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Polycystic Ovary Syndrome Diagnosis | Jindal IVF Chandigarh

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Polycystic Ovary Syndrome Diagnosis | Jindal IVF Chandigarh

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  1. Polycystic Ovary Syndrome Diagnosis Shimla, FOGSI 25.06.11 Umesh N. Jindal Jindal IVF & Sant Memorial Nursing Home Chandigarh

  2. History • Described first in 1935 • Histology : • Twice cross-sectional area • Same number of primordial follicles • Double the developing and atretic h follicles. • 50 % thick tunica • 4 fold greater number of hilar call nests

  3. SpectrumofclinicalconditionsassociatedwithPCOS Infertility PCOS DUB Anovulation Obesity Hypertension Diabetes MS Acne Cancers Hirsutism InsulinResistance Atherosclerosis Alopecia CVD Sleep Apnea Depression Fatty liver

  4. The Root Cause ?

  5. Functional disorder • Any chronic anovulatory state will lead to a polycystic picture provided HPO axis is intact. • Hyper estrogenism and / or hyper androgensim due to any cause will lead to PCO.

  6. The steady state

  7. Hormone Status • Estradiol fluctuate but remain within normal range. • Increased Estrone peripheral conversions. • Increased Testosterone • Increased Androsternedione Ovary LH dependent • Increased17-OHP • Increased DHEA • Increased DHEA-S Adrenal

  8. Insulin resistance and PCOS

  9. Causes of PCOS Genetic Gn regulation and action Weight and energy regulation PCOS Complex metabolic disorder Insluin secretion and action Androgen synthesis and regulation Environmental

  10. Pathophysiology • Complex metabolic disorder • Functional derangement of follicular development • Increased estogens and androgens, LH and loss of cyclicity due self propogating feed back loop. • Insulin resistance in 70 %. • Polygenic inheritance.

  11. Diagnosis of PCOD

  12. Evaluating Androgen excess Clinical Hyperandrogenemia • Hirsuitism • 60-70% • More gradual • Variation with age and ethnicity • Ferrimen and Gallway score->15 severe

  13. Polycystic Ovarian Morphology • Early follicular phase(day3-5) • Oligo/Amenorrhoeic-At random or3-5 days • Stromal area/total area ratio and or increased stromalechogenesity • The usefullness of 3-D,Doppler or MRI (Ultrasound assessment of the polycystic ovary-International consensus definition-Human reproduction;9:505-13)

  14. Evaluating PCOM Swanson and Co-Workers-1981 • General population-20-33% • > 12 follicles at 2 - 9 mm in at least 1 ovary • Volume > 10cc • If a follicle is >10mm, repeat scan next cycle. • Transvaginal is preferable • Does not apply to women on OC pills • Single ovary-sufficient to diagnose

  15. PCOM PCOM (Polycystic Ovarian Morphology)

  16. Clinical features • Obesity-BMI>25 in 35-50% • Android appearance • Waist to hip ratio • Acanthosis Nigricans-Non specific • HAIR-AN SYNDROME • Hyperpigmented velvety patch-nape of the neck,axilla,inner thigh and vulva

  17. Biochemical Investigations Gonadotrophins-LH/FSH • Increase in amplitude and frequency of LH • Elevated in 95% • LH increased in 60-70% • ?Reliability of a single measurement • Increased LH levels and its treatment-controversial • Lack on agreement on abnormal result

  18. Biochemical investigations • 2 hr GTT-F-110-125mgm/dl 2hr-140-199mgm/dl With severe stigmata of insulin resistance and hyperandrogenemia or undergoing ovulation induction • Fasting insulin->25microIU/ml • Fasting G/I ratio of 4.5 or less (Suggested evaluation in PCOS-ACOG2009)

  19. Biochemical investigations Tests for metabolic syndrome(Updated adult t/t panel lII) • Cholestrol,LDL • HDL<50mgm/dl • Triglycerides>150mgm/dl • BP-130/85 • F blood glucose>100mgm/dl • Waist circumference>35 inches (Suggested evaluation in PCOS-ACOG2009)

  20. Diagnosis of exclusion • Hypergonadotrophichypogonadism • Hypogonadotropichypogonadism • Non classic congenital adrenal hyperplasia • Suspected PCOS-1-19% • Screening-17OHP-<200ng/dl,>500 certain • ACTH stimulation test-25USP • 17OHP>1000 • CUSHING SYNDROME 24 hour free cortisol and 17 hydroxysteroids

  21. Diagnosis of exclusion • Adrenal and ovarian tumours • Rapid virilization • Testosterone >200ngm/dl • DHEAS >700ng/dl • Imaging techniques • ? Hyper prolactinamia • ?Hypothyroidism

  22. Complete Evaluation • HISTORY-Menstral disturbances, Hyperandrogenism, Infertility, weight gain, Galactorrhoea, Symptoms of hypothyroidism, Drug intake, Family history • Examination-BMI, Type of obesity, Hypertension, Hirsuitism, Signs of virilization, Signs of Cushings disease, Galactorrhoea, Acanthosis nigricans, Abdominal examination, PV /PR Examination

  23. Complete Evaluation • Free testosterone • Total testosterone • DHEAS • LH/FSH Ratio • 17OH progesterone • Test for hyperinsulinemia • Test for dyslipidemias • Prolactin • TSH

  24. Conclusions • Early diagnosis and intervention is imperative • Rotterdam criteria should be used • Somatic or Lab Hyperandrogenism • Oligo-anovulation • Polycystic Ovarian Morphology • Exclude • Non-classical 17-hydroxylase deficiency, adrenal tumor, Cushing’s, prolactinemia, thyroid disorders, hypothalamic amenorrhea Make a diagnosis of PCOS before starting treatment

  25. Thank You

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