Age: 26 G1P1 (1001) Date of 1st Consultation Nov.

22, 2011

Missed

menses for 4months, Decreased amount and duration of menses for 2 months

Jan 2011

Feb

Mar

April

May

June

July

Augu st

Sept

Oct

Nov

III

IIII

IIII

II

II

DMPA

DMPA

Pregnan cy test (-)

Pregnan cy test (-) 2nd week

Pregnan cy test (-) Nov. 22, 2011

LMP : May 2011

PMP: April 2011

1 month and 22 days prior to last consultation

Patient had irregular menses for 6 months now (Nov. 19, 2011)
(-) dysuria
(-)fever (-) hypogastric pain (-)Pregnancy test Nov. 22, 2011

 Had

mumps, measles, chickenpox during childhood hypertension, no diabetes, no bronchial asthma previous hospitalization, no blood transfusion, no allergy to food and drugs

No

No

Family History

Father No

and mother are apparently well.

other known heredofamilial diseases such as hypertension, diabetes and bronchial asthma

Menarche: 14 years old

Subsequent menses

Interval-irregular
(60-120

Duration:5 days

days)

Amount:3-4 pads/day
Symptoms: (-)dysmenorrhea

Duration:5 days Amount:3-4 pads/day

Symptoms:

(-)dysmenorrhea

Total Pregnancies: G1 P1 (1001)

Gravid Date Where How Pregnancy

Dec. 26, 2002

Home

Normal Spontaneous Delivery

No complications

Last

Pap smear(Dec. 2011)

Oral Contraceptive pills (April 2010-January 2011)

Depot Medroxy progesterone acetate (DMPA) (January 2011) *last DMPA (May 2011)

CNS: No headache, no blurring of vision CVS: No palpitation Respiratory: No difficulty of breathing, no cough, HEENT: no blurring of vision, no hearing loss, no tinnitus GIT: no nausea, no vomiting GUT: no dysuria, no frequency, no urgency, no retention, no hematuria

NMS: no arthralgia, no myalgia, no numbness, no paresthesia

 General

Survey: conscious, coherent, not in cardiorespiratory distress Vital signs:

BP: 110/ 70 mmHg RR: 19 cpm

PR: 84 bpm Temp: 37.0C

Weight:

82 kg/m Height: 157.2 cm BMI: 33.6 kg/m2

HEENT: Pink palpebral conjunctivae, white sclerae, no tonsillopharyngeal congestion, no nasoaural discharge, neck is supple, (+) upper lip hair, (+) acne

Neck: Neck is supple, no palpable lymph nodes Chest/lungs: Symmetrical chest expansion, no retraction, no lagging, clear breath sounds, no wheezes, no crackles Heart: Adynamic precordium, normal rate, regular rhythm, no murmur Abdomen: Flabby, soft, no mass, no tenderness, normoactive bowel sounds

 Genitalia:

speculum exam: clean looking cervix with minimal whitish discharge Internal Examination: Normal looking external genitalia, parous introitus, vagina admits 2 finger with ease ,firm cervix, uterus and adnexae cannot be assessed due to thick abdomen

Extremities

: No gross deformities, full equal pulses

Skin: no active dermatoses

 Gravida

1 Para 1 (1001)

Abnormal

Uterine bleeding probably secondary to chronic anovulation Consider Polycystic Ovarian Syndrome

To

 Well

balanced diet Increase fluid intake Start Medroxyprogesterone 10mg/tab, 1 tablet OD x 5 days For Transvaginal Sonogram c/o OB sonologist on Day 3-5 of menses Advised daily perineal hygiene Advised to come back on Day 1 of menses or after 2 weeks if with no menstrual bleeding

1 month and 9 days prior to last consult

Subjective complaints:
no dysuria, no fever, no hypogastric pain BMI: 34.32 kg/m2 (34.4 previous BMI)

Still for Transvaginal sonogram on Day 3-5 of menses

1 month and 2 days prior to last consult has completed Medroxyprogesterone 1 tab once a day for 5 days still without menses PE: BMI: 34.02 kg/m2 (34.32 previous BMI ) PLAN: Still for Transvaginal sonogram on Day 3-5 of menses

Transvaginal Ultrasound
uterus

1 month and 2 days prior to last consult Dec. 12, 2011(still without menses)
4.46x 2,.12x2.21 Anteverted, w/ homogenous matl echopattern 0.65cm Thick, hyperechoic 1.80x 2.47cm Unremarkable 2.12 x 2.21x 1.67cm w/ multiple immature follicles arranged subcapsularly 2/ dens central stroma 2.54x 2.29x1.54cm w/ multiple immature follicles arranged subcapsularly 2/ dens central stroma anterverted unenlarged uterus, secretory endometerium, unremarkable cervix, polycystic bilateral ovaries

Endometrium Cervix Right ovary

Left ovary

Impression

Cont1 month and 2 days prior to last consult

PE: Weight: 84.4 kg Height: 156.7 cm 34.02 kg/m2 (previous BMI 34.32) BMI:

Refer to Reproductive Endocrinology and Infertility

1 month prior to last consult

BMI: 34 kg/m2 (previous BMI 34.02)

Refer to Reproductive Endocrinology and Infertility

1 month prior to last consult (Reproductive Endocrinology Infertility notes) regularly menstruating until had Depot Medroxy Progesterone Acetate last May 2011 did not have menses upto now 1 day prior to consult had spotting-brownish

PE:
HEENT: with facial hair, with acne ABDOMEN: Abdominal circumference= 42 inches, flabby, soft, no palpable mass nor tenderness Speculum examination: clean looking cervix, minimal brownish discharge per os Internal examination: cervix firm, closed, corpus anteverted unenlarged, no adnexal mass nor tenderness BMI:34 kg/m2 (34.02)

Cont.
G1 P1 (1001), Secondary Amenorrhea 2 to DMPA, PCOS, T/C Metabolic Syndrome Advised weight loss and lifestyle modification For TSH, FSH,Prolactin For 75 gm OGTT For lipid profile To come back with results, if normal results, start Oral Contraceptive pills Start Provera on day 16-25 of cycle while awaiting lipid profile results

21 days prior to last consult

test result

hour: less than 200 mg/dL 2.6 UIU/ml 0.4-5.5 UIU/ml N 2 hours: less than 140 mg/dL. Between 1404-30 ng/ml Prolactin: 27.9 ng/ml N 200 mg/dL indicates impaired glucose N FSH: 16.7 MIU/ml 5-20 tolerance (prediabetes). If test results are in this range, 5.80patient is 3.9-6.1 increased risk a mmol/L at an N FBS: mmol/L for developing diabetes. GreaterN than 200 1hr PPBS 8.1 mmol/L/ 145.8 <200 mg/dl mg/dl mg/dL indicates diabetes
Thyroid Function TSH: 2hr PPBS 7.4 mmol.L /133.2 <140 mg/dl

reference range

interpretation

Cholesterol: Triglyceride: HDL: LDL: VLDL:

5.6 1.68 1.27 3.49 0.84

3.5-5.2 mmol/L 0.3-1.9 mmol/L 0.7-2.1 mmol/L 0-3.9 mmol/L N N N

0-1.02mmol/L N

21 days prior to last consult

*Reproductive Endocrinology Infertility notes

advise diet modification Start Metformin 500mg/tab once a day for 7 days; then twice a day then 3 times a day Continue Provera 10mg/tab for 3 more days

52 days 39 days 32 days 30 days 21 days 4 days prior to PTC PTC PTC PTC PTC last consult
34.4 34.32 34.02 BMI Below 18.5 18.5 to 24.9 25.0 to 29.9 30 or higher 34.0 34.65 34.07

Last consult

33.6

Considered Underweight Healthy weight Overweight Obese

 26

years old Chief complaint:Amenorrhea for 4 months, oligomenorrhea for 2 months Acne Facial hair (upper lip) BMI=34 (obese) Pregnancy test (-) Contraceptive method:

April 2010-Jan. 2011 (OCP) Jan. 2011, May 2011( Injectable DMPA )

OB o

history: G1P1(1001) LMP: May 2011 PMP: April 2011

 Pregnancy
Polycystic

ovarian syndrome

Rule in

Rule out

Amenorrhea for 4 months Oligomenorrhea for 2 months

Pregnancy test negative (August, October, November 2011) Transvaginal ultrasound Dec. 12, 2011: uterus unenlarged with

homogenous myometrial echopattern

Internal Examination: Normal looking external genitalia, parous introitus, vagina admits 2 finger wi th ease ,firm cervix, uterus and adnexae cannot be assessed due to thick abdomen

Rule in

Rule out

Amenorrhea for 4 months Oligomenorrhea for 2 months Transvaginal ultrasound: bilateral polycystic ovaries Signs of hyperandrogenism (increased facial hair, acne)

Cannot totally rule out

 Probably

the most common endocrine disorder in women

char. by findings of irregular (anovulatory) cycles symptoms or signs of androgen excess and polycystic ovaries on ultrasound

Classically

Revised 2003 consensus on diagnostic criteria and longterm health risks related to PCOS
concluded that PCOS is a syndrome of ovarian dysfunction along with the cardinal features hyperandrogenism and polycystic ovary (PCO) morphology. remains a syndrome, and as such no single diagnostic criterion (such as hyperandrogenism or PCO) is sufficient for clinical diagnosis.

 Most

common endocrinopathy among women of reproductive age Menstrual irregularity and insulin resistance in 70% Prevalent markers of premature cardiovascular disease

PCOS: Diagnostic criteria 1990 NIH: requires both criteria1

Chronic anovulation

2003 ESHRE/ASRM: requires 2 of 3 criteria

Oligo- and/or anovulation

Clinical and/or biochemical signs of hyperandrogenism

Clinical and/or biochemical signs of hyperandrogenism (HA)

Polycystic ovaries

*With exclusion of other etiologies

In both NIH and ESHRE/ASRM definitions, the diagnosis assumes exclusion of other diagnoses that may have similar clinical presentation as PCOS4 such as:

non-classical congenital adrenal hyperplasia due to 21hydroxylase deficiency, Cushings syndrome and androgen-secreting tumours

exclusion of other related disorders:

High-dose exogenous androgens Hyperprolactinemia Thyroid dysfunction

CLINICAL S/S
Ovarian Tumor
Pelvic mass on bimanual examination

LABORATORY
Testosterone > 2ng/ml DHEA-S normal Confirm by UTZ, CT scan and MRI

Androgen Producing Adrenal Tumor

Cushing syndrome PCOS

Rapidly progressive signs of virilization.

DHEA-S > 8ug/ml

hirsutism or virilization is prolonged and gradual Hirsutism or virilization is prolonged and gradual Menstrual irregularity

dexamethasone test/ Liddle test elevated LH levels mild increase in testosterone and DHEA-S levels UTZ findings

 Presence

of >=12 follicles in each ovary measuring:

2-9 mm in diameter increased ovarian volume (>10ml).

Diagnostic tests used to diagnose PCOS/ rule out conditions that mimic pcos

Diagnostic procedures done in the patient

Rule out other endocrine problems

TSH Prolactin FSH Blood Chemistry

(FBS, Cholesterol, Triglycerides, HDL, LDL, VLDL)

Biochemical signs of hyperandrogenism (testosterone, dhea-s) Ultrasound

Ultrasound

 Hirsutism Acne male pattern balding, and/or male distribution of body hair

Hirsutism

Acne
Lobo RA, et al. Ann Intern Med. 2000;132:989-993.

A summary score of greater than 8 is considered indicative of hirsutismexcessive hairgrowth

What is the pathophysiology of the PCOS?

Insulin
acts

synergistically with LH to enhance androgen production hepatic synthesis of SHBG

inhibits

Diagnosis of PCOS: Workup for hyperandrogenism

Clinical
Hirsutism-primary
indicator
Acne

Biochemical
Free testosterone

Free androgen index

Book description SIGNS

Patient

>Hyperandrogenism Hyperandrogenism (Hirsutism, Facial hair elevated blood Acne level of androgentestosterone, DHEA-S) >enlarged polycystic ovaries (ultrasound) transvaginal ultrasound): Polycystic bilateral ovaries 4 months amenorrhea

SYMPTOMS

amenorrhea

 may

also include:

Obesity
Insulin resistance and elevated levelsalso common features serum LH

Assoc. w/ an increased risk of type 2 diabetes and cardiovascular events.

Menstrual Irregularity& hyperandrogenemia

may manifest at puberty w/ a delayed menarche ff. by onset of irregular periods or as the breakdown of a previously regular cycle w/in a few years & often associated w/ weight gain(50% obese) Anovulation >usually chronic & presents as oligomenorrhea / amenorrhea >usually assoc.w/ varying degrees of infertilityFreq. cause of anovulatory infertility(75%)

LH
LH/FSH ratio androgen levels*

sex hormone binding globulin

may increase free testosterone levels

Duncan S. Epilepsia. 2001;42(suppl 3):60-65.

LDL cholesterol triglycerides

Strongly linked to CVD

HDL cholesterol -most common

Impaired fibrinolytic activity*

plasminogen activator inhibitor levels*= predict occurrence of MI

 Hyperinsulinemia and insulin resistance

*Women with PCOS tend to be hyperinsulinemic, regardless of whether they are lean or obese

a greater frequency &degree of both hyperinsulinemia + insulin-resistance vs. weight-matched controls

Insulin resistance
may be independent of the effect of obesity both lean and obese women
sensitivity to insulin in peripheral tissues but not hepatic resistance, (unlike in type 2 DM)
decreased

peripheral insulin sensitivity & consequent hyperinsulinemia

may

play an impt. role in the pathogenesis of PCOS

inhibit the prodn of SHBG in the liver SHBG free testosterone

Insulin

Therefore,

insulin resistance : secretion of ovarian androgen promotes free (biologically active) hormone

COMPLAINT
Infertility

TREATMENT OPTIONS

Patients medications

Metformin;
Clomipene;Letrozole; gonadotropins;ovarian cautery

weight./metabolic concerns

Diet/lifestyle management/ Metformin*

Metformin-1st line Tx

Skin manifestations

Dysfunctional bleeding

Oral contraceptive+antian drogen(spironolactone , flutamide, finestride);gnrh agonist Cyproterone Acetate+Ethinyl Cyclic progestogen; estradiol(Althea) ocps

Insulin

resistance & elevated serum LH levels Assoc. w/ increased risk of type 2 diabetes & cardiovascular events.

importance of diagnosing PCOS warrant lifelong surveillance long-term consequences:

Endometrial cancer ovarian cancer DM hypertension

 syndrome

Constellation

of dyslipidemia, elevated bp,IGT, and central obesity of the major health problems assoc. w/ obesity not only in Western and European countries but also in Asia Pacific region
resistance and hyperinsulineamia

Insulin

-implicated in etiology of glucose intolerance, dyslipidemia and obesity

 Glucose

intolerance/ insulin resistance Raised arterial pressure Raised plasma triglycerides Central obesity Microalbuminuria
PATHOLOGY:

fundamental defect in pts. w/ Metab syndromeinsulin resistance in both adipose and muscle tissue

 Central

obesity defined as waist

circumference:
>= 90 cm (35.4 inches) for Asian men

>= 80 cm (31.5 inches) for asian women (pts= 42 inches) w/ ethnicity specific values for other groups + any 2 of the ff. factors:

Raised

TG level: >= 150 mg/dl (1.7 mmol/L) or specific treatment for this abnormality
Pts 149 mg/dl(1.68 mmol/L )

 Low

HDL cholesterol (high-density

lipoprotein cholesterol), or being on medicine to treat low HDL.

< 50 mg/dL for women and <40 mg/dL for men (pts49)

High

blood pressure, or being on medicine to

treat high blood pressure.

BP130/85 or higher ( pts 110/70)

High

fasting blood sugar , or being on

medicine to treat high blood sugar

FBS of 100 mg/dL or higher (pts 104.4)

 Ovaries-being

exposed to consistenetly highlevels of insulinincreases testosterone secretion

Major factor in the devt of pcos

THANK YOU!