pcos patient handout

8/22/2019 PCOS Patient Handout

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POLYCYSTIC OVARY SYNDROME (PCOS)

Characterized by multiple ovariancysts, obesity, hirsutism, menstrual

abnormalities and infertility

Polycystic Ovary Syndrome

First described by Drs. Stein andLeventhal in 1935

Stein IF, LeventhalML: Amenorrhea associated with bilateralpolycystic ovaries. Am J ObstetGynecol 1935; 29: 181.

PCOS was first described as an entity by Drs. Stein and

Leventhal in 1935. They described a group of women with

obesity, excess hair growth, and ovaries with multiple cysts.

We have learned a great deal about PCOS since their originaldescription. We now understand the cause of PCOS and know

that it affects thin women as well as women who areoverweight.

Affects 5% of all American Women

Most common endocrine abnormalityin reproductive age women

Most common cause of femaleinfertility in the United States

PCOS

PCOS affects far more women than Stein and Leventhal ever

imagined. It is the most common cause of female infertilityand ovulatory dysfunction in the United States.

Polycystic Ovary Syndrome

Irregular or absent ovulation and menstrual periodsObesityHirsutismHyperinsulinemia

PCOS is characterized by ovulatory dysfunction. Periods do

not necessarily have to be absent. Many women with PCOScontinue to ovulate, but do so either irregularly or with

compromised progesterone production. Many women with

PCOS are not obese, and many women with PCOS do not haveexcess hair growth, but to some extent virtually all women

with PCOS have some degree of insulin resistance. Insulin

resistance implies that the peripheral tissues - skin, muscle, fat

etc, do not respond to insulin normally. The pancreasresponds to this by increasing insulin production which results

in increased insulin levels.

PCOS - Diagnosis

HistoryClinical examUltrasoundLaboratory

The diagnosis of PCOS can be made by many different

criteria. History is very important, and is usually characterizedby some degree of menstrual irregularity or ovulatory

dysfunction. Laboratory tests may also be needed to be surethat there is not some other problem. Finally, ultrasound hasbecome the most important tool for diagnosing PCOS. An

ultrasound picture of the ovaries can give one great insight into

the status of the ovaries and how they function.


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TestosteroneAndrostenedione

DHEAS17-OH ProgesteroneProlactinTSHLHFSH

Laboratory Evaluation

One of the primary goals of laboratory evaluation is to be surethere is not some other problem affecting the ovaries and their

function. For example, elevated Prolactin levels can cause

irregular periods. (Prolactin is a pituitary hormone that

controls breast milk production. If mildly elevated, it can

adversely affect ovulation.) Abnormal thyroid function canalso alter ovarian function, be it hypo- (low) or hyper- (high)

thyroidism. LH and FSH are the pituitary hormones thatcontrol ovarian function. Normally, FSH is higher than LH.

In women with PCOS, this ratio can be reversed, with LH

being higher than FSH.

The first four tests in the previous slide are male hormones. If

there is excess hair growth or other evidence of increased male

hormone production, these four hormones may be checked tobe sure that the problem is arising in the ovary and not from

some other condition.

Insulin Resistance 2 hr GTT, glycemic clamp, insulin

tolerance test, fasting G/I, HOMA (Homeostasis Model

Assessment), QUICKI (Quantitative Sensitivity Check Index)

A uni form finding

Laboratory Evaluation (contd)

The discovery of the role of insulin and insulin resistance in

PCOS has changed the entire approach to PCOS. There are

many techniques for measuring insulin levels and determiningthe extent of insulin resistance. In our experience, this testing

is not necessary except in unusual circumstances. One can

assume that there is some degree of insulin resistance in everywoman with PCOS. The exact extent of the insulin resistance,and the insulin level, do not really matter. The degree of

insulin resistance is related to the level of obesity and excess

hair growth obese women have more insulin resistance thando thin women. We rarely measure insulin levels anymore.

PCOS

The presence of oligo- or an-ovulation

Clinical or biochemical signs ofhyperandrogenismPolycystic ovaries and exclusion of

other etiologiesUltrasound: The presence of 12 or

more follicles in each ovary (2-9mm), and/or increased ovarianvolume.

The Rotterdam ESHRE/ASRM-Sponsored PCOS ConsensusWorkshop Group, 2003

In 2003, an international workshop defined PCOS, focusing

primarily on ultrasound criteria. This is the criteria upon

which we base the diagnosis of PCOS if the ultrasounddemonstrates the presence of an excess number of small

follicles in the ovaries, the diagnosis of PCOS is made.


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These are pictures of a polycystic ovary as seen as the time of

laparoscopy and by ultrasound. The laparoscopy picture

shows the classic appearance of a PCOS ovary, a large ovarywith a smooth capsule and neo-vascularizations, the

multiple small blood vessels on the surface. The ultrasoundpicture shows the many small follicles. There are at leasttwenty present on just this one view. The cysts of PCOS are

not large; they are small follicles as seen in this picture.

This picture demonstrates a normal ovary. In every ovarythere are a few follicles that are developing, and one of these

eventually will develop into a mature follicle that will ovulate.

In PCOS, the follicles that start to develop cant do so, andthey stack up at an immature phase of development. It is a

relative excess of male hormones that prevents the folliclesfrom maturing. In essence, the excess of male hormonesalmost acts like a barrier preventing them from progressing.

They continue to stack up until the ovaries look like the one

seen in the previous slide.

Significantly greater density offollicles per mm3

Fewer healthy primordial follicles thannormal ovaries (growth arrestedbetween 5 and 8 mm)

This is the result of relativehyperandrogenicity

PCOS Ovaries

This results in there being many more small follicles. And theeggs contained in those follicles are not healthy. The follicles

have been arrested, and so has the development of the eggs.Once again, it is the relative excess of male hormones that

results in these changes.

Insulin resistanceHyperinsulinemia

Ovarian androgen productionAnovulation, hirsutism, amenorrhea,and infertility

PCOS In individuals with a significant degree of insulin resistance,the elevated insulin levels directly affect the ovary and the

ovary makes higher than normal levels of androgens (male

hormones). It is the elevated androgens that result in thechanges that characterize PCOS. In thin women, the relative

excess of androgens occurs for other reasons that we will

discuss later. The end result is the same PCOS.


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Adverse effects on lipo-proteinsCauses weight gain

Makes weight loss virtually impossible.

Elevated Insulin

Elevated insulin levels affect other organ systems than just

the ovary. Women with PCOS complain all the time that they

dont eat that much and still gain weight. Well, its the truth.

Because of the elevated insulin levels, any carbohydratestaken are almost immediately converted to fat and stored in

fat cells. And insulin makes it almost impossible to lose

weight insulin works very hard to prevent mobilization offat from fat cells. Weight loss is virtually impossible at

least until the insulin levels are lowered.

Implications for not only ovulationand infertility, but also for long-term

healthHeart diseaseDiabetesUsually weight dependent

Insulin ResistanceInsulin has adverse effects on lipo-proteins. The effect onlipids and the cardio-vascular system results in about a ten

fold increase in the risk of heart disease. The risk of diabetes

is increased to about the same extent the pancreas just cantmake that much insulin forever, and eventually cant make

enough and diabetes results.

GlucophageActosAvandia

PCOSFortunately, there are medications available that are veryeffective in lowering the insulin levels. Metformin

(glucophage) is by far the most commonly prescribed forwomen with PCOS. It is cheaper, it is more effective, andActos and Avandia are only used when using Glucophage is

not an option.

Improves peripheral insulinsensitivity

Decreases hepatic glucoseproduction

Directly affects aromatase (anovarian enzyme that convertsandrogens to estrogens).

Metformin (Glucophage)

Glucophage has several mechanisms of action. It does

increase peripheral insulin sensitivity. In other words, it

decreases the lack of responsivity of the tissues to insulin.More importantly, it dramatically reduces the production of

sugar by the liver. If sugar levels are decreased, insulin levelswill decrease. With decreased insulin, the production of malehormone from the ovaries decreases and the PCOS improves.

Glucophage also works very well in thin women without

significant insulin resistance. Almost as a side effect, it

increases the activity of an enzyme call aromatase.Aromatase increases the conversion of male hormones to

female hormones less androgens and more estrogens result.


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Thin Women Glucophage 500 mg tidHeavier Women GlucophageXR

2000 mg/day

Taper upAvoid carbsLots of waterVitamins

Metformin

Glucophage comes in a couple of forms, and our experience

is that some women tolerate one form better than the other.

Thin women typically do better taking regular glucophagethree times a day, whereas heavier women seem to do very

well on the extended release form taking four tablets everyevening with dinner. Everyone has to get used to glucophageand slowly taper up their dose, beginning with one pill a day

and increasing as tolerated.

Build up tolerance

Monitor BUN and CreatinineThree month lag time then re-

evaluate

Metformin

The major side effects of glucophage are diarrhea and

abdominal cramping- these can be avoided if one eliminates

carbohydrates from the diet. Thin women can slowly add

carbohydrates back into their diet as tolerated. Heavierwomen should not our goal with them is to lower insulin

levels and it doesnt do much good to decrease the productionof glucose by the liver if one keeps eating carbohydrateswhich are converted to glucose. It takes about three months

for glucophage to have maximal effect on the ovaries. Many

women conceive with no other intervention than glucophage,and couples should go ahead and try to conceive during those

three months.

Metformin three month lag time?

Mullerian-Inhibiting substance

(MIS)

A dimeric glycoprotein ( a transforming

growth factor)

Regulates early follicular development

directly

Not in primordial follicles, but

present in primary stage through

small antral follicles

Increased in women with PCOS

To understand the three month delay in the maximal effect ofglucophage, one must understand Mullerian Inhibiting

substance (MIS), a hormone produced by the developing

follicles.

Increased in women with PCOS

MIS levels correlate with the extentof ovarian dysfunction

In women with PCOS, the numberof developing and atretic follicle isdoubled

PCOS leads to a build up ofimmature follicles

MIS decreases aromatase activity

MIS

MIS is increased in women with PCOS, which is notunexpected given the number of follicles that are present.

MIS decreases aromatase activity, which results in anincrease of androgens and a decrease in estrogens. This

perpetuates the PCOS changes.


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MISAndrostenedione and MIS levels after

glucophage treatment

While glucophage treatment will lower androgens ratherquickly (androstenedione in this slide), MIS really does not

decrease significantly for almost three to four months.

MISDissociation between MIS levels and

A-dione

3 months from initial recruitment to

antral stage

A key abnormality in PCOS is initial

follicle recruitment

A new cohort, recruited under

decreased insulin and (perhaps

androgen) levels, is developed

This makes sense if one understands that it takes about three

months to turn over the follicles in the ovary. In other

words, it takes about three months to get rid of those folliclesand eggs that have developed under the influence of high

male hormone levels and have had their development

arrested, and get a new cohort of follicles and eggs that can

develop more appropriately under a more normal hormonalenvironment.

MIS

Metformin treatment results in asmaller follicle cohort because theyare recruited under normal insulinlevels, with increases aromatase

activity and better follicles andoocytes.

Glucophage decrease insulin, and/or increases aromatase

activity. The decrease in male hormone levels decreases

MIS, and the combined effect of these changes is a healthier

environment for follicles and eggs to develop.

Improves insulin sensitivity

Food plan (low amylose) plusglucophage + exercise - 10pounds per month

Weight loss

If heavier women take glucophage and follow what we call a

low amylose diet (no simple carbs, no potatoes, no bananas,no corn, no bread, no pasta, no cereal) they will lose about ten

pounds a month. In fact, thin women on glucophage must

take care not to lose additional weight while on glucophage.


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Peripheral Insulin sensitization

More expensiveWeight gain(?)Reserved for women who dont

tolerate glucophage

Rosiglitazone, Pioglitazone

As mentioned earlier, we only use these medications when we

cant use glucophage.

A particular challengeClomiphene an anti-estrogenGonadotropins (FSH) excessive

response

Oocyte qualityLetrozole

Thin Woman PCOSFor many years, helping thin women with PCOS conceive

was very frustrating. Clomiphene was not successful for this

group because of its anti-estrogen properties- it would resultin the lining of the uterus getting too thin, or cervical mucus

production being too poor or side effects that just were not

tolerable. Gonadotropins would result in an excessiveresponse. And regardless of what approach was used, oocyte

quality was compromised for the reasons we have already

discussed. We will discuss Letrozole in detail later, but it hasessentially replaced clomiphene for ovulation induction.

20% do not have elevated androgenlevels

No hirsutismThin, athletic (low body fat)

Normal androgen levelsLow estrogen levelsContinuing ovarian functionRelative hyperandrogenicity

Thin Woman PCOS

For heavier women, PCOS occurs because of the excess

production of male hormone, which results in the abnormal

androgen/estrogen ratio. Thin women dont really haveexcess androgen production. Instead, they typically have

normal androgen levels. However, at one point in time their

estrogen levels were low. (Estrogen comes from two places the ovaries and the fat cell.) In young, thin athletic women

with very low percent body fat, estrogen levels are low. Theend result of this is that the androgen/estrogen ratio is alteredjust like that in the heavier women (the androgen level is

normal but he estrogen level is low). The absolute levels are

lower in the thin women, but the ratio is still altered.

Relative Hyperandrogenicity

May account for improved athleticperformance

Even brief exposure to elevatedandrogen levels sets up a self-propagating cycle of abnormalfollicular growth and function

The pattern is established at a youngage and persists into adulthood

This is why we discuss relative hyperandrogenism, the

alteration of the normal androgen/estrogen ratio. Two of the

standard questions we ask are What is the least you haveweighed in your adult life? and were you an athlete? We

want to know if there was a time of low estrogen production

that may have set up the pattern of PCOS. There is

excellent evidence that once this ratio is altered, it sets up apattern of functioning in the ovaries that will persist into

adulthood, i.e., PCOS.


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We used to think that thin, athletic women who stoppedhaving regular periods had hypothalamic amenorrhea. We

now know that if we do an ultrasound evaluation of the

ovaries, many of these women will have changes of PCOS.The process in thin women should probably have a different

name from the process that occurs as a result of insulin

resistance in the heavier women, but for now we just call itThin woman PCOS.

PCOS

The presence of irregular or absentovulation in the presence ofrelativehyperandrogenism and ultrasoundevidence of PCOS.

While most current definitions of PCOS discusshyperandrogenism as a criterion of PCOS, we feel this should

be relative hyperandrogenism. PCOS can often occur in

women with normal androgen levels and no evidence of

hirsutism (excess hair growth). Many thin women with

PCOS exhibit only irregular periods or less than optimalovulation.

Baillargeon, 2004: 90% of thinwomen with PCOS ovulated inresponse to metformin treatment

Caution against weight loss

Increases aromatase activity

Metformin in Thin WomanPCOS

Dr. Baillargeon was the first to demonstrate that glucophage

was of value in treating thin women with PCOS. 90% of her

patients ovulated after treatment with glucophage. Thinwomen must be cautioned about weight loss with glucophage,

as this is not the goal in this group. As noted earlier, we

know that glucophage works in this group because of theincrease in the activity of aromatase, with the resulting

increase in estrogens and decrease in androgens in other

words, correction of the androgen/estrogen ratio.

Metformin in Thin Woman PCOS

Increased aromatase activity

Decreased androgen levels

Increased insulin sensitivity

Decreased insulin levels

Glucophage does improve insulin sensitivity in this group as

well, but this does not appear to be the primary mechanism of

action.


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Metformin in Thin WomanPCOS

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6

Metformin

placebo

combination

FromBaillargeon

This slide demonstrates the percentage of women that

ovulated as a result of treatment with glucophage. It is

apparent that the effect of glucophage does not really begin tooccur for at least three months, and maximal effectiveness

occurs after four to five months of treatment. This is just like

in the heavier women a new cohort of follicles must

develop under the improved androgen/estrogen ratio thatresults from glucophage treatment.

Thin Woman PCOS

50%Insulin

30%Androstenedione

58%Free testosterone

38%Total testosterone

Six months of Metformin treatment

From Maciel et al Fertil Steril 2004;81:335-60.

Profound hormonal changes result from glucophagetreatment. Testosterone and androstenedione, the principle

androgens produced by the ovary are dramatically decreased,

as is insulin.

Most commonly used fertility drugRelatively inexpensive

Orally administeredIncreases FSH levelsOvulation - 90%; conception - 50%

Clomiphene Citrate

For many years, clomiphene has been the first line treatment

choice for women with PCOS. Because it lowers estrogen

levels, it increases FSH (Follicle Stimulating Hormone)production which increases the stimulation to the ovaries to

develop mature follicles. Unfortunately, clomiphene does not

work very well in thin women with PCOS. The anti-estrogen

effects are profound enough that although egg developmentand ovulation may occur, pregnancy will not. (This is just anobservation, but women that experience side effects from

clomiphene such as hot flashes will not conceive on

clomiphene.)

This data looks at the percent of pregnancies that result fromclomiphene treatment. It is pretty clear that if pregnancy does

not result within the first four cycles of clomiphene use, itprobably is not going to something else has to be tried.


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85% of all clomiphene pregnancies occur in the firstthree months of use.

%

P

R

E

G

N

A

N

T

Months

85% of all clomiphene pregnancies occur within the firstthree months of treatment with clomiphene. After four

months, very few additional pregnancies result.

Menopur FSH/LH sub-QBravelle FSH sub-QGonal-F FSH sub-Q

Follistim FSH sub-Q

Gonadotropins The goal of clomiphene treatment is to increase theproduction of FSH. We actually have FSH available in the

formulations on the left. We can administer FSH directly andthereby increase the stimulation to the ovaries. If monitored

appropriately, the risk of multiple pregnancies with this

approach is low. And if the underlying problem is addressed

first, i.e., glucophage treatment is initiated, the response evenof PCOS ovaries to FSH administration is controllable.

Correction of insulin status is ofparamount importance

Avoidance of hyperstimulationOocyte quality Poor embryo

quality the answer lies (mostly) inthe eggKrey and Grifo, Fertil Steril: 2001:75, 466

Implantation

PCOS and IVF

Even if we consider IVF, the androgen/estrogen ratio must becorrected first. IVF is clearly more successful if we get good

eggs. There is also evidence that part of the difficulty

conceiving that women with PCOS experience is related to

the negative impact of relative hyperandrogenism ondevelopment of the lining of the uterus and implantation.

PCOS and IVF

Clinical pregnancies

Fertilization rate

#of embryos 4 cells or

more

Mature oocytes

70%30%

64%43%12.55.9

1813

MetforminNo metformin

From Stadtmaueret al Fertil Steril2001:75:505-509

This is just one piece of data that demonstrates the

improvement in IVF rates as a result of treatment withglucophage. The results are dramatic a 70% clinical

pregnancy in those that were treated vs. a 30% rate in those

that were not.


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A non-steroidal aromatase inhibitorLetrozole decreases estrogen levels,

resulting in increased FSHIncreased FSH stimulates the ovaryNo anti-estrogen effects

More specific, better tolerated, andmore potent then clomiphene

Letrozole

Letrozole is a medication that is approved only for the

treatment of post menopausal women with breast cancer.

Using Letrozole to induce ovulation is an off-label use, butLetrozole has proven to be very effective and safe for

ovulation induction. It does have some anti-estrogen effects,

but these are much shorter in duration and less profound thanthose induced by clomiphene.

Letrozole

Relatively short acting (T =45 hrs)

Does not deplete estrogen

receptors

Improves ovarian sensitivity to FSH

Dramatically decreases FSHdosage requirements (1/3)

Improves endometrial dating

parameters

Letrozole has a short half life, and is cleared from the body by

the time conception occurs. Letrozole and FSH aresynergistic using Letrozole first allows us to use FSH in

relatively low doses and achieve an excellent response by the

ovaries.

Letrozole/FSH

Letrozole 2.5 or 5 mg days 2-6

FSH 37.5 225 days 7-10

We have found this combination to be so effective that we

now use it almost exclusively. Three cycles with thiscombination is more successful than four months of

clomiphene, and then three or four cycles of FSH. It also

takes much less time and costs much less. On day 10 an

ultrasound is performed to evaluate for follicular developmentand if mature follicles are present, hCG is administered to

trigger ovulation within the next 36 hours.

ThinNon-hirsute? insulin resistanceUltrasound evidence

GlucophageOvulation Induction

Diathermy

ObeseHirsuteInsulin resistanceUltrasound evidence

2 hr GTTGlucophage

DietOvarian diathermy

PCOS

We have seen that while there are significant differences inthe cause of the PCOS in thin women and heavier women, the

end result is essentially the same. The underlying principle inboth is to correct the androgen/estrogen ratio.


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Regular ovulation (pregnancy)

3 months minimum

Oligo-/anovulation

Ovarian diathermy

Re gula r ovula t ion ( pr egnancy) Oligo-/anovula t ion

Pregnancy

Letrozole + FSH

No pregnancy

Letrozole + FSH

IVF

Metformin

Weight loss

Diet

Exercise

Obese PCOS Treatment Algorithm

This is the algorithm used to treat heavier women with PCOS.This is just a general outline, but does detail the steps along

the way.

Regular ovulation (pregnancy)

3 months minimum

Oligo-/anovulation

Letrozole + FSH

Regular ovulation (pregnancy) Oligo-/anovulation

Pregnancy

Ovarian diathermy

No pregnancy

Letro

zole/

FSHIVF

Metformin

Thin Woman PCOS Treatment Algorithm

This is the same information for thin women with PCOS.

Surgical Treatment of PolycysticOvaries

Wedge Resection

Ovarian drilling (laser)

Capsule resection

Multiple punch biopsies

Drs. Stein and Leventhal developed a surgical procedure

called a wedge resection for PCOS. In this procedure one

would make a major incision in the abdomen, incise the ovaryand literally scoop out the inside of the ovary and then sew it

back together. This worked great it is the inside part of the

ovary that makes the androgens and removing this loweredthe androgen levels. The problem was that it required major

surgery, adhesion (scar tissue) formation was common, and

the effects only lasted for six months or so. Since then manylaparoscopic procedures have been developed to treat PCOS

we do not feel there is any role for procedures that cauterize

or laser the surface of the ovary these can cause terriblescarring and do not address the fact that the problem is not

with the multiple follicles, but with the excess androgensfrom the inner part of the ovary.

Laparoscopic Ovarian Diathermy

Introduced by Gjonnaess 1984

Critical dose 600 J oules/ovary

Three to ten diathermy points

Ovulation rates 73-87%

Pregnancy rates of ~50%

Ovarian Diathermy is a procedure developed in Scandinavia.

Using a specially designed needle that is insulated at all butthe very tip, cautery is delivered to the inner part of the ovary,effectively accomplishing the same things as a wedge

resection. Because the needle is insulated, there is no damage

to the surface of the ovary where the eggs are. This can bedone at the time of laparoscopy and is a minor surgical

procedure.


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Laparoscopic Ovarian Diathermy

In this schematic drawing, the small blue circles represent the

follicles and the large red circles represent the areascauterized at the time of the diathermy. One can think of the

ovary as having two compartments an outer one where the

eggs are and an inner one where the androgens are produced.

There are very few if any eggs in the inner part of the ovary.

This is a picture at the time of surgery. The tip of the needlecan be seen before it is placed into the ovary.

The needle is now in the ovary and the cautery is being

performed.

Ovarian Diathermy

This is an ovary immediately after a diathermy. One can seethat there is no damage to the surface of the ovary or to the

part containing the eggs.


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Ovarian Drilling

This is a picture of an ovary that has undergone laser drilling.

Note the extensive damage to the surface of the ovary. In thisprocedure the laser has been used to drain all the little

follicles. It is not the follicles that are the problem it is the

abnormal hormone ratio that causes the development of all

the little follicles.

Reduced pregnancy loss ratesBetter control with FSHBetter oocyte quality - IVF

Ovarian Diathermy and PCOSThere are a number of studies demonstrating that diathermy

improves IVF outcomes in women with PCOS. Diathermy is

not the first line treatment we really only do diathermywhen all else has failed. If we still cant achieve good

ovulation even after glucophage therapy and attempts at

ovulation induction with Letrozole and FSH, then the nextstep is diathermy.

A semi-permanent procedureRisks

Adhesions NoneOvarian Failure NoneLong-term - None

Ovarian Diathermy

Because the inner part of the ovary is cauterized, diathermy

lasts much longer than did the effects of wedge resection. We

have had the opportunity, as have others, to repeat

laparoscopies after a prior diathermy and have seen nosignificant adhesion formation.

Ovarian Diathermy in ThinWomen with PCOS

Seemingly counter-intuitive (normalandrogen levels)

Relative hyper-androgenism (20%or more have normal androgen levels)

Most studies of diathermy have looked at the results in

heavier women with PCOS. In 2004 we published the firststudy looking at diathermy results in exclusively thin women

with PCOS. There were some misgivings about doing

diathermy in thin women with normal androgen levels, butthe relative hyperandrogenism theory convinced us this

would be worthwhile.


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8/98-7/03 108 diathermyprocedures

74 had a body mass index of 25 orless (23.9)

59 available for f/u and desired

conception3.7 years of infertility49 (83%) conceived - mean time to

conception of 4.2 months

Ovarian Diathermy in ThinWomen with PCOS

During the study period we did 108 diathermies, and 74 ofthese were on women with a body mass index of 25 or less.

We had follow-up data available on 59 women. 83% of these

women conceived following the diathermy.

Total Patients 59

Pregnant 49 (83.0%)Without intervention - 23Ovulation induction - 12IVF - 14

Not everyone conceived without intervention. If a perfect

result is achieved, normal ovulation will result and patients

may conceive without any other help. Sometimes this is notthe case, and ovulation induction may be warranted. Some of

these women needed IVF because of other problems such as

male factor issues or tubal disease. Diathermy is indeed avery valuable tool for improving ovarian responsivity in thin

women with PCOS.

Diathermy has been shown tosignificantly improve pregnancyrates in women with PCOSundergoing IVF

Letrozole/FSH/Ganirelix

PCOS and IVF

Diathermy is of value in treating women with PCOS, both

heavier and thin, prior to IVF.

Reduces miscarriage rate from 30% to

3%.No apparent adverse effects

Glucophage and PregnancyWomen with PCOS have a significantly increased risk of

miscarriage. This risk has been quoted to be as high as 30%.A review of all the literature available, which is not

voluminous, suggested that with glucophage treatment this

risk can be dramatically reduced. We encourage women withPCOS to continue glucophage during the first 12 weeks or so

of pregnancy.


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Oral ContraceptivesProscarGlucophage

Hirsutism

If a woman with PCOS does not desire pregnancy, oral

contraceptives are an excellent option. Proscar is amedication normally used for men to shrink the prostate. It is

also very effective in women in reducing any excess hair

growth. It takes about six months to achieve significantreduction of hair growth, but the combination or oral

contraceptives and proscar will get rid of the excess hair.

Conclusions

Metformin is useful in both thin and heavywomen with PCOS.

Letrozole, particularly coupled with FSH ispreferable.

Ovarian diathermy is a useful adjunct in

difficult patients.

Correction of insulin/androgen levels iscrucial for success.

In conclusion, glucophage is effective in both thin and heavy

women with PCOS. The mechanism of action may differ, but

it still works very well in both groups. Letrozole is a

preferred medication to clomiphene, and is very effectiveparticularly when coupled with FSH. Ovarian diathermy is

an excellent treatment option for women whose ovaries do

not respond to more conservative treatment. Correction ofinsulin levels, and correction of the androgen/estrogen ratio is

crucial for success.

Thank you

Questions?

Thank you, and please do not hesitate to contact us with any

questions you may have concerning PCOS.

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