Holistic Care for Women with PCOSNIRRH Initiative

Dr. Anushree D. Patil MD DGO

Scientist CNational Institute for Research in Reproductive Health

(Indian Council of Medical Research), Mumbai

Greetings from NIRRH!

Polycystic Ovary Syndrome (PCOS)NIRRH Infertility Clinic Experience

64

9.926 4 4 6 6 6.53

0

10

20

30

40

50

60

70

Female factors (n=383)

Perc

en

t

Emerges at puberty and ends with menopause

Needs a life course approach of different treatment at different stages

Presents through different health care providers

Body Mass Index (n=100 PCOS women)

6.3

27

11.6

55.2

0

10

20

30

40

50

60

< 19 19.1-23 23.1-24.9 Obese 25 and above

Pe

rce

nt

Waist Hip Ratio (n=100 PCOS women)

Hormone profile (n=100 PCOS women)

30

12

2

6

0

5

10

15

20

25

30

35

LH above 10 Testo above 0.8 FBS > 120 PGBS > 140

Pe

rce

nt

Multidisciplinary Model of Care for PCOS

Genesis of Model of PCOS Clinic

NIRRH is a premiere research institute of ICMRfocussed on reproductive health

Conducts basic, clinical and public healthresearch in PCOS

Annually more than 300 women with PCOS(adolescent and infertile) are treated at NIRRH

Women participate in various research projectson PCOS.

NIRRH is in a unique position to implement thismultidisciplinary model

Expert Group meeting for Initiation of Multidisciplinary clinic

at NIRRH (Dec 2015)

Team composition, Case Record Form and Logistics finalised

Partners

IIT Powai

Kaivalya

Dham

yoga

Institute

Lonavala

Nirmala

Niketan

Institute of

Nutrition

Mumbai

Kasturba

Health

Society

NIRRH

Mumbai

KEM Hospital

Mumbai

Inauguration of NIRRH PCOS ClinicHon Secretary Department of Health Research and Director General ICMR

Dr. Soumya Swaminathan- 30th April 2016.

Multidisciplinary Model of Care in PCOS at NIRRH

First of its kind in the government health system of India

Objectives:

To address complete set of medical problems that come in the way of women suffering from PCOS including psychological issues

Develop a database of clinical, biochemical and ultrasound profile of patients with PCOS in different age groups

Develop simple management algorithms

To develop a cohort for research on PCOS

NIRRH PCOS Clinic

Patient Profile Management Goals

Diagnosis of PCOSPatient education

Assessment of Risk factors

QOL

Treat symptoms

Prevent sequelae

Existing cohorts

Adolescent girls: 149

Infertile women: 211

• Adolescents

• Married women

Contraception

Anxious to conceive

Requiring spacing

Secondary infertility

• Perimenopausal

Case Record Form and Electronic Data Entry

Socio-demographic details

Chief complaints

Medical history

Examination

Emotional health screening

Diet and exercise history

Investigations

Diagnostic criteria

Risk factors assessment

Treatment details

Treatment outcome

Developing IEC Material

Counseling

PCOS: No cure but control

Life stage approach for PCOS

Importance of treatment

Body Image issues

Fertility concerns

Long term complications

Adherence to Lifestyle modification

Anthropometry

Anthropometric parameters Body mass composition machine

(Omron) Weight (kg)

Height (cm)

BMI (kg/m2)

Waist Circumference (cms)

Hip circumference (cms)

Waist to Hip ratio

MUAC (cm)

Skeletal muscle%

Total fat %

Visceral fat%

BMR (Kcal) Body Water% Bone Mass%

Investigations

• Hormonal

Hormonal Biochemical Ultrasound

FSH FBS USG pelvis for PCOS and endometrial thickness

LH PGBS (post 75g) USG abdomen for Non Alcoholic Fatty Liver (NAFL) and cholelithiasis

TSH, Free T4 Lipid profile

PRL LFT (only in NAFLD)

S. Testosterone Calcium (R)

SHBG Hb CBC (routine)

17-OHP (R) CRP (R)

Insulin fasting (R)

Insulin post glucose (R)

25(OH)D (R)

AMH (R)

Free Androgen Index & HOMAIR

Psychological Assessment

Emotional Health Screening Questionnaire

• Psychological state

• Body Image

• Disordered eating

• Psychosexual dysfunction

• Sleep pattern

Patient Health Questionnaire-9

(PHQ-9)

Nutrition Consultation

Diet history

Customised diet sheet

Avoid refined flour, sugars, fried foods and outside food

Carbohydrate and fat restricted diet

Inclusion of locally available complex carbohydrates, fiber, greens

Avoid use of plastics

Young concepts

Yoga for PCOSAsanas Beneficial in PCOS

• Nadisodhan Pranayama

• Bhramri Pranayama

• Meditation

• Bhadrasana (Butterfly pose)

• Sun Salutation (Surya Namaskar

• Bhujangasana (Cobra pose)

• Naukasana (Boat pose)

• Dhanurasana (Bow pose)

• Warrior pose (Superman pose)

• Supta Badhakonasana

• Bharadvajasana

• Chakki Chalanasana (moving the grinding wheel)

• Shavasana (Corpse pose)

• Padmasana

Cosmetic Management

Hirsutism

• Modified F-G score

• Bleaching

• Epilating creams

• Waxing

• LASER

Acne

• Topical and oral medication

Acanthosis Nigricans

Alopecia

Joint Consultation and Monthly review

Dermatologist

Endocrinologist

IVF expert

Evidence based medical management protocols

Outreach Activities

Local schools

Parents Teachers Associations

Mumbai Municipal Corporation

Adolescent Friendly Health Services

General Practitioners

Support groups

Developing cohorts of women with PCOS

ADOLESCENCE

FETAL

CHILDHOOD AND

PRE ADOLESCENCE

PREGNANCY

REPRODUCTIVE

MENOPAUSE

Project Title

1 Determining Prevalence of PCOS among adolescent girls in Mumbai (P.I : Dr. Beena Joshi)

2 Study of PON1 gene variants and its association with cardiovascular disease (CVD) risk factors in women with PCOS(P.I: Dr. Srabani Mukherjee)

3 Genetic study of Non Classical Congenital Adrenal Hyperplasia as a cause of Female Infertility(P.I: Dr. Suparna Chaterjee)

4 Study of T lymphocyte subsets and their relation with autoimmunity and PCOS(P.I: Dr. Srabani Mukherjee)

5 Determination of plasma levels of endocrine disrupting chemicals(Bisphenol A, Phthalates and Polychlorinated Biphenyls) in cohort ofinfertile women.(P.I: Dr. Prajakta Pednekar)

Collaborative Projects in PCOS

Way Forward...................Replication of this model through 31 Field units of NIRRH across India

Thank You!