PCOS and Obesity DUB is better treated by OCPs Dr. Ritu Joshi Senior consultant Fortis escorts Hospital, Jaipur Chairperson Family welfare com. FOGSI (20092012) Vice President FOGSI 2014
Introduction One of the most common endocrinopathy. Unknown etiology. Prevalence in India of 3.7% to 22.5% with 9.13% to 36% adolescents. Common symptoms range from menstrual disorders Infertility Hyperandrogenemia Metabolic syndrome.
In India rapid increase in prevalence of PCOS is associated with morbid conditions such as IR Excess body fat Adverse body fat patterning Hypertriglyceridemia Obesity related diseases like diabetes, and cardiovascular diseases.
Category Androgen status Menstrual History Mid luteal progesteron e test for anovulatory bleeding in women with regular ovulation Ovarian appearance Specific abnormality Clinical Hyper Androgenism Biochemical hyperandrogenism Oligo or anovulation Recommended diagnosis NIH Rotterda m Hirsutism, acne, and Central alopecia Increased total bioavailability or free serum testosterone level Anovulation frequent (<21 d) or infrequent (>55d) bleeding intervals XX X XX Ovarian size/morphology on ultrasound PCO morphology presence of 12 follicles of 29mm dia and/or ovarian vol >10ml without a cyst or dominant follicle >10mm XX XX X X X AE PCOS XX XX X Diagnostic criteria for PCOS which has been adapted from Legro et al 2013
Malik, et al.: A Consensus Evidencebased Good Clinical Practice Recommendations
Obesity and PCOS Obesity has been linked to abnormal function of the hypothalamicpituitaryovarian axis through multiple mechanisms that contribute to PCOS. Obesity is associated with insulin resistance and compensatory hyperinsulinemia. Insulin serves as cogonadotropin to stimulate ovarian androgen production. Inputs from adipokines such as leptin are key to controlling ovulatory function.
Effect of obesity in PCOS Obesity is associated with increased likelyhood of metabolic sequelae, like glucose intolerance, dyslipidemia. Obesity is associated with anovulation and hyperandrogenemia.
Obesity and DUB Hyperandrogenism contributes to ovulatory and menstrual dysfunction. Management of hyperandrogenism focuses on treating its clinical consequences. OCPs are the first line management for the treatment of menstrual abnormalities. They suppress the gonadotropin release and consequently inhibit ovarian androgen secretion in women with PCOS. The estrogen in the OCPs also stimulates hepatic production of sex hormone binding globulin (SHBG), which inturn reduces the free fraction of circulating androgens.
Obese adolescent with PCOS OCPs are the first line option They regulate the menstrual cycles. Lower the risk of endometrial hyperplasia, acne and hirsutism. Act by regulating the GnRh pulses and suppress FSH and LH resulting in decreased ovarian stromal proliferation and reducing ovarian steroidogenesis and androgen production.
Mechanism of action of OCPs Estrogen increases the production of SHBG thereby decreasing the circulating free androgens. Reduction in adrenal androgen secretion and inhibiting peripheral conversion of testosterone to dihydrotestostrone and binding of dihydrotesterone to androgen receptors. Progestogens counteract the unopposed estrogen thereby reducing endometrial hyperplasia.
Choice of OCP Type of estrogen compound used.most current OCPs contain 3035ug of ethinyl estradiol combined with a progestin with minimal androgenic activity. Choice of progestin compound used. Dosage of estrogen and progestin compounds in combination.
Existing guidelines ACOG RCOG Endocrine society PCOS Australian alliance PCOS guidelinegcpr by Indian fertility society All suggest use of OCPs as the first line primary treatment option in menstrual irregularities.
Oral Contraceptives Pills Suppress ovarian androgen Increase SHBG Regular menstrual cyclicity Progestin opposition Contraception
Oligomenorrhea Combination estrogenprogestin pill first line when fertility is not desired Decrease in LH secretion and decrease in androgen production Increase in hepatic production of sexhormone binding globulin Decreased bioavailablity of testosterone Decreased adrenal androgen secretion Regular withdrawal bleeds Prevention of endometrial hyperplasia
A comparison of various progestins Progestin Estrogenic Antiestrogenic Androgenic Antiandrogenic Antimineralo corticoid Progesterone + + Older progestins: MPA Norethisterone Levonorgestrel + + + + + Newer progestins: Desogestrel Cyproterone acetate + Drospirenone + +
Advantages Best for adolescents. In adults who do not wish to conceive Best for regulating menstrual cycles. Simultaneously also treats acne and hirsutism when present.