1. PANEL DISCUSSION
Management Of Adolescent PCOS
And Associated Fertility Concern
HELD ON 21/09/2014
At Hotel Latit
NEW DELHI
Dr. Sharda Jain
Organized by FOGSI / ICOG /CIPLA

2. Management of Adolescent PCOS
and Associated Fertility Concern
MODERATOR : Dr. Abha Majumdar
PANELISTS : Dr. Sharda Jain
Dr. Kaveri Benerjee
Dr. Kandhari (Dermotologist)
Dr. Saptrishi Bhattachayra
(Endocrinologist)

3. IMPORTANCE OF PCOS
It is NOT A DISEASE, it is a syndrome with
varied presentations
PCOS Constitutes a
CONTINUUM SPECTRUM
starting from the EARLY PREPUBERTAL
YEARS and continuing after Menopause
S/S peak through 2nd / 3rd decade of life

4. Q 1.
EPIDEMIOLOGY
Q 1. Is the incidence of PCOS in adolescents
rising or has the diagnosis improved ?
Ans. Yes, Both things are working
• There is a increase in incidence of PCOS in
adolescents
• Secondly because diagnosis has improved from
NIH-(1990) – TO ROTTERDOM(2004) – TO AES-PCOS
SOCIETY DIAG.CRITERIA (2009)
– many cases are picked –up now

5. Improvement in
Diagnosis of Polycystic Ovarian Syndrome over the years
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 Syndrome

7. Incidence of adolescent
PCOS
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. Q 2 (A)
What are the conditions that may
mimic PCOS ?
• 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)

9. Q 2 (B)
Any Genetic or familial basis ?
• Family History :
Risk of PCOS
• 40% - if her sister is having
PCOS
• 20% - if her mother suffered
from PCOS
GENETIC ETIOLOGY NO LAST WORD AS YET

10. Q 3.
DIAGNOSTICS – BLOOD TESTS
Q 3. (A) Which hormonal/blood tests are
done to confirm the diagnosis of PCOS?
Q 3. (B) Which tests should be done
before starting insulin sensitizers –
fasting / PP blood sugar, insulin,
glycosylated Hb?

11. DIAGNOSTICS – BLOOD TESTS
ANS. 3 (A)
 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

12. DIAGNOSTICS – BLOOD TESTS
ANS. 3 (B)
• 2 hrs GTT using fasting & 2 hrs blood
sugar levels are needed
Category Fasting 2hrs PP
Normal <100 mg/dl <140 mg/dl
Impaired <100-126 mg/dl > 140 -199
NIDDM Over 126 Over 200
Insulin Levels are Really Not Needed for
diagnosis of PCOS

13. Q 4.
DIAGNOSTICS - USG
Q 4. How is PCO and PCOM different
than PCOS?

14. UUSSGG CCrriitteerriiaa ooff
PPOOLLYYCCYYSSTTIICC OOVVAARRIIAANN MMOORRPPHHOOLLOOGGYY
• PPrreesseennccee ooff 1122 oorr mmoorree ffoolllliicclleess iinn eeaacchh
oovvaarryy ,, 22 -- 99 mmmm iinn ddiiaammeetteerr aanndd oorr
iinnccrreeaasseedd oovvaarriiaann vvoolluummee >> 1100 mmll
• NNoo ssuubbjjeeccttiivvee aasssseessssmmeenntt
• OOmmiitt ssttrroommaall
eecchhooggeenniicciittyy aanndd vvoolluummee

15. PCO, PCOM & PCOS
• It is a fact that PCOM ie POLYCYSTIC
OVARIAN MORPHOLOGY is present in 20
-35% girls with normal menstrual cycles &
• In Contrast there are patients of typical PCOS
who do not have PCOM on ultrasound.

16. Four Different Phenotypes of
PCOS are now identified
• TYPE A: hyperandrogenism, chronic anovulation and
<
polycystic ovaries.
• TYPE B: hyperandrogenism and chronic anovulation.
• TYPE C : hyperandrogenism and polycystic ovaries
• TYPE D : chronic anovulation and polycystic ovaries
Hyperandrogenemia is the
Hallmark :

17. Q 5. SYMPTOMS
Q 5. Which are the commonest symptoms
that women with PCOS present with?
Ans.5 Three Commonest Presentation are
• MENSTRUAL DISORDERS when they consult
gynaecologists
•OBESITY when they consult endrocrinologits
•HISUITISM & ACNE when they consult
dermatologist
Co-operations / Coordination
among specialists is needed

18. Symptoms & There Frequency
in PCOS in Adolescents
Menstrual Cycle disturbance – 70%
- Oligomenorrhoea 50%
- Amenorrhoea 10%
- Abnormal heavy bleeding 10-15%
Hyperandrogenism 70%
Acne – 70%
Hirsutism 70%
Alopecia 10% as seen by Gynaecologits
(Dermatologist feel - Alopecia is not all that uncommon around 20%)
Acanthosis Nigricans 1-3% lean & 20% obese
OBESITY 50- 60 %
NORMAL MENSTRUATION 20%
INFERTILITY ?

19. Clinical Manifestation of PCOD
AAccnnee AAccaanntthhoossisis HHirirssuuttisismm OObbeessitityy
HAIR
LOSS
HAIR InInffeerrttiliiltityy
LOSS
IRREGULAR
MENSES
IRREGULAR
MENSES

20. Q 5(B)
What is the Pattern of Menstrual
Irregularity in Adolescent PCOS
DELAYED PERIODS is most common
presentation
Other Presentations are:
• Withdrawal bleeding only
• Absent periods
• Heavy menstrual bleeding or
• Menometrorrhagia with Anemia

21. Q5 (B) 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)

22. Q (a) Is treatment for hirsutism based on
FG scoring?
Q (b) what all tests are needed to diagnose
hyperandrogenemia
Q (b) Does acne require systemic treatment
or only topical is sufficient?
Q (c) How common is alopecia?
Q (D) Guidelines to gynaecologits on treatment
of hirsutism
Q6
COSMETIC CONCERNS
HIRSUTISM , ACNE, ALOPECIA

23. ANS. Ferring Gallway Scale
This model quantities the extent of heir
growth I nine key anatomic sites: the hair
growth is graded using a scale from 0
(no terminal hair) to 4 (maximum growth),
for a maximum score of 36
A score of 8 or more indicates the
presence of androgen exces.
However, we do not use it in day to
day practice to grade our patients

24. What All Test Are Needed To Diagnose
Hyperandrogenism
Hirsutism, acne, alopecia
BIOCHEMICAL Testing Total Testosterone
levels & 17 – hydroxyprogesterone level to
R/O late onset CAH is all that is needed
Free Testosterone &
% Free Androgen index have NO ROLE in
diagnosis. It is 10 times costly & is not standard in all
labs.
• ANDROSTENADIONE-NO ROLE
SUDDEN ONSET of these symptoms suggests other D/D
* Cushing’s syndrome
* Adrenal or ovarian tumor.

25. ACNE
• Grade 1: Acne are
classified non
inflammatory
• Grade 2:
Inflammatory
• Grade 3 :
Combination of
above

26. 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

27. Systemic – Management
is needed for infected or severe acne
• 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

28. Hormonal Therapy in Acne
– Recalcitrant acne (severe variety)
– Acne not responding to topical /oral
Isotretenoin
– Co- prescribed with Isotretenoin
–PILL CPA 6-9 MONTHS
Any pill containing Desogestrel (Femilon) is
also effective in good 80% cases

29. Treatment – Other Modalities
• Chemical peels
• Comedon removal
• IPL
• Cryotherapy
• Microneedling
• Use of steroids
Good Dermatologist
help is needed.
Gynaecologist can’t
treat on there own

30. Alopecia
Incidence
in adolescent PCOS
Dermatologist feel that it is not all that uncommon
• Less common
(according to
gynaecologits)
• Diffuse thinning
With preservation of
frontal line
• Bitemporal
recession
CAUSE
• Decrease in 5a
reductase -
in DHT

31. Treatment Hirsutism

32. TREATMENT - HIRSUITISM
• All combination OCPs effective
• OCPs decrease androgen levels by
suppressing LH and stimulating sex
hormone binding globulin (SHBG).
• It takes almost 6 months when decrease
growth of hair is noted.
•OCPs with low androgenic
Progestins (norgestimate, desogestrel)
may be Most effective for acne and hirsuitism

33. Hirsuitism Treatment
• METFORMIN perse are not needed
– To reduce hirsuitism.
• ANDROGEN RECEPTOR BLOCKERS
– A full clinical effect may take 6 months or
more
– Spironolactone 25-100mg bid (Level A)

34. Topical cream
• Effornithine Hydrochloride Cream are
effective & take almost 3 months to show
effect.
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

35. 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.
ELECTROLYSIS IS GOING OUT
LASER THERAPY is not permanent. Repeated
sittings may be needed
OCP & Adactone are Needed

36. Q 7.
CHOICE OF COC
Q 6. Which COC is most preferred?
Containing
• Levonorgestrel / Desogestrel
• Cyproterone acetate
• Drospirenone

37. CHOICE of COC
ANS. ANY LOW DOSE COC CAN BE GIVEN
• OC’s containing progestins such as NORGESTREL
/ LEVONORGESTREL / DESOGESTREL are preferable.
• If HIRSUTISM is a problem then Cyproterrone
Acetate is preferred.
• DROSPIRENONE HAS NO ADVANTAGE

38. Two Types OF OCPs
• 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)

40. Q8
ETHINYLESTRADIOL – HOW MUCH?
Q. What is the patient profile for choosing
COCs containing 35, 30, 20 mcg
ethinylestradiol?
ANS. Low Dose COC pill is the choice
(<35 ug EE is the choice).
In adolescent people start with EE 20 ug pill
– if BTB – occurs, higher dosage pill is used

41. Q9.
CHOICE OF PROGESTIN
Q. What is the patient profile for
choosing the type of progesterone in
COCs?
Ans. Safety of the pill is most important
Like venus thromboembolism , mycardial
infaction & cancer etc.

42. SAFETY ON OCP
Noethindrone
Norgestril / Levonorgestril Low DVT
• 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)
Desogestrel DVT ? Risk
Drosperinone DVT ? Risk

43. Q10.
DURATION OF TREATMENT
Q. How long can women take
hormonal treatment for PCOS
management ?
ANS. At least for a year or even longer
DERMATOLOGIST feel it should not be
discontinue unless women wants to become
pregnant .

44. Q11.
CONCERNS WITH COC
Q. What are common complaints with the use of
COCs?
* HYPERTENSION * WEIGHT GAIN * ACNE
ANS. HYPERTENSION – in few 10 mm rise of BLOOD
PRESSURE may be there which settles once the drug is off
WEIGHT GAIN is not the complication with low dose COC
pills.
ACNE : Infact OCP is the treatment. We preferred pill with
Antiandrogens with progestational activity eg CPA pill

45. Q12.
INSULIN RESISTANCE
QA. How frequently do you see insulin
resistance in your PCOS patients?
QB. Are insulin sensitizers prescribed to all
women with PCOS or only those with insulin
resistance?

46. Q12(A).INSULIN RESISTANCE
Ans. In Research situations IR is
seen in good 60 to 65% patients
Clinically it is seen in 20 – 25%obese
PCOS patients &
5% in lean PCOS patients.

47. Significant Findings in Insulin Resistance
which gynaecologits should always note
• SKIN : Acanthosis nigricans (darkly shaded skin in the
flexures of the neck , axilla, or groin – IR/DM)
Skin tags – IR/DM
10 %
Acanthosis nigricans
Over 20% obese
5% in lean

48. IInnssuulliinn RReessiissttaannccee
DDiiaaggnnoossiiss –– JJuusstt DDoo
• 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.

49. You should Know
Insulin Resistance is present
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

50. Q12(B).
INSULIN RESISTANCE
Q. Are insulin sensitizers prescribed
to all women with PCOS or only those
with insulin resistance?
Ans. Insulin sensitizers like metformin is
used in patients with impaired glucose
tolerance patients not otherwise

51. Q13.
INSULIN SENSITIZERS - YOUR OPINION?
Q(A) In patients who do not respond to one
COC, do you change the COC (consisting of
another progestin) or shift them to or add an
insulin sensitizer?
Q(B). Metformin / Myoinositol

52. METFORMIN—PRESENT ROLE
• Use of metformin in PCOS should be
restricted to those patients with glucose
intolerance
ESHRE/ASRM-Sponsored PCOS
Consensus Workshop *,2007,
Thessaloniki, Greece
• Metformin may be added to CC in women
with clomiphene resistance who are older
and have visceral obesity (I-A)
SOGC guidelines, 2010

53. OCTOBER 2010

54. MYOINOSITOL
advantage will be known
5 yrs down the line - at
present it is only a
concept

55. Q 14
PREGNANCY & PCOS
Q. If the female wishes to conceive, when
would you adviseher to stop taking the insulin
sensitizers and / or COCs?
ANS. COCs need to be stopped & drugs for
ovarian stimulation to be used.
CLOMIPHENE CITRATE IS
Widely used Simple to use
Minimal side effects Cost effective

56. Clomiphene in
ANOVULATORY PCOS
• 50-80% will ovulate on CC
• Only 40-50%will conceive

57. Q15
PREGNANCY & PCOS
Q. What is the line of treatment in women
with PCOS who have conceived naturally?
Ans. PCOS patients have high chance of
miscarriages so they need micronised vaginal
progesterone
If they have conceived while taking metformine - it
has to be continued throughout pregnancy. This
decreases miscarriage rate.

58. Q16.
LONG-TERM COMPLICATIONS
Q. Are the women sensitized to the
long- term complications of PCOS?
Infertility, Diabetes, Cardiovascular diseases,
Cancer…
Ans. Counseling is important at the first visit
detailing them of short term & long term
consequences. It helps them in reducing weight,
strictly following life style modifications & become
proactive about conception & metabolic disorders
timely.

59. 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

60. Long Term Complications &
The Most
Common
Endocrine
disorder
In women
Consequences
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

61. Counseling
Counseling also helps them to get
regular screening / monitor from time to
time detect problems early.
•Infertility ,
•Diabetes
•Cardiovascular disease,
•Endometrial Cancer..

62. Q 17 INFERTILITY
Guidelines of infertility
are summarize
beautifully that is
First Line
Second Line
Third Line
THESSALONIKI CONSENSUS ON INFERTILITY
TREATMENT IN PCOS, GREECE 2007

63. THESSALONIKI CONSENSUS ON INFERTILITY
TREATMENT IN PCOS, GREECE 2007
FFIIRRSSTT LLIINNEE
CLOMIPHENE CITRATE
SSEECCOONNDD LLIINNEE
LOD/GONADOTROPINS
TTHHIIRRDD LLIINNEE
IVF
The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group March
2–3, 2007, Thessaloniki, Greece. Human Reproduction 2008
RR
EE
SS
II
SS
TT
AA
NN
CC
EE
RR
EE
SS
II
SS
TT
AA
NN
CC
EE
FF
AA
II
LL
UU
RR
EE

64. Q 18
PCOS & INFERTILITY
Q (a) Ovulation induction aim
(B) First & second line management of
infertility in women with PCOS?
(c) Role of LOD
(D) Role Luteal phase support
(E) OHSS

65. Goals of Ovulation induction
in IUI / IVF
Minimize Complications &
Risk
AIM
Ideal Outcome
Singleton live
Birth at term
Cycle
Cancellation
Multiple
Pregnancy OHSS

66. 1. First Line Management
Clomiphene is drug of Choice
2. In CC Resistant cases
metformine has a role
3. 2nd line treatment Lap. Ovarian
drilling has a role for women who
can’t came for closed follow – up
pregnancy role is 50%
4. Gonadotrophines in PCOS have
promise, but OHSS & multiple
pregnancy, should never before
gotten complication
•Tamoxiphene
people have just
staring using it
•Letroz is
banned in india
•Metformine role
dealt

67. The Truth is that
OHSS MUST
BE PREVENTED RATHER than
treated

68. HCG Trigger plays the key Role
Albert et al. Mol Hum Reprod. 2002;8:409; Chen et al. Hum Reprod.
2000;15:1037; Gómez et al. Endocrinology. 2002;143:4339

69. Can we do Laparoscopic Ovarian
Drilling in ADOLESCENTS who
do not respond to OCP
Not
Recommended
except for infertility problems

70. Q20.
PCOS & Cancer in Women
Would you like to comment on
a) Endometrial Cancer
b) Breast cancer in PCOS

71. Ans. 20 A
Endometrial Cancer in PCOS
• Gynaecologists should not forget that there
is 3 fold increase in incidence of endometrial
cancer.
• There Should be screening & monitoring for
the same from time to time with TVS & EB
Dr. Sharda Jain
Dr. Abha Majumdar shared their personal
experiences

72. Ans. 20B
PCOS & Breast Cancer ??
Limited data exist that Do Not Support the
conclusion that women with PCOS are a
increased risk for BREAST CANCER.

73. Obesity Issue in
PCOS was not
discussed
Discussed in detail in our presentation
“Management of Adolscent PCOD Made Easy”
At Sldehsrae.net

74. Q21
ROLE OF VIT – D ?
Vitamin – D Role
in PCOS
was suggested by
all Panelist

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

76. CONCLUSION
TAILOR MADE THERAPY in
Adolescent PCOS is our attempt
in this panel discussion
Your comments are needed by
SMS / Watsapp 9650588339
Or Facebook

77. More & More PCOS CLUBS
should be formed
to shoot
Information for
teens & young
PCOS patients
on its various
aspects

78. ADDRESS
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Morh Flyover, Delhi - 51
CONTACT US
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E-MAIL ID
Sharda.lifecare@gmail.com
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info@lifecareivf.com
&
Thank You