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

2. PCOD & Hyperandrogenism in Adolescents
There is Need to Update as
Lately it is confusing
The Gynaecologists !!

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. 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. 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. 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. 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. Prevalence of PCOD In India
Girls

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. 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. Complete Pathophysiology of PCOD

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. 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. Uploaded in slideshare.net
Newer concepts of managing
With Myo-Inositol
Dr. Jyoti Agarwal
Dr. Sharda Jain
Dr. Jyoti Bhaskar

15. DIAGNOSIS

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. History & symptoms
• Family History :
Risk of PCOS
• 40% - if her sister is having
PCOS
• 20% - if her mother suffered
from PCOS

18. Symptoms & Signs
• Hyperandrogenism
• Acne
• Hirsutism
• Metabolic syndrome
• Central obesity
• Insulin resistance
• Glucose intolerance
Anovulation & Menstrual
irregularities
Infertility

19. Clinical Manifestation of PCOD
AAccnnee
OObbeessiittyy
AAccaannttoossisis HHirirssuuttisismm
HAIR
LOSS
HAIR
LOSS
IRREGULAR
MENSES
IRREGULAR
MENSES

20. Common Signs And Symptoms of PCOD
AAccnnee HHirirssuuttisismm
IRIRRREEGGUULLAARR M MEENNSSEESS
OObbeessitityy

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. 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. 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. Criteria
HMB in PCOS
• More then 6 pads/ day
• >80 ml per cycles
• Ultrasound typical picture - PCO
• Increased total testosterone

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. 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. Acne – 30%
Severe -80%
Moderate – 50%
Mild - 30%

28. Alopecia
• Less common
• Diffuse thinning
With preservation
of frontal line
• Bitemporal
recession
Cause
• Decrease in 5a
reductase -
in DHT

29. HIRSUITISM
10% young girls have hirsutism
In 60-70% - PCOS is the cause

30. Insulin Resistance

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. • 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. 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. 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. • 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. MMeettaabboolliicc SSyynnddrroommee && PPCCOODD
• Insulin resistance ,
• obesity
• atherogenic dyslipidemia , and
• hypertension
Increase CVD and type 2 DM

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. Obesity

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. FAT DISTRIBUTION
–CENTRAL OBESITY
android,
APPLE SHAPE
Central Obesity is High Risk
For Co-Morbidities /
Complications
– LOWER BODY OBESITY
Gynecoid
PEAR SHAPE

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. Lab Diagnosis

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. CHALLENGES

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. Challenges of PCOD in Different Age
Groups
Irregular menaces
But the Root Cause is The Same

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. PCOS can’t be cured
but the symptoms can be managed
50 %
by just WEIGHT CONTROL

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. 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. 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. Treatment
Acne / Hirsutism

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. 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. 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. 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. 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. 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. 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. 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. 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. Classifying Acne
A. Non Inflammatory Acne or Comedonal
Acne
Black Heads
White Heads
B. Inflammatory Acne
Red Papules
Pustules
Cysts
C. Combination of above

77. 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

78. 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

79. Management - Systemic
• Hormonal therapy
– Recalcitrant acne
– Acne not responding to oral Isitretenoin
– Coprescribed with Isotretenoin
– PCOS

80. 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

81. Acne

82. Obesity in PCOD

83. 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)

84. 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

85. 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

86. 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.

87. Diet
Increase intake of
 Protein rich food such as meat, sea food, nuts, pulses, dry beans and egg

88. Why Exercise ?
Daily exercise
•Decreases insulin resistance
•Decreases Occurrence of
-- Diabetes
-- CV Incidents
A 30 minutes daily exercise
can improve many symptoms

89. Weight loss is actually due
to REDUCED
CALORIES and …
Walking.

90. Cola Drink

91. You’ve probably heard we should be
taking
10,000 Steps a
Day
< 5000 steps is sedentary

92. The result - Is obesity
We’re sitting
A lot
And sitting is bad for us
SITTING increases Risk of DEATH upto 40%

93. 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

94. Solutions?
If you enjoy running, by all means, run
But if like me, you hate running
Consider walking

95. 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.

96. 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

97. 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

98. wearable devices and step counting
NOW AVAILABLE IN INDIA

99. 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

100. 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

101. Treatment of Obesity BMI > 30
Behavioural Counselling
Lifestyle Modification – Diet, exercise
Pharmacolgical Agents – Orlistat,
Sibutramine ????
Bariatric Surgery ????

102. 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.

103. 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

104. 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

105. Menstrual Irregularity

106. MENSTRUAL DISORDERS
• Weight Stabilisation
• Cyclic or continuous OCP/
• Progestins
• Metformin

107. 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.

108. 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)

111. Other Drugs which can be used with
OCP

112. Metformin

113. Metformin

115. 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

116. ADD VITAMIN D Too
GIVE HER A GIFT FOR LIFE TIME

117. TAILOR MADE THERAPY in
Adolescent PCOD is our attempt
Your comments are needed by
SMS / Watsapp 9650588339
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118. More & More PCOS CLUBS
should be formed
to shoot
Information for
teens & young
PCOS patients
on its various
aspects

119. ADDRESS
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Morh Flyover, Delhi - 51
CONTACT US
9650588339, 011-22414049,
WEBSITE :
www.lifecarecentre.in
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www.lifecareivf.com
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