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• What particular aspects of history & clinical features would you like to look for?
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Clinical assessment
History The following items are important::
• Family History of HA/Obesity/temporal balding/infertility• Hx of Precocious adrenarche• More than 2 years of oligomenorrhea
6Dr Mona Shroff www.obgyntoday.info
Clinical assessment..
Physical examination
• Degree of hirsutism, acne• Obesity ,increased W/H ratio Acanthosis nigricans- r/o PCOS,HAIR-AN• Rapidly growing hirsutism or Virilizing symptoms – r/o TUMOR• Symptoms of hypercorticism –r/o CUSHING• Galactorrhea – r/o HYPERPROLACTINEMIA
7Dr Mona Shroff www.obgyntoday.info
What is this C/F?
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9Dr Mona Shroff
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•Would you like to investigate this patient at this juncture?
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• Would you like to start treatment at this time?
• In which particular patients would you evaluate & treat at an early age?
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J Pediatr. 2004 Jan;144(1):23-9.
Insulin sensitization early after menarche prevents progression from precocious pubarche to polycystic ovary syndrome in a high-risk group of formerly LBW girls.
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LIFESTYLE MODIFICATIONS
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Adult v/s Adolescent HA
•FOH or Organic cause???•USG not reliable-ovaries may
• Same patient comes to you after 2 yrs (age 16 yrs) - still having same clinical picture but worsened
delayed periods mod. acne & hirsutism BMI 32
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• Would you like to evaluate this patient now?
• What initial screening investigations would you like to go for & why?
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INITIAL LAB SCREENING
• TESTOSTERONE• PROACTIN• TSH• Evaluation for
HYPERINSULINEMIA• 17 OH PROGESTERONE
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INITIAL LAB SCREENING• Testosterone total – may be N in hirsute woman if T> 200 screen for tumor
free T?? Should we ask for? – no clinical need to check - if HA effect seen then free T must be raised - does not help in D/D or
treatment
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• TSH - esp if alopecia• PROLACTIN - DHEAS ,free T (SHBG )• HYPERINSULINEMIA Fasting glucose : Insulin <
4.5 Fasting insulin > 20 2 hr GTT > 140
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• 17 OH P - for NCAH , follicular ph/morning -routine screen in HA indicated (esp if sev hirsutism at younger age ,short stature)
* <200 ng/dl : N * 200 – 800 : ACTH stimulation test * > 800 : diagnostic
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• Screen for Cushings if clinical suspicion
late eve. plasma cortisol single dose overnight DST
• Imaging of adrenals & ovaries (USG/CT/MRI)
* if rapid virilization * T > 200 micgm/ dl
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Audience question• Would you like to
include S.DHEAS in her list of investigations?
If YES - WHY? If NO – WHY NOT?
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DHEAS ???
• Moderate elevation common in anovulatory females
• > 700 micgm/dl – v.rare• if T> 200 – screen for tumor must• Mod. elevated DHEAS does not
necessitate or prove the need & benefit of treatment with dexamethasone
• No further benefit by testing,not cost effective
Gordon,Speroff 2002
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Lab resultsof this patient
TSH, Prolactin, 17OH P : normal Total T : 70 ng/mL [<72 ng/mL] Fasting Insulin : 22 mIU/mL [<20 mIU/mL] Fasting Glucose 92 mg/dL
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• What are the options available for treating HA?
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COCPs
ANTIANDROGENSSPIRONOLACTONE
FUTAMIDEFINASTERIDE
CYPROTERONEDEXAMETHASONEKETOCONAZOLE
CIMETEDINEGnRH AGONISTS
INSULIN SENSITIZERSMECHANICAL AGENTS(hirsutism)
ANTIBIOTICS (acne)
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• Considering our diagnosis of PCOS in this girl what are your aims of treatment
• What treatment would you like to start in this patient?
• How long should you continue with this treatment?
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Management of excess ovarian androgen production :
Standard therapy is :combined E+P OCs
• It reduces ovarian androgen production
• It increases SHBG• It induces competition at the
cellular level for binding to the androgen receptor
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METFORMIN• In addition to the expected improvements in insulin sensitivity and glucose metabolism• Ameliorates hyperandrogenism and menstrual
irregularity.• Reduces total cholesterol, LDL and triglycerides of
PCOS adolescents while increasing HDL cholesterol .• Decrease C-reactive protein and a normalization of the
neutrophil/lymphocyte ratio , which are predictive of cardiovascular disease.
Benefits both obese & non obese Hum Reprod. 2005 Sep;20(9):2457-62.
Hum Reprod. 2002 Jul;17(7):1729-37.
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ANTIANDROGENS
•According to currenty available evidence no antiandrogen is superior to other in terms of clinical efficacy, so choice depends upon S/E & cost.Further studies needed.
16 y/o female • Menses q 3-4 months• Moderate facial acne• FG Score of 5 (1 lip, 1 chin, 2 lower abd, 1 back)• Tanner Stage breast 4, pubic hair 4• BMI 26..3 kg/m2• No galactorrhoea
INITIAL SCREENING ??35Dr Mona Shroff
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Lab results
• TSH,, Prolactin normal• 17OH P : 2.5 ng/mL [<2 ng/mL]• Total T : 70 ng/mL [<72 ng/mL]• Fasting Insulin 14 mIU/mL [<17 mIU/mL]• Fasting Glucose 92 mg/dL
What would you do next?36Dr Mona Shroff
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ACTH Stimulation Test
Baseline 17 OH P 2..5 ng/dL 60 min 17 OH P 18 ng/dL
What is your inference? How would you treat this patient?
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•Treat hyperandrogenism with dexamethasone or CPA or spironolactone or flutamide• Treat irregular menses with combined oral contraceptive pills• Treat infertility when patient desires pregnancy• Consider adding dexamethasone to ovulation induction
Cyproterone acetate versus hydrocortisone treatment in late-onset adrenal hyperplasia.
• Peripheral antiandrogen therapy may be more appropriate in late-onset adrenal hyperplasia patients than conventional adrenal inhibition using cortisone therapy.
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CONCLUSIONS
• HA is a common adolescent probem• Our main aim is early PCOS diagnosis
& ruling out tumor/NCAH.• Watch for premature pubarche.• Initial screen –T, TSH, Prolactin,
fasting glucose:insulin, 17 OH P• Imaging for tumor if T>200 or rapid