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, participants will be able to: Understand the current views of PCOS definition and etiology Understand the differential diagnosis and work-up of PCOS Follow evidence based practices regarding the treatment of patients with PCOS 3
What is PCOS? Definition remains controversial Current understanding- PCOS encompasses multiple phenotypes with varying associated morbidities Fertil Steril. 2017 Nov;108(5):748-749 4
Definition 5
Classifying PCOS by phenotype P H E N O T Y P E A P H E N O T Y P E B P H E N O T Y P E C P H E N O T Y P E D Hyperandrogenism Ovulatory dysfunction PCO morphology R E A D M O R E Hyperandrogenism Ovulatory dysfunction R E A D M O R E Hyperandrogenism PCO morphology R E A D M O R E Ovulatory dysfunction PCO morphology R E A D M O R E National Institutes of Health. Evidence-based methodology workshop on polycystic ovary syndrome, December 3-5, 2012. https://prevention.nih.gov/docs/programs/pcos/finalreport.pdf. 6
PCOS morbidity Metabolic 1 2 Endometrial cancer PCOS Infertility 4 3 Obstetric 7
Prevalence Depends on definition 5 21% higher with Rotterdam 2003 criteria, lower with NIH 1999 criteria May be impacted by the quality of androgen assay High degree of bias in studies 8
Why is PCOS so common? Ünlütürk et al. Fertil Steril. 2016 Jul;106(1):33-41 9
Etiology of PCOS Dumesic DA, Richards JS.Fertil Steril. 2013 Jul;100(1):23-38 10
Differential diagnosis of PCOS Androgen secreting tumor Exogenous androgens Cushing syndrome Non-classic CAH Acromegaly Genetic defects in insulin action Hypothalamic amenorrhea Ovarian failure Thyroid disease Prolactin disorders ACOG. Obstet Gynecol. 2009 Oct;114(4):936-49 11
Suggested work-up for PCOS Physical exam Weight, BMI, waist circumference Stigmata of hyperandrogenism Lab work Total testosterone, SHBG, free testosterone, DHEAS TSH, PRL, 17 OHP, gonadotropin levels Screen for Cushing or acromegaly 2 Hour GTT, hemoglobin A1c Ultrasound 12 or more follicles 2-9mm in diameter, or increased ovarian volume; one PCO ovary is enough for diagnosis Endometrial abnormalities ACOG. Obstet Gynecol. 2009 Oct;114(4):936-49 12
Treatment for infertility Treatment for metabolic disorder/hyperandrogenism Clomiphene citrate Letrozole Combined oral contraceptive pills Metformin Metformin Spironolactone Hair removal, eflornithine cream 13
Combined oral contraceptive pills Gonadotropin secretion SHBG Total and free T Treat menstrual disorders, prevent endometrial hyperplasia Improvement in hirsutism Treat acne 3rd generation progestin, progestin with antiandrogenic activity 14
Metformin Insulin sensitivity Androgen production Ovulatory function Good evidence for: Treatment of metabolic disorder Restoration of ovulatory function Improvement of ovulation rate in clomiphene resistant women Insufficient evidence for: Prevention of SAB Impact on live birth Metformin plus clomiphene or plus letrozole 15
Metformin plus clomiphene citrate hello ASRM. Fertil Steril. 2017 Sep;108(3):426-441 16
Treatment of hirsutism Combined oral contraceptive pills Spironolactone Hair removal Topical eflornithine Rosenfield RL, Deplewski D. The role of androgens in the development of biology of the pilosebaceous unit. Am J Med 1995; 98:80S 17
Ovulation induction for PCOS Clomiphene citrate Letrozole Gonadotropins Metformin Combined therapy 18
Laparoscopic ovarian drilling Pirwany et al., Tulandi T. Fertil Steril. 2003 Aug;80(2):241-51 19
Environmental factors and PCOS Diet and carbohydrates, exercise, lifestyle change Vitamin D Weight loss Myo-Inositol 20
PCOS and obstetric outcome de Wilde et al. Fertil Steril. 2017Aug;108(2):333-340 21
Take home message PCOS has four phenotypes which are associated with varying morbidities Treatment of PCOS depends on patient goals i.e. ovulatory function, metabolic, fertility, hirsutism Ovulation induction in patients with PCOS is effective- refer to a specialist if no pregnancy after a trial with oral agents 22
Questions 23