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Management of Adolescent PCOD Made Easy ,Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Jyoti Bhaskar Dr. Abhihsek parihar


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Management of Adolescent PCOD Made Easy ,Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Jyoti Bhaskar Dr. Abhihsek parihar

  1. 1. Management of Adolescent PCOD Made Easy Dr. Sharda Jain Dr. Jyoti Agarwal Dr. Jyoti Bhaskar Dr. Abhihsek parihar
  2. 2. PCOD & Hyperandrogenism in Adolescents There is Need to Update as Lately it is confusing The Gynaecologists !!
  3. 3. Learning Objectives • Prevalence and onset • Etiology / Pathophysiology • Update on clinical presentation • Update of diagnostic criteria for PCOD. • Short & long term consequences PCOD •Tailor Made Therapy
  4. 4. Importance of PCOD PCOD constitutes a CONTINUUM SPECTRUM starting from the EARLY PREPUBERTAL YEARS and continuing after Menopause S/S peak through 2nd / 3rd decade of life
  5. 5. Diagnosis of Polycystic Ovarian Disease 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. 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 Disease
  7. 7. Prevalence of adolescent PCOD 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. 8. Prevalence of PCOD In India Girls
  9. 9. Experience Near 18-20% girls going to private schools in Delhi have PCOS Obese – 50% Menstrual Problems – 60% Delayed Periods Most Common Heavy Menstrual Bleeding – 20% HIRSUTISM – 60-70% ACNE – 30% DGF Survey of 2 schools 2004
  10. 10. PCOS has a complex & incompletely understood - Etiology • Exact etiology of PCOS is still Unknown – likely due to a steady state of high estrogen, androgens, luteinizing hormone (LH) and insulin levels. • High estrogen levels can cause suppression of pituitary FSH and relative increase in LH. • Increased LH stimulates the ovary, which results in anovulation, multiple cysts and theca cell hyperplasia with excess androgen output. • High insulin levels may also increase the production of testosterone by the ovaries.
  11. 11. Complete Pathophysiology of PCOD
  12. 12. Genetic of PCOS PCOS is a familial disorders with a single autosomal dominant gene defect The current litrature on genetics of PCOS is disappointing, Full of controversies & lack of clear consensus l
  13. 13. VITAMIN D DEFICIENCY IS AN INDEPENDENT PREDICTOR OF Obesity 80% PCOS women are obese PCOS Women with VIT-D deficiency • Higher mean BMI • Hypertension • Hypertriglyceridemia • Lower high-density cholesterol (all p<0.05) Exp Clin Endocrinol Diabetes. 2006 Nov;114(10):577-83.) ACOG
  14. 14. Uploaded in Newer concepts of managing With Myo-Inositol Dr. Jyoti Agarwal Dr. Sharda Jain Dr. Jyoti Bhaskar
  15. 15. DIAGNOSIS
  16. 16. Conforming the diagnosis •History & symptoms •Clinical examination •Biochemical investigation •Ultrasonography 20% normal girls have polycystic ovaries while Polycystic ovaries may not be seen in PCOS girls
  17. 17. History & symptoms • Family History : Risk of PCOS • 40% - if her sister is having PCOS • 20% - if her mother suffered from PCOS
  18. 18. Symptoms & Signs • Hyperandrogenism • Acne • Hirsutism • Metabolic syndrome • Central obesity • Insulin resistance • Glucose intolerance Anovulation & Menstrual irregularities Infertility
  19. 19. Clinical Manifestation of PCOD AAccnnee OObbeessiittyy AAccaannttoossisis HHirirssuuttisismm HAIR LOSS HAIR LOSS IRREGULAR MENSES IRREGULAR MENSES
  20. 20. Common Signs And Symptoms of PCOD AAccnnee HHirirssuuttisismm IRIRRREEGGUULLAARR M MEENNSSEESS OObbeessitityy
  21. 21. Symptoms of PCOD Over weight /Obesity 50-80% Abnormal Uterine Bleeding 30 - 50% Obese patients – Over 50% NON obese - 20 - 25% Around 50-70% PCOS girls Have hirsutism & around 30-35% Girls Have acne
  22. 22. 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)
  23. 23. PCOS in Adolescent Pattern of Menstrual Irregularity Delayed periods is most common presentation Other Presentations are: • Withdrawal bleeding only • Absent periods • Heavy menstrual bleeding or • Menometrorrhagia with Anemia
  24. 24. Criteria HMB in PCOS • More then 6 pads/ day • >80 ml per cycles • Ultrasound typical picture - PCO • Increased total testosterone
  25. 25. AAEESS RREECCOOMMMMEENNDDAATTIIOONNSS • PPCCOOSS iiss aa HHYYPPEERRAANNDDRROOGGEENNIICC DDIISSOORRDDEERR • TThhee oovvaarriiaann mmoorrpphhoollooggyy sshhoouulldd bbee ccoonnssiiddeerreedd wwhheenn eessttaabblliisshhiinngg tthhee ddiiaaggnnoossiiss bbeeccaauussee ppoollyyccyyssttiicc oovvaarriieess aarree ffoouunndd iinn tthhee mmaajjoorriittyy,, aalltthhoouugghh nnoott aallll,, wwoommeenn wwiitthh PPCCOOSS
  26. 26. Physical Exam – Significant Findings • SKIN – Acanthosis nigricans (darkly shaded skin in the flexures of the neck , axilla, or groin – IR/DM) Is seen in young girls very frequently Skin tags – IR/DM 1-2 % Acanthosis nigricans NON obese - 10-20% Obese – 50%
  27. 27. Acne – 30% Severe -80% Moderate – 50% Mild - 30%
  28. 28. Alopecia • Less common • Diffuse thinning With preservation of frontal line • Bitemporal recession Cause • Decrease in 5a reductase - in DHT
  29. 29. HIRSUITISM 10% young girls have hirsutism In 60-70% - PCOS is the cause
  30. 30. Insulin Resistance
  31. 31. IInnssuulliinn RReessiissttaannccee • 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.
  32. 32. • PCOS is a major risk factor for developing IG and T2D (level A). • Obesity (by amplifying insulin resistance) is an exacerbating factor in the development of IGT and T2D in PCOS (level A). • The increasing prevalence of obesity in the Population suggests that a further increase in diabetes in PCOS is to be expected (level B). • Screening for IGT and T2D should be performed by OGTT (75 g, 0- and 2-hour values). There is no utility for measuring insulin in most cases (level C).
  33. 33. Insulin Resistance & 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
  34. 34. IInnssuulliinn RReessiissttaannccee • IINNTTEERRPPRREETTAATTIIOONN -NNoorrmmaall ffaassttiinngg→→<<1155 mmiiccrroo IIUU//mmll AAfftteerr 22hhrr PPPP <<3300 mmiiccrroo IIUU//mmll -- IINNSSUULLIINN RREESSIISSTTAANNCCEE lliikkeellyy →→ 110000 --115500 -- IINNSSUULLIINN RREESSIISSTTAANNCCEE →→115511 –– 330000 -- sseevveerree iinnssuulliinn rreessiissttaannccee →→ >> 330000 • FFaassttiinngg gglluuccoossee ttoo ffaassttiinngg iinnssuulliinn rraattiioo iiss nnoo lloonnggeerr rreeccoommmmeennddeedd bbeeccaauussee ooff iittss vvaarriiaabbiilliittyy
  35. 35. • Screening should be performed in the following conditions: hyperandrogenism with anovulation, acanthosis nigricans,obesity (BMI >30 kg/m2, or >25 in Asian populations), in women with a family history of T2D or GDM (level C). • Metformin may be used for IGT and T2 (level A). Avoid use of other insulin sensitizing agents such as thiazolidinediones (GPP).
  36. 36. MMeettaabboolliicc SSyynnddrroommee && PPCCOODD • Insulin resistance , • obesity • atherogenic dyslipidemia , and • hypertension Increase CVD and type 2 DM
  37. 37. PCOS in adolescents may have few special features • Above average or low birth weight for gestational age. • Premature aderenarche, • Atypical sexual precocity • Obesity with acanthosis nigricans PCOS remains largely UNDIAGNOSED as irregular menses after menarche for 2 years & acne is common in adolescents& • Transabdominal ultrasound resolution has poor sensitivity to diagnose PCOS
  38. 38. Obesity
  39. 39. BMI Cutoff for INDIAN -2.5 in each category BMI Cutoff Weight Status Comments <18.5 UNDERWEIGHT Being underweight also puts you at risk for developing many health problems. 18.5 - 23.9 HEALTHY WEIGHT RANGE Your weight is within normal range. You can continue to keep a healthy weight through physical activity and healthy eating. Keep up with the good work! 24 - 26.9 OVERWEIGHT Being overweight can put you at risk for developing many chronic diseases >27 OBESE Obesity increases risks for developing many chronic diseases such as heart disease and diabetes, and decreases overall quality of life.
  40. 40. FAT DISTRIBUTION –CENTRAL OBESITY android, APPLE SHAPE Central Obesity is High Risk For Co-Morbidities / Complications – LOWER BODY OBESITY Gynecoid PEAR SHAPE
  41. 41. Target WAIST Circumference for Indians Sometimes even when BMI is within Normal range, having too much fat around the abdomen (APPLE SHAPE BODY) will still put one at risk for heart disease and diabetes. Below are the target goals for waist circumference measurements. INDIAN WOMEN Equals or less than 80cm (31.5 in)
  42. 42. Lab Diagnosis
  43. 43. Summary of Suggested Lab Test by ACOG  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
  44. 44. Bio chemical and Diagnostic Markers of PCOD Accepted everywhere – Elevated androgen (i.e. testosterone > 60 or free testosterone >0.75) levels – Elevated LH:FSH ratio > 2:1 – Increased Insulin levels – Insulin resistance , (Clinical / Lab) Lab diagnosis of insulin resistance is not needed – Ultrasound appearance of PCO
  45. 45. Screening Tests For PCOD ACOG Recommendation • ACOG recommends that all women with a suspected diagnosis of PCOD should be screened with 17-hydroxyprogesterone level to R/O late onset CAH (Level C). • PCOD and late onset CAH are distinguished from each other only by laboratory testing.
  46. 46. A Lab Tests suggested for SUDDEN onset of Hyperandrogenism Test Result Total testosterone level Slightly elevated in PCOS Total testosterone > 200 ng/dL -- suspicious for adrenal or ovarian tumor therefore additional evaluation with pelvic US, CT or MRI indicated Serum DHEAS level Slightly elevated in PCOS DHEAS level > 8 ng/ml -- suspicious for adrenal tumor therefore additional evaluation should include adrenal gland imaging with CT or MRI 24 hour urine cortisol or overnight dexamethasone Urine free cortisol >20 ug/d is suggestive of Cushing’s Syndrome
  47. 47. Hyperandrogenism Hirsutism, acne, alopecia BIOCHEMICAL Testing • Free Testosterone –NO ROLE & 10 times costly • ANDROSTENADIONE-NO ROLE SUDDEN ONSET of these symptoms suggests other D/D * Cushing’s syndrome * Adrenal or ovarian tumor.
  48. 48. Ultrasound Rotterdam Criteria • In one or both ovaries Ovarian volume > 10 ml • 12 follicles, 2-9 mm in diameter • Echo dense stroma Typical “Black Pearl” Necklace
  49. 49. Ultrasound • Ultrasound : during puberty polycystic ovary should be distinguished from multicystic ovaries. • Typical : large size of cyst and thick ovarian stroma is hallmark • Use of the abdominal instead of TVS in teenage virgins decreases ultrasound sensitivity.
  50. 50. EExxcclluussiioonn ooff RReellaatteedd DDiissoorrddeerrss • 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)
  51. 51. 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
  52. 52. Summary of presentations and Consequences of PCOD in adolescents The Most Common Endocrine disorder In women 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
  53. 53. Cancer & PCOD •There are moderate quality data to support that women with PCOS have a 2.7-fold (95% confidence interval [CI],1.0–7.3) increased ris for ENDOMETRIAL CANCER. (level B). •Limited data exist that do not support the conclusion that women with PCOS are at increased risk for OVARIAN CANCER (level B).
  54. 54. PCOD & Breast Cancer ?? Limited data exist that do not support the conclusion that women with PCOS are a increased risk for BREAST CANCER (level B).
  55. 55. CHALLENGES
  56. 56. It is good to RULE OUT Diagnosis of following before start of Treatment Pre-Diabetes Fatty Liver Diabetes type II Hyperlipidemia Insulin Resistance Hypo-Thyroidism Metabolic Syndrome Vitamin-D Deficiency Diagnostic criteria for various conditions are not discussed here
  57. 57. Challenges of PCOD in Different Age Groups Irregular menaces But the Root Cause is The Same
  58. 58. OBESITY in PCOD & PSYCHOSOCIAL HEALTH of GIRL 1. Poor body image 2. Social stigmatisation (‘a laughing matter’) 3. Lower education levels 4. Lower rates of marriage 5. Lower socio economic levels BIG CHALLENGE
  59. 59. PCOS can’t be cured but the symptoms can be managed 50 % by just WEIGHT CONTROL
  60. 60. Treatment Her concerns are Cosmetic Concerns - Acne - Hirsutism - Hair Loss Obesity •Menstrual Irregularity Team approach is a must for best results Gynaecologist Dermatologist & Endocrinologist
  61. 61. She is just NOT BOTHERED of the Following - Infertility - Early pregnancy loss -During pregnancy - PIH - GDM -Metabolic Syndrome -Ca Endometrium COUNSELLING OF LONG TERM CONSEQUENCES IS VITAL TO NORMALISE HER WEIGHT
  62. 62. Implications of diagnosis & counseling at adolescent age Optimization of lifestyle is better Regular metabolic screening Proactive fertility planning with consideration of planning for conception at an earlier age
  63. 63. Treatment Acne / Hirsutism
  64. 64. Treatment- Acne And Hirsuitism • All combination OCPs effective • OCPs decrease androgen levels by suppressing LH and stimulating sex hormone binding globulin (SHBG). •OCPs with low androgenic progestins (norgestimate, desogestrel) may be Most effective for acne and hirsuitism (Level B)
  65. 65. Hirsuitism Treatment • METFORMIN – Reduces hirsuitism after 12 mos tx (Level A) • ANDROGEN RECEPTOR BLOCKERS – A full clinical effect may take 6 months or more – Spironolactone 25-100mg bid (Level A) – Flutamide 250 mg daily x 12 mos ( Level A) – Cyproterone acetate-ethinylestradiol 50-100mg daily (Level A) Finasteride 1 mg a day (Level C)
  66. 66. Hirsutism • Prolonged (>6 months) medical therapy for hirsutism is necessary to document effectiveness (level B) • Antiandrogens should not be used without effective contraception (level B) • Flutamide is of limited value because of its dose-dependent hepatotoxicity (level B). • Drospirenone in the dosage used in some OCPs is not antiandrogenic(level B).
  67. 67. Treatment of Hirsuitism •Mechanical – Shaving or depilation – Electrolysis – Laser epilation (Level A) • 30-50% reduction at 6 mos after multiple txs •Topical – Ornithine Decarboxylase Inhibitor (Hinder ) • 13.9% cream BID (Level C)
  68. 68. Topical cream • Effornithine hydrochloride Cream 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
  69. 69. Hirsuitism Treatment Few tips by Dermatologist • Combination Therapy to be started 3 months prior to treatment • OCP + antiandrogen may be most effective (Level C)
  70. 70. 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.
  71. 71. Few Tips Of Solution By Dermatologist • Permanent Methods – Destroy the hair follicles. • Electrolysis – Application of electric current via a fine electric probe to individual hair follicle which leads to its destruction. However it is extremely time consuming, painful, needs several sessions and may result in scarring of surrounding skin due to non selective destruction of tissue. • All most given up technique
  72. 72. Few tips of Solution by Dermatologist • Laser Hair Removal a. Laser cause selective destruction of hair follicles. b. Laser do not achieve permanent hair destruction after single treatment. Several sessions between 4 to 8 are needed for significant hair reduction. c. Laser targets melanin which is present only in the anagen state of the hair cycle and younger the hair,more the melanin, better the destruction. d. Resting hairs (Telogen Stage) and grey hairs which do not contain melanin and hence are not effected by laser. e. These resting hairs reach growing stage in 3 to 4 weeks and hence laser needs to be repeated at that interval. To remove this 2nd generation of hairs. This is why many sessions are required.
  73. 73. Classifying Acne A. Non Inflammatory Acne or Comedonal Acne Black Heads White Heads B. Inflammatory Acne Red Papules Pustules Cysts C. Combination of above
  74. 74. 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
  75. 75. Management - Systemic • 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
  76. 76. Management - Systemic • Hormonal therapy – Recalcitrant acne – Acne not responding to oral Isitretenoin – Coprescribed with Isotretenoin – PCOS
  77. 77. Treatment – Other modalities • Chemical peels • Comedon removal • IPL • Cryotherapy • Microneedling • Use of steroids Good Dermatologist help is needed. Dr. V.K. Upadhyay Gynaecologist cant treat on there own
  78. 78. Acne
  79. 79. Obesity in PCOD
  80. 80. Is Obese PCOD Girl at Risk of Infertility Yes an obese girl is about THRICE as likely to be infertile as a normal woman Polotsky AJ, hailper SM skurnick JH, LO JC sternfeld B, santoro N associated of adolescent women’s health across the nation (SWAN) fertility steril 2010;93:2004- 11)
  81. 81. Management in General • Obese patients are advised to lose weight which may be accomplished by one or a combination of following methods - – Diet – Diet & Exercise – Anti-obesity Medicines – BARIATRIC SURGERY
  82. 82. Management of Obesity in general 1st LINE OF MANAGEMENT : Lifestyle changes like modification of diet , physical activity and daily habits 2nd line of Management : introduction of pharmacotherapy for patients with BMI above 24 with co – morbidities and BMI above 27.5 with no co- morbidity BARIATRIC SURGERY : may be an option for treatment of morbid obesity (BMI > 32.5) when diet and exercise do not work 1 2 3
  83. 83. Diet Try to AVOID food which are known to increase blood sugar levels  Reduce intake of refined carbohydrates such as white bread and white rice and saturated fats like coconut oil, animal fat, dairy fat (butter, chees) etc.
  84. 84. Diet Increase intake of  Protein rich food such as meat, sea food, nuts, pulses, dry beans and egg
  85. 85. Why Exercise ? Daily exercise •Decreases insulin resistance •Decreases Occurrence of -- Diabetes -- CV Incidents A 30 minutes daily exercise can improve many symptoms
  86. 86. Weight loss is actually due to REDUCED CALORIES and … Walking.
  87. 87. Cola Drink
  88. 88. You’ve probably heard we should be taking 10,000 Steps a Day < 5000 steps is sedentary
  89. 89. The result - Is obesity We’re sitting A lot And sitting is bad for us SITTING increases Risk of DEATH upto 40%
  90. 90. so if you WORK OUT for 1 hour a day then SIT FOR 6.25 hours you’ve pretty much LOST ALL THE BENEFIT of working out
  91. 91. Solutions? If you enjoy running, by all means, run But if like me, you hate running Consider walking
  92. 92. but it’s about health, not weight Walking alone isn’t a quick ticket to weight loss. Just walking 10,000 steps, you won’t lose a lot of weight. It’s about overall health.
  93. 93. benefits of walking •Walking burns 3-5 times the calories of sitting •Decreased depression – increases neuro-transmitters like serotonin, dopamine and norepinephrine •Improved attention span – people who stop exercising can develop ADHD symptoms •Increased creativity – from a 10-minute walk •Lower blood pressure •Increased self esteem •Improved metabolism •Improved neurogenesis •Reduced risk of Alzheimer's •Reduced risk of diabetes, heart disease, arthritis and more
  94. 94. But how? • Skip an hour of TV and go for a walk • Get off the subway a stop or two early • Take the stairs • Go for a walk on your lunch break • Park your car further away from your destination • Walk while you make all your personal phone calls • Don’t stand still on the escalator • Take the long way home • Get a standing desk* • Ride a cycle to work place • Practice “aimless walking” • Count your steps *some restrictions may apply **not officially walking, but still fun
  95. 95. wearable devices and step counting NOW AVAILABLE IN INDIA
  96. 96. Weight Reduction • Moderate exercise, low calorie (500 kcal/day deficit), low fat & reduced glycemic load improves insulin sensitivity MOA-- Weight Loss ↑SHBG ↓Insulin ↓ Peripheral Aromatization ↓ ↓ of Androgens & ↓ Free E2 & ↓Androgen Estrogens Testosterone
  97. 97. Weight Reduction is must 5-7 % weight loss results in: -Resumption of normal menstruation in 30-60% of cases. -Improvement in endocrine parameters (decreased IR, decreased T, increased SHBG) -Increased spontaneous conception rates. Hence, Cost effective
  98. 98. Treatment of Obesity BMI > 30 Behavioural Counselling Lifestyle Modification – Diet, exercise Pharmacolgical Agents – Orlistat, Sibutramine ???? Bariatric Surgery ????
  99. 99. PHARMACOLOGICAL TREATMENT • SIBUTRAMINE: appetite suppressant, 5- 15mg/day - increase suicide tendency on its way out • ORLISTAT: blocks intestinal absorption of fat, 60-120mg TDS along with meals • To be used along with Diet Restriction & Exercise.
  100. 100. Morbid Obese BMI >35 Indian Over 32.5 BMI • Pharmacological TT NOT to be recommended as a first line in Morbidly obese patients. What To Do Is a BIG Question !! • It is seen diet restriction & Exercise do not decrease weight in cases of morbid Obesity
  101. 101. Bariatric Surgery in adolescent girls ?? • Bariatric Surgery --brings ~ 15–30% weight loss that is sustained in long-term, and significant reductions in healthcare costs and comorbidities (diabetes, hypertension, hyperlipidaemia, sleep apnoea and certain cancers) • Bariatric surgery is considered for patients with a – BMI above 40 kg/m2 (37.5 for indian) – BMI above 35 kg/m2 in the presence of obesity related comorbidities – BMI above 50kg/m2: first-line treatment RRCOG SAC Opinion Paper, March 2010 -2.5 BMI for Indians
  102. 102. Menstrual Irregularity
  103. 103. MENSTRUAL DISORDERS • Weight Stabilisation • Cyclic or continuous OCP/ • Progestins • Metformin
  104. 104. ORAL CONTRACEPTIVE PILLS • Decreases adrenal and ovarian androgen production and increases SHBG. • Reduces hair growth in hirsuite patients with success rate of less than 10% only. • OC’s containing new progestins such as (desogestrel, gestodene, norgestimate, drospirenone) are preferable.
  105. 105. ROLE OF OCP IN Adolescent PCOS • 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)
  106. 106. Other Drugs which can be used with OCP
  107. 107. Metformin
  108. 108. Metformin
  109. 109. METFORMIN VERSUS THE COMBINED ORAL CONTRACEPTIVE PILL FOR SYMPTOMS AND RISKS OF Adolescent PCOS. • No evidence of difference in effect between metformin and the OCP on hirsutism and acne. • Metformin was less effective than the OCP in improving menstrual pattern (OR 0.08) • Metformin resulted in a higher incidence of gastrointestinal (OR 7.75), and a lower incidence of non-gastrointestinal (OR 0.11) severe adverse effects. • Metformin was less effective in reducing serum androgen levels, free androgen index. • Metformin was more effective than the OCP in reducing fasting insulin. Cochrane library:2010
  111. 111. TAILOR MADE THERAPY in Adolescent PCOD is our attempt Your comments are needed by SMS / Watsapp 9650588339 Or Facebook
  112. 112. More & More PCOS CLUBS should be formed to shoot Information for teens & young PCOS patients on its various aspects
  113. 113. ADDRESS 11 Gagan Vihar, Near Karkari Morh Flyover, Delhi - 51 CONTACT US 9650588339, 011-22414049, WEBSITE : E-MAIL ID &