13 th Annual Women s Health Day PCOS. Saturday 02/09/2017 Dr Mathias Epee-Bekima O&G Consultant KEMH

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Lucinda Parker
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1 13 th Annual Women s Health Day PCOS Saturday 02/09/2017 Dr Mathias Epee-Bekima O&G Consultant KEMH

2 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

3 PCOS Stein & Leventhal 1935 NJEM 7 patients hirsutism/sterility/enlarged ovaries Surgery

4 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

5 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

6 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

7 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

8 Clinical or biochemical evidence of excess androgens Clinical Hirsutism Acne - Alopecia Or Biochemical: Free testosterone- Free Androgen index (20% difference with laboratory values= endocrinologist)

9 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

10 Differential diagnosis Hypothyroid Hyperprolactinemia Androgen secreting tumours (adrenals, ovaries) Exogenous androgens Cushing's syndrome Congenital Adrenal Hyperplasia (17-OH progesterone)

11 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

12 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

13 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

14 Treatment No cure for PCOS Targeted against symptoms and concerns Prevention and early detection of long term complications

15 Short term medical issues Hair and acne Fertility Irregular periods Depression Excessive weight gain Sleep apnea

16 Hirsutism/acne/alopecia Cosmetic: Gel/cream to reduce pore blocking Shaving Waxing Laser or electrolysis (dermatologists) Eflornithine (takes up to 8 weeks- lifetime)

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

18 Fertility Weight loss (5-10%) in obese PCOS improves ovulation Clomiphene- 1 st 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

19 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?

20 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

21 Weight loss Exercise 30 mn daily- need to sweat Diet Bariatric surgery

22 Other problems Emotional well-being Reassurance- information- support grouppsychologist Weight loss- CPAP Sleep apnea

23 Long term concern Prevention of endometrial cancer Impaired glucose tolerance/diabetes Cardiovascular risk

24 Long term concern: COC Prevention of endometrial cancer Progesterone medroxyprogesterone 10 mg for 7-10 days every 3 months to achieve a withdrawal bleed IUS Weight loss

25 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

26 Long term concern Cardiometabolic risk Smoking cessation advice Hypertension (yearly) Dyslipidemia (check every 2 years) Lifestyle changes (diet/excercise/behavourial interventions)

27 PCOS and pregnancy Miscarriage GDM (early GTT + repeat at 28/40) Hypertension/preeclampsia Increased intervention at birth

28 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?)

29 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)

30 Quizz 6- How do you manage an incidental report of an ultrasound report of PCO? (label the patient PCOSreassess the patient- refer to the gynecologist) 7- What is the percentage of women with PCOS? ( ) 8- Metformin is teratogenic (T/F)

31 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)

32 Tie break Metformin

33 Want to know more? PCOSAA Verity UK- fabulous links Ranzcog/RCOG guidelines

34 Merci

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