Kembara Xtra - Medicine - Polycystic Ovarian Syndrome Six to ten percent of Americans are afflicted by PCOS, a prevalent endocrine condition with a variety of symptoms. Menstrual dysfunction, infertility, hirsutism, acne, obesity, and metabolic syndrome are some of the diagnostic clinical features of this condition. It is also characterized by hyperandrogenism, insulin resistance, and anovulation, and typically manifests as amenorrhea or oligomenorrhea. On imaging, the ovaries are frequently polycystic. Although the cause of PCOS is unknown, lifestyle variables can alter the condition's presentation and course. reproductive, endocrine/metabolic, skin/exocrine, and other system(s) affected Synonym(s): Polycystic ovarian disease; Stein-Leventhal syndrome Precaution: Condition may start throughout puberty. Obesity may make PCOS worse, but it is not a diagnostic indicator. 20% of PCOS-afflicted women do not have obesity. Increases the risk of and is linked to conditions such as uterine cancer, endometrial hyperplasia, obesity, high blood pressure, diabetes, metabolic syndrome, and hyperlipidemia. Prevention Incidence Due to a wide range of diagnostic characteristics, incidence and prevalence are still hotly contested; the National Institutes of Health (NIH) standards call for chronic anovulation and hyperandrogenism. Prevalence According to NIH standards, 7% of women of reproductive age have the condition. Predominant sex: females alone Predominant age: reproductive age Pathophysiology and Etiology Recent research suggests that insulin resistance plays a major part in hyperinsulinemia. Increased GnRH pulsations in the hypothalamus cause an increase in LH production at the expense of FSH. Hyperandrogenism: The majority of extra androgens come from the ovaries (75% of the circulating testosterone comes from the ovary). Thecal layers have thickened and LH receptors have been overexpressed in polycystic ovaries, which results in an excess of androgen output. Ovarian follicles: aberrant androgen signaling may be to blame for polycystic ovaries' aberrant folliculogenesis. Compensatory hyperinsulinemia from obesity causes insulin resistance similar to type 2 diabetes in women with PCOS. Increased insulin levels reduce sex hormone-binding globulin (SHBG), improving testosterone bioavailability. To increase androgen production, insulin may also have a direct effect on the adrenal glands, ovaries, and brain. Elevated insulin levels and the metabolic syndrome, or frank diabetes mellitus, are brought on by insulin resistance. Genetics: DENND1A and THADA are two genes that may be involved, as well as a combination of polygenic and environmental variables. Basic Prevention Focus on early diagnosis and treatment to avoid long-term effects; none known. Infertility, obesity, obstructive sleep apnea, hypertension, diabetes, endometrial hyperplasia/carcinoma, fatty liver disease, mood swings and depression, and hirsutism are all associated conditions. In making a differential diagnosis, it's critical to have a thorough history that includes information on diabetes in the family and the beginning of cardiovascular disease early in life. Pay close attention to the beginning and persistence of the numerous indications of androgen excess, the history of the menstrual cycle, and any concurrent drugs, such as the use of exogenous androgens. Periods that are unpredictable, heavy, or nonexistent clinical assessment General appearance: central obesity, hirsutism, acne; vital signs: raised body mass index (BMI), hypertension; skin: male hair pattern, balding, acne, seborrhea, acanthosis nigricans Pelvic: clitoromegaly and enlarged ovaries Caution Look out for virilization-specific symptoms including hair pattern, deeper voice, and clitoromegaly because these signify elevated testosterone levels that go beyond PCOS. Differential diagnosis includes Cushing syndrome, HAIR-AN syndrome, androgen-secreting ovarian or adrenal tumors, prolactin-producing pituitary adenomas, hyperthecosis, adult-onset adrenal hyperplasia, partial congenital adrenal hyperplasia (21-hydroxylase deficiency), 11-hydroxylase deficiency, 17-hydroxysteroid dehydrogenase deficiency, acromegaly, drug- Laboratory Results Although the efficacy of circulating androgen measurements to identify PCOS is unclear, they should include measuring SHBG and determining the free testosterone concentration from total testosterone using mass spectrometry. The Rotterdam criteria (require any 2 of 3) are the diagnostic standards that are most frequently applied: - Amenorrhea or oligomenorrhea - Hyperandrogenism-related clinical and/or biochemical symptoms - Polycystic ovaries on transvaginal ultrasound Must rule out further causes such as Cushing disease, congenital adrenal hyperplasia, and tumors that secrete androgen. Polycystic ovaries detected with ultrasonography are not required for PCOS diagnosis. While accepting that there may be types of PCOS without overt hyperandrogenism, more recent criteria also emphasize the same requirements. Initial examinations (lab, imaging) Pregnancy, thyroid illness, hyperprolactinemia, congenital adrenal hyperplasia, and early ovarian failure should all be ruled out throughout the screening process. - Human chorionic gonadotropin (hCG), TSH, prolactin, 17-OH progesterone, and FSH are among the hormones that can be tested in serum. Hirsute women should also get a free testosterone determination (total testosterone less SHBG) and a DHEA-S. Based on the clinical characteristics, a workup to exclude hypothalamic amenorrhea (LH and FSH), androgen-secreting tumors (FSH, estradiol, testosterone, DHEA-S), Cushing syndrome (24-hour urine free cortisol), and acromegaly (IGF-1) should be taken into consideration (4). Typical PCOS findings include elevated testosterone levels, but only to 200 ng/dL (6.94 nmol/L), mildly elevated DHEA-S levels, but only to 800 g/dL (20.8 mol/L), mildly elevated levels of 17-OH progesterone, elevated estrogen levels, and decreased SHBG. A midluteal phase progesterone level (>3 ng/mL if the woman has ovulated) can be used to identify anovulation. LH/FSH levels range from 2.5 to 3.0 in 50% of women with PCOS, while such testing is typically not required. - Antidepressants - Steroids - Oral contraceptive pills (OCPs) - Transvaginal ultrasound findings: one or both ovaries have at least 12 follicles that are 2 to 9 mm in size or have grown ovarian volume to 10 cm3 Tests in the Future & Special Considerations If there is any ambiguity about the diagnosis, fasting serum glucose, insulin level, and plasminogen activator inhibitor-1 measurements should all be taken into account. Endometrial biopsy, if necessary, to rule out hyperplasia and/or cancer. If the syndrome is identified, fasting glucose and lipid levels should be measured, and a formal glucose tolerance test should be taken into consideration. Caution An endometrial biopsy should be performed in the event of persistent or excessive bleeding in order to check for endometrial hyperplasia and potential malignancy. Interpretation of Tests The ovaries are often big and have a smooth, white, shiny capsule. Follicles in diverse phases of development, but mostly atretic, line the ovarian cortex. Proliferation of thecal cells and an expansion of the stromal compartment Management Insulin sensitivity can be improved and ovulation can be restored with a change in lifestyle that includes optimal eating and exercise. Based on the needs and preferences of the patient, the treatment strategy should be tailored. Medication The aim of PCOS treatment depends on the patient's fertility objectives and symptomology. The four basic goals of treatment are to (i) reinstate menstruation, (ii) lessen insulin resistance, (iii) reduce excess testosterone, and (iv) support fertility. Initial Line When pregnancy is not desired, restore menstruation: - OCPs and progestins help to reduce menstrual irregularity and protect the endometrium. - All OCPs increase SHBG and lower excess androgens, although low-dose OCPs (30 to 35 g) and newer formulations with progestins with lower androgenicity (such as norethindrone, desogestrel, norgestimate, and drospirenone) may be especially helpful. Discuss the advantages of third- and fourth-generation progestins compared to earlier progestins while weighing them against a minor increase in thrombotic hazard. Levonorgestrel IUDs prevent pregnancy and offer endometrial protection, however they do not work to reduce hyperandrogenism. - In the event that OCPs are not tolerated, intermittent medroxyprogesterone (Provera) 10 mg PO or micronized progesterone (Crinone and Prometrium) 200 mg PO for 10 to 14 days may be administered every 1 to 3 months. These provide endometrial defense. However, neither of these will prevent pregnancy nor combat hyperandrogenism. Reduce insulin resistance: Metformin may help insulin-resistant ladies with their metabolic problems. Take the first dose, which is 500 mg per day for a week, and then increase by 500 mg each week until you're taking 1,500 to 2,000 mg per day, divided BID. Overall, the evidence points to metformin's benefits for reducing cardiometabolic risk and promoting pregnancy in PCOS women. Thiazolidinediones may improve the chances of ovulation and treat insulin resistance, but they do not boost the number of live births. If conceiving is desired: - Previously, clomiphene (Clomid, Serophene) and/or exogenous gonadotropins were the first-line treatments for ovulation induction. With clomiphene (Clomid), live birth rates are 10.1%. - Recent evidence demonstrates that letrozole (an aromatase inhibitor) has higher rates of clinical pregnancy, live births, and ovulation than clomiphene (Clomid). With letrozole, the live birth rate is 27.5%. Starting on day 3, 4, or 5, the dosage is 2.5 mg per day for 5 days; it can be increased to 5 mg per day with a maximum dose of 7.5 mg per day for 5 days (5). - Inform patients that the FDA has not approved letrozole for the stimulation of ovulation. - Metformin: It has been demonstrated that 500 to 2,000 mg PO split BID can reduce hyperandrogenism and restart ovulation. If there is a history of spontaneous abortion or glucose intolerance, some healthcare professionals may decide to continue metformin throughout the first trimester or the entire pregnancy. When taken for ovulation induction, it does increase ovulation rates and insulin resistance but does not increase live birth rates on its own or when combined with clomiphene. Gestational diabetes incidence is decreased by metformin. All ovulation-inducing medications raise the chance of multiple births and obstetric issues such premature birth and hypertensive conditions. Next Line OCPs with low-androgenicity progestins, such as norethindrone, desogestrel, norgestimate, and drospirenone, are effective for treating acne. - Spironolactone: For acne and hirsutism that are not treated by OCP therapy, take 50 to 200 mg daily in 1 to 2 divided doses. When using this drug, potassium levels must be carefully monitored because it is dangerous during pregnancy. Finasteride 2.5 to 5.0 mg daily; must use highly effective contraception as this medication is teratogenic; eflornithine hydrochloride 13.9% cream BID Referral To endocrinologist if Cushing syndrome, congenital adrenal hyperplasia, or adrenal or ovarian tumors are discovered during the workup To reproductive endocrinologist for all women who are unable to become pregnant with clomiphene (Clomid) or letrozole Further Therapies Mechanical methods of hair removal, such as laser, electrolysis, waxing, and depilatory, may enhance appearance if the excess hair is bothersome. Surgical Techniques Ovarian wedge removal and laparoscopic laser drilling are controversial procedures that are no longer frequently used. Alternative Therapies Weight loss and cycle regulation may both benefit from acupuncture. Follow-up at 6-month intervals to assess treatment response and keep an eye on weight and drug side effects patient observation Discuss with the patient the dangers of breast and endometrial cancer, insulin resistance, and diabetes, as well as obesity's connection to infertility. Throughout the menstrual cycle, depending on the medicine combination used to trigger ovulation, see the patient frequently. Endometrial biopsy should be performed on all PCOS patients who have been amenorrheic for a year without using medication or an IUD to protect their endometrium. Diet Weight loss is the most effective treatment for overweight patients since it lowers cardiovascular risk, insulin sensitivity, menstrual patterns, and infertility: Advice on diet and lifestyle adjustments; take into account a nutritionist and weight center referral. There is no evidence to support any one diet plan over another. Modification of Lifestyle Inform the patient about PCOS using resources like http://www.acog.org/. Talk about the chronic nature of the ailment, its prospective therapies' advantages, disadvantages, and side effects. Review the significance of weight loss and exercise, if necessary. It has been shown that modest weight loss of 5–10% of starting weight can relieve a number of PCOS symptoms. The outlook for fertility is favorable, however assisted reproductive technologies may be required. Endometrial cancer can be avoided with appropriate monitoring and screening. Early diabetes identification may reduce cardiovascular risk factor-related morbidity and mortality. Complications: Predisposes to endometrial hyperplasia and as high as 9% lifetime risk of endometrial cancer; Reproductive: infertility; Metabolic: insulin resistance, diabetes mellitus, cardiovascular disease; Psychosocial: increased anxiety, mood disorder, eating disorder, depression; Women with PCOS appear to be at increased risk for pregnancy complications like gestational diabetes and hypertensive disorders.
0 Comments
Leave a Reply. |
Kembara XtraFacts about medicine and its subtopic such as anatomy, physiology, biochemistry, pharmacology, medicine, pediatrics, psychiatry, obstetrics and gynecology and surgery. Categories
All
|