pcos 2nd

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Ahmad Nabil B Md Rosli

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Management should be individualized

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Non-pharmacology Weight reduction

10 15% weight reduction results in spontaneousovulation & conception in 30% women with PCOS (1)

Regulate irregular menses (2)

Normalization of glucose metabolism

.(1) , (2) Crosignani PG et al. Overweight and obeseanovulatory HumReprod 2003;18:1928 32

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MedicalInsulin sensitizing therapy Fertility treatment

Menstrual regulation Anti-androgen

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[Medical]: Insulin sensitizing

therapyMetformin

Has been shown to have short term effect on insulinresistance in non-diabetic PCOS ptn Associated with reduction in serum levels of bioavailable androgens by 11%, LH & athrerogenic lipids Able to restore menstrual cyclicity & induce ovulation by itself or with Clomiphene

RCOG Green top Guideline (No 33); Long term consequences of

Polycystic Ovarian Syndrome, December 2007

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[Medical]: Insulin sensitizing

therapy- Start with Metformin 500mg at night and slowly

increase the dose 500mg/week

- Optimal dosage is 500 mg tds- a/e: bloating, nausea, vomitting, diarrhea- Alternative: Metformin XR 500 mg BD

Quick Management Guide in Gynaecology, Lee Say Fatt, 1st

edition 2007

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Anovulation in PCOS

Clomiphene 50, 100, 150 mg Assess response

Clomiphene resistant

metfotminLaparoscopic drilling Ovulation induction withFSh

Ovulation present

Continue same dose3 6 cycle

Timed coitus/IUI


edition 2007

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[Medical]: Menstrual regulation1. COCs- i.e 3rd generation COC

AdvantagesIncrease SHBG level, reduce free testosterone levelReduces acne & hirsuitismRegulate menstrual cycle and prevents endometrial

hyperplasiaProvides effective contraception

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[Medical]: Menstrual regulation2. Progestogens

Suitable for oligo or secondary amenorrhearegulate menses & prevent endometrial hyperplasia withdrawal bleed every 3-4 months in a year preventingendometrial hyperplasia & carcinoma

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[Medical]: Menstrual regulation Progestogen can be given for 21 days each calendar month MPA 20-30 mg or dydrogestrone 10 mg daily Start on 1st day in each calendar month Withdrawal bleed will occur after few days stopping

medication

Repeat the cycle next month

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[Medical]: Anti-androgenSome of these growth-promoting effect (of androgen)is irreversible

Treatment aimed at reducing testosterone levels willnot restore hair to its pre-PCOS patternLowering free androgen will only reduce the rate of hair growth

Gynaecology by Ten Teachers; 18th edition

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[Medical]: Anti-androgenSpironolactone

Aldosterone antagonist & inhbit dyhydrotestosteronebinding and androgen productionStart with 25 mg od and slowly increase over several weeks to 100-200mg odCheck BP and BUSEC 2-4 weekly

Need to avoid pregnancy A/e: diuresis, headache, breast tenderness

Quick Management Guide in Gynaecology, Lee Say Fatt, 1stedition 2007

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[Medical]: Anti-androgenCyproterone acetate (CPA)

Competitively inhibit androgen receptors

Use at low dose 25-100 mg OD added to first 10 days of any low-dose 3 rd generation COCs pack or Diane 35,Estelle 35


edition 2007

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[Medical]: Anti-androgenFlutamide

250-500 md OD +/- COCs

Hepatotoxicity is a complicationMonitor LFT


edition 2007

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[Medical]: Anti-androgenFinasteride

Blocks conversion of testosterone tpdihydrotestosterone by inhibiting 5 alpha reductaseenzyme at the skin2.5-5.0 mg daily


edition 2007

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SurgicalLaparoscopic ovarian drilling

Increases the sensitivity of ovary to exogenousstimulation & correct the disordered pituitary-ovarianaxisSelected for clomiphene resistance and those with highLH levels80% ovulation rate and a 50% pregnancy rate (1)

(1) American College of Obstetricians and Gynecologists (2002, reaffirmed

2008). Management of infertility caused by ovulatory dysfunction. ACOGPractice Bulletin No. 34. Obstetrics and Gynecology, 99(2): 347-358.

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Factors affecting the outcome of laparoscopic ovarian drilling for PCOS... ; British Journal of Obstetrics and Gynaecology

March 1998, Vol. 105 ,

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Follow-upRegular review

Early detection & treatment of endometrial hyperplasia& metabolic complication Any change in reproductive needs

Review at closer interval (3-6 months)

DUB or hyperandrogenism


edition 2007

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Summary of treatment options for PCOS

Lifestyle Diet, exercise & weight reductionMedical Anovulation

Menstrual irregularity

Hirsutism

Hyperinsulinemia

Clomiphen +/-metformin

COCs / Progestogen

COCs +/- Crproteroneacetate

MetforminSurgical Anovulation Laparoscopic drilling


edition 2007

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SourcesTextbook:Gynaecology by ten teachers; 18th edition

Quick Management Guide in Gynaecology, Lee Say Fatt, 1st edition 2007

RCOG Green top Guideline (No 33)Long term consequences of Polycystic OvarianSyndrome, December 2007

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Journal:Crosignani PG et al

Overweight and obese anovulatory patients with polycystic ovaries: parallel improvements inanthropometric indices, ovarian physiology and fertilityrate induced by diet . Hum Reprod 2003;18:1928 32

Norman RJ et alReproductive performance in overweight/obese womenwith effective weight management. Hum Reprod Update 2004;10:267 80.

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John E et alEffect of metformin on spontaneous and

clomiphene induced ovulation in the PolycysticOvary Syndrome., N Engl J Med 1998;338:1876-80

Li T.C at alFactors affecting the outcome of laparoscopicovarian drilling for polycystic ovarian syndrome inwomen with anovulatory infertility ; British Journal of Obstetrics and Gynaecology March 1998,Vol. 105, pp. 338-344

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