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1
Q

hyperandrogenism

A

hirsutism
acne
alopecia

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2
Q

menstrual disturbances

A

amenorrhea
oligomenorrhea
anovulation

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3
Q

pathophysiology of PCOS

A

three possible mechanisms
insulin resistance with hyperinsulinemia
excessive androgen production

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4
Q

ovulation

A

day 14 on cycle
highest level of LH

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5
Q

inapproprate gonadotroopin secretion

A

increase in GnRH
increase of LH surge TOO SOON

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6
Q

what happens if the LH surge happens too soon?

A

you get polysystic ovaries

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7
Q

increase in GnRH turns to

A

cause an increases in LH surge too soon

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8
Q

an increase in LH surge too soon causes..

A

no rise in FSH (levels stay normal or low)

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9
Q

no rise in FSH causes…

A

no dominant follicle

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10
Q

no dominant follicle causes….

A

unopposed estrogen

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11
Q

unopposed estrogen causes…

A

luteal phases never entered

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12
Q

luteal phase never entered causes…

A

elevated levels of androgen

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13
Q

normal GnRH level

A

LH and FSH levels spike during the cycle
one dominant follicle form

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14
Q

increase in GnRH

A

high LH level in baseline
FSH levels stay normal/low and never spike
No dominant follicle form

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15
Q

insulin resistance

A

occurs in obese and nonobese women
potential defects in insulin receptor

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16
Q

normal ovaries produce

A

androgen

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17
Q

in a pt with pcos, they have increased insulin sensitivity which…

A

causes an iNCREASE in androgen production. this is called hyperandrogenism

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18
Q

PCOS insulin

A

insulin resistance

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19
Q

hyperinsulinemia leads to

A

hyperandrogenism

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19
Q

what happens when there is insulin resistance?

A

body will make more insulin to compensate to maintain normal blood sugar levels (compensatory hyperinsulinemia)

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20
Q

what is the major contributor to hyperandrogenism in PCOS?

A

HYPERINSULINEMIA

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21
Q

PCOS diagnosis

A

hyperandrogenism, polycystic ovaries, chronic anovulation
2 of the 3 criteria must be present

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22
Q

treatment considerations for PCOS

A

patient priorities
efficacy vs risks of tx
desire to become pregnant

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22
Q

Non-pharm tx of pcos

A

lifestyle interventions
weight los (5-15%)
improved prega=nancy rates
improve pvarian function
reduce free test.
reduce hyperinsulinemia
exercise

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23
COC for PCOS
1st line of treatment for hyperandrogenism and/or menstrual irregularity
24
progestin component
prefer low androgenic effect: 1. norethindrone 2.levonorgestrel 3.norgestimate lower VTE risk
25
what to look for when picking what birth control regimen is best when given COC options
BMI, is it the first time they are taking it?
26
in PCOS, avoid....
drospirenone and desogestrel
27
Spironolactone
anti-androgen tx 50mg-100mg BID blocks androgenic effects at the follicle monitor K MUST USE RELIABLE FORMS OF CONTRACEPTION used as an add-on therpay for hirsutism/acne
28
5-a reductase inhibitor
anti-androgen therapy prevent conversion of test. to its more form of DHT When COC and spironolactone are relativley ineffective for severe hirsutism
29
Finasteride
side effects: HA, orthostasis MUST USE RELIABLE FORMS OF CONTRACEPTION
30
Metformin
1st line tx in PCOS + BMI >25 2nd line tx for menstrual irrgularity 500 mg PO daily-> 1000mg BID NOT ENDOMETRIAL PROTECTION until regualr menses and ovulationa re established
31
Tx for pts with PCOS and insulin resistance/metabolic features
1. Lifestyle modifications 2. metformin (bmi >25)
32
Tx for pt with PCOS and menstrual irregularity
1. COC 2. cyclic progestin therapy -medroxyprogesterone -micronized progesterone Progestin only OC (norethindrone) LNG IUD Metform
33
tx for pt with PCOS and hyperadrongenism
1. COC 2. anti-androgen spironolactone, finasteride 3.topical vaniqa (FOR FACIAL HAIR ONLY) 4.cosmetic procedures
34
What if the patient wants to get pregnant?
Use aromatase inhibitors
35
Letrozole (femara)
FDA approved for tx of breast cancer increasing popularity for ovulatory disorders -less side effects than clomiphene -better outcomes than clomiphene Not FDA approved for infertility MOA: non-steroidal competitive inhibitor of the aromatase enzyme
36
low levels of estrogen means
menopause, hot flashes,
37
Letrozole for ovulation
dose 2.5-7.5 mg orally for 5 days, starting day 3 of menses if ovulation does not occur, increase by 2.5 mg increment in subsequent cycle up to 5 cycles
37
aromatase inhibitors
highly selective, reversible, highly potent inhibit aromatase enzyme=result in significant lowering of estrogen level Induce ovulation oby trigger hypothalamus to increase LH and FSH secretion CAUSES OVULATION
38
side effects of aromatase inhibitors
hot flashes edema dizziness headache PREGNANCY CONTRAINDICATED
39
Laparoscopic ovarian drilling (ovarian diathermy)
electrocautery or laser to destroy parts of the ovaries decreases androgen levels and can improve hirsutism and acne
40
Tx for anovulation
1. letrozole 2. clomiphene and metformin low dose gonadotropic therapy laparoscopic ovarian drilling 3. in vitro fertilization in vitro maturation
41
`PCOS tx option
COC- 1 active tab/day for 21/24 days Anti-androgens (spironolactone, finasteride) 50-100MG bid (SPRIONO) 2.5-5 mg daily (FINASTERIDE) Metformin- 500 mg QD up to 2000 mg a day Letrozole- 2.5-7.5 mg/day for 5 days
42
how can you tell someone has pcos?
menstrual irrgularity, weight gain, hirsutism
43
Female infertility
cervical mucus not receptive to sperm
43
infertility
inability to become pregnant after 12 months
44
rates of infertility increasing
later marriage delayed childbearing age more prevalent use of contraception increased rate of abortion concern over environment/economics
45
causes of infertility
1/3 of infetility cases can be attributed to male factors 1/3 of infertility cases can be attributed to female factors 1/3 of infertility cases are caused by a combo of factors in both partners
46
nonpharm tx for infertility
weight adjustment avoid smoking,, alc, caffeine, and illicit drugs reduce stress expectant management
47
Expectant management
regualr menstrual periods present -> confirm evidence of ovulation urine ovulations pred. kids change in mucus
48
urine ovulation predictor kids
detect surge in LH levels use like pregnancy tests test around time of suspected ovulation test morning urine daily a change from - to + indicated ovulation in 18-36 hours -> peak fertility generally in 1-2 days
49
quality of timing is critical
fertile window is 6 days
50
how long does sperm live
1-2 days after ejaculation, up to 5 days
51
women <35 yo
initiate evaluation if unable to become pregnant after 12 months of frequent, unprotected intercourse
52
what is the egg lifespan
12-24 hours after ovulation
53
women 35-40 yo
initiate evaluation if unable to become pregnancy after 6 months of frequent, unprotected sex
54
women >40
initiate evalution is unable to beome pregnany after less than 6 months of frequent, unprotected sex
54
pharm tx for infertility
controlled ovarian hyperstimulation
55
Aromatase inhibitor (letrozole)
controlled ovarian hyperstimulation
56
Intrauterine insemination (iui)
directly delivers spern to egg
57
in vitro IVF
combine egg and sperm outside of body and then they transfer embryo inside
58
complication of infertility tx
overian hyperstimulation syndrome (OHSS) fertility tx does NOT increase risk of invasive breast, cervical, endometrial and ovarian cancers, thyroid, melanoma, and colon cancer
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PHRM 825 (11 decks)

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