48: PCOS Flashcards by Brooke Thornburg

Polycystic Ovary Syndrome (PCOS)

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PCOS clinical presentation

-HYPERandrogenism (hirsutism, acne, alopecia)
-menstrual disturbances (amenorrhea, oligomenorrhea, anovulation)
-obesity

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Pathophysiology of PCOS

-unknown
-inappropriate gonadotropin secretion
-insulin resistance w hyperinsulinemia
-excessive androgen production

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Inappropriate gonadotropin secretion

-inc GnRH leads to LH surge to happen too soon
=not enough time to develop follicles
-stops maturation of follicles in ovary
-multiple immature follicles prevent ovulation
=unopposed estrogen
=no luteal phase
=inc androgen levels

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regular vs PCOS graph

-regular has LH and FSH spike and one dominant follicle
-PCOS has high LH level that stays at baseline
-FSH levels stay normal/low and never spike
-no dominant follicle form

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Insulin resistance in PCOS

-unrelated to weight
-potential defects in insulin receptor
-body makes more insulin to compensate to maintain sugar levels (hyperinsulinemia)
-inc insulin going to insulin sensitive ovaries = inc androgens

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PCOS diagnostic critera

-need 2/3

-hyper androgenism
-chronic anovulation
-polycystic ovaries

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Anti-mullerian hormone

-can be use instead of ultrasound to diagnose PCOS

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Complications from PCOS

-infertility
-CVD
-DVT
-diabetes
-dyslipidemia
-HTN
-fatty liver disease
-endometrial CANCER
-depression/anxiety
-eating disorders
-obstructive sleep apnea
-preg complications

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Treatment goals for PCOS

-maintain normal endometrium
-block actions of androgen on target tissues
-reduce insulin resistance and hyperinsulinemia
-reduce weight
-prevent long term complications
-ovulation induction if pregnancy desired

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Treatment considerations for PCOS

-patient priorities
-pros vs cons
-desire to become pregnant

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Nonpharmacologic treatment of PCOS

-core focus
-weight loss
-exercise

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effect of weight loss on PCOS

-lose 5-15%
-improve preg rates
-improve ovarian function
-dec testosterone
-dec hyperinsulinemia

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Exercise treatment of PCOS

-minimum of 150-300 min/week of moderate exercise
-muscle strengthening dec development of metabolic syndrome

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1st line treatment of PCOS (HYPERandrogenism and/or menstrual irregularity)

-combined oral contraceptive
-usually monophasic
-low dose EE
-prefer norgestimate then LNG then norethindrone for low androgenic effects

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COC for PCOS

-low EE dose (LH suppression = dec androgens)
-low androgenic progestin: norgestimate < LNG < norethindrone

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progestins to avoid

-desogestrel
-drospirenone
-cyproteone acetate

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Anti-androgen therapy

-Spironolactone
-5-a reductase inhibitor

spironolactone dosing

50mg -100mg BID

Spironolactone mech

-blocks androgenic effects at the follicle

Spironolactone adverse effects

-vag bleeding
-breast tenderness
-headache
-dizziness
-TERATOGENIC (must use contraception)

Sprionolactone bits

-monitor K+
-use as add-on therapy for hirsutism and acne

5-a reductase inhibitor use

-anti-androgen therapy
-use when COC and spirinolactone are ineffective for hirsutism

5-a reductase inhibitor mech

-prevent conversion of testosterone to its more potent form of DHT

5-a reductase inhibitor dosing

-Finasteride (Proscar) 2.5-5mg daily

5-a reductase inhibitor side effects

-headache -orthostasis -must use reliable form of contraception

1st line of treatment in PCOS + BMI over 25 kg/m2

-insulin sensitizer

Insulin sensitizer use (metformin)

-1st line for PCOS + BMI over 25 -2nd line for menstrual irregularity

insulin sensitizer mech

-reduces insulin conc and androgen production in ovary -help improve metabolic issues for pts who failed lifestyle interventions

insulin sensitizer dosing

-500mg PO qd up to 1000mg BID

insulin sensitizer monitoring and follow up

-up to 6 months to see results -monitor low B12 -disc if pregnant -NOT endometrial protective until regular menses and ovulation are established

Treatment plan for insulin resistance/metabolic features

1. lifestyle mods 2. metformin

Treatment plan for menstrual irregularity

1. COC 2. progestin therapy, LNG IUD, metformin

Treatment plan for Hyperandrogenism

1. COC 2. anti-androgens (spironolactone, finasteride) 3. Topical Vaniqa for facial hair 4. cosmetic procedures

What if pregnancy is desired?

-aromatase inhibitors

Aromatase inhibitors

-PCOS treatment for when pregnancy is desired -Letrozole (Femara) -FDA approved for breast cancer treatment -inc popularity to treat infertility

aromatase inhibitor mech

-Nonsteroidal competitive inhibitor of aromatase =stops conversion of androgens to estrogen =dec estrogen -induces ovulation by triggering hypothalamus to inc LH and FSH -high selective -reversible -highly potent

side effects of aromatase inhibitors

-hot flashes -edema -dizziness/fatigue -headachea

aromatase inhibitor contraindication

-pregnancy -avoid use with CYP2A6 substrate -monitor use with tamoxifen and methadone

aromatase inhibitor dosing

-2.5-7.5mg orally x 5 days starting day 3 of menses -inc by 2.5mg next cycle if no ovulation -up to 5 cycles

Laparoscopic Ovarian drilling (ovarian diathermy)

-electrocautery or laser to destroy parts of ovaries -dec androgen levels and can improve hirsutism and acne

Treatment plan for anovulation

1. Letrozole 2. Clomiphene + metformin, low-dose gonad therapy, or drilling 3. IVF or IVM

summary!

slide 35!