PCOS treatment Flashcards

Question

Study : lifestyle intervention and weight loss

Answer 1

Kiddy: 24 women on very calorie-restricted diet (1000 calories) * Target was to loose 5% of body weight (Kiddy et al, 1992, Clin. Endocrinol. (Oxf) 36:105-11) – Of the 13 who succeeded → 5/7 conceived – 11 who didn’t → 1/8 conceived * Subsequent trials shown that if overweight/obese women with PCOS have 5-15% weight loss then significant improvement in following parameters : – Serum lipids – Serum T and SHBG – Glucose tolerance and fasting insulin – Hirsutism – Ovulation and menstrual cycle regularityLifestyle (Harrison CL et al, 2011, Hum. Reprod. Update 17:171-83)

Answer 2

Studies from Australia show diet is as successful as medical intervention (Anne Clarke) but drop-out rate high » requires support system and frequent attendance and exercise programme.

Answer 3

Weight loss notoriously hard to achieve * Use weight loss drugs? * Orlistat (lipase inhibitors)...reduces uptake of fat from bowel and increases it in stools – side effects of anal leakage * For morbidly obese (BMI>40) bariatric surgery

Answer 4

Meta-analysis of 2130 women who had bariatric surgery: » 46% identified as having PCOS pre-op → dropped to 7% one year post-op (p<0.001) » Incidence of hirsutism pre-op was 67% & dropped to 39% one year post-op (p=0.03) » Menstrual irregularity was 56% pre-op and dropped to 8% one year post-op » Pre-op fertility was 18% and post-op was 43%

Answer 5

* Diabetes drugs such as metformin * Metformin is a biguanide (insulin sensitiser) * Decreases hepatic glucose production therefore less in serum * Enhances glucose uptake into muscle * Increases oxidation by adipose tissue * Good for PCOS?

Answer 6

- improvement in ovulation rates -may be used to treat gestational diabetes - can be used in women who cant tolerate hormonal contraception to regulate periods - adolescents with PCOS are put on

Answer 7

- Even when amenorrhoeic( absence of period), women with PCOS are well-oestrogenised -antral follicles are still there which release oestrogen. * Unopposed oestrogen on endometrium → risk factor for hyperplasia * Probably exacerbated by obesity * Recent meta-analysis showed 3 fold increased risk of endometrial CA...even under 50 Another study found an increase only in obese women with PCOS (Fuberg & Thune (2003) Int. J. Cancer) * Recommendation to have bleed at least every 3 months, more often if very heavy => contraceptive pills are first line of treatment for menstrual abnormalities

Answer 8

* Important to limit endometrial hyperplasia and menorrhagia * Increased risk of endometrial cancer with prolonged amenorrhoea in PCOS as well-oestrogenised * Progestins in HCs suppress LH levels and hence ovarian androgen production * Avoid androgenic progestogens * Risk...appetite stimulant so need advice regarding weight gain

Answer 9

* Hyperinsulinemia from IR acts at dermis to induce acanthosis nigricans (velvety, light-brown-to-black markings) on neck, under arms, in groin & skin tags * Treatment to just improve the appearance includes tretinoin (derivative of Vitamin A), 20% urea, alpha hydroxyacids and lactic or salicylic acid.

Answer 10

* 75% women with hirsutism/acne have PCO * even higher in women with h/a and oligomenorrhoea * consistently reported as most distressing symptom * cause of significant reduction in quality of life by questionnaire, cause of low- self esteem * Hirsutism assessed by modfied Ferriman-Galway score (ethnic differences) * >80% of patients presenting to dermatology clinic for acne had PCOS

Answer 11

less frequent and presents later, but very distressing with significant psychological comorbidities. Poor association with biochemical hyper-androgenism, maybe associated with IR and metabolic syndrome

Answer 12

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Answer 13

* Electrolysis – Electrical current causes high temperature in hair shaft – Must destroy dermal papillae to prevent regrowth – Not really practical for large areas – Often worth removing hair by another means a short while before, then growing hairs can be focussed on. – May be best combined with medical treatment * Laser.. – heat destroys the hair follicle. Need dark pigment to absorb the heat of the light/laser – Needs dark hair on light skin – Not often available on NHS – Hair follicle cycle is long → many sessions

Answer 14

Vaniqa. Eflornithine Hcl topical cream inhibits enzyme - Ornithin Decarboxylase – that is needed for hair shaft growth.

Answer 15

* Weight reduction is primary goal in the overweight – Increased chance of spontaneous ovulation – Reduced chance of miscarriage – Need less drugs for induction of ovulation – Reduction in GDM – Improved outcome for baby – Improved long term outcome for patient * Which diets are best? – Hard to say......but low calorie of any kind seems to work

Answer 16

– Clomiphene Citrate - raised acyclical oestrogen results in disordered pituitary LH and more importantly FSH * given for 5 days to mimic inter-cycle rise in FSH – CC is a SERM (selective oestrogen receptor modulator) and binds to ER in hypoth/pit & removes negative feedback, allowing for GnRH & FSH release * 70-90% responders in the best hands * Multiple pregnancy around 10% * high miscarriage rate......up to 40% → blocks ER on endometrium * risk of multiple follicles/ovulation & OHSS...ultrasound monitoring 1st cycle

Answer 17

– Metformin + CC * Improves clinical pregnancy rates but not live birth rates – Aromatase inhibitors (eg Letrozole) * Same effects as the anti-oestrogen but inhibits production of oestrogen (Legro et al, NEJM (2014) 371:119-129) – FSH treatment (low dose) * Daily injections of FSH: aim for single follicle

Answer 18

* 748 women with PCOS and anovulation (18-40 years) – AMH measured at baseline – Treated with clomiphene citrate or letrozole for 5 days per cycle & for 5 cycles – AMH levels significantly lower in women who achieved ovulation vs women who did not overall and also within each treatment group

Answer 19

High serum AMH associated with a reduced response to ovulation induction among women with PCOS

Answer 20

– Ovarian laser diathermy/ovarian puncture or wedge resection* ovary “drilled” laparoscopically with laser * mechanism of action unknown → may act by destroying stroma, reducing size of matrix and lowering endogenous androgen production → disrupts hippo signalling to allow for follicle activation* Return of cycles for up to 6 months in high percentage of women * no risk of hyper-stimulation but ↑ risk peritoneal adhesions * should be used only as a last resort as long term damage unknown.....although recent study suggested better outcome than those not receiving it * Reduced response rate to subsequent IVF – IVF* Recommended use of metformin as adjuvant to prevent OHSS which is very common in women with PCOS

Answer 21

* Some publications on acupuncture – Cochrane review (2011) found no randomized trials to investigate effect of acupuncture treatment for PCOS * Herbal preps also suggested – Agnus castus – Saw palmetto etc

Answer 22

* New development of evidence- based free AskPCOS app * Co-developed with women and health professionals * Many apps available but for PCOS, but commercially developed and lack quality and evidence-based information * Used in over 100 countries * Helps to meet women’s information needs and enhance self-management

PCOS treatment Flashcards

(47 cards)