POLYCYSTIC OVARIAN SYNDROME Laura Tatpati, MD Reproductive Endocrinology and Infertility. Based on: ACOG No. 108 Oct 2009; reaffirmed 2015

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1 POLYCYSTIC OVARIAN SYNDROME Laura Tatpati, MD Reproductive Endocrinology and Infertility Based on: ACOG No. 108 Oct 2009; reaffirmed 2015

2 NO DISCLOSURES

3 PATIENT 26 years old presents with complaint of irregular menstrual cycles Your focused history should include what? What tests would you like to order and why?

5 LABORATORY Document biochemical hyperandrogenemia Total T and SHBG or bio or free T Exclusion of other causes TSH, Prl 17OHP Random <4 ng/ml Morning fasting < 2ng/mL Screen for Cushings and acromegaly per sx Eval for Metabolic abnormalities 2h GTT (>99 IFG, >126 DM at fasting and IGT, >200 DM at 2h) Fasting lipids: HDL <50 mg/dl and Tg > 150 mg/dl

6 OPTIONAL TESTS Gonadotropins to determine cause of amenorrhea Fasting insulin levels in younger woman, those w/ severe stimgmata or those undergoing ovulation induction 24h urinary free cortisol excretion or LDDST w/ late onset of PCOS symptoms or stigmata of Cushing s

7 US EXAMINATION PCO in one or both ovaries: 12 or more follicles measuring 2-9mm Ovarian volume > 10cm3 Repeat scan if volume unable to be calculated due to cyst, single ovary can meet definition

8 PCOS DIAGNOSIS

9 METABOLIC SYNDROME ATPIII Criteria commonly used BP > 130/85 Waist circumference > 35 in Elevated fasting glucose >=100 mg/dl Low HDL < 50 mg/dl Elevated Tg > 150 mg/dl

10 SO, AGAIN YOU ARE THINKING DID I MISS

11 TREATMENTS: NOT TRYING TO CONCEIVE Lifestyle modification OCPs Progesterone/progestin only Sprironolactone, antiandrogens Eflornithine Treatment of assoc metabolic conditions: Insulin sensitizers/statins

12 TREATMENT: TRYING TO CONCEIVE Aromatase inhibitors: Letrozole* SERMs: Clomiphene Citrate, tamoxifen (ERa) CC + Dex Metformin rfsh Ovarian drilling IVF

13 IMPACT ON HEALTH Insulin Resistance NAFLD Hyperplasia Sleep apnea Metabolic syndrome Hirsutism, Acne & Alopecia Infertility Depression

14 ACOG RECOMMENDATIONS The following recommendations and conclusions are based on good and consistent scientific evidence (Level A) An increase in exercise combined with dietary change has consistently been shown to reduce diabetes risk comparable to or better than medication. Improving insulin sensitivity with insulin-sensitizing agents is associated with a decrease in circulating androgen levels, improved ovulation rate, and improved glucose tolerance. The recommended first-line treatment for ovulation induction remains the antiestrogen clomiphene citrate.* The addition of eflornithine to laser treatment is superior in the treatment of hirsutism than laser alone.

15 ACOG RECOMMENDATIONS The following recommendations and conclusions are based on limited and inconsistent scientific evidence (Level B) Screen for T2DM & IGT with a 2h GTT w/ 75g load Screen for CV risk by BMI, fasting lipid and lipoprotein levels, and metabolic syndrome risk factors. Reduction in body weight has been associated with improved pregnancy rates and decreased hirsutism, as well as improvements in glucose tolerance and lipid levels. There may be an increase in pregnancy rates by adding clomiphene to metformin, particularly in obese women with PCOS. If clomiphene fails, the second-line intervention is either exogenous gonadotropins or laparoscopic ovarian surgery.

16 ACOG RECOMENDATIONS The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C) Combination low-dose hormonal contraceptives are most frequently used for long-term management and are recommended as the primary treatment of menstrual disorders. Women in groups at higher risk for nonclassical congenital adrenal hyperplasia and a suspected diagnosis of PCOS should be screened to assess the 17-hydroxyprogesterone value (Ashkenazi Jewish, Hispanic, Yugoslav, Native American Inuit, Italian). A low-dose regimen is recommended when using gonadotropins in women with PCOS. There is no clear primary treatment for hirsutism in PCOS

Polycystic Ovary Syndrome (PCOS):

Polycystic Ovary Syndrome (PCOS): Current diagnosis and treatment Anatte E. Karmon, MD Disclosures- Anatte Karmon, MD No financial relationships to disclose 2 Objectives At the end of this presentation,