Polycystic Ovary Syndrome
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Transcript Polycystic Ovary Syndrome
Polycystic Ovary Syndrome
in Adolescence
Lee Ching Yin
CMC
May, 2004
Definition of PCOS
1st described by Stein and
Leventhal 1935
NIH criteria (National
Institute of Health) 1990
Hyperandrogenism
Chronic Anovulation
with exclusion of other Ax:
Cushing,
CAH,
hyperprolactinemia
USS – polycystic ovaries
ESHRE (European Society
for Human Reproduction)
& ASRM (American Society
of Reproductive Medicine)
2003
2 of the 3 elements:
Hyperandrogenism
(clinical or biochemical)
Chronic anovulation
Polycystic ovaries
Minerva Ginecologica 2004
LFL
CFY
WYK
AKM
Age of presentation
17 yr
12 ½ yr (on Epilim)
17 yr
18 yr
BMI
32.2 (Obese)
31.7 (Obese)
18.9
18.6
20 amenorrhoea
20 amenorrhoea
Oligomenorrhoea
Age of menarche
Onset irregular cycle
Oligomenorrhoea/
20 amenorrhoea
12 yr
Since menarche
9 ½ yr old
1½ yr after menarche
10 yr
Since menarche
12 yr
Since menarche
Hyperandrogenism
Hirsutism
Acne
Testosterone nmol/L
+ve (F-G score =7)
+ve
5.9
+ve (F-G score =8)
Mild
2.5
Nil
Nil
1.3
Nil
Nil
1.6
USS Ovary
Polycystic
Volume
No
R-7.8 ml, L-7.3 ml
No
R-10.8 ml, L-7.7 ml
Yes
R-9.3 ml, L-7.9 ml
Yes
R-16 ml, L-18.4 ml
LH
LH:FSH ratio
9.3
1.6
7.6
1.4
16
2.4
31.7
5.2
Insulin reistance
Acanthosis Nigricans
Fasting insulin mIU/L
HOMA
+ve (OGTT normal)
24
5.2
+ve (OGTT normal)
36
4.48
Nil
9.2
1.96
Nil
14
2.92
Prolactin ng/ml
(N: 1.4-24.2 ng/ml)
normal
normal
Transient to 61.7
MRI brain - normal
normal
Family Hx
Normal
Normal
Mother-Prolactinoma
Normal
Anovulation
Presentation
Prevalence
Prevalence
~ 4-4.7% Screening 277 women 18-45 yr
Knochenhauer et al 98
10 diagnosis in
Oligomenorrhoea
Anovulatory infertility
Hirsutism
20 amenorrhoea
87%
>75%
90%
32%
Definition of PCOS
ESHRE (European Society for Human Reproduction)
& ASRM (American Society of Reproductive
Medicine) 2003
2 of the 3 elements:
Hyperandrogenism
(clinical or biochemical)
Chronic anovulation
Polycystic ovaries
Minerva Ginecologica 2004
Hyperandrogenism
Clinical signs / symptoms
Hirsutism
assessment– Ferriman-Gallwey score > 5 (ref: 18-38 yr white women)
8 in Paed studies
(Ibanez et al 2001)
‘male-pattern’ hair – upper lip, chin, lower abdomen, inner thigh
Acne
Androgenetic alopecia
Biochemically
serum testosterone / androstenedione
Subclinical hyperandrogenism
Hyperandrogenism
Source of hyperandrogenemia
Ovary & / or Adrenal
Rosenfield et al, J Ped Endo & Meta, 2000
Ovary
In-vivo culture of theca cells from PCOS vs normal ovaries:
general steroidogenesis
Augmented expression of CYP11A, CYP17 mRNA
CYP17, 3 -hydroxysteroid dehydrogenase enzyme activity
Nelson et al, Mol Endo, 99
Nelson et al, JCEM, 2001
Hyperandrogenism
Source of hyperandrogenemia
Adrenal
Mechanism:
Ovarian products promote adrenal androgen production
studies – GnRH analog DHEAS in PCOS
generalized hyperresponsiveness of adrenal cortex to ACTH
Dysregulation (overactivity) of adrenal 17,22 lyase
Hyperinsulinemia –promote adrenal 17-hydrxylase & 17,22 lyase
Rosenfield, JCEM, 96
Anovulation
Clinical signs
Menstrual disturbance:
amenorrhoea (estrogen replete) – oligomenorrhoea – DUB
6 spontaneous vaginal bleed per year
irregular menses from menarche- consistent feature
may start from menarche with delayed menarche
or 10 amenorrhoea
Infertility
Polycystic ovary
International consensus definitions
at least 1 of the following in USS:
12 follicles 2-9 mm diameter
Ovarian volume > 10 cm3
(ovarian volume= dimension 1x dimension 2 x dimension 3 x 0.5233)
Prolate spheroid volume = /6 x transverse dia x AP dia2
Spherical volume method = /6 x [(transverse dia+AP dia+long dia)/3]3
Nardo et al, Fert & Ster, 2003
Dx is sufficient that only 1 ovary is affected
Balen et al, Human Reprod Update 2003
Polycystic ovary
Distribution of follicles
Subcapsular cysts, produce a ‘string of pearls’ sign
Description of stroma
stromal echogenicity &/or stromal volume
Pathogenesis
circulating insulin level Ovarian size
Exaggerated LH pulsatile messages
Markussis et al 94
multifollicularity, stroma, androgen production
Porcu et al, Curr Op Ped, 94
Other conditions with Polycystic ovaries
Normal women with normal ovulatory function (16%)
Hyperprolactinaemia
(50%)
Hypothyroidism
(36.4%)
Hypogonadotrophic hypogonadism
(23.7%)
CAH
(100%)
Androgen-producing adrenal tumours
Prevalence in PCOS
(~ 53%)
Abdel Gadir et al 92
Associated Clinical features in PCOS
Obesity
~50% PCOS women are obese
Gambineri et al 2002
An independent predictor of conversion to IGT or T2 DM
Norman et al 2001
Acanthosis nigricans
Pathogenesis
Insulin resistance
Gn-RH dynamics
Insufficient FSH
Genetics
Premature pubarche
Low birth weight
Pathogenesis – Insulin resistance
Insulin resistance
In both lean & obese PCOS women
more severe in obese PCOS > obese control > lean PCOS
(clamp study)
Dunaif et al, Diabetes, 89
Not universal finding in PCOS
Robinson et al 93
Pathogenesis – Insulin resistance
Mechanisms of Insulin Resistance:
insulin sensitivity in: Peripheral tissue Liver
Peripheral tissues – muscle (85%), adipose tissue
cellular mechanisms:
? binding of insulin to receptor
insulin-mediated glucose transport
expression of glucose-transporter protein GLUT-4
Pathogenesis - Insulin resistance
Liver ()
Obese adult PCOS - hepatic production less suppressed with
insulin
Dunaif et al, Diabetes, 92
obese adolescents PCOS 120.7 yr old – hepatic production not
suppressed with insulin
Lewy et al, J Ped 2001
BUT other studies in adult PCOS show:
no insulin sensitivity in liver
Peiris et al JCEM 89
Franks NEJM 95
Insulin resistance basal insulin secretion
& hepatic insulin clearance
Hyperinsulinemia
Dunaif et al, Endocrine Review 97
Pathogenesis - Insulin resistance
Hyperinsulinemia Hyperandrogenism
diazozide that insulin conc
weight loss
insulin sensitizers
androgen conc
Nestler, JCEM 89; Dunaif JCEM 96
in-vitro insulin (& IGF-1)
ovarian growth &
synergizes with LH promote androgen production by ovary
Nobels et al, Medline review, 92; Bergh et al 93 (but no support from in-vivo models)
Insulin hepatic production of SHBG
Sharp et al 91
Insulin & insulin growth factors signal intracellular pathways in ovary
promote androgen production
Guzick 2004
Insulin may potentiate adrenal 17-hydroxylase & 17,22 lyase activity
adrenal sensitivity to ACTH
Rosenfield, JCEM, 96
Nobel et al, Fert & Ster, 92
Pathogenesis – Insulin resistance
Insulin resistance + Hyperandrogenism may Anovulation
Carmina , Minerva Ginecol 2004
Hyperandrogenism Anovulation
ovarian wedge resection androgen producing tissue
restore follicular maturation & ovulation
Jeroma et al, Ann NY Acad Sci, 2003
Hyperinsulinism IGF system - IGFBP-1, free IGF-I
normal total IGF-I
adrenal hyperandrogenism & peripheral androgen conversion
in non-obese PCOS
Homburg et al 92, Silfen at al 2003
Pathogenesis – Insulin resistance
Insulin resistance – underlying Ax
Genetic
Obesity
LBW
Premture pubarche
Pathogenesis - Gn-RH dynamics
gonadotropin-releasing hormone dynamics
LH pulse frequency & amplitude 24 hr mean conc
Morales et al JCEM 1996
Kalro et al 2001
LH may excess androgen production:
androgen production by theca cells is LH dependent
LHRH analog LH testosterone & androstenedione
BUT blunting of pulse amplitude in obese (BMI>30) PCOS
24 hr mean LH conc ~ normal cycling women
Arroyo et al, JCEM 97
Pathogenesis - Gn-RH dynamics
Ax of Gn-RH dynamics ( GnRH pulse frequency):
? Metabolic, central neuromodulators, paracrine factors
: catecholamines, IGF1, opiods, leptin, insulin / insulin resistance
androgens, inhibin (ovary)
Kalro et al, Obst & Gyne Clin N Am, 2001
? 10 neuroendocrine abnormality driving excess Gn secretion
? abnormal feedback of another factor
(in adolescents or older women)
Taylor, J Ped Endo & Meta, 2000
? Genetic predisposition to hypersecrete ovarian androgens
hypothalamic-pituitary function
Jerome et al, Ann NY Acad Sci, 2003
Pathogenesis – Insufficient FSH
Insufficient FSH Anovulation
Guzick, Am Ob & Gyne 2004
Inappropriate hypothalamic GnRH secretion
relative low FSH
not permit effective aromatization
excess androgen & poor estrogen
maturation of follicles (direct effect or induce stroma hypertrophy)
anovulation
Venturolli et al, Clin Endo, 1988
Adequate conc of FSH essential for
pre-ovulatory follicle development
& selection of a single preovulatory follicle
van Weissenbruch et al 1993
Pathogenesis - Genetics
Genetics
AD gene effect with variable phenotype of PCOS
study on 92 patients
41% sisters & 19% mothers have PCOS
phenotypic heterogeneity within affected families determined by
other factors ? Diet, ex, peripubertal stress, hormone
genetic defects of insulin secretion
Kahsar-Miller et al, 1998
Pathogenesis - Genetics
Region 1 MB centromeric to the insulin receptor gene on
chromosome 19
Linkage & association studies of
1st degree relatives (with hyperandrogenism) of PCOS
Susceptible gene on chromosome 19p13.3 in insulin receptor
gene region - Insulin receptor gene marker D19S884
- significant association with PCOS
- study of 85 PCOS women (case-control)
- ? INSR gene itself or a closely related gene
Urbanek et al 2000
Tucci et al, JCEM, 2001
Locus on chromosome 19p13.3
linkage with testosterone level (steroid phenotype) in Caucasians
HERITAGE Family study with genomewide scan Ukkola et al, JCEM, 2002
Pathogenesis - Genetics
CYP11a gene
in association & linkage studies
a major genetic susceptibility locus for PCOS with hirsutism
Gharani et al,Hum Mol Genet, 97
VNTR regulatory polymorphism in chromosome 11p15.5
of insulin gene ( insulin production)
study 17 families of PCOS
Waterworth et al, Lancet, 97
Genetic abnormality (kinase)in serine-phosphorylation (hyper-) of
Insulin receptor signalling insulin resistance
P450c17 post-translational regulation of 17,20-lyase activity
androgen
BUT the kinase not identified yet
(explain association of PCOS & insulin resistance)
Auchus et al, TEM, 98
Pathogenesis - Genetics
Genetic mechanism
?
androgen
programme hypothalamus-pit with excess LH
preferential abdominal adiposity & IR (also genetics)
Abbott et al, J Endo 2002
Insulin resistance, Hyperinsuliniemia
Jerome et al, Ann NY Acad Sci, 2003
Pathogenesis - Premature Pubarche
~30% have marked adrenal Hyperandrogenism (Pre-pubertal)
- have Insulin resistance (FSIGT)
- continue to have these features & obesity & irregular menses
Nardi, J Ped Endo Meta, 2000
41% have polycystic ovaries on USS
exaggerated ovarian androgen synthesis (FOH) throughout
puberty
Ibanez et al, Fert Ster, 97
Battaglia et al, JCEM, 2002
Ibanez et al, JCEM, 93
Hyperinsulinemia
Ibanez et al, JCEM, 97
Pathogenesis - Premature Pubarche
? Pathogenesis (Premature pubarche PCOS)
cytochrome P450c17 activity (in adrenal & gonads)
Ibanez et al, JCEM, 93
Hyperinsulinemia as underlying 10 mechanism
Rosenfield, JCEM, 96
Premature pubarche
Antecedent of
FOH
Hyperinsulinemia
Dyslipidemia
PCOS – premature pubarche being the earliest recognized
PCOS phenotype in life
Kent et al, Adolesc Med, 2002
BUT ? How often
Pathogenesis – Low birth weight
Low Birth Weight
associated with postnatal
Insulin resistance – T2 DM
Dyslipidemia
BP
Barker et al, Diabetologia 93
Exaggerated adrenarche (study in post-menarche girls)
Hyperinsulinemia
Ibanez et al, JCEM 99
Ovary dysfunction, ovary development
Study ovary volume & primordial follicles in foetus
deBruin et al 98
Pathogenesis – Low birth weight
Low Birth Weight ? PCOS in adult
? belong to the ‘classic’ PCOS
Screening PCOS in general population of 2007 women
26% have symptoms of PCOS
no association with SFD, LBW, gestation
Laitinen et al 2003
Pathogenesis – LBW + Premature pubarche
Premature Pubarche + LBW
risk of PCOS
Premature pubarche (PP) + LBW vs PP + normal birth weight
Pre-puberty – no difference
Early puberty - triglyceride & LDL
Post-menarche - insulin sensitivity (HOMA), insulin (OGTT)
ovarian dysfunction ( 17OHP to leuprolide test,
FSH)
BMI SD score in both groups in all stages
(catch-up growth may greater insulinemia)
Ibanez et al, Clin Endo 2001
DDx of PCOS
Menstrual irregularities / Hirsutism
Congenital Adrenal Hyperplasia
premature pubarche, androgen excess
21-hydroxylase deficiency
3 -hydroxysteroid dehydrogenase deficiency
Hyperprolactinemia
Acromegaly
Androgen-secreting tumour of ovary or adrenal gland
Cushing’s disease
Dx Approach
Hx
Clinical exam
Lab Ix
Dx – Laboratory Ix
LH , LH:FSH ratio > 2:1, normal FSH
Lower LH in obese (BMI >30) PCOS
BUT usually normal (in ~40%)
Arroyo et al, JCEM, 97
because of pulsatile nature of Gn
lower lab result with immunofluorometic assay
an insensitive test but quite specific ( LH with normal FSH)
FSH
level ~ mid-follicular phase of normal menstrual cycle
essential Ix to exclude 10 ovarian failure in DDx
Dx – Laboratory Ix
Androgens
Testosterone > 60 ng/dL (2 nmol/L)
17 OH-progesterone < 2 ng/ml
Cutoff = 2 SD above mean in cycling women
Free testosterone assay – more expensive, variable reliability
To rule out CAH
ACTH test- rule out 21-hydroxylase deficiency
& 3 -hydroxysteroid dehydrogenase deficiency
DHEAS (> 21.6 µmol/L – suggest adrenal tumour)
Dx – Lab Ix
Subclinical Hyperandrogenism
Nafarelin test (Leuprolide acetate 500 µg sc)
study performed in follicular phase (Day 3-8) of menstrual cycle
17 OHP (peak > 160 ng/dL or 4.57 nmol/L), androstenedione
LH, estradiol
at baseline, 6 hr (maxi pit ) & 24 hr (maxi gonadal ) in PCOS
ACTH stimulation test - 17OH pregnenolone or androstenedione
adrenal source
Dx - Ix
USS ovaries
Hyperprolactinemia
Follicles
Ovarian volume
Prevalence in PCOS
5-30%
Need exclude other Ax of hyperprolactinemia
Thyroid function test
To exclude hypothyroidism
Other Ix
Obesity, acanthosis nigricans, premature pubarche:
Dyslipidemia
Screen for Glucose intolerance / DM
Fasting glucose
OGTT
2 hr post-challenge plasma glucose more reliable than fasting
glucose in PCOS to screen IGT / DM
Adolescent PCOS
Palmert et al, 2002
Adult & adolescent (14-44 yr old) PCOS
Legro et al, JCEM 99
Legro, Obst Gyn Clin N A, 2001
Other Ix
Insulin resistance (IR)
Fasting insulin
correlate with Insulin resistance in obese adolescent PCOS vs clamp study
Lewy et al, J Ped, 2001
Fasting glucose: insulin (glucose in mg/dL, insulin u/L)
<4.5 indicate IR in adult obese PCOS
<7 useful index of IR in adolescents
2.3 for IGT in adolescent PCOS
mean ~1.9 in obese adolescents PCOS
( < adult may because of insulin secretion)
Not appropiate if fasting glucose
Legro et al, JCEM 98
Kent et al, Adol Med 2002
Palmert et al, JCEM 2002
Lewy et al, J Ped, 2001
Quon, JCEM 2001
Other Ix
HOMA-IR (G0 x I0) 22.5
sensitivity 78%, specificity 89%
Palmert et al, JCEM 2002
QUICKI (1 (log G0 + logI0))
Quon, JCEM 2001
Good correlation with IS (Euglycemic clamp study)
in non-diabetic PCOS adolescents
Fasting insulin
Fasting Glucose / Insulin
HOMA IS (=1/HOMA-IR)
QUICKI
Gungor et al, J Ped, 2004
PCOS – origin in Adolescence
Clinical features - acne
hirsutism
anovulatory menstruation
Biochemical abnormalities
of adult PCOS
are observed in adolescents in normal general population
Adolescence –Anovulatory Cycles
Development of menstrual cyclicity in Adolescents
(measure serum progesterone)
1st yr after menarche
3rd yr
6th yr
anovulatory in 85%
59%
25%
Apter and Vihko, Year Book, 85
Adolescence – Ovarian volume
Ovarian volume centiles
in normal children
& adolescents
Bridges et al 1993
Adolescence –Polycystic ovaries
Prevalence of Polycystic
ovaries (PCO) in adolescence
Prevalence of polycystic
ovaries throughout puberty
6% at 6 yr old
26% by 15 yr old
Bridges, Brook et al 1993
Adolescence – Insulin resistance
Insulin resistance & insulin secretion – pubertal changes
OGTT test – significant results
Mean serum insulin
- at Tanner stage II & then similar in III-V
SI (insulin sensitivity) - lower at Tanner stage II then higher in stage III-V
insulin-resistant state coincide with Tanner stage II
Potau et al, Hormone Research 97
FSIGT test
SI – significant in Tanner stage II & further insignificant in stage III-V
Cook et al, JCEM, 93
Hyperinsulinemia
ovarian & adrenal steroid / androgen synthesis
Nobel et al, Fert & Ster, 92
Leuteinizing hormone in Normal Puberty
LH pulse frequency & amplitude
Early puberty – nocturnal pulse amplitude
Advancing puberty - further pulse frequency & amplitude
Immediately before menarche - accentuation of circadian profile –
night time LH > adult
Ovulatory – pulse amplitude ~ adult
Anovulatory – normal mean LH, daytime LH amplitude & freq ~ ovulatory
night time LH ~ premenarche
OR
- mean LH level > adult , LH frequency, amplitude,
- higher value during daytime-desynchronization rhythm
~ PCOS
Porcu et al 87; Venturoli et al, Curr Op Ped 94
Physiological changes in Adolescence
Hyperinsulinemia & Insulin resistance
(exaggerated by genetic & / or obesity)
Hyperpulsatile gonadotrophin secretion
Hyperactive ovarian androgen synthesis
Hyperactive adrenal androgen synthesis
Menstrual irregularities
level of IGFBP-1, SHBG
~ PCOS
insulin levels, IGF-1 activity, androgen, during puberty
probably as inducing factors in development of PCOS
in susceptible subjects
Nobel et al, Fert & Ster, 92
(After puberty, insulin & IGF-1 progressively in most females normal)
PCOS in Adolescence
Risk factors
Premature pubarche (before 8 yr old)
- more common in – African-American
Obesity
Family Hx
Ethnicity
PCOS in Adolescence
Risk for development of adult life PCOS
Persistent irregular cycles by 6th Gyne yrs
40% cycles remain anovulatory
Higher testosterone, androstendione, LH
Lower premenstrual 17OHP, progesterone, E1, E2
vs ovulatory cycle / adult control
Venturoli et al, Ster Fert 87
Adolescents with anovulatory cycles after menarche x 3-4 yrs
high LH group
normal LH
57% anovulation (43% ovulation)
83% normal ovulation
PCOS pattern exist > 2 yrs high risk of life-long abnormality
Venturoli et al 94
PCOS in Adolescence
Clinical findings adult PCOS
cf Adolescents ( 18 yr) & Adults ( 19 yr) with PCOS
No statistically significant differences in :
prevalence of hirsutism
prevalence of menstrual irregularities
estradiol, LH, FSH, prolactin, testosterone, 17OHP,
androstenedione, DHEAS
ovarian volume
+ve correlation of ovarian volume with LH, testosterone, DHEAS,
androstenedione
in both adolescents & adult
Gulekli et al, Gyne Endo, 93
PCOS in Adolescence
Clinical findings adult PCOS
LH pattern
Augmented LH pulsatility – LH pulse amplitude & frequency
mean LH level
LH/FSH ratio
production of ovarian androgens
Taylor, J Ped E M, 2000
Apter et al, JCEM, 94 & 95
PCOS in Adolescence
Clinical findings adult PCOS
Higher Insulin resistance vs control
Adolescents 12 0.7 yrs old (clamp study)
obese PCOS (oligomenorrhoea + hyperandrogenism)
vs obese control
Peripheral insulin sensitivity 50% lower
Lewy et al, J Ped, 2001
Adolescents 11-18 yr old (IVGTT)
PCOS (Hyperandrogenism + ovarian volume)
vs age-matched control
Decreased insulin sensitivity (IVGTT)
Apter et al, JCEM, 94 & 95
PCOS in Adolescence
Clinical findings may adult PCOS
Insulin secretion
Obese Adolescents (120.7 yr)- 1st phase & 2nd phase secretion
Lewy et al, J Ped, 2001
Obese Adolescent with IGT
- 1st phase insulin secretion
Arslanian et al, JCEM 2001
Obese & non-obese Adult without IGT / T2 DM
- cell dysfunction with insulin secretion (+ IR)
( disposition index)
Dunaif et al, JCEM, 96
(different may because of duration of PCOS
Lewy et al, 2001)
PCOS in Adolescence
Study on 12.9 -18 yr old , obese vs non-obese PCOS
(hyperandrogenism + oligo- / amenorrhoea) vs Obese control
USS – ovaries–polycystic 100% (non-obese) 75% (obese) >control
- ovary volume : no difference & ~ adult PCOS
Mean LH
non-obese > obese PCOS > obese control
DHEAS/4-A
non-obese > obese
> obese control
Testosterone
non-obese ~ obese
> obese control
SHBG
non-obese < obese
< obese control
Lipid
non-obese < obese
~ obese control
Insulin sensitivity (Fasting insulin, I0/G0, QUICKI, ISI comp in OGTT)
non-obese > obese
~ obese control
IGFBP-1
non-obese < obese PCOS
Free IGF-1 level non-obese > obese PCOS
more pronounced H-P-A axis in non-obese PCOS
more marked insulin sensitivity in obese PCOS
IGF system different in non-obese & obese PCOS
Silfen et al JCEM 2003
Long-term Sequaelae of PCOS
Irregular menstruation
Infertility -73% of anovulatory infertility
risk of IGT / Type 2 diabetes
Prevalence IGT
x3 control
T2 DM x7 control
IGT 35%, T2 DM 10%
IGT or DM at 40 yr old - 40%
Dahlgren et al 92
Ehrmann et al 99
Legro 2001
non-obese (14-44 yr old)
IGT 10.3% , DM 1.5%
Hull et al 87
Legro et al 99
Lean & *obese adolescent PCOS (13.9-19 yr old, 27 subjects)
IGT 30%, T2 DM 3.7%
Palmert et al, JCEM, 2002
Long-term Sequaelae of PCOS
Lipid abnormalities
Sign lower HDL, higher total chol, LDL, TG
risk of CVS disease
risk factors for CVS disease
subclinical athersclerotic disease
(greater carotid intimamedia wall thickness & coronary Ca++)
Talbott et al 95
BUT no data on prevalence of cardiovascular events
vs general population
risk of endometrial carcinoma
Talbott et al 2001
Unopposed estrogen on endometrium
PCOS in Epilepsy
prevalence in patients on antiepileptic drugs
study 69 patients with epilepsy
: 42 off Px
27 taking antiepileptic drugs
51 control
27 still taking antiepileptic drugs:
Significant higher testosterone, androstenedione
PCOS 38% (off Px: 6%, control 11%, p=0.005)
on Na valproate (Epilim) 63%
other antiepileptic
25%
Mikkonen et al, Neurology 2004
Treatment
Early recognition & Mx
Screening parameters
BMI
BP
Fasting lipid profile
Fasting glucose / OGTT
(obese, acanthosis nigricans, premature pubarche)
Treatment
Obese
Weight reduction – Diet + Exercise / Lifestyle modification
wt loss 2-5% testosterone by 21%
resume regular ovulation in 50% women
JCEM 99
most important long-term Px in obese females
Other general lifestyle factors
Avoid alcohol, smoking, psychosocial stressors
TEM 2002
Treatment
Anovulation
Oral contraceptives
advantages: regular withdrawal bleeding
risk of endometrial hyperplasia or cancer
LH secretion ovarian androgen
SHBG production free testosterone
improvement of hirsutism & acne
use non-androgenic progestogen, norethindrone-only (not IR)
? Long-term benefit on reproduction
stop Px androgen return to pre-Px level
Siegberg et al 87
choice for sexually active women / adolescents
Cyclical progestins
-avoid with androgenic activity : norgestrel, norethindrone
-medroxyprogesterone 5 mg daily x 13 days Q 1-2 month
Infertility – ovulation induction
Treatment
Hirsutism
Cosmetic Px – waxing, laser, eflornithine cream
Anti-androgen
Spironolactone 200 mg/day
- may associated with erratic vaginal bleeding
usually + low dose OC
Cyproterone acetate – also progestogenic
2 mg + ethinyl estradiol 35 mcg daily x 21 days (Diane-35)
( SHBG, prevent pregnancy)
Flutamide
Treatment
Metformin
Meta-analysis of RCT
achieve ovulation OR= 3.88 (95%CI 2.25-6.69)
(rate wt loss with lifestyle intervention
Clark et al 98)
fasting insulin
mean difference 5.37 IU/L
BP
mean difference 9 (systolic), 5.69 (diastolic)
LDL
mean difference 0.44
BUT no data on safety of long term use in young women
Lord et al, BMJ, 2003
Treatment
Adolescent PCOS with oligo- or amenorrhoea
Metformin 1.5-2.55 gm/day x 10 6.4 months + low CHO diet
91% resume regular normal menses
testosterone
cholesterol
Glueck et al, J Adolesc Health 2001
Adolescents (mean age 16.8 yr) non-obese, premature pubarche
with hirsutism, ovarian hyperandrogen, oligomenorrhoea, lipid, insulin
Metformin 1.275 gm /day x 6-10 months
100% had regular menses by 4/12
significant hirsutism score, androgen (testosterone, DHEAS…)
improve lipid profile
BUT stop Px reversal to pre-Px conditions in 3/12
Ibanez et al, JCEM 2000
Treatment
Early post-menarche 24 girls (12.40.2 yr old), non-obese, LBW
& Precocious pubarchy
Ovarian Hyperandrogenemia (leuprolide test 17OHP >160 ng/ml) +
Hyperinsulinemic (OGTT insulin peak >150 or mean > 84 mU/L)
Dyslipidemia
Excess truncal fat (W-H ratio) & lean body mass (DEXA)
Higher androgen, IGF-1, GH
cf. weight & height matched normal
Metformin 850 mg / day for 12 months in 12 girls (RCT)
Px group
– abnormalities significantly improved at 6 month
Control group
body composition further improve 6/12-1 yr
– significantly deterioate further
Metformin prevent progression to PCOS in this high risk group
Role of hyperinsulinemic IR in ontogeny of PCOS
Ibanez et al, J Ped, 2004
Treatment
BUT
- ? This group classic PCOS patient in adulthood
- no effect on reducing obesity
- no documented adverse outcome in this group
- no data on long-term risk-benefit ratio
- ? Should start long-term Px in adolescence
Cedars, Editorial, J Ped, 2004
LFL
CFY
WYK
AKM
Age of presentation
17 yr
12 ½ yr (on Epilim)
17 yr
18 yr
BMI
32.2 (Obese)
31.7 (Obese)
18.9
18.6
20 amenorrhoea
20 amenorrhoea
Oligomenorrhoea
Age of menarche
Onset irregular cycle
Oligomenorrhoea/
20 amenorrhoea
12 yr
Since menarche
9 ½ yr old
1½ yr after menarche
10 yr
Since menarche
12 yr
Since menarche
Hyperandrogenism
Hirsutism
Acne
Testosterone nmol/L
+ve (F-G score =7)
+ve
5.9
+ve (F-G score =8)
Mild
2.5
Nil
Nil
1.3
Nil
Nil
1.6
USS Ovary
Polycystic
Volume
No
R-7.8 ml, L-7.3 ml
No
R-10.8 ml, L-7.7 ml
Yes
R-9.3 ml, L-7.9 ml
Yes
R-16 ml, L-18.4 ml
LH
LH:FSH ratio
9.3
1.6
7.6
1.4
16
2.4
31.7
5.2
Insulin reistance
Acanthosis Nigricans
Fasting insulin mIU/L
HOMA
+ve (OGTT normal)
Pending result
Pending result
+ve (OGTT normal)
36
4.48
Nil
9.2
1.96
Nil
14
2.92
Prolactin ng/ml
(N: 1.4-24.2 ng/ml)
normal
normal
Transient to 61.7
MRI brain - normal
normal
Family Hx
Normal
Normal
Mother-Prolactinoma
Normal
Anovulation
Presentation