13th Annual Women’s Health Day

PCOS

Saturday 02/09/2017 Dr Mathias Epee-Bekima

O&G Consultant KEMH

Learning objectives

• Perform the appropriate investigations in women where there is a clinical suspicion of PCOS

• Diagnose PCOS

• Counsel about PCOS and the associated short and long term medical issues

• Discuss treatment options

• Composition of the PCOS team

PCOS

• Stein & Leventhal

• 1935 NJEM

• 7 patients hirsutism/sterility/enlarged ovaries

• Surgery

What do we know about PCOS?

• Common: 5-12 % of reproductive female population

• Unknown etiology - Autosomal dominant

• PCOS expressed shortly after menarche

• PCOS persists for most of the reproductive life

• The phenotypes are variable according to weight

• Short and long term consequences

PCOS is the commonest endocrine disorder in women

• 90 % of women with oligomenorrhea

• 40 % of amenorrheic women (exclud. pregnancy)

Amongst women with PCOS:

70% are hirsute

50% are obese

30% have acne

10% have alopecia

Definition?

Rotterdam 2004: Diagnosis 2 out of 3

• Polycystic ovaries on ultrasound

• Clinical or biochemical evidence of excess androgens

• Oligo-anovulation

But also exclusion of differential diagnosis

Polycystic Ovaries

Better at D3-D5 of the menstrual cycle, TVS

• more than 12 (25) follicules and 2-9 mm in size (USS machine dependant)

• Uni/bilateral

• Volume of the ovary 10 ml or more

Clinical or biochemical evidence of excess androgens

Clinical

Hirsutism – Acne - Alopecia

Or Biochemical:

Free testosterone- Free Androgen index

(20% difference with laboratory values= endocrinologist)

Oligo-anovulation

• Oligo/amenorrhea

• Practically, less than 9 periods in 12 months or no period in 3 months or more

• Cycle lasting more than 35 or less than 21 days

Differential diagnosis

• Hypothyroid

• Hyperprolactinemia

• Androgen secreting tumours (adrenals, ovaries)

• Exogenous androgens

• Cushing's syndrome

• Congenital Adrenal Hyperplasia (17-OH progesterone)

Mode of presentation

Self-referral (family, friend, google…)

Abnormal periods

Subfertility (real or fear of)

Acne/hirsutism/alopecia

Incidental findings on USS or blood tests

Early onset type 2 diabetes

Depression/anxiety/sexual dysfunction/eating disorders/body image issues

What tests should I ask?

• Pregnancy test

• USS- TVS ovaries

• TFT

• Prolactin

• Free Testosterone (screening test)

• If Testosterone is above 5 – consider DHEA-S, 17 hydroxyprogesterone (CAH), 24h urine cortisol (Cushing) and speak to an endocrino

Multidisciplinary approach: The team PCOS

The GP is the team Leader Gynaecologist (period regulation, fertility, prevention of endometrial hyperplasia) Dermatologist Endocrinologist Psychologist Dietitian Exercise physiologist Bariatric surgeon Physician Sleep specialist

Treatment

• No cure for PCOS

• Targeted against symptoms and concerns

• Prevention and early detection of long term complications

Short term medical issues

• Hair and acne

• Fertility

• Irregular periods

• Depression

• Excessive weight gain

• Sleep apnea

Hirsutism/acne/alopecia

Cosmetic:

Gel/cream to reduce pore blocking

Shaving

Waxing

Laser or electrolysis (dermatologists)

Eflornithine (takes up to 8 weeks- lifetime)

Hirsutism/acne/alopecia

Medical:

1- To reduce the amount of androgens circulating in the body • COC –Metformin to reduce insulin resistance 2- To reduce the action of androgens • Spironolactone- Cyproterone acetate- finasteride-

isotretinoin- minoxidil NB: specialist drugs- fetal abnormalities- side effects profile)

Fertility

• Weight loss (5-10%) in obese PCOS improves ovulation

• Clomiphene- 1st line ovulation in 80% - 50% conceive (multiple birth, ?increased risk of ovarian cancer?)

• FSH – will induce ovulation in remaining 80%

• Ovarian drilling as effective as FSH ovulation

• Metformin in insulin resistant patient (better when coupled with clomiphene)

• Aromatase inhibitor (letrozole)

• ART

Irregular periods

• Low dose COC in the absence of fertility desire and after assessment of risk factor for DVT/PE

They act by stopping the ovarian production of androgens and by increasing SHBG which binds to free testosterone

• Weight loss

• Metformin?

Weight loss

For all with BMI above 25 Improves ovulation Regulates menstrual cycle Reduces insulin resistance by 50% Improves Spontaneous pregnancy rate Reduction in miscarriage rate Improves self-esteem Reduce risk factors for metabolic disease

Weight loss

• Exercise 30 mn daily- need to sweat

• Diet

• Bariatric surgery

Other problems

Emotional well-being

Reassurance- information- support group- psychologist

Sleep apnea

Weight loss- CPAP

Long term concern

• Prevention of endometrial cancer

• Impaired glucose tolerance/diabetes

• Cardiovascular risk

Long term concern:

Prevention of endometrial cancer

• COC

• Progesterone – medroxyprogesterone 10 mg for 7-10 days every 3 months to achieve a withdrawal bleed

• IUS

• Weight loss

Long term concern

Screening for type 2 diabetes

GTT every second year

And yearly if additional high risk factors: (age, gender, ethnicity, smoking, raised BMI, use of antypertensives)

So in real life: EVERY YEAR

Long term concern Cardiometabolic risk

• Smoking cessation advice

• Hypertension (yearly)

• Dyslipidemia (check every 2 years)

• Lifestyle changes (diet/excercise/behavourial interventions)

PCOS and pregnancy

Miscarriage

GDM (early GTT + repeat at 28/40)

Hypertension/preeclampsia

Increased intervention at birth

Quizz

1- How long would you wait to assess the androgen status of woen taking the COC before testing them (1-3-6 months?)

2- How long would you wait after menarche before using “irregular periods” as part of your diagnosis criteria (1-2-3 years?)

Quizz

3- Who is the care coordinator of women with PCOS? (GP-Gynae-endocrinologist)

4- What is the first line test to assess androgen levels? (free testosterone –SHBG- DHEA-S)

5- What is the first line drug to assist fertility?

(metformin, Clomiphene, FSH)

Quizz

6- How do you manage an incidental report of an ultrasound report of PCO? (label the patient PCOS- reassess the patient- refer to the gynecologist)

7- What is the percentage of women with PCOS?

(5- 10- 20)

8- Metformin is teratogenic (T/F)

Quizz

9- The majority of teenagers have PCOS (T/F)

10- PCOS is a transient disease (T/F)

11- The PCOS Australian Alliance document is the reference for assessment and management of PCOS in Australia (T/F)

Tie break

Metformin

Want to know more?

• PCOSAA

• Verity UK- fabulous links

• Ranzcog/RCOG guidelines

Merci