Polycystic Ovary Syndrome-Emam
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Transcript of Polycystic Ovary Syndrome-Emam
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BY
Mohammad EmamProf. OB& GYN
Mansoura Faculty of Medicine
Mansoura integrated fertility center (MIFC)
EGYPT
Polycystic Ovary Syndrome In
The Era Of Metabolic Syndrome
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Syndrome X =IRMetabolic Syndrome ( MS) =
Is a cluster of metabolicdisorders, with a
subnormal biologicalresponse to insulinoccurring mainly invisceral obesity.
The more components of the syndrome ,
the greater the risks .
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ooGlucoseGlucoseV. ObesityV. Obesity
qq HDLHDL--CC
oo BPBP
oo TGTG
Glucose u 6.1mmol/L
Waist Circumference
bu 102cm
cu 88cm
HDL-C
b1.0 mmols/L
c 1.3 mmols/L
BP u130/u85 mmHg
Triglycerides u 1.7mmol/L
Diagnostic Criteria forDiagnostic Criteria forMetabolic SyndromeMetabolic Syndrome
Diagnosis is made when 3 or more
of these risk criteria are met
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Two of the following three features are present,
after exclusion of other etiologies :
(i) Oligomenorrhoea and or Anovulation
(ii) Hyperandrogenism and/or hyperandrogenemia.
(iii) Polycystic ovaries (sonar).
Definition PCOSDefinition PCOS
( Rotterdam( Rotterdam 20032003))
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Phenotypes (Rotterdam)Phenotypes (Rotterdam)
PCOS WITH PCO .PCO + HYPERANDROGENISM + ANOVULATION.
PCO + Hyperandrogenism.
PCO + Anovulation.
PCOS WITHOUT PCO .Hyperandrogenism + Anovulation.
PCO WITHOUT PCOS.( Isolated PCO = Asymptomatic PCO ).
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What is The significance of PCO in PCOS??What is The significance of PCO in PCOS??
The presence of PCO
usually correlateswith the presence of
insulin resistance(Richard J 2002).
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Prevalence Of MS In PCOS
MS is present in 2/3 of thePCOS (2-fold higher than
women in the generalpopulation).
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Pitfalls Rotterdam Definition
1. doubts still exist regarding borderlinegroups of patients ,such as hirsute
ovulatory Normoandrogenic women
with PCO???.
2. Neglect role of IR
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PCOS + IR (70 % ).
PCOS without IR (Legro etal 2004).
Phenotypes Of PCOSAccording to IR
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1) IR Phenotype of PCOS
Abdominal obesity ( Minority may be lean)
Acanthosis Nigericans.
Hirsutism. Resistance to CC,
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2) PCOS Without IR
Lean.
Euinsulinemic/Euglycemic
Enhanced OvarianSensitivity to insulin(although no hyperinsulinemia).
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RATIONALE
MSIs associated with medical and psychosocial co-
morbidities that are both immediate and long-term
( PCOS Is one of these co-morbidities ).
PCOS:
PCOS is now recognized as an importantmetabolic and reproductive disorder .
So, Overlap and vicious circle can be present
between PCOS and MS.
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Co-morbidities With IR
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Objective
To illustrate the link between two current
,intimate and hidden epidemics , MS and
PCOS .
To pinpoint the role of gynecologists
regarding the management ofPCOS in the
era of MS.
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Link between MS & PCOS
PCOSPCOSMSMS
IRIR
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The Central Player
( Insulin Resistance & Vicious circle )
Genetics
AgingPregnancy Drugs Lifestyle
obesity
HyperinsulinemiaIncreased lipid storage
Altered lipoprotein &
cholesterol metabolismAltered steroid
hormone metabolism
PCOS
Insulin
Resistance
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The high ovarianresponse to insulin.
Opposed by the wholebody resistance.
IR : The central paradox
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Genetic Of (MS) & PCOS
There is evidence for linkage
of the hyperandrogenemiaphenotype with an allele of amarker locus on chromosome
19, in the region ofthe geneencoding the insulin receptor.
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E E
F F
Insulina
Types of insulin resistanceTypes of insulin resistance
Type B
Type A
Type C
Autoantibodies
to insulin receptorsGenetic defectof insulin receptor
(Kahn syndrome)
Defect of tyrozine
kinase
tyrozine kinase
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How IR Can Be Confirmed ??
Fasting glucose / insulin < 4.5
Fasting insulin > 24 uU / ml
One hour insulin post OGTT-75 gm > 150
uU/ml
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Targets for ttt
IR None IR
Causative ttt
( Insulin sensitizers)
Symptomatic ttt + Insulin
sensitizers ( prevent
Hyperandrogenism IRVicious circle ) :
Acne.
Hirsutism.
INFERTILITYT
PCOS
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Causative
ttt
Life- style modifications:
Diet modificationWeight loss
Exercise
Psychosocial support.
Cessation smoking.
Improve IR ( Metformin)
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Proposed Approach for ttt of Anovulation In PCOS
Baseline evaluation ( Semenogram , HSG , Midluteal p)
Life style modification ( Exercise , Wt loss , Prohibit smoking
Metformin 500mg / day x first week , then 500 bd on week 2 ,then 500 tds from week 3 till 6-12 month . ( Ensure liver and
renal functions prior ttt )
Not pregnant addCC for 6 cycles
Pregnant: continueMetformin first
trimesterNot pregnant , consider GN ,
OVDrilling , IUI , I
VFOR ICSI
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The advantages of Metformin over drilling
continue beyond conception:
It reduces the miscarriage rate.
Decreases the development of
gestational diabetes.
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Indications OfD
rilling
Regressed behind.Failure of :
Change of life style.
Insulin sensitizing agents.CC +/- HMG.
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Role Of Metformin In None IR( PCOS)
Prevents starting vicious circle of hyperandrogenemia -IR.
Improve spontaneous and CC-induced ovulation.
Improve follicular maturation in IVF cycles.
The continuation in the first trimester appearsto reduce the risk of abortion
( Metformin = FDA group B ).
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Conclusions
We are facing two current
intimate epidemics ( MS &PCOS ) which affect a large scale
of population and also affecttheir reproductive future.
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Gynecologists should categorize any case of PCOS,depending on :
1. Rotterdam criteria.
2.IR or not
Conclusions
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conclusionsInsulin sensitizers are the milestone in ttt of PCOS :
whether as a causative therapy in( IR) sub phenotype.
OR AS
A prohibitor of the starting
Hyperandrogenemia- IR vicious circle
in (none IR) sub phenotype
Conclusions
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We are inAt The Endneed for an applicable
integrated classification ofPCOS to satisfy different
specialists at the same
time!!!!
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Telfax 0020502319922 & 0020502312299
Email. [email protected]