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Therapeutics > 48: PCOS > Flashcards

48: PCOS Flashcards

1
Q

Polycystic Ovary Syndrome (PCOS)

A
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2
Q

PCOS clinical presentation

A

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

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3
Q

Pathophysiology of PCOS

A

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

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4
Q

Inappropriate gonadotropin secretion

A

-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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5
Q

regular vs PCOS graph

A

-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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6
Q

Insulin resistance in PCOS

A

-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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7
Q

PCOS diagnostic critera

A

-need 2/3

-hyper androgenism
-chronic anovulation
-polycystic ovaries

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8
Q

Anti-mullerian hormone

A

-can be use instead of ultrasound to diagnose PCOS

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9
Q

Complications from PCOS

A

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

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10
Q

Treatment goals for PCOS

A

-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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11
Q

Treatment considerations for PCOS

A

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

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12
Q

Nonpharmacologic treatment of PCOS

A

-core focus
-weight loss
-exercise

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13
Q

effect of weight loss on PCOS

A

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

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14
Q

Exercise treatment of PCOS

A

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

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15
Q

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

A

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

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16
Q

COC for PCOS

A

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

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17
Q

progestins to avoid

A

-desogestrel
-drospirenone
-cyproteone acetate

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18
Q

Anti-androgen therapy

A

-Spironolactone
-5-a reductase inhibitor

19
Q

spironolactone dosing

A

50mg -100mg BID

20
Q

Spironolactone mech

A

-blocks androgenic effects at the follicle

21
Q

Spironolactone adverse effects

A

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

22
Q

Sprionolactone bits

A

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

23
Q

5-a reductase inhibitor use

A

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

24
Q

5-a reductase inhibitor mech

A

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

25
Q

5-a reductase inhibitor dosing

A

-Finasteride (Proscar) 2.5-5mg daily

26
Q

5-a reductase inhibitor side effects

A

-headache
-orthostasis
-must use reliable form of contraception

27
Q

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

A

-insulin sensitizer

28
Q

Insulin sensitizer use (metformin)

A

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

29
Q

insulin sensitizer mech

A

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

30
Q

insulin sensitizer dosing

A

-500mg PO qd up to 1000mg BID

31
Q

insulin sensitizer monitoring and follow up

A

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

32
Q

Treatment plan for insulin resistance/metabolic features

A
  1. lifestyle mods
  2. metformin
33
Q

Treatment plan for menstrual irregularity

A
  1. COC
  2. progestin therapy, LNG IUD, metformin
34
Q

Treatment plan for Hyperandrogenism

A
  1. COC
  2. anti-androgens (spironolactone, finasteride)
  3. Topical Vaniqa for facial hair
  4. cosmetic procedures
35
Q

What if pregnancy is desired?

A

-aromatase inhibitors

36
Q

Aromatase inhibitors

A

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

37
Q

aromatase inhibitor mech

A

-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

38
Q

side effects of aromatase inhibitors

A

-hot flashes
-edema
-dizziness/fatigue
-headachea

39
Q

aromatase inhibitor contraindication

A

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

40
Q

aromatase inhibitor dosing

A

-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

41
Q

Laparoscopic Ovarian drilling (ovarian diathermy)

A

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

42
Q

Treatment plan for anovulation

A
  1. Letrozole
  2. Clomiphene + metformin, low-dose gonad therapy, or drilling
  3. IVF or IVM
43
Q

summary!

A

slide 35!

Therapeutics (78 decks)

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