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PANEL DISCUSSION Management Of Adolescent PCOS And Associated Fertility Concern HELD ON 21/09/2014 At Hotel Latit NEW DELHI Dr. Sharda Jain
1. PANEL DISCUSSION
Management Of Adolescent PCOS
And Associated Fertility Concern
HELD ON 21/09/2014
At Hotel Latit
NEW DELHI
Dr. Sharda Jain
Organized by FOGSI / ICOG /CIPLA
2. Management of Adolescent PCOS
and Associated Fertility Concern
MODERATOR : Dr. Abha Majumdar
PANELISTS : Dr. Sharda Jain
Dr. Kaveri Benerjee
Dr. Kandhari (Dermotologist)
Dr. Saptrishi Bhattachayra
(Endocrinologist)
3. IMPORTANCE OF PCOS
It is NOT A DISEASE, it is a syndrome with
varied presentations
PCOS Constitutes a
CONTINUUM SPECTRUM
starting from the EARLY PREPUBERTAL
YEARS and continuing after Menopause
S/S peak through 2nd / 3rd decade of life
4. Q 1.
EPIDEMIOLOGY
Q 1. Is the incidence of PCOS in adolescents
rising or has the diagnosis improved ?
Ans. Yes, Both things are working
• There is a increase in incidence of PCOS in
adolescents
• Secondly because diagnosis has improved from
NIH-(1990) – TO ROTTERDOM(2004) – TO AES-PCOS
SOCIETY DIAG.CRITERIA (2009)
– many cases are picked –up now
5. Improvement in
Diagnosis of Polycystic Ovarian Syndrome over the years
NIH (1990)
1. Oligo ovulation
2. Hyperandrogenism and / or hyperandrogenemia
(with exclusion of related disorders)
ESHRE /ASRM (Rotterdam 2003)
To include TWO OUT OF THREE of the following:
1. Oligo – or anovulation
2. Clinical and / or biochemical signs of hyperandrogenism
3. Polycystic ovarian (with exclusion of related disorders)
AES – PCOS (2009)
1. Hyperandrogenism : hirsutism and / or
hyperandrogenemia and
2. Ovarian dysfunction : oligo – anovulation and / or
polycystic ovaries and
3. Exclusion of other androgen excess or related disorders
6. PCOS
Definition
1990 - 2009
Hyperandrogenism
(Clinical or
Biochemical )
Oligo- menorrhea
or
Oligo-Ovulation
Polycystic Ovaries
on USG
NIH (1990) yes yes no
Rotterdam
(2003)
yes Yes
2 of the 3 criteria
yes
AE-PCOS
Society
(2009)
yes Yes
1 of 2 criteria
yes
Diagnosis of Polycystic Ovarian Syndrome
7. Incidence of adolescent
PCOS
IF WE USE STRICTLY
NIH criteria = 6-8%
Rotterdam criteria = 15-25%
In Indian Asian Urban Community– this number
is more & seems to be rising for reasons
unknown ??
8. Q 2 (A)
What are the conditions that may
mimic PCOS ?
• Thyroid disorders
SSrr..TTSSHH,,SSrr..PPrrll
• Hyperprolactinemia
• Cushing’s syndrome
DDeexxaa ssuupprreessssiioonn tteesstt
• Late onset congenital adrenal hyperplasia (CAH)
• Basal morning 17-OHP,(2-3 ng/ml))
• Ovarian and adrenal tumors DHEAS
• WHO I &III –FSH,LH,E2
• Syndromes of severe insulin resistance(HAIRAN syn)
9. Q 2 (B)
Any Genetic or familial basis ?
• Family History :
Risk of PCOS
• 40% - if her sister is having
PCOS
• 20% - if her mother suffered
from PCOS
GENETIC ETIOLOGY NO LAST WORD AS YET
10. Q 3.
DIAGNOSTICS – BLOOD TESTS
Q 3. (A) Which hormonal/blood tests are
done to confirm the diagnosis of PCOS?
Q 3. (B) Which tests should be done
before starting insulin sensitizers –
fasting / PP blood sugar, insulin,
glycosylated Hb?
11. DIAGNOSTICS – BLOOD TESTS
ANS. 3 (A)
Prolactin level
Testosterone level
LH and FSH
TSH
Fasting glucose level or 2 hr OGTT
Lipid profile, including total, LDL,HDL
17-hydroxyprogesterone level*
*--Fasting level to r/o CAH
12. DIAGNOSTICS – BLOOD TESTS
ANS. 3 (B)
• 2 hrs GTT using fasting & 2 hrs blood
sugar levels are needed
Category Fasting 2hrs PP
Normal <100 mg/dl <140 mg/dl
Impaired <100-126 mg/dl > 140 -199
NIDDM Over 126 Over 200
Insulin Levels are Really Not Needed for
diagnosis of PCOS
13. Q 4.
DIAGNOSTICS - USG
Q 4. How is PCO and PCOM different
than PCOS?
15. PCO, PCOM & PCOS
• It is a fact that PCOM ie POLYCYSTIC
OVARIAN MORPHOLOGY is present in 20
-35% girls with normal menstrual cycles &
• In Contrast there are patients of typical PCOS
who do not have PCOM on ultrasound.
16. Four Different Phenotypes of
PCOS are now identified
• TYPE A: hyperandrogenism, chronic anovulation and
<
polycystic ovaries.
• TYPE B: hyperandrogenism and chronic anovulation.
• TYPE C : hyperandrogenism and polycystic ovaries
• TYPE D : chronic anovulation and polycystic ovaries
Hyperandrogenemia is the
Hallmark :
17. Q 5. SYMPTOMS
Q 5. Which are the commonest symptoms
that women with PCOS present with?
Ans.5 Three Commonest Presentation are
• MENSTRUAL DISORDERS when they consult
gynaecologists
•OBESITY when they consult endrocrinologits
•HISUITISM & ACNE when they consult
dermatologist
Co-operations / Coordination
among specialists is needed
18. Symptoms & There Frequency
in PCOS in Adolescents
Menstrual Cycle disturbance – 70%
- Oligomenorrhoea 50%
- Amenorrhoea 10%
- Abnormal heavy bleeding 10-15%
Hyperandrogenism 70%
Acne – 70%
Hirsutism 70%
Alopecia 10% as seen by Gynaecologits
(Dermatologist feel - Alopecia is not all that uncommon around 20%)
Acanthosis Nigricans 1-3% lean & 20% obese
OBESITY 50- 60 %
NORMAL MENSTRUATION 20%
INFERTILITY ?
19. Clinical Manifestation of PCOD
AAccnnee AAccaanntthhoossisis HHirirssuuttisismm OObbeessitityy
HAIR
LOSS
HAIR InInffeerrttiliiltityy
LOSS
IRREGULAR
MENSES
IRREGULAR
MENSES
20. Q 5(B)
What is the Pattern of Menstrual
Irregularity in Adolescent PCOS
DELAYED PERIODS is most common
presentation
Other Presentations are:
• Withdrawal bleeding only
• Absent periods
• Heavy menstrual bleeding or
• Menometrorrhagia with Anemia
21. Q5 (B) PCOS in Adolescent
Menstrual Irregularity
• Mestrual problems are present in 80% obese
PCOS & 30% with lean PCOS
• 20% PCOS have normal cycles
• It is well accepted that If menstrual
Irregularities persist for 2 years
After Menarche,
Then The Risk for PCOS is
Extremely High (70% of Cases)
22. Q (a) Is treatment for hirsutism based on
FG scoring?
Q (b) what all tests are needed to diagnose
hyperandrogenemia
Q (b) Does acne require systemic treatment
or only topical is sufficient?
Q (c) How common is alopecia?
Q (D) Guidelines to gynaecologits on treatment
of hirsutism
Q6
COSMETIC CONCERNS
HIRSUTISM , ACNE, ALOPECIA
23. ANS. Ferring Gallway Scale
This model quantities the extent of heir
growth I nine key anatomic sites: the hair
growth is graded using a scale from 0
(no terminal hair) to 4 (maximum growth),
for a maximum score of 36
A score of 8 or more indicates the
presence of androgen exces.
However, we do not use it in day to
day practice to grade our patients
24. What All Test Are Needed To Diagnose
Hyperandrogenism
Hirsutism, acne, alopecia
BIOCHEMICAL Testing Total Testosterone
levels & 17 – hydroxyprogesterone level to
R/O late onset CAH is all that is needed
Free Testosterone &
% Free Androgen index have NO ROLE in
diagnosis. It is 10 times costly & is not standard in all
labs.
• ANDROSTENADIONE-NO ROLE
SUDDEN ONSET of these symptoms suggests other D/D
* Cushing’s syndrome
* Adrenal or ovarian tumor.
25. ACNE
• Grade 1: Acne are
classified non
inflammatory
• Grade 2:
Inflammatory
• Grade 3 :
Combination of
above
26. Management - Topical
1. Apply the preparation over the whole
affected area and not just spot
application
2. Apply the product very miserly as Acne
treatments are often irritating and drying
3. Excessive washing of face is to be
avoided as it further aggravates the
irritation
4. Stop application moment excessive
drying or irritation develops
5. Cream based applications should be
preferred as they reduce the concomitant
dryness
27. Systemic – Management
is needed for infected or severe acne
• 1. Oral Antibiotics – Minocycline,
Doxycycline, Azithromycin,
Cephalosporins
• Isotretenoin – 0.5 -1 mg/ Kg body
weight. Cumulative dose of 120 – 150
mg /Kg over a period of 6 – 9 months.
• Low dose therapy
28. Hormonal Therapy in Acne
– Recalcitrant acne (severe variety)
– Acne not responding to topical /oral
Isotretenoin
– Co- prescribed with Isotretenoin
–PILL CPA 6-9 MONTHS
Any pill containing Desogestrel (Femilon) is
also effective in good 80% cases
29. Treatment – Other Modalities
• Chemical peels
• Comedon removal
• IPL
• Cryotherapy
• Microneedling
• Use of steroids
Good Dermatologist
help is needed.
Gynaecologist can’t
treat on there own
30. Alopecia
Incidence
in adolescent PCOS
Dermatologist feel that it is not all that uncommon
• Less common
(according to
gynaecologits)
• Diffuse thinning
With preservation of
frontal line
• Bitemporal
recession
CAUSE
• Decrease in 5a
reductase -
in DHT
32. TREATMENT - HIRSUITISM
• All combination OCPs effective
• OCPs decrease androgen levels by
suppressing LH and stimulating sex
hormone binding globulin (SHBG).
• It takes almost 6 months when decrease
growth of hair is noted.
•OCPs with low androgenic
Progestins (norgestimate, desogestrel)
may be Most effective for acne and hirsuitism
33. Hirsuitism Treatment
• METFORMIN perse are not needed
– To reduce hirsuitism.
• ANDROGEN RECEPTOR BLOCKERS
– A full clinical effect may take 6 months or
more
– Spironolactone 25-100mg bid (Level A)
34. Topical cream
• Effornithine Hydrochloride Cream are
effective & take almost 3 months to show
effect.
Dosages & Applications
• Remove the heir from the affected areas and wait for
minimum 5 minutes
• Apply a thin layer of hinder cream to the affected areas of
the face and adjacant involved areas under the chin
• Rub in thoroughly
• The treated area should not be washed for 4 hours
• Cosmetics and sunscreens may be applied over the
treated areas after the cream has dried
• To be used twice daily at least 8 hours apart
• For optimal results, use hinder fo a minimum of 6-12
months along with other methods of hair removal
35. Few Tips of Solution by
Dermatologist
• Temporary Methods – Remove the hair
shafts but leave the hair follicle intact.
Example – waxing, shaving, depilatory
creams & plucking.
The process needs to be repeated indefinitely.
Though cheap, are time consuming, repetitive and
often lead to pigmentation and thickening of skin.
ELECTROLYSIS IS GOING OUT
LASER THERAPY is not permanent. Repeated
sittings may be needed
OCP & Adactone are Needed
36. Q 7.
CHOICE OF COC
Q 6. Which COC is most preferred?
Containing
• Levonorgestrel / Desogestrel
• Cyproterone acetate
• Drospirenone
37. CHOICE of COC
ANS. ANY LOW DOSE COC CAN BE GIVEN
• OC’s containing progestins such as NORGESTREL
/ LEVONORGESTREL / DESOGESTREL are preferable.
• If HIRSUTISM is a problem then Cyproterrone
Acetate is preferred.
• DROSPIRENONE HAS NO ADVANTAGE
38. Two Types OF OCPs
• NON ANDROGENIC PROGESTOGENS
Desogestrel 0.15 mg + EE 30mcg(novelon)
Desogestrel 0.15 mg + EE 20mcg( femilon)
• ANTIANDROGENS WITH PROGESTATIONAL
ACTIVITY
Cyperoterone acetate
(EE 30 mcg + C 2 mg - Diane35)
Drosperinone- (EE 30 mcg + D 3 mg -Yasmin)
39.
40. Q8
ETHINYLESTRADIOL – HOW MUCH?
Q. What is the patient profile for choosing
COCs containing 35, 30, 20 mcg
ethinylestradiol?
ANS. Low Dose COC pill is the choice
(<35 ug EE is the choice).
In adolescent people start with EE 20 ug pill
– if BTB – occurs, higher dosage pill is used
41. Q9.
CHOICE OF PROGESTIN
Q. What is the patient profile for
choosing the type of progesterone in
COCs?
Ans. Safety of the pill is most important
Like venus thromboembolism , mycardial
infaction & cancer etc.
42. SAFETY ON OCP
Noethindrone
Norgestril / Levonorgestril Low DVT
• Non Androgenic Progestogens
Desogestrel 0.15 mg + EE 30mcg(novelon) ,
Desogestrel 0.15 mg + EE 20mcg( femilon)
•Antiandrogens with progestational activity
• Cyperoterone acetate
• (EE 30 mcg + C 2 mg - Diane35)
• Drosperinone- (EE 30 mcg + D 3 mg Yasmin)
Desogestrel DVT ? Risk
Drosperinone DVT ? Risk
43. Q10.
DURATION OF TREATMENT
Q. How long can women take
hormonal treatment for PCOS
management ?
ANS. At least for a year or even longer
DERMATOLOGIST feel it should not be
discontinue unless women wants to become
pregnant .
44. Q11.
CONCERNS WITH COC
Q. What are common complaints with the use of
COCs?
* HYPERTENSION * WEIGHT GAIN * ACNE
ANS. HYPERTENSION – in few 10 mm rise of BLOOD
PRESSURE may be there which settles once the drug is off
WEIGHT GAIN is not the complication with low dose COC
pills.
ACNE : Infact OCP is the treatment. We preferred pill with
Antiandrogens with progestational activity eg CPA pill
45. Q12.
INSULIN RESISTANCE
QA. How frequently do you see insulin
resistance in your PCOS patients?
QB. Are insulin sensitizers prescribed to all
women with PCOS or only those with insulin
resistance?
46. Q12(A).INSULIN RESISTANCE
Ans. In Research situations IR is
seen in good 60 to 65% patients
Clinically it is seen in 20 – 25%obese
PCOS patients &
5% in lean PCOS patients.
47. Significant Findings in Insulin Resistance
which gynaecologits should always note
• SKIN : Acanthosis nigricans (darkly shaded skin in the
flexures of the neck , axilla, or groin – IR/DM)
Skin tags – IR/DM
10 %
Acanthosis nigricans
Over 20% obese
5% in lean
48. IInnssuulliinn RReessiissttaannccee
DDiiaaggnnoossiiss –– JJuusstt DDoo
• IMPAIRED Glucose Tolerance /
Type 2 Diabetes
– Up to 40% of women with PCOS have impaired
glucose tolerance (IGT).
– Risk of IGT and Type 2 Diabetes Mellitus (DM) is
increased in both obese and non-obese women
with PCOS.
– Retrospective studies have shown 2 to 5 fold
increase of type 2 diabetes in women with PCOS.
49. You should Know
Insulin Resistance is present
Various Clinical Syndrome
• Type 2 diabetes
• Cardiovascular disease
• Essential hypertension
• Polycystic ovary syndrome
• Non-alcoholic fatty liver disease (NASH)
• Certain forms of cancer -
breast,colon,liver,prostate
• Sleep apnea
Because all are interrelated
50. Q12(B).
INSULIN RESISTANCE
Q. Are insulin sensitizers prescribed
to all women with PCOS or only those
with insulin resistance?
Ans. Insulin sensitizers like metformin is
used in patients with impaired glucose
tolerance patients not otherwise
51. Q13.
INSULIN SENSITIZERS - YOUR OPINION?
Q(A) In patients who do not respond to one
COC, do you change the COC (consisting of
another progestin) or shift them to or add an
insulin sensitizer?
Q(B). Metformin / Myoinositol
52. METFORMIN—PRESENT ROLE
• Use of metformin in PCOS should be
restricted to those patients with glucose
intolerance
ESHRE/ASRM-Sponsored PCOS
Consensus Workshop *,2007,
Thessaloniki, Greece
• Metformin may be added to CC in women
with clomiphene resistance who are older
and have visceral obesity (I-A)
SOGC guidelines, 2010
55. Q 14
PREGNANCY & PCOS
Q. If the female wishes to conceive, when
would you adviseher to stop taking the insulin
sensitizers and / or COCs?
ANS. COCs need to be stopped & drugs for
ovarian stimulation to be used.
CLOMIPHENE CITRATE IS
Widely used Simple to use
Minimal side effects Cost effective
57. Q15
PREGNANCY & PCOS
Q. What is the line of treatment in women
with PCOS who have conceived naturally?
Ans. PCOS patients have high chance of
miscarriages so they need micronised vaginal
progesterone
If they have conceived while taking metformine - it
has to be continued throughout pregnancy. This
decreases miscarriage rate.
58. Q16.
LONG-TERM COMPLICATIONS
Q. Are the women sensitized to the
long- term complications of PCOS?
Infertility, Diabetes, Cardiovascular diseases,
Cancer…
Ans. Counseling is important at the first visit
detailing them of short term & long term
consequences. It helps them in reducing weight,
strictly following life style modifications & become
proactive about conception & metabolic disorders
timely.
59. Consequences of Polycystic
Ovarian disorders
Short Term consequences
• Obesity
• Infertility
• Irregular menses
• Abnormal lipid levels
• Hirsutism/acne/androgenic alopecia
• Glucose intolerace / acanthosis nigricans
Long – Term consequences
• Dibetes mellitus
• Endometrial cancer
• Cardiovascular disease
60. Long Term Complications &
The Most
Common
Endocrine
disorder
In women
Consequences
Symptoms may
Include chronically
irregular and / or
Absent or delayed
periods
Symptoms may
include facial
hair , central
obesity and
acne
Let untreated it
may lead to
Heart
Disease
Left untreated,
it may lead to
Uterine cancer
Leading cause
of
Infertility
P C O D
61. Counseling
Counseling also helps them to get
regular screening / monitor from time to
time detect problems early.
•Infertility ,
•Diabetes
•Cardiovascular disease,
•Endometrial Cancer..
62. Q 17 INFERTILITY
Guidelines of infertility
are summarize
beautifully that is
First Line
Second Line
Third Line
THESSALONIKI CONSENSUS ON INFERTILITY
TREATMENT IN PCOS, GREECE 2007
63. THESSALONIKI CONSENSUS ON INFERTILITY
TREATMENT IN PCOS, GREECE 2007
FFIIRRSSTT LLIINNEE
CLOMIPHENE CITRATE
SSEECCOONNDD LLIINNEE
LOD/GONADOTROPINS
TTHHIIRRDD LLIINNEE
IVF
The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group March
2–3, 2007, Thessaloniki, Greece. Human Reproduction 2008
RR
EE
SS
II
SS
TT
AA
NN
CC
EE
RR
EE
SS
II
SS
TT
AA
NN
CC
EE
FF
AA
II
LL
UU
RR
EE
64. Q 18
PCOS & INFERTILITY
Q (a) Ovulation induction aim
(B) First & second line management of
infertility in women with PCOS?
(c) Role of LOD
(D) Role Luteal phase support
(E) OHSS
65. Goals of Ovulation induction
in IUI / IVF
Minimize Complications &
Risk
AIM
Ideal Outcome
Singleton live
Birth at term
Cycle
Cancellation
Multiple
Pregnancy OHSS
66. 1. First Line Management
Clomiphene is drug of Choice
2. In CC Resistant cases
metformine has a role
3. 2nd line treatment Lap. Ovarian
drilling has a role for women who
can’t came for closed follow – up
pregnancy role is 50%
4. Gonadotrophines in PCOS have
promise, but OHSS & multiple
pregnancy, should never before
gotten complication
•Tamoxiphene
people have just
staring using it
•Letroz is
banned in india
•Metformine role
dealt
67. The Truth is that
OHSS MUST
BE PREVENTED RATHER than
treated
68. HCG Trigger plays the key Role
Albert et al. Mol Hum Reprod. 2002;8:409; Chen et al. Hum Reprod.
2000;15:1037; Gómez et al. Endocrinology. 2002;143:4339
69. Can we do Laparoscopic Ovarian
Drilling in ADOLESCENTS who
do not respond to OCP
Not
Recommended
except for infertility problems
70. Q20.
PCOS & Cancer in Women
Would you like to comment on
a) Endometrial Cancer
b) Breast cancer in PCOS
71. Ans. 20 A
Endometrial Cancer in PCOS
• Gynaecologists should not forget that there
is 3 fold increase in incidence of endometrial
cancer.
• There Should be screening & monitoring for
the same from time to time with TVS & EB
Dr. Sharda Jain
Dr. Abha Majumdar shared their personal
experiences
72. Ans. 20B
PCOS & Breast Cancer ??
Limited data exist that Do Not Support the
conclusion that women with PCOS are a
increased risk for BREAST CANCER.
73. Obesity Issue in
PCOS was not
discussed
Discussed in detail in our presentation
“Management of Adolscent PCOD Made Easy”
At Sldehsrae.net
74. Q21
ROLE OF VIT – D ?
Vitamin – D Role
in PCOS
was suggested by
all Panelist
76. CONCLUSION
TAILOR MADE THERAPY in
Adolescent PCOS is our attempt
in this panel discussion
Your comments are needed by
SMS / Watsapp 9650588339
Or Facebook
77. More & More PCOS CLUBS
should be formed
to shoot
Information for
teens & young
PCOS patients
on its various
aspects
78. ADDRESS
11 Gagan Vihar, Near Karkari
Morh Flyover, Delhi - 51
CONTACT US
9650588339, 011-22414049,
WEBSITE :
www.lifecarecentre.in
www.drshardajain.com
www.lifecareivf.com
E-MAIL ID
Sharda.lifecare@gmail.com
Lifecarecentre21@gmail.com
info@lifecareivf.com
&
Thank You
Hinweis der Redaktion
Testosterone needed if considering treatment with antiandrogen for hisuitism as levels can then be followed.
DHEAS not needed.
Fasting morning 17-hydroxyprogesterone
Levels &gt; 800 ng/dL (8ng/ml) highly suspicious for late-onset congenital adrenal hyperplasia (CAH)
Levels between 200-800 ng/dL (2-8ng/ml) unclear
Levels &lt; 200 ng/dL (2ng/ml) usually no CAH
A ratio of less than 4.5 of fasting glucose to insulin levels correlates significantly with insulin resistance and has been studied for use as a screening test in obese patients with PCOS. Suggested only in selected patients. Information from Legro RS. Polycystic ovary syndrome: current and future treatment paradigms. Am J Obstet Gynecol 1998;179:S101-8.
Increased SHBG leads to decreased free testosterone
Yasmin (drospirenone/ ethinyl estradiol) contains an anti-androgen roughly equivalent to spironolactone 25mg.
Orthotricyclen with norgestimate has FDA approval fot the tx of hirsuitism but most experts believe all the 3rd generation ocps to be as efficacious for hirsuitism as they all have less androgenic progestins.
All non-FDA approved indications!
These androgen receptor blockers can be used in combination with ocp in cases when ocp alone is not adequate
Testosterone levels can be followed to show efficacy with goal &lt; 60.
It is postulated that topical eflornithine HCl irreversibly inhibits skin ODC (ornithine decarboxylase) activity which slows the rate of hair growth. Marked improvement was seen consistently at 8 weeks after initiation of treatment and continued throughout the 24 weeks of treatment. Hair growth approached pretreatment levels within 8 weeks of treatment withdrawal. Vaniqa has only been studied on the face and adjacent involved areas under the chin of affected individuals. If skin irritation or intolerance develops, direct the patient to temporarily reduce the frequency of application (e.g., once a day). If irritation continues, the patient should discontinue use of the product.Apply a thin layer of Vaniqa to affected areas of the face and adjacent involved areas under the chin and rub in thoroughly. Do not wash treated area for at least 4 hours. Use twice daily at least 8 hours apart or as directed by a physician. IV vaniqa is used to treat sleeping sickness caused by Trypanosoma brucei gambiense.
Cost $52.90 for 30gm tube.
Propecia (finasteride), a synthetic 4-azasteroid compound, is a specific inhibitor of steroid Type II 5α-reductase, an intracellular enzyme that converts the androgen testosterone into 5α-dihydrotestosterone (DHT).
Cost about $54 for 30d supply.
Flutamide warning-Serum transaminase levels should be measured prior to starting treatment with flutamide. Flutamide is not recommended in patients whose ALT values exceed twice the upper limit of normal. Serum transaminase levels should then be measured monthly for the first 4 months of therapy, and periodically thereafter. Liver function tests also should be obtained at the first signs and symptoms suggestive of liver dysfunction, e.g., nausea, vomiting, abdominal pain, fatigue, anorexia, &quot;flu-like&quot; symptoms, hyperbilirubinuria, jaundice or right upper quadrant tenderness. If at any time, a patient has jaundice, or their ALT rises above 2 times the upper limit of normal, flutamide should be immediately discontinued with close follow-up of liver function tests until resolution. Cost $374 for 3 month supply. In animal studies, flutamide demonstrates potent antiandrogenic effects. It exerts its antiandrogenic action by inhibiting androgen uptake and/or by inhibiting nuclear binding of androgen in target tissues or both. One metabolite of flutamide is 4-nitro-3-flouro-methylaniline. Several toxicities consistent with aniline exposure, including methemoglobinemia, hemolytic anemia and cholestatic jaundice have been observed in both animals and humans after flutamide administration. In patients susceptible to aniline toxicity (e.g., persons with glucose-6-phosphate dehydrogenase deficiency, hemoglobin M disease and smokers), monitoring of methemoglobin levels should be considered. There is a drug interaction with warfarin.
Spironolactone- competitively binds androgen receptors as well as inhibits alpha-reductase activity.
Concomitant administration of potassium-sparing diuretics and ACE inhibitors or nonsteroidal anti-inflammatory drugs (NSAIDs), e.g., indomethacin, has been associated with severe hyperkalemia. Cost $82 for 100 tablets of 50 mg.
A prospective study of 254 women with PCOS without known diabetes was compared to a control group without PCOS or diabetes. In the PCOS group (obese and non-obese), the overall prevalence of IGT and type 2 diabetes was 31.1% and 7.5%, respectively. In the control group, the prevalence of IGT and type 2 diabetes was 14% and 0%, respectively .
75% of PCOS women have IR
Breast cancer patients found to be hyperinsulinemic and best data to support IR association.
Prostate, colon and liver cancers also more common in obese pts with type 2 DM or pts with increased insulin levels.
Up to 50% of all pts with essential HTN are IR.
Metabolic syndrome is defined to capture subset of people with IR at risk for CVD so as to be a practical dx to address CVD risk but IR syndrome may be better way to describe etiology and more studies are looking at IR.
insulin resistance is not a disease but the description of a physiologic state that greatly increases the chances of an individual developing several closely related abnormalities and associated clinical syndromes.
PCOS pts may have IR and it is not obesity dependent.