Management of the Commonest
Endocrine disorder in females
Miss Bini Ajay
Cases
 25 year old with BMI 35, with history of
infrequent periods, facial hair
 30year old, normal BMI with irregular
periods and unable to conceive for 3 years
PCOS
•Definition
•Pathophysiology
•Management
•Long term consequences
•Summary
Facts
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Stein & Levanthal in 1935
5-10% PCOS,20% PCO
Heritable disorder
30%of PCOS- normal periods, 85-90% of
oligomenorrhoea,30-40 % of amenorrhoea
70%- hyperandrogenism
50-70%- insulin resistance, 30-40% -IGTT, 7.5-10% type II
40% - subfertility
42-73%-miscarriages
35%- depression
Pathophysiology
Pathophysiology
Insulin Resistance
Hyperinsulinemia
Stimulates Hypothalamus
Stimulates adrenal gland
Stimulates ovaries
Suppresses Liver – less SHBG- Increased Androgen
Diagnosis
Rotterdam Criteria
- 12 or more follicle <10mm
- Oligoovulation /anovulation
- hyperandrogenism
PCOS
Biochemical tests
-TFT/ Prolactin
- Free androgen & SHBG
- Androgen secreting tumours/
CAH(17OHprogesterone)
- LH:FSH > 2:1
- AMH
- GTT(fasting insulin)
- Lipid profile
Treatment
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Exercise ,weight loss(5%)
Oral contraceptive pill- Dianette, Yasmin
Spironolactone ,Finasteride
Isotretinoin
Laser, electrolysis
Vaniqa
• Eflornithine Monohydrate
chloride
• Blocks the action of
ornithine decarboxylase
in skin
• Twice daily
• 4 months
Metformin
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Decreases androgens
Use insulin
Reduces cholesterol
Improves metabolism
Increases ovulation
If pregnant can continue Metformin
Inositol
• Myo-inositol- carbohydrate essential for insulin
modulation
• Increases action of insulin –improves insulin
sensitivity
• Reduces cholesterol and BP
• Reduces androgen
• Increases ovulation-69.5%
Laparoscopic drilling
• Drills into the outer capsule
• Decreases testosterone
• Increase FSH
Long term Effects
• Diabetes, cardio and cerebrovascular disease-lipid
profile, BP, HbA1c
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Endometrial cancer –hyperplasia
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Obstructive Sleep Apnoea- obese, insulin resistance –
CPAP
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Psychological –Depression , sexual difficulties, eating
disorder
PCOS and Trigycerides
• Obesity and high insulin – promotes high triglyceridesincreases VLDL
• Insulin resistance – reduced clearance of VLDL and
chylomicrons
• Hepatic content of triglycerides is high larger VLDL
particles are produced- metabolised to small, dense LDL
particles- poorly cleared and atherogenic
• Statins improve hyperandrogenemia
PCOS and hypertension
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Increased endothelin_1 levels
Increased aldosterone concentrations
Czech-22% Dutch-28%
Coronary artery calcium (CAC scores) and
carotid intima –media thickness (CIMT)subclinical atherosclerosis- stroke ,MI
Endometrial hyperplasia
• Endometrial cancer
• Withdrawl bleed -3-4months
• TVS- ET-7mm
PCOS and Pregnancy
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Gestational diabetes- GTT at 16 and 28weeks
Preeclampsia
Preterm birth
Perinatal mortality
Multiple pregnancy
Summary
• PCOS is a common endocrine and metabolic disorder
with long term consequences