Management of the Commonest Endocrine disorder in females Miss Bini Ajay
Dec 19, 2015
CasesCases
25 year old with BMI 35, with history ofinfrequent periods, facial hair
30year old, normal BMI with irregular periods and unable to conceive for 3 years
• Stein & Levanthal in 1935• 5-10% PCOS,20% PCO• Heritable disorder• 30%of PCOS- normal periods, 85-90% of oligomenorrhoea,30-40 % of amenorrhoea• 70%- hyperandrogenism• 50-70%- insulin resistance, 30-40% -IGTT, 7.5-10% -type II• 40% - subfertility• 42-73%-miscarriages• 35%- depression
Facts
PathophysiologyPathophysiology
Insulin Resistance
Hyperinsulinemia Stimulates Hypothalamus Stimulates adrenal gland Stimulates ovaries Suppresses Liver – less SHBG- Increased Androgen
DiagnosisDiagnosis
Rotterdam Criteria - 12 or more follicle <10mm
- Oligoovulation /anovulation
- hyperandrogenism
BiochemicalBiochemical teststests
-TFT/ Prolactin
- Free androgen & SHBG
- Androgen secreting tumours/ CAH(17OHprogesterone)
- LH:FSH > 2:1
- AMH
- GTT(fasting insulin)
- Lipid profile
TreatmentTreatment
• Exercise ,weight loss(5%)• Oral contraceptive pill- Dianette, Yasmin• Spironolactone ,Finasteride• Isotretinoin• Laser, electrolysis
VaniqaVaniqa
• Eflornithine Monohydrate chloride
• Blocks the action of ornithine decarboxylase in skin
• Twice daily • 4 months
MetforminMetformin
• Decreases androgens• Use insulin• Reduces cholesterol• Improves metabolism• Increases ovulation• If pregnant can continue Metformin
InositolInositol• Myo-inositol- carbohydrate essential for insulin
modulation• Increases action of insulin –improves insulin
sensitivity• Reduces cholesterol and BP• Reduces androgen • Increases ovulation-69.5%
LaparoscopicLaparoscopic drillingdrilling
• Drills into the outer capsule• Decreases testosterone• Increase FSH
Long termLong term EffectsEffects
• Diabetes, cardio and cerebrovascular disease-lipid profile, BP, HbA1c
• Endometrial cancer –hyperplasia
• Obstructive Sleep Apnoea- obese, insulin resistance –CPAP
• Psychological –Depression , sexual difficulties, eating disorder
PCOS and TrigyceridesPCOS and Trigycerides• Obesity and high insulin – promotes high triglycerides-
increases VLDL• Insulin resistance – reduced clearance of VLDL and
chylomicrons• Hepatic content of triglycerides is high larger VLDL
particles are produced- metabolised to small, dense LDL particles- poorly cleared and atherogenic
• Statins improve hyperandrogenemia
PCOS and hypertensionPCOS and hypertension• Increased endothelin_1 levels• Increased aldosterone concentrations• Czech-22% Dutch-28%• Coronary artery calcium (CAC scores) and
carotid intima –media thickness (CIMT)- subclinical atherosclerosis- stroke ,MI
EndometrialEndometrial hyperplasiahyperplasia
• Endometrial cancer• Withdrawl bleed -3-4months• TVS- ET-7mm
PCOS and PregnancyPCOS and Pregnancy
• Gestational diabetes- GTT at 16 and 28weeks• Preeclampsia• Preterm birth• Perinatal mortality• Multiple pregnancy