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PCOS Made Easy Through Case Discussion Moderator DR. Sharda Jain , DR. raj Bokaria
1. Moderator : Dr. Sharda Jain
Dr. Raj Bokaria
Speaker : Dr Dipti Nabh
Dr Meenakshi Sharma
Dr Vandana Gupta
PCOS MADE EASY
(through Case Discussion)
Delhi Gynaecologist Forum’s CME
on PCOS in Delhi
2. Objective To discuss real-world case-based scenarios to
enable clinicians manage PCOS-related
hyperandrogenism more efficiently
3. Case 1
17 years old girl presents with irregular infrequent
periods since past 8 months (age of menarche: 12 years)
Associated complaints of acne not responding to topical
therapy, causing embarrassment
History of excessive weight gain in past 6 months, with
inability to lose gained weight
On Examination
• Height: 160.8 cm; Weight: 83 kg
• BMI: 32.1 kg/ m2
• Multiple papules, nodules and comedones present on face
4. Investigations Case 1
• Fasting Blood Sugar- 87
mg/dl [Normal]
• Post Prandial blood sugar -
97 mg/dl
• HbA1C- 5.7% [below 6%]
• Serum LH – 8.7 mIU/ml [5-20
mlU/ml]
• Serum FSH – 5.3 mIU/ml [5-20
mIU/ml]
• Total Testosterone - 97 ng/dl
[14- 76 ng/dl]
• Free Testosterone – 3.6 ng/l
[0.3- 1.0 ng/dl]
• Serum SHBG – 19 [18-144
nmol/L]
• Serum TSH - 2.5 µIU/ml [ 0.3-
5.5 uIU/ml]
Abdominal ultrasound - Normal
appearing uterus, with bilateral normal
ovaries. Specifically, there was no
evidence for polycystic ovaries.
DIAGNOSIS: Polycystic Ovary Syndrome in Adolescent
6. Answer
1. Rotterdam criteria
2. IFS guideline – atleast 1 Biochemical Characteristic in
conjunction with 1 Clinical symptom
(a) Biochemical - BMI
FH of DM, PCOS,
Altered Lipid profile
(b) Clinical - Pubertal deviation
Menstrual irregularity
Hirsutism
Early Acne, Persistent, Sever Acne, Frequent
Relapse in Acne , Acne in facial V area
Acanthosis Nigricans
7. Question
2
What is the role of Lifestyle modifications in
an adolescent PCOS patient?
What lifestyle changes would you advise?
8. Answer
(A) Role of Lifestyle Modifications - WEIGHT LOSS
Reduces or Reverses Insulin Resistance
Improves Menstrual Irregularity
Normalizes Hyperandrogenism
Improves Metabolic state
Reduces incidence of DM
Improves pregnancy rate
(B) Lifestyle Changes
Diet – Balanced, Low Fats, Low Carbohydrates, High Protien
At regular intervals small quantity
Increase Fiber intake
Increase Low glycemic index foods
Decrease refined foods
Exercise – 150 minutes per week
Boost metabolism
Burns calories
9. Question
3
When should combined hormonal preparations
be started in an adolescent patient?
Which is the progestin of choice? Why?
For how long should CHPs be given to a patient?
* CHPs: Combined Hormonal Pills
10. Answer
3A When should combined hormonal preparations be started in an adolescent
patient?
For management of MI
(a)12 – 16 years. – Low dose COC only for 7 days.
4 cycles per year is the aim.
(b) After 16 – regular low dose COC
For management Acne / Hirsutism / other cutaneous manifestation s
(a) Once other Pharmacological options no longer help.
(b) 2 years post menarche
3B Which is the progestin of choice? Why?
For MI – Drosperinone, Desogestrel
For Acne, Hirsutism – Cyproterone Acetate
These progestins - Have anti androgenic property
Do not alter lipid profile
Decrease SHBG & 5 alpha reeducates.
CV – protective profile
* CHPs: Combined Hormonal Pills
11. Answer
3 C For how long should CHPs be given to a patient?
Ideal time to stop hormones for hyperandrogenism can
not be established
Pause treatment for 3 months after one year of
treatment & assess hormonal levels
Continue treatment till - Patient is gynaecologically
mature i.e. 5 years post menarche.
- Patient has lost substantial amount of
weight
* CHPs: Combined Hormonal Pills
13. Answer
Reproductive health consequences.
Cosmetic concerns
Use of COC is not curative
Cardiometabolic risk factor survey
BMI
BP
Altered lipid profile
Deranged glucose metabolism
Fatty liver
OSA
Management & Risk reduction
14. Case 2
32 years old married female presents with complaints of increased
facial hair and excessive weight gain over past 2 years, causing her to
avoid social interactions
Associated complaints of dark patches on skin, repeated fungal skin
infections and UTIs, for past 6 months
Age of menarche: 11 years; G1P1L1; history of Impaired Glucose
Tolerance during pregnancy
History of Type II diabetes in mother
Height: 166 cm; Weight: 80 kg; BMI: 28.98 kg/ m2
Ferriman-Gallwey Score: 12
16. Question
1
What are the most common problems faced
by adult women in the reproductive age-
group who have PCOS?
17. Answer
Most Common problems in PCOS women
Obesity
Infertility
Menstrual irregularity
Hirsutism
Insulin Resistance/ Diabetes
Metabolic syndrome
18. Question
2
Which is the progestin of choice for managing
hyperandrogenic manifestations of PCOS?
For how long should CHCs be administered?
Does long CHC use affect the future fertility of such
patients?
* CHPs: Combined Hormonal Pills
19. Answer
Low Dose CHC 30µg EE with CPA, Drospirenone or
desogesterel is preferred as progestin component
because of antiandrogenic effects of progestins
CPA showed strongest antiandrogenic activity
Bhattacharya SM, Fertil Steril, 2012
Drospirenone more beneficial in regularisation of
menstrual cycle and reduction of Hirsuitism score
when compared to desogestrel in Indian conditions
Kriplani A, Contraception, 2010
Duration of CHC treatment not established but must
pause after 1 year for 3 months in patients high risk
for VTE
No effect on infertility after long term use of COC- 79-
96% women conceives within one year of cessation of
21. Answer
Multidisciplinary management
Obesity
Lifestyle modification-diet and exercise
Menstrual Irregularity
Low dose CHC with CPA/drospirenone
Diabetes
Metformin with OHA or Insulin for euglycemia
Hirsutism
Mechanical hair removal methods- Photoepilation/LASER therapy,
Electrolysis
Topical Eflornithine
Pharmacological therapy –CHC, with CPA or drospirenone,
Spironolactone 25-50mg/day or finasteride 5 mg/day can be added as second
line
22. Guideline Recommendations:
Adults with PCOS
Women not intending to conceive: Low-dose CoCs with anti-androgen
progestins (Grade A, EL 1)
CPA is more beneficial in Indian conditions
Direct hair removal methods recommended along with CoCs as first
line (Grade A, EL 1)
No improvement with/ intolerance to CoCs: Spironolactone or Finasteride
recommended (Grade A, EL 2)
Hirsutism in
Adults
Guidelines for management of PCOS-related Hirsutism
Malik et al. Management of Polycystic Ovary Syndrome in India. Fertility Science & Research. Jan-Jun 2014; 1(1): 23-4
Anti-androgen Progestins: Cyproterone acetate, Drospirenone, Desogestrel
CoCs: Combined Oral Contraceptives
• PCOS Certification Modules •
24. Answer
Long term complications in PCOS
Type 2 Diabetes
CVD
Endometrial hyperplasia and cancer
Obstructive sleep apnea
Non alcoholic fatty liver disease or nonalcoholic
steatohepatitis
Prevention
Lifestyle modifications
Regular screening with OGTT, Lipid profile, BP, BMI-
6mthly for borderline cases and annually for normal
profiles
Regular screening with TVS for ET, EB for menstrual
irregularity
Progestin therapy for atleast 3-4 months in a year or
25. Case 3
Female, 29 years, unable to conceive despite regular unprotected
intercourse for past 3 years
c/o irregular, usually prolonged menstrual cycles (sometimes once in
2 months), with scanty to heavy bleeds
Past history of acne, history of diabetes in mother
On examination
• BMI: 28.5 kg/ m2
• Increased facial hair
• Ferriman Gallway Score - 15
28. Answer
Other investigations to be advised are-
AMH
Lipid Profile
DHEAS
17OHP
Basal AFC
Husband Semen Analysis
29. Question
2
Is there any role of combined estrogen-progesterone
preparations in management of PCOS-related infertility?
Please specify which preparations should be used?
How long should they be administered?
30. Answer
COC decreases
Insulin resistance
Decreases LH
Improves ovulation
COC preparations to be used are
Ethinyl estradiol 30mcg with antiandrogenic
progesterones – CPA, Drospirenone, Desogestrel
COC should be administered for 3-4 months
depending on patients age
31. Question
3
What are the drugs that can be used for
ovulation induction in this patient?
Which will you prefer? Why?
32. PCOS-related Infertility:
Management Algorithm
•
A. Estrogen modulators
•Clomiphene citrate (CC)
•Letrozole
B. CC resistant/failure
•Low-dose gonadotropins
•Glucocorticoids
C. Insulin sensitizers
•Metformin + CC
• Metformin (if BMI ≥30 kg/m2 and prevent
OHSS
•Laparoscopic surgery +gonadotropins (Gn)
•Bariatric surgery if BMI ≥35 kg/m2
First-line
Second-line
Third-line
No improvement
No improvement
34. Answer
IUI in young patients with no tubal factor
IVF should be planned earlier in older patients
35. Question
5
When and in which patients will you advise
surgery?
What are the different surgical methods?
Which one will you prefer?
36. Answer
When no pregnancy on medical treatment
Laparoscopic ovarian drilling should be offered to
CC resistant cases
Bariatric surgery should be offered when BMI
greater than 35 (32.5)