Upload
joseph-deniel-isidro
View
221
Download
0
Embed Size (px)
Citation preview
7/31/2019 Pcos Report Den Edited
1/60
7/31/2019 Pcos Report Den Edited
2/60
Age: 26
G1P1 (1001)
Date of 1st Consultation Nov. 22, 2011
7/31/2019 Pcos Report Den Edited
3/60
Missed menses for 4months,
Decreased amount and duration
of menses for 2 months
7/31/2019 Pcos Report Den Edited
4/60
LMP : May 2011 PMP: April 2011
Jan2011
Feb Mar April May June July August
Sept Oct Nov
III IIII IIII IIII
DMPA DMPAPregnancy test (-)
Pregnancy test (-)2nd week
Pregnancy test (-)Nov. 22,2011
7/31/2019 Pcos Report Den Edited
5/60
1 month and 22 days prior to last consultation
Patient had irregular menses for 6 months
now (Nov. 19, 2011)
(-) dysuria
(-)fever
(-) hypogastric pain
(-)Pregnancy test Nov. 22, 2011
7/31/2019 Pcos Report Den Edited
6/60
Had mumps, measles, chickenpox during
childhood
No hypertension, no diabetes, no bronchial
asthma
No previous hospitalization, no blood
transfusion, no allergy to food and drugs
7/31/2019 Pcos Report Den Edited
7/60
Family History
Father and mother are apparently well.
No other known heredofamilial diseases such
as hypertension, diabetes and bronchial
asthma
7/31/2019 Pcos Report Den Edited
8/60
Menarche: 14 years old Subsequent menses
Duration:5 days
Amount:3-4 pads/day
Symptoms:
(-)dysmenorrhea
Interval-irregular
(60-120 days)
Duration:5 days
Amount:3-4 pads/day
Symptoms:
(-)dysmenorrhea
7/31/2019 Pcos Report Den Edited
9/60
Total Pregnancies: G1 P1 (1001)
Last Pap smear(Dec. 2011)
Gravid Date Where How Pregnancy
1 Dec. 26,
2002
Home Normal
Spontaneous
Delivery
No
complications
7/31/2019 Pcos Report Den Edited
10/60
Oral Contraceptive pills (April 2010-January
2011)
Depot Medroxy progesterone acetate (DMPA)
(January 2011)
*last DMPA (May 2011)
7/31/2019 Pcos Report Den Edited
11/60
CNS: No headache, no blurring of vision CVS: No palpitation
Respiratory: No difficulty of breathing, no cough,
HEENT: no blurring of vision, no hearing loss, no tinnitus GIT: no nausea, no vomiting
GUT: no dysuria, no frequency, no urgency, no
retention, no hematuria
NMS: no arthralgia, no myalgia, no numbness, no
paresthesia
7/31/2019 Pcos Report Den Edited
12/60
General Survey: conscious, coherent, not in
cardiorespiratory distress
Vital signs: BP: 110/ 70 mmHg PR: 84 bpm
RR: 19 cpm Temp: 37.0C
Weight: 82 kg/mHeight: 157.2 cm
BMI: 33.6 kg/m2
7/31/2019 Pcos Report Den Edited
13/60
HEENT: Pink palpebral conjunctivae, white sclerae,
no tonsillopharyngeal congestion, no nasoauraldischarge, neck is supple, (+) upper lip hair, (+)acne
Neck: Neck is supple, no palpable lymph nodes Chest/lungs: Symmetrical chest expansion, no
retraction, no lagging, clear breath sounds, no
wheezes, no crackles
Heart: Adynamic precordium, normal rate, regularrhythm, no murmur
Abdomen: Flabby, soft, no mass, no tenderness,
normoactive bowel sounds
7/31/2019 Pcos Report Den Edited
14/60
Genitalia:
speculum exam: clean looking cervix with minimal
whitish discharge Internal Examination: Normal looking external
genitalia, parous introitus, vagina admits 2 fingerwith ease ,firm cervix, uterus and adnexae cannot
be assessed due to thick abdomen
Extremities : No gross deformities, full equal pulses
Skin: no active dermatoses
7/31/2019 Pcos Report Den Edited
15/60
Gravida 1 Para 1 (1001)
Abnormal Uterine bleeding probably secondary
to chronic anovulation
To Consider Polycystic Ovarian Syndrome
7/31/2019 Pcos Report Den Edited
16/60
Well balanced diet
Increase fluid intakeStart Medroxyprogesterone 10mg/tab, 1
tablet OD x 5 days
For Transvaginal Sonogram c/o OBsonologist on Day 3-5 of menses
Advised daily perineal hygiene
Advised to come back on Day 1 of menses
or after 2 weeks if with no menstrualbleeding
7/31/2019 Pcos Report Den Edited
17/60
1 month and 9 days prior to lastconsult
Subjective complaints:no dysuria, no fever, no hypogastric pain
BMI: 34.32 kg/m2 (34.4 previous BMI)
Still for Transvaginal sonogram on Day 3-5 of menses
7/31/2019 Pcos Report Den Edited
18/60
1 month and 2 days prior to last consult
has completed Medroxyprogesterone 1 tab once a dayfor 5 days
still without menses
PE: BMI: 34.02 kg/m2 (34.32 previous BMI )
PLAN:
Still for Transvaginal sonogram on Day 3-5 of menses
7/31/2019 Pcos Report Den Edited
19/60
TransvaginalUltrasound
1 month and 2 days prior to last consultDec. 12, 2011(still without menses)
uterus 4.46x 2,.12x2.21
Anteverted, w/ homogenous matl
echopattern
Endometrium 0.65cm Thick, hyperechoic
Cervix 1.80x 2.47cmUnremarkable
Right ovary 2.12 x 2.21x 1.67cm
w/ multiple immature follicles arranged
subcapsularly 2/ dens central stroma
Left ovary 2.54x 2.29x1.54cmw/ multiple immature follicles arranged
subcapsularly 2/ dens central stroma
Impression anterverted unenlarged uterus, secretoryendometerium, unremarkable cervix,
polycystic bilateral ovaries
7/31/2019 Pcos Report Den Edited
20/60
Cont1 month and 2 days prior to lastconsult
PE:
Weight: 84.4 kg Height: 156.7 cm BMI:34.02 kg/m2 (previous BMI 34.32)
Refer to Reproductive Endocrinology and
Infertility
7/31/2019 Pcos Report Den Edited
21/60
1 month prior to last consult
BMI: 34 kg/m2 (previous BMI 34.02)
Refer to Reproductive Endocrinology and Infertility
7/31/2019 Pcos Report Den Edited
22/60
1 month prior to last consult(Reproductive Endocrinology Infertility notes)
regularly menstruating until had Depot Medroxy Progesterone Acetatelast May 2011
did not have menses upto now
1 day prior to consult had spotting-brownish
PE:HEENT: with facial hair, with acneABDOMEN: Abdominal circumference= 42 inches, flabby, soft, nopalpable mass nor tenderness
Speculum examination: clean looking cervix, minimal brownish
discharge per os
Internal examination: cervix firm, closed, corpus antevertedunenlarged, no adnexal mass nor tenderness
BMI:34 kg/m2 (34.02)
7/31/2019 Pcos Report Den Edited
23/60
Cont.
G1 P1 (1001), Secondary Amenorrhea 2 to DMPA,PCOS, T/C Metabolic Syndrome
Advised weight loss and lifestyle modification
For TSH, FSH,Prolactin
For 75 gm OGTTFor lipid profile
To come back with results, if normal results, start
Oral Contraceptive pills
Start Provera on day 16-25 of cycle while awaitinglipid profile results
7/31/2019 Pcos Report Den Edited
24/60
1 hour: less than 200 mg/dL
2 hours: less than 140 mg/dL. Between 140-
200 mg/dL indicates impaired glucose
tolerance (prediabetes). If test results are inthis range, a patient is at an increased risk
for developing diabetes. Greater than 200
mg/dL indicates diabetes
test result referencerange
interpretation
Thyroid Function
TSH:
2.6 UIU/ml 0.4-5.5 UIU/ml
Prolactin: 27.9 ng/ml 4-30 ng/ml
FSH: 16.7 MIU/ml 5-20
FBS: 5.80 mmol/L 3.9-6.1
mmol/L
1hr PPBS 8.1 mmol/L/ 145.8
mg/dl
7/31/2019 Pcos Report Den Edited
25/60
Cholesterol: 5.6 3.5-5.2mmol/L
Triglyceride: 1.68 0.3-1.9
mmol/L
N
HDL: 1.27 0.7-2.1mmol/L
N
LDL: 3.49 0-3.9 mmol/L N
VLDL: 0.84 0-1.02mmol/L N
7/31/2019 Pcos Report Den Edited
26/60
21 days prior to last consult
*Reproductive Endocrinology Infertility notes
advise diet modification
Start Metformin 500mg/tab once a day for 7 days;
then twice a day then 3 times a day
Continue Provera 10mg/tab for 3 more days
7/31/2019 Pcos Report Den Edited
27/60
52 daysprior tolastconsult
39 daysPTC
32 daysPTC
30 daysPTC
21 daysPTC
4 daysPTC
Lastconsult
34.4 34.32 34.02 34.0 34.65 34.07 33.6
BMI Considered
Below 18.5 Underweight
18.5 to 24.9 Healthy weight
25.0 to 29.9 Overweight
30 or higher Obese
7/31/2019 Pcos Report Den Edited
28/60
26 years old
Chief complaint:Amenorrhea for 4 months,oligomenorrhea for 2 months
Acne
Facial hair (upper lip)
BMI=34 (obese) Pregnancy test (-)
Contraceptive method:
April 2010-Jan. 2011 (OCP)
Jan. 2011, May 2011( Injectable DMPA )
OB history: G1P1(1001)
o LMP: May 2011 PMP: April 2011
7/31/2019 Pcos Report Den Edited
29/60
Pregnancy
Polycystic ovarian syndrome
7/31/2019 Pcos Report Den Edited
30/60
Rule in Rule out
Amenorrhea for 4
months
Oligomenorrhea for 2
months
Pregnancy test negative(August, October, November2011)
Transvaginal ultrasound Dec.12, 2011: uterus unenlarged withhomogenous myometrial echopattern
Internal Examination:Normal looking externalgenitalia, parous introitus,vagina admits 2 finger wi thease ,firm cervix, uterus and
adnexae cannot be assesseddue to thick abdomen
7/31/2019 Pcos Report Den Edited
31/60
Rule in Rule out
Amenorrhea for 4months
Oligomenorrhea for 2months
Transvaginalultrasound: bilateralpolycystic ovaries
Signs ofhyperandrogenism(increased facial hair,acne)
Cannot totally rule
out
7/31/2019 Pcos Report Den Edited
32/60
7/31/2019 Pcos Report Den Edited
33/60
Probably the most common endocrine
disorder in women
Classically char. by findings of irregular(anovulatory) cycles symptoms or signs of
androgen excess and polycystic ovaries on
ultrasound
7/31/2019 Pcos Report Den Edited
34/60
Revised 2003 consensus on diagnostic criteria and long-term health risks related to PCOS
concluded that PCOS is a syndrome of ovarian dysfunction
along with the cardinal features hyperandrogenism and
polycystic ovary (PCO) morphology.
remains a syndrome, and as such no single diagnosticcriterion (such as hyperandrogenism or PCO) is sufficientfor clinical diagnosis.
7/31/2019 Pcos Report Den Edited
35/60
Most common endocrinopathy among women
of reproductive age
Menstrual irregularity and insulin resistancein 70%
Prevalent markers ofpremature
cardiovascular disease
7/31/2019 Pcos Report Den Edited
36/60
PCOS: Diagnostic criteria
1990 NIH: requires both
criteria12003 ESHRE/ASRM:
requires 2 of 3 criteria
Chronic anovulation Oligo- and/or anovulation
Clinical and/or biochemicalsigns of hyperandrogenism
Clinical and/or biochemicalsigns of hyperandrogenism (HA)
Polycystic ovaries
*With exclusion of other etiologies
In both NIH and ESHRE/ASRM definitions, the diagnosis
7/31/2019 Pcos Report Den Edited
37/60
In both NIH and ESHRE/ASRM definitions, the diagnosis
assumes exclusion of other diagnoses that may havesimilar clinical presentation as PCOS4such as:
non-classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency,
Cushings syndrome and
androgen-secreting tumours
exclusion of other related disorders:
High-dose exogenous androgens
Hyperprolactinemia
Thyroid dysfunction
7/31/2019 Pcos Report Den Edited
38/60
CLINICAL S/S LABORATORY
Ovarian
Tumor
Pelvic mass on bimanual
examination
Testosterone > 2ng/ml
DHEA-S normal
Confirm by UTZ, CT scan
and MRI
Androgen
Producing
AdrenalTumor
Rapidly progressive signs of
virilization.
DHEA-S > 8ug/ml
Cushing
syndrome
hirsutism or virilization is
prolonged and gradual
dexamethasone test/ Liddle
test
PCOS Hirsutism or virilization isprolonged and gradual
Menstrual irregularity
elevated LH levelsmild increase in
testosterone and DHEA-S
levels
UTZ findings
7/31/2019 Pcos Report Den Edited
39/60
Presence of
>=12 follicles in
each ovary
measuring: 2-9 mm in diameter
increased ovarian
volume (>10ml).
7/31/2019 Pcos Report Den Edited
40/60
7/31/2019 Pcos Report Den Edited
41/60
HirsutismAcne
male pattern balding, and/or
male distribution of body hair
Lobo RA, et al.Ann Intern Med. 2000;132:989-993.
Hirsutism Acne
7/31/2019 Pcos Report Den Edited
42/60
A summary score of greater than 8 is considered
indicative of hirsutismexcessive hairgrowth
What is the
7/31/2019 Pcos Report Den Edited
43/60
What is the
pathophysiology of the
PCOS?
7/31/2019 Pcos Report Den Edited
44/60
Insulin
acts synergistically with LH to enhance androgen production
inhibits hepatic synthesis of SHBG
Diagnosis of PCOS: Workup for
7/31/2019 Pcos Report Den Edited
45/60
Clinical Biochemical
Hirsutism-primaryindicator
Free testosterone
Acne Free androgen index
Diagnosis of PCOS: Workup forhyperandrogenism
7/31/2019 Pcos Report Den Edited
46/60
Book description Patient
SIGNS >Hyperandrogenism(Hirsutism,
elevated blood
level of androgen-
testosterone,DHEA-S)
>enlarged
polycystic ovaries
(ultrasound)
HyperandrogenismFacial hair
Acne
transvaginal
ultrasound):
Polycystic bilateralovaries
SYMPTOMS amenorrhea 4 months
amenorrhea
7/31/2019 Pcos Report Den Edited
47/60
may also include:
Obesity
Insulin resistance and elevated serum LH
levelsalso common features
Assoc. w/ an increased risk of type 2 diabetes and
cardiovascular events.
7/31/2019 Pcos Report Den Edited
48/60
Menstrual Irregularity& hyperandrogenemia
may manifest at puberty w/ a delayed menarche ff. by onset ofirregular periods
or as the breakdown of a previously regular cycle w/in a few
years & often associated w/ weight gain(50% obese)
Anovulation>usually chronic & presents as oligomenorrhea / amenorrhea
>usually assoc.w/ varying degrees of infertilityFreq. cause of
anovulatory infertility(75%)
7/31/2019 Pcos Report Den Edited
49/60
LH
LH/FSH ratio
androgen levels*
sex hormone binding globulinmay increase free testosterone levels
Duncan S. Epilepsia. 2001;42(suppl 3):60-65.
7/31/2019 Pcos Report Den Edited
50/60
LDL cholesterol
triglycerides
HDL cholesterol -most common
Impaired fibrinolytic activity*
plasminogen activator inhibitor levels*=predict occurrence of MI
Strongly
linked to CVD
7/31/2019 Pcos Report Den Edited
51/60
Hyperinsulinemia and insulinresistance
*Women with PCOS tend to be hyperinsulinemic,regardless ofwhether they are lean or obese
a greater frequency °ree of both hyperinsulinemia +
insulin-resistance vs. weight-matched controls
Insulin resistance may be independent of the effect of
obesity both lean and obese womendecreased sensitivity to insulin in peripheral tissues but
not hepatic resistance, (unlike in type 2 DM)
i h l i li i i i
7/31/2019 Pcos Report Den Edited
52/60
peripheral insulin sensitivity & consequent
hyperinsulinemia
may play an impt. role in the pathogenesis of
PCOS
Insulin inhibit the prodn of SHBG in the liver SHBG free testosterone
Therefore, insulin resistance :
secretion of ovarian androgen
promotes free (biologically active) hormone
7/31/2019 Pcos Report Den Edited
53/60
COMPLAINT TREATMENT OPTIONS Patients medications
Infertility Metformin;Clomipene;Letrozole;
gonadotropins;ovarian
cauteryMetformin-1st line
Txweight./metabolic
concerns
Diet/lifestyle
management/
Metformin*
Skin manifestations Oral
contraceptive+antian
drogen(spironolactone
, flutamide,
finestride);gnrhagonist Cyproterone
Acetate+Ethinyl
estradiol(Althea)Dysfunctional
bleeding
Cyclic progestogen;
ocps
7/31/2019 Pcos Report Den Edited
54/60
Insulin resistance & elevated serum LH levels
Assoc. w/ increased risk oftype 2 diabetes &cardiovascular events.
importance of diagnosing PCOSwarrant lifelong surveillance
long-term consequences:
Endometrial cancer
ovarian cancer
DM
hypertension
7/31/2019 Pcos Report Den Edited
55/60
syndrome X
Constellation of dyslipidemia, elevated
bp,IGT, and central obesity
1 of the major health problems assoc. w/
obesity not only in Western and European
countries but also in Asia Pacific region
Insulin resistance and hyperinsulineamia
-implicated in etiology of glucose intolerance,
dyslipidemia and obesity
7/31/2019 Pcos Report Den Edited
56/60
Glucose intolerance/ insulin resistance
Raised arterial pressure
Raised plasma triglycerides
Central obesityMicroalbuminuria
PATHOLOGY: fundamental defect in pts. w/
Metab syndromeinsulin resistance in both
adipose and muscle tissue
7/31/2019 Pcos Report Den Edited
57/60
Central obesity defined as waistcircumference: >= 90 cm (35.4 inches) for Asian men
>= 80 cm (31.5 inches) for asian women (pts= 42 inches)
w/ ethnicity specific values for other groups + any 2 of
the ff. factors:
Raised TG level: >= 150 mg/dl (1.7 mmol/L)
or specific treatment for this abnormality
Pts 149 mg/dl(1.68 mmol/L )
Low HDL cholesterol (high-density
7/31/2019 Pcos Report Den Edited
58/60
lipoprotein cholesterol), or being on medicine
to treat low HDL.
< 50 mg/dL for women and
7/31/2019 Pcos Report Den Edited
59/60
Ovaries-being exposed to consistenetly
highlevels of insulinincreases testosterone
secretion
Major factor in the devt of pcos
7/31/2019 Pcos Report Den Edited
60/60
THANK YOU!