PCOS over 40YRS
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PCO Over 40PCO Over 40The Lost AreaThe Lost Area
Hesham Al-Inany, PhDHesham Al-Inany, [email protected]@yahoo.com
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An international consensusAn international consensus
Defines PCOS as the presence of at least Defines PCOS as the presence of at least 12 follicles measuring 212 follicles measuring 2--9 mm in diameter 9 mm in diameter and/or an ovarian volume in excess of 10and/or an ovarian volume in excess of 10 mL mL
The Rotterdam ESHRE/ASRM , 2004The Rotterdam ESHRE/ASRM , 2004
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AgeAge Most women present in their thirties Most women present in their thirties
Kahsar-Miller , 2001Kahsar-Miller , 2001
Complaining ofComplaining of
irregular menstrual cycles, irregular menstrual cycles, scanty or absent menses, scanty or absent menses, hirsutismhirsutisminfertility infertility
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Recent interestRecent interest Adolescent PCOAdolescent PCO More recently, PCO over FortyMore recently, PCO over Forty
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Lost AreaLost Area
PCOS is the most common endocrine PCOS is the most common endocrine abnormality of abnormality of reproductive-agedreproductive-aged women women
>40 = fading reproduction>40 = fading reproduction
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Lost Area IILost Area II
The main difficulty lies in the absence of The main difficulty lies in the absence of prospective studies in women over 40 ysprospective studies in women over 40 ys
• Loverro GLoverro G. , 2004 . , 2004
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EVIDENCE
The Evidence PyramidThe Evidence Pyramid
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ProspectiveProspective
RetrospectiveRetrospective
Observational StudiesObservational Studies
ExposureExposure
Study DirectionStudy Direction
OutcomeOutcome
ExposureExposure OutcomeOutcome
Cohort Study
Case Control Study
OutcomeOutcome
ExposureExposureCross
Sectional Study
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Cohort StudyCohort Study
Advantages: Advantages: Ethically safeEthically safe Can establish causality (temporal Can establish causality (temporal
relationship)relationship) Allow studying multiple outcomes for 1 Allow studying multiple outcomes for 1
exposureexposure
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PCO over FortyPCO over Forty Why such an interestWhy such an interest There is some evidence that women with There is some evidence that women with
PCOS are at increased risk of developingPCOS are at increased risk of developing type 2 diabetes type 2 diabetes cardiovascular disorderscardiovascular disorders endometrial hyperplasia and, later, endometrial hyperplasia and, later,
endometrial carcinoma. endometrial carcinoma.
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ART: ART: New problemNew problem Pregnancies after 40yPregnancies after 40y PIHPIH DiabetesDiabetes Miscarriage rate Miscarriage rate Low birth weightLow birth weight
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How patient would presentHow patient would present
Classic PCO caseClassic PCO caseSeeking conceptionSeeking conceptionMenstrual troubleMenstrual troubleHirsutismHirsutism
Pregnant after assisted conceptionPregnant after assisted conception Long term consequences of PCO Long term consequences of PCO
(probably will not be you)(probably will not be you)
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Most Important ManagementMost Important Management
Prevention of Long term consequencesPrevention of Long term consequences Increase awareness Increase awareness Spot your potential casesSpot your potential cases
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Infertility TreatmentInfertility Treatment
Ovulation induction by anti-oestrogen Ovulation induction by anti-oestrogen (Clomiphene citrate or Tamoxifen) is not a (Clomiphene citrate or Tamoxifen) is not a valid optionvalid option
Risk of OHSS is remoteRisk of OHSS is remote Gonadotrophins can be used Gonadotrophins can be used
(Al-Inany, 2005)(Al-Inany, 2005)
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Infertility TreatmentInfertility Treatment
IVF vs OI + IUIIVF vs OI + IUI IVF is the optimum solution IVF is the optimum solution
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HirsutismHirsutism
No hormonal therapy (OC, Dian, etc..)No hormonal therapy (OC, Dian, etc..)
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Long term HazardsLong term Hazards It is a premenopausal endocrino-metabolic It is a premenopausal endocrino-metabolic
disorderdisorder As a consequence of insulin-resistance, As a consequence of insulin-resistance,
women affected by PCOS often present women affected by PCOS often present abnormalities of glucose metabolism and abnormalities of glucose metabolism and lipid profile . lipid profile .
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Another FactorAnother Factor
Besides insulin-resistance, it has been Besides insulin-resistance, it has been demonstrated that some of these women demonstrated that some of these women also have alterations in beta-cell-function. also have alterations in beta-cell-function. Both disorders (insulin-resistance and Both disorders (insulin-resistance and beta-cell-dysfunction) are recognized as beta-cell-dysfunction) are recognized as major risk factors for the development of major risk factors for the development of type 2 diabetes. type 2 diabetes.
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clear evidenceclear evidence
women with PCOS are at increased (3–7 women with PCOS are at increased (3–7 times) risk of developing type 2 diabetes times) risk of developing type 2 diabetes (Legro(Legro et al et al., 1999 ; Wild., 1999 ; Wild et al et al., 2000 ) ., 2000 )
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AccordinglyAccordingly
Obese women with PCOS should be Obese women with PCOS should be screened for the metabolic syndrome, screened for the metabolic syndrome, including glucose intolerance with an oral including glucose intolerance with an oral glucose tolerance test. glucose tolerance test.
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CVSCVS
No clear evidence of increase incidence of No clear evidence of increase incidence of death from CVS events in women with death from CVS events in women with PCOS, PCOS,
Evidence of significant association Evidence of significant association between PCOS and IHD, due to between PCOS and IHD, due to dyslipidaemia (Legrodyslipidaemia (Legro et al et al., 2001 ) and ., 2001 ) and markers of abnormal vascular function markers of abnormal vascular function (Christian(Christian et al et al., 2003 ). ., 2003 ).
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PCOS and cancer risk PCOS and cancer risk
ovarian cancer: Limited dataovarian cancer: Limited data Women with PCOS are also thought to be Women with PCOS are also thought to be
at increased risk for endometrial cancer at increased risk for endometrial cancer through chronic anovulation with through chronic anovulation with unopposed estrogen exposure of the unopposed estrogen exposure of the endometrium. However, epidemiological endometrium. However, epidemiological evidence to support this hypothesis is evidence to support this hypothesis is limited (Hardimanlimited (Hardiman et al et al., 2003 ). ., 2003 ).
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Why such limited EvidenceWhy such limited Evidence
Well designed cohort studies are still not Well designed cohort studies are still not availableavailable
Only retrospective studies and some Only retrospective studies and some Cross sectional studies are availableCross sectional studies are available
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ConclusionConclusion
insulin sensitizers, and modifying life style insulin sensitizers, and modifying life style are the key for managementare the key for management
Long-term prospective trials are needed Long-term prospective trials are needed to better delineate the nature and to better delineate the nature and magnitude of disease risks associated with magnitude of disease risks associated with PCOS PCOS