polycystic ovary syndrome pcos pcos zeev blumenfeld, m.d. reproductive endocrinology, rambam health...
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Polycystic Ovary SyndromePolycystic Ovary Syndrome
PCOSPCOSPolycystic Ovary SyndromePolycystic Ovary Syndrome
PCOSPCOSZeev Blumenfeld, M.D.Zeev Blumenfeld, M.D.
Reproductive Endocrinology, Reproductive Endocrinology,
Rambam Health Care Campus, Faculty of Medicine,Rambam Health Care Campus, Faculty of Medicine,Technion- Israel Institute of Technology (IIT)Technion- Israel Institute of Technology (IIT)
Haifa, IsraelHaifa, Israel
Zeev Blumenfeld, M.D.Zeev Blumenfeld, M.D.
Reproductive Endocrinology, Reproductive Endocrinology, Rambam Health Care Campus, Faculty of Medicine,Rambam Health Care Campus, Faculty of Medicine,
Technion- Israel Institute of Technology (IIT)Technion- Israel Institute of Technology (IIT)Haifa, IsraelHaifa, Israel
PCOSPCOSPCOSPCOS•Irregular menses (oligo-Irregular menses (oligo-amenorrhea)amenorrhea)
•HirsutismHirsutism
•ObesityObesity
•AndrogenizationAndrogenization
•PCOPCO
•InfertilityInfertility
•Insulin ResistanceInsulin Resistance
RisksRisks
•Cardiovascular diseaseCardiovascular disease
•HypertensionHypertension
•Thromboembolic diseaseThromboembolic disease
•DiabetesDiabetes
•Endometrial Ca.Endometrial Ca.
•25-35% of obese PCOs will 25-35% of obese PCOs will have NIDDM or impaired have NIDDM or impaired G.T. by 30 years.G.T. by 30 years.
Prof Roy HomburgProf Roy Homburg
PCOSPCOSPCOSPCOS
PCOPCOPCOPCO
Prof Roy HomburgProf Roy Homburg
One in every One in every five womenfive womenhas polycystichas polycysticovaries.ovaries.
One in every One in every five womenfive womenhas polycystichas polycysticovaries.ovaries.
Prof Roy HomburgProf Roy Homburg
Fertil Steril & Hum Reprod, 2004Fertil Steril & Hum Reprod, 2004
PCOS Revised DefinitionPCOS Revised Definition
ESHRE / ASRM Criteria 2003ESHRE / ASRM Criteria 2003
AnovulationAnovulation HyperandrogenismHyperandrogenism
PCO morphology
PCO morphology
& Exclusion of related disorders& Exclusion of related disorders
PCOS Pathophysiology – “Vicious Cycle”PCOS Pathophysiology – “Vicious Cycle”PCOS Pathophysiology – “Vicious Cycle”PCOS Pathophysiology – “Vicious Cycle”
Stromal Stromal HyperthecosisHyperthecosis
AndrAndr
Acyclic Acyclic Peripheral Peripheral Conversion Conversion
of Aof AEE
Acyclic Acyclic Peripheral Peripheral Conversion Conversion
of Aof AEE
Increased Pituitary Increased Pituitary Sensitivity & Sensitivity &
Hypothalamic Hypothalamic PulsatilityPulsatility
LH /FSHLH /FSH
PCOS –פתופזיולוגיההפרשה לא תקינה של גונדוטרופינים
PCOS –פתופזיולוגיההפרשה לא תקינה של גונדוטרופינים
Two cell two gonadotropin theoryTwo cell two gonadotropin theory
PCOS- The Final Common Pathway?PCOS- The Final Common Pathway?PCOS- The Final Common Pathway?PCOS- The Final Common Pathway?
P.C.OP.C.O..P.C.OP.C.O..
Exagerrated Adrenarche?Exagerrated Adrenarche?Exagerrated Adrenarche?Exagerrated Adrenarche?
Inhibin B?Inhibin B? Inhibin B?Inhibin B?
Follistatin Follistatin gene?gene?Follistatin Follistatin gene?gene?
Thyroid DisordersThyroid DisordersThyroid DisordersThyroid Disorders
Serine Phosphorylation?Serine Phosphorylation?Serine Phosphorylation?Serine Phosphorylation?
Chromosome 2- Chromosome 2- Male baldness geneMale baldness geneChromosome 2- Chromosome 2- Male baldness geneMale baldness gene
LO-CAHLO-CAHLO-CAHLO-CAHVNTR- VNTR- Variable Variable Number Tandem RepeatNumber Tandem Repeat- - a promising candidatea promising candidate
VNTR- VNTR- Variable Variable Number Tandem RepeatNumber Tandem Repeat- - a promising candidatea promising candidate
Insulin Insulin genegeneInsulin Insulin genegene
CYP11a-CYP11a- P450 S.C.C. P450 S.C.C.CYP11a-CYP11a- P450 S.C.C. P450 S.C.C.
P450-17 P450-17 HyperactivityHyperactivityP450-17 P450-17 HyperactivityHyperactivity
-OH-ase-OH-ase-OH-ase-OH-ase
-17-20- lyase-17-20- lyase-17-20- lyase-17-20- lyaseFollistatin?Follistatin?Follistatin?Follistatin?
Activin?Activin?Activin?Activin?
Insulin in PCOSInsulin in PCOS(JCEM- editorial 2000;85:3520)(JCEM- editorial 2000;85:3520)
*““The actual role of insulin in PCOS is controversial” and The actual role of insulin in PCOS is controversial” and no consensus exists.no consensus exists.
*An increase in serine/threonine phosphorylation ofAn increase in serine/threonine phosphorylation of PP450-17450-17
17,20 lyase activity17,20 lyase activity ovarian ovarian
androgens.androgens.
*Increased serine phosphorylation of insulin receptor Increased serine phosphorylation of insulin receptor chain chain insulin resistance by inhibiting insulin resistance by inhibiting tyrosine phosphorylationtyrosine phosphorylation
Insulin in PCOSInsulin in PCOS(JCEM- editorial 2000;85:3520)(JCEM- editorial 2000;85:3520)
*““The actual role of insulin in PCOS is controversial” and The actual role of insulin in PCOS is controversial” and no consensus exists.no consensus exists.
*An increase in serine/threonine phosphorylation ofAn increase in serine/threonine phosphorylation of PP450-17450-17
17,20 lyase activity17,20 lyase activity ovarian ovarian
androgens.androgens.
*Increased serine phosphorylation of insulin receptor Increased serine phosphorylation of insulin receptor chain chain insulin resistance by inhibiting insulin resistance by inhibiting tyrosine phosphorylationtyrosine phosphorylation
Common molecular pathway?Common molecular pathway?Hyperactivity of a single serine kinaseHyperactivity of a single serine kinase
hyperandrogenism hyperandrogenism insulin resistanceinsulin resistance
CAH(21-ase)CAH(21-ase)
CAH(21-ase)CAH(21-ase)
HAIR-ANHAIR-AN
HA.IR.-ANHA.IR.-AN (Acanthosis Nigricans) (Acanthosis Nigricans)
Blumenfeld ZKupershmidt L
Kerner H *Offer A **Engel A **
Zila Shen Orr
Blumenfeld ZKupershmidt L
Kerner H *Offer A **Engel A **
Zila Shen Orr
Ovarian and adrenal venous catheterization for the
investigation of postmenopausal
virilization
Ovarian and adrenal venous catheterization for the
investigation of postmenopausal
virilization
TestoTesto 17OH17OH CortCort D-SD-S מיקום דגימה
מיקום דגימה
שעהשעה
מס. דגימהמס.
דגימה4.074.07 4.74.7 539539 1.7
31.7
3Rt. Common
IliacRt. Common
Iliac00 5949
5949
150150 >75>75 437437 1.78
1.78
Lt.Ov.VeinLt.Ov.Vein 11:40
11:40
5950
5950
>52>52 >75>75 415415 1.68
1.68
Lt.Ov.VeinLt.Ov.Vein 11:45
11:45
5951
5951
4.64.6 6.36.3 427427 1.70
1.70
Lt. Renal VeinLt. Renal Vein 11:50
11:50
5952
5952
3.773.77 3.93.9 266266 1.52
1.52
Rt. Renal VeinRt. Renal Vein 12:00
12:00
5953
5953
3.863.86 7.17.1 800800 1.64
1.64
Lt. Adrenal Vein
Lt. Adrenal Vein
12:10
12:10
5954
5954
3.563.56 6.26.2 657657 1.72
1.72
Lt. Adrenal Vein
Lt. Adrenal Vein
12:13
12:13
5955
5955
3.953.95 3.43.4 315315 1.52
1.52
Rt. Ov. כניסה ל-Vein
.Rt. Ovכניסה ל-Vein
12:16
12:16
5956
5956
3.683.68 3.63.6 294294 1.68
1.68
I.V.C בגובה(הכליה הימנית(
I.V.C בגובה(הכליה הימנית(
12:20
12:20
59575957
40.7940.79 25.525.5 221221 1.32
1.32
Rt. Ov. VeinRt. Ov. Vein 12:32
12:32
5958
5958
אין דםאין דם אין דםאין דם אין דם אין דם אין דם
אין דם
IVC-Rt. Adrenal Vein
באזור הכניסה
.IVC-RtAdrenal Vein
באזור הכניסה
12:39
12:39
59595959
4.464.46 2.92.9 169169 1.74
1.74
IVC-Rt. Adrenal Vein
באזור הכניסה
.IVC-RtAdrenal Vein
באזור הכניסה
12:42
12:42
5960
5960
3.283.28 2.42.4 171171 1.22
1.22
גבוה, קרוב לעליה ימנית
IVC
גבוה, קרוב לעליה ימנית
IVC
12:45
12:45
59615961
Obese PCOSObese PCOS
HyperinsulinemiaHyperinsulinemia
IGF- BPIGF- BPII
IGF-IIGF-I
P450C17P450C17- activity- activity SHBGSHBG
Free AndrogensFree Androgens
Ovarian Ovarian androgen secretionandrogen secretion
LHLHaugmentationaugmentation
Insulin Effects in PCOSInsulin Effects in PCOS)JCEM- editorial 2000;85:3520()JCEM- editorial 2000;85:3520(
*Direct effect on Direct effect on ovarianovarian cytochrome cytochrome PP450 450 1717Androgen secretionAndrogen secretion
*Increases Increases ovarianovarian LH receptors LH receptors
*Stimulates LH release from Stimulates LH release from pituitarypituitary gonadotropes gonadotropes
*Augments Augments adrenaladrenal androgen synthesis androgen synthesis
*Decreases Decreases hepatichepatic SHBG production SHBG production
*Decreases Decreases in vitroin vitro IGF- BP IGF- BP11 IGF-1 IGF-1
Insulin Effects in PCOSInsulin Effects in PCOS)JCEM- editorial 2000;85:3520()JCEM- editorial 2000;85:3520(
*Direct effect on Direct effect on ovarianovarian cytochrome cytochrome PP450 450 1717Androgen secretionAndrogen secretion
*Increases Increases ovarianovarian LH receptors LH receptors
*Stimulates LH release from Stimulates LH release from pituitarypituitary gonadotropes gonadotropes
*Augments Augments adrenaladrenal androgen synthesis androgen synthesis
*Decreases Decreases hepatichepatic SHBG production SHBG production
*Decreases Decreases in vitroin vitro IGF- BP IGF- BP11 IGF-1 IGF-1
PCOS- Metabolic AbnormalityPCOS- Metabolic AbnormalityPCOS- Metabolic AbnormalityPCOS- Metabolic Abnormality
““Syndrome X”Syndrome X”““Syndrome X”Syndrome X”•DyslipidemiaDyslipidemia
•HypertensionHypertension
•Insulin ResistanceInsulin Resistance
•DyslipidemiaDyslipidemia
•HypertensionHypertension
•Insulin ResistanceInsulin Resistance ))Editorial- JCEM 2000;85:3520Editorial- JCEM 2000;85:3520(( ))Editorial- JCEM 2000;85:3520Editorial- JCEM 2000;85:3520((
Recently, the International Diabetes Federation (IDF) developed a simple clinical tool to define the metabolic syndrome:
Central Obesity, * DM, * Dyslipidemia, &
* Hypertension [Alberti et al; Lancet 2005; 366: 1059-1062].
Recently, the International Diabetes Federation (IDF) developed a simple clinical tool to define the metabolic syndrome:
Central Obesity, * DM, * Dyslipidemia, &
* Hypertension [Alberti et al; Lancet 2005; 366: 1059-1062].
Prof. Roy HomburgProf. Roy Homburg
DyslipidemiaDyslipidemiaHypertensionHypertensionInsulin Insulin ResistanceResistance
DyslipidemiaDyslipidemiaHypertensionHypertensionInsulin Insulin ResistanceResistance
The National Cholesterol Education Program Adult Treatment Panel )NCEPATP III( guidelines define the MBS as having three or more of the following abnormalities:
Waist circumference > 88 cm;
Fasting serum glucose > 110 mg/dl;
Fasting serum triglycerides > 150 mg/dl;
Serum HDL-C < 50 mg/dl; &
Blood pressure > 130/85mmHg.
The National Cholesterol Education Program Adult Treatment Panel )NCEPATP III( guidelines define the MBS as having three or more of the following abnormalities:
Waist circumference > 88 cm;
Fasting serum glucose > 110 mg/dl;
Fasting serum triglycerides > 150 mg/dl;
Serum HDL-C < 50 mg/dl; &
Blood pressure > 130/85mmHg.
Insulin resistanceInsulin resistance
HyperandrogenismHyperandrogenismObesity
Obesity
-cell dysfunction-cell dysfunction
HyperestrogenismHyperestrogenism
Genetic factorsGenetic factors
Acquired factorsAcquired factors
The Obesity-PCOS AssociationThe Obesity-PCOS Association
PCOSPCOS
Metabolic Syndrome Metabolic Syndrome
Abdominal obesity Insulin resistance ± glucose intolerance Atherogenic dyslipidemia Elevated blood pressure Proinflammatory state Prothrombotic state
Abdominal obesity Insulin resistance ± glucose intolerance Atherogenic dyslipidemia Elevated blood pressure Proinflammatory state Prothrombotic state
PCOS & Insulin Resistance
Therapeutic Endeavours(Endo. Rev. 1999; 20:535)
(1) Diet- weight reduction
(2) Insulin sensitizing agents: Metformin(Biguanide)
Troglitazone Rosiglitazone(thiazolidinedione)
Beta-3 adrenergic receptor agonists
Vanadate
D- chiro- Inositol (INS-1)
PCOS & Insulin Resistance
Therapeutic Endeavours(Endo. Rev. 1999; 20:535)
(1) Diet- weight reduction
(2) Insulin sensitizing agents: Metformin(Biguanide)
Troglitazone Rosiglitazone(thiazolidinedione)
Beta-3 adrenergic receptor agonists
Vanadate
D- chiro- Inositol (INS-1)
PCOSPCOSInsulin resistance
Hyperinsulinaemia
Hyperandrogenaemia
Menstrual Irregularity
Hirsutism
Acne
Weight loss
Exercise
Metformin
PCOS (n=117)Control (n=84)
36.8%
6.0%0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
High CRP Levels ( >5 mg/L) in PCOS & Controls
p<0.001
PCOS (n=117)Control (n=84)
36.8%
6.0%0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
High CRP Levels ( >5 mg/L) in PCOS & Controls
p<0.001
CRP<11<CRP<3
CRP>3CRP>5
22.8
%45
.2%
30.7
%29
.8%
46.5
%25
.0%
36.0
%6.
0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Distribution of CRP Levels (mg/L) in PCOS & Controlsp=0.0004
PCOS (n=114)
Control (n=84)
CRP<11<CRP<3
CRP>3CRP>5
22.8
%45
.2%
30.7
%29
.8%
46.5
%25
.0%
36.0
%6.
0%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Distribution of CRP Levels (mg/L) in PCOS & Controlsp=0.0004
PCOS (n=114)
Control (n=84)
Treatment regimens directed towards lowering CRP levels (such as diet, smoking cessation, exercise, blood pressure control, low-dose aspirin, metformin, and possibly statins in the future) should probably be more aggressive for those PCOS women with increased CRP levels.
Treatment regimens directed towards lowering CRP levels (such as diet, smoking cessation, exercise, blood pressure control, low-dose aspirin, metformin, and possibly statins in the future) should probably be more aggressive for those PCOS women with increased CRP levels.
ConclusionConclusionConclusionConclusion
CRP – a marker of CVD CRP – a marker of CVD
Insulin resistanceHyperinsulinaemia
Hyperandrogenaemia
Menstrual Irregularity
Hirsutism
Acne
Weight loss
Exercise
Metformin