PCOSPCOS Polycystic ovary syndrome is a relatively Polycystic ovary syndrome is a relatively

common clinical disorder that affects 5-10% common clinical disorder that affects 5-10% of women in the reproductive age groupof women in the reproductive age group

PCOS is associated with :PCOS is associated with : Clinical featuresClinical features

BiochemicalBiochemical features features

Ultrasound Ultrasound featuresfeatures

PCOSPCOS-Diagnostic dillema’s--Diagnostic dillema’s-

Clinical features• Menstrual disorder• hirsutism• Acne• obesity• anovulation

Endocrine features• high androgens• high LH• insulin resistance• Hyperinsulinemia

Polycystic ovaries• increased follicle• increased stroma• increased ovarian volume

Ultrasound assessment : Ultrasound assessment : international consensus international consensus

definitiondefinition

1. >=12 follicles of 2-9mm 1. >=12 follicles of 2-9mm in diameter in at least in diameter in at least one ovary or twoone ovary or two 2. Increased ovarian 2. Increased ovarian volume(>=10cm3)volume(>=10cm3) (Balen et al. 2003)(Balen et al. 2003)

EuropeanEuropean

North AmericanNorth American

PCO ovariesPCO ovaries ++ Menstrual disturbanceMenstrual disturbance and/or signs of hyperandrogeand/or signs of hyperandroge

nismnism (hirsutism,acne or alopoecia).(hirsutism,acne or alopoecia).

No hormonal parameters are No hormonal parameters are repaired to make the diagnosirepaired to make the diagnosis.s.

Biochemical evidence of hypeBiochemical evidence of hyperandrogenismrandrogenism

++ Ovarian dysfunction(in the abOvarian dysfunction(in the ab

sence of non classical adrenal sence of non classical adrenal hyperplasia)hyperplasia)

PCO ovariesPCO ovaries not an essential of the diagnonot an essential of the diagno

sis.sis.

RevisedESHRE/ASRM 2003 Consensus RevisedESHRE/ASRM 2003 Consensus on Diagnostic Criteria for PCOSon Diagnostic Criteria for PCOS

Oligo-and /or anovulationOligo-and /or anovulation Clinical and/or biochemical signs of hyClinical and/or biochemical signs of hy

perandrogenismperandrogenism Polycystic ovarian morphologyPolycystic ovarian morphology (exclusive of Congenital adrenal hyper(exclusive of Congenital adrenal hyper

plasia, androgen-secreting tumors, and plasia, androgen-secreting tumors, and Cushing’s syndrome)Cushing’s syndrome)

2 of 3 criteria must be present for diagnosis of PC2 of 3 criteria must be present for diagnosis of PCOSOS

Oligo/anovulation

PCOHyperandrogenemia

PCOS

PathophysiologyPathophysiology Primary defects in the hypothalamic-pituiPrimary defects in the hypothalamic-pitui

tary axis and ovarian functiontary axis and ovarian function HyperandrogenemiaHyperandrogenemia LH hypersecretionLH hypersecretion Insulin resistance, and compensatory hypInsulin resistance, and compensatory hyp

erinsulinemiaerinsulinemia A gene or several genes predispose to PCOA gene or several genes predispose to PCO

S susceptibilityS susceptibility Autosomal dominant pattern of inheritanAutosomal dominant pattern of inheritan

cece

Life-time consequences of Life-time consequences of PCOSPCOS

In uterusIn uterus PeripubertPeripubertyy

AdolescencAdolescencee

AdulthoodAdulthood

AgingAging

FetusFetus PCOSPCOS Syndrome XSyndrome X

Adrenal Adrenal androgensandrogens

AnovulationAnovulation DiabetesDiabetes

InsulinInsulin HyperandrogenHyperandrogenismism

HypertensionHypertension

Ovarian Ovarian androgensandrogens

Obesity(50%)Obesity(50%) DyslipidimiaDyslipidimia

LH/FSH ratioLH/FSH ratio CV diseaseCV disease

IntrinsicIntrinsic LH PulsatilityLH Pulsatility B-cell B-cell deficiencydeficiency

ExtrinsicExtrinsic Trand of ObesitTrand of Obesityy

Long term Long term healthhealth

Precocious Precocious pubertypuberty

Reproductive Reproductive disorderdisorder

MetabolicMetabolic

Long term issue in PCOSLong term issue in PCOS Established and handled wellEstablished and handled well Cancer of the uterusCancer of the uterus FertilityFertility Cosmetic concernsCosmetic concerns Established-recognition partially and badly Established-recognition partially and badly

handledhandled DiabetesDiabetes Lipid disorderLipid disorder Unproven-recognition and handling uncertainUnproven-recognition and handling uncertain heart disease heart disease breast cancerbreast cancer

TreatmentTreatment

General practitioner

Medical endocrinologist

Dermatologist

Gynecologist

PCOS

For women who do not wish to For women who do not wish to conceiveconceive

Low dose contraceptive pillsLow dose contraceptive pills restore menstrual regularityrestore menstrual regularity decrease ovarian hormone productiondecrease ovarian hormone production reverse the effects of the excessive andreverse the effects of the excessive and

rogen levelsrogen levels Progesterone: smoke, >35yrsProgesterone: smoke, >35yrs Diane-35: hirsutism or severe acneDiane-35: hirsutism or severe acne

Insulin sensitising agentsInsulin sensitising agents Diet and exercise in lifestyle managemDiet and exercise in lifestyle managem

entent MetforminMetformin Combination therapy: lifestyle and meCombination therapy: lifestyle and me

tformintformin Diazioxide, acarbose, somatostatin, D-Diazioxide, acarbose, somatostatin, D-

chiroinositedchiroinosited

Metformin and PCOSMetformin and PCOS Established efficacyEstablished efficacy - ovulation induction with or without clomife- ovulation induction with or without clomife

nen citratenen citrate - additional benefit to lifestyle change- additional benefit to lifestyle change Promising efficacyPromising efficacy - use in pubertal and teenage years to reduce - use in pubertal and teenage years to reduce

PCOS effectsPCOS effects Logical but unproven useLogical but unproven use - amelioration of long term metabolic proble- amelioration of long term metabolic proble

ms in PCOSms in PCOS Unproven useUnproven use - recurrent miscarriage prevention- recurrent miscarriage prevention

Diet and exercise in Diet and exercise in PCOSPCOS

Many publications on role of dietary manageMany publications on role of dietary management and weight lossment and weight loss

- Little weight loss needed - Little weight loss needed (clark et al. 1995,1998)(clark et al. 1995,1998)

- Effects are due to caloric restriction rather t- Effects are due to caloric restriction rather than han

dietary composition dietary composition (kiddy et al. 1992,Moran et al. 2003)(kiddy et al. 1992,Moran et al. 2003)

- Important of metabolic outcomes such as - Important of metabolic outcomes such as glucose and insulin sensitivity glucose and insulin sensitivity (Kiddy et al. 1992, (Kiddy et al. 1992, Pasquali et al. 1998,2000)Pasquali et al. 1998,2000)

- Group organization superior to individual - Group organization superior to individual motivation motivation (Norman et al. 1999)(Norman et al. 1999)

PCOS and anovulationPCOS and anovulation Anovulation is the major problem faceAnovulation is the major problem face

d by the cliniciand by the clinician

AnovulationAnovulation Surgical approachSurgical approach

Medical Medical approachapproach

Ovulation inductionOvulation induction

Pregnancy +

Gonadotropins

Ovarian responseComplications +/-

Pregnancy +/-

IVF

Clomiphene

Ovulation +

Ovulation -

Ovulation +

Ovarian responseComplications +/-

Pregnancy +/-

Surgical management of Surgical management of PCOSPCOS

L/S removal of ovarian tissue was L/S removal of ovarian tissue was introduced by Palmer in 1967introduced by Palmer in 1967

Multiple ovarian puncture performed Multiple ovarian puncture performed either by diathermy or by laser is either by diathermy or by laser is well known as “ Ovarian drilling”well known as “ Ovarian drilling”

Ovarian drilling Ovarian drilling is a modification ofis a modification of ovarian wedge resectionovarian wedge resection but less invasivebut less invasive

Complication of the Ovalation indComplication of the Ovalation inductionuction

Medical approachMedical approach Ovarian hyperstimulationOvarian hyperstimulation Multiple pregnaciesMultiple pregnacies

Surgical approachSurgical approach Bleeding from the hlolesBleeding from the hloles Adhesion post-opAdhesion post-op Premature ovarian failurePremature ovarian failure

SummarySummary Clinical features associated with PCOS incluClinical features associated with PCOS inclu

de obesity , hirsutism, or acne, cycle abnorde obesity , hirsutism, or acne, cycle abnormality and infertilitymality and infertility

Revised diagnosis: 2 out of 3 criteria includeRevised diagnosis: 2 out of 3 criteria includes oligo/anovulation , hyperandrogenismia als oligo/anovulation , hyperandrogenismia along with PCOong with PCO

Ovulation induction can be applied successfOvulation induction can be applied successfully in the great majority of womenully in the great majority of women

GDM and long-term health consequence sucGDM and long-term health consequence such as high chances for developing type 2 diabh as high chances for developing type 2 diabetes and cardio-vascular disease have gained etes and cardio-vascular disease have gained increasing attention in recent yearsincreasing attention in recent years