obese omen
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Response to .ertility 9reatment
( &ncreased len%t! o" ovarianstimulation "or ovulation induction
( >oer oocyte yield in &?.
( 7i%!er cancellation rates "or poorresponse
( >ar%est study (n@') s!oedloer pre%nancy rates "or obeseomen (OR #-#')
( ;Bects pronounced in &?. scenario
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Adverse ObstetricalOutcomes
( Compared to normal-ei%!t omen, obeseomen !ave a -"old increase ris* o"abortion
( irt! de"ects associated it! 2& 3') ?entral all de"ects OR@'#'
) =eural tube de"ects OR@#
) Cardiac de"ects OR@ #
) 2ultiple anomalies OR@#
( eyond birt! de"ects: .etal ori%ins o" adultdiseaseD !ypot!esis
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Adverse Obstetrical OutcomesAssociated it! Obesity
OR 65 C&
Preeclampsia 4.8 +#+E#+
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Pat!op!ysiolo%y:
Obesity and Reproduction
( ;ndocrine c!an%es caused by abdominalobesity (38cm) result in menstrual cyclec!an%es:) 7i%!er insulin levels
( 2ost pronounced in omen it! PCOS independento" obesity
) >oer S7eptin levels
) 7i%!er
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onFt "or%et t!e ot!er !al"G
( Obese men !ave a '-"old ris* o"abnormal semen analysis comparedto normal ei%!t men#
( 7i%! ratio o" adipocyte perip!eralconversion o" andro%en to estro%ensuppresses %onadotropins and
testosterone( 7i%!er body mass increases
testicular temperature and inHuence
sperm parameters
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9reatment
( ietary and li"estyle c!an%es:) .irst line o" treatment#
) Structured ei%!t loss pro%rams, caloric
restrictions by reducin% -1*cal/day (more important t!an dietarycomposition)@ 1- lbs o" t loss/ee*
) A minimum o" ' minutes o" moderatelyintense eIercise, ' I/ee*
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9reatment
( 2edical 9reatment) .or 2& 3 ' or i" 2& 3 it!
additional morbidity (79=, 2,
dyslipidemia)) Anti-absorptive a%ents (Orlistat),
appetite suppressants (sibutramine),and insulin sensitiJin% a%ents(2et"ormin 1-m%/d)
) ariatric sur%ery "or patients it! 2&3+ or 3' it! co-morbidities#
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PCOS is a Syndrome
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PCOS
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PCOS
( 9!e most common endocrinopat!y inomen (-1 million omen in t!e 4#S#)
( 9!e conver%in% point o" metabolic
alterations, endocrinopat!ies, andreproductive dys"unction#
( ApproIimately 5 o" omen it!
PCOS are clinically obese( ;tiolo%y still elusive since described in
16' (Stein->event!al)
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ConseKuences o" PCOS
( Cosmetic (acne, !irsutism, alopecia)
( 4nopposed estro%en (uterine ca #-"old)
( &n"ertility (ovulatory "actors)
( 2etabolic Syndrome (2etS)L 11I in PCOS
) &ncrease ris* o" C?( Abdominal Obesity
( yslipidemia
( P 31+/6
( &nsulin resistance
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PCOS Symptoms
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e0nition o" PCOS
( 166 =&C7) Clinical or bioc!emical hyperandrogenism
) Oligo- or anovulation
( ' Rotterdam) Added PCO-4S appearance (at least one
ovary 31cm' or 31 antral "ollicles)
) out o" t!e ' above
( &n bot!, must rule out Cus!in%Fs, CA7and Andro%en producin% tumors#
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1 PCOS Consensus
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1 PCOS Consensus
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ia%nosis o" PCOS
( Adolescence) Acne and menstrual irre%ularities are common
) All ' Rotterdam criteria s!ould be present
) &rre%ular cycles "or yrs a"ter menarc!e
( ;t!nic considerations) Asian: loer 2&, milder andro%enic sI
) Sout! Asian: !i%!er 9, 2etS
) A"rican American: 79=, C?
) 7ispanic: 2&, 2etS
) 2iddle ;astern: !irsutism
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;valuation o" PCOS( Anovulation evaluation: 9S7/Prolactin
( 9otal and "ree testosterone
( 7;AS
( 1-!ydroIy-pro%esterone ("ollicular p!ase)
( .astin% %lucose or !r-%m-
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2ana%ement o" PCOS
( Cornerstone o" treatment "oroverei%!t or obese omen it!PCOS, re%ardless o" t!eir desire to
conceive is:
( &ntensive li"estyle modi0cationt!rou%! diet, eIercise and ei%!t
loss( -15 loss o" body ei%!t may lead
to resumption o" normal ovulation
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Mei%!t >oss:2ost iNcult ut 2ost ;NcientG
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2ana%ement o" PCOS
( 7irsutism/Acne/Alopecia) OCPs still best option (?aniKa, >aser, ;-
lysis)
) =o si%ni0cant value to add an anti-andro%en (spironolactone, Hutamide, or0nasteride)
) M!ile anti-andro%ens are eBective,insulin sensitiJin% a%ents are not
) Prolon%ed 3 mos o" treatment reKuired
) =o treatment "or alopecia
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2ana%ement o" PCOS
( 2enstrual &rre%ularities/Cancer Ris*) Overall OCPs outei%! t!e ris*s in most PCOS
patients#( Alternative: cyclic pro%estin#
) =o proo" one OCP is better t!an t!e ot!er) Cycles become more re%ular later in li"eL no
increased ris* "or menopausal omen
) =o a%reement on optimal modality or timin% o"monitorin% "or endometrial !yperplasia/cancer
( >en%t! o" amenorr!ea, bleedin% pattern, ;2t!ic*ness/appearance, a%e
( ' menses per year may be bestpredictor
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2ana%ement o" PCOS
( &n"ertility) OptimiJe !ealt! to reduce
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Post-Q1: A patient it! PCOS s!ould !ave an endometrial biopsyper"ormed:
a# $early even i" s!e is !avin% re%ularit!draal menstrual cycles, eit!er dueto ovulation or !ormonal t!erapy
b# &" s!e is !avin% "eer t!an ' cycles a year
c# &" s!e is over ' years o" a%e it! re%ularovulatory cycles
d# &" an ultrasound reveals !er endometrium
to be mm in t!ic*nesse# At least once i" s!e is over + years o"
a%e independent o" !er menstrual cycles
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Post-Q: Overei%!t patients it! PCOS s!ould beevaluated "or type && diabetes mellitus typically usin%:
a# '-!our %lucose tolerance test
b# .astin% blood su%ar
c# .astin% blood su%ar to insulin ratio
d# -!our %lucose tolerance test usin% %rams o" %lucose solution
e# 1-!our test usin% %rams o" %lucosesolution
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97A=S G
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