48: PCOS Flashcards
Polycystic Ovary Syndrome (PCOS)
PCOS clinical presentation
-HYPERandrogenism (hirsutism, acne, alopecia)
-menstrual disturbances (amenorrhea, oligomenorrhea, anovulation)
-obesity
Pathophysiology of PCOS
-unknown
-inappropriate gonadotropin secretion
-insulin resistance w hyperinsulinemia
-excessive androgen production
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
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
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
PCOS diagnostic critera
-need 2/3
-hyper androgenism
-chronic anovulation
-polycystic ovaries
Anti-mullerian hormone
-can be use instead of ultrasound to diagnose PCOS
Complications from PCOS
-infertility
-CVD
-DVT
-diabetes
-dyslipidemia
-HTN
-fatty liver disease
-endometrial CANCER
-depression/anxiety
-eating disorders
-obstructive sleep apnea
-preg complications
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
Treatment considerations for PCOS
-patient priorities
-pros vs cons
-desire to become pregnant
Nonpharmacologic treatment of PCOS
-core focus
-weight loss
-exercise
effect of weight loss on PCOS
-lose 5-15%
-improve preg rates
-improve ovarian function
-dec testosterone
-dec hyperinsulinemia
Exercise treatment of PCOS
-minimum of 150-300 min/week of moderate exercise
-muscle strengthening dec development of metabolic syndrome
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
COC for PCOS
-low EE dose (LH suppression = dec androgens)
-low androgenic progestin: norgestimate < LNG < norethindrone
progestins to avoid
-desogestrel
-drospirenone
-cyproteone acetate
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
- lifestyle mods
- metformin
Treatment plan for menstrual irregularity
- COC
- progestin therapy, LNG IUD, metformin
Treatment plan for Hyperandrogenism
- COC
- anti-androgens (spironolactone, finasteride)
- Topical Vaniqa for facial hair
- 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
- Letrozole
- Clomiphene + metformin, low-dose gonad therapy, or drilling
- IVF or IVM
summary!
slide 35!
