This presentation briefly discuss the polycystic ovary syndrome in terms of pathogenesis, features and management. Then, It moves on to discuss the various guidelines laid down by Endocrine Society in 2013 for the management of patients with polycystic ovary syndrome.

1. Polycystic Ovary
Syndrome
28 May 2014 1Presenter : Dr. Jagjit Khosla
Presentation : Dr. Jagjit Khosla
Junior Resident, Endocrinology,
GuruTeg Bahadur Hospital, Delhi

2. Polycystic Ovary Syndrome
• First described by Stein & Leventhal (1935)
• Incidence : 5-10%
• Leading cause of female infertility
• Insulin resistance described
later by Burghen (1980)
28 May 2014 2
Polycystic
Ovary
Amenorrhea
ObesityHirsutism
Presenter : Dr. Jagjit Khosla

3. PCOS - Pathophysiology
28 May 2014 3Presenter : Dr. Jagjit Khosla

4. PCOS – Clinical Features
• Hyperandrogenism
• Hirsutism
• Modified Ferriman Gallwey Score
• Acne
• Androgenic alopecia
• Menstrual Irregularity
• Oligomenorrhea (70-75%)
• Amenorrhea (20%)
• Infertility (30-70%)
28 May 2014 4Presenter : Dr. Jagjit Khosla

5. PCOS – Clinical Features
• Obesity
• Insulin resistance
• Acanthosis nigricans
• Skin tags
• Impaired Glucose tolerance
• Type 2 DM
28 May 2014 5Presenter : Dr. Jagjit Khosla

6. PCOS – Evaluation
• Biochemical evidence of hyperandrogenism
• S. Total testosterone
• USG evidence of Polycystic ovary
• 12 or more follicles in each ovary
measuring 2-9 mm in diameter
+/- inc. ovarian volume (>10 mL)
[Rotterdam criteria]
28 May 2014 6Presenter : Dr. Jagjit Khosla

7. PCOS – Evaluation
• Exclusion of other differential diagnoses
• Hyperprolactinemia, hypothyroidism
• Non-Classical Congenital Adrenal Hyperplasia
• Ovarian & Adrenal tumors
• Cushing’s syndrome, Glucocorticoid resistance
• Drugs : Danazol, OCPs
28 May 2014 7Presenter : Dr. Jagjit Khosla

8. PCOS – Diagnostic criteria
NIH (1990)
• Menstrual
Irregularity
• Hyperandrogenism
• Exclusion of other
etiologies
28 May 2014 8
Rotterdam (2003)
• 2 out of 3 required
1. Menstrual
Irregularity
2. Hyperandrogenism
3. USG – Polycystic
ovary
• Exclusion of other
etiologies
AES (2006)
• Menstrual
irregularity
+/- USG - Polycystic
ovary
• Hyperandrogenism
• Exclusion of other
etiologies
Presenter : Dr. Jagjit Khosla

9. PCOS – Management
• Lifestyle modifications –
• Low calorie diet
• Regular brisk walk 25-35 min daily
• Hormonal contraceptives –
• 1st line T/t of hirsutism, acne and menstrual irregularity
• Spironolactone
• Added to OCPs if suboptimal results after 6 months
28 May 2014 9
Legro, Richard S., et al. "Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical
practice guideline." Journal of Clinical Endocrinology & Metabolism 98.12 (2013): 4565-4592.
Presenter : Dr. Jagjit Khosla

10. PCOS – Management
• Clomiphene citrate –
• 1st line t/t for infertility
• Insulin sensitizing agents –
• Metformin – limited recommendations
• Screening patients for long term complications
• Endometrial cancer, Mood disorders, OSA, DM, CVD
28 May 2014 10
Legro, Richard S., et al. "Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical
practice guideline." Journal of Clinical Endocrinology & Metabolism 98.12 (2013): 4565-4592.
Presenter : Dr. Jagjit Khosla

11. Spironolactone
• Actions
• Androgen receptor blockade
• Steroid synthesis inhibitor
• Aldosterone receptor blockade
• Status is PCOS management
• 2nd line drug for T/t of hirsutism, acne
• If used alone, alternative contraception needed
• No endometrial protection
28 May 2014 11Presenter : Dr. Jagjit Khosla

12. Metformin
• Actions
• Increase insulin sensitivity
• Directly inhibit human theca cell androgen synthesis
• Status is PCOS management
• Women with PCOS and type 2 DM or IGT
• Women who cannot take oral contraceptives
• Adjuvant therapy in women undergoing IVF – prevent
ovarian hyperstimulation
28 May 2014 12Presenter : Dr. Jagjit Khosla

13. ES Guidelines for PCOS 2013
• 3 Recommendations
Diagnosis of PCOS
• 12 Recommendations
Associated Comorbidity & Evaluation
• 12 Recommendations
Treatment of PCOS
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 13

14. ES Guidelines for PCOS 2013
1 - Diagnosis of PCOS

15. ES Guidelines for PCOS 2013
1.1 - Diagnosis of PCOS in Adults
• Rotterdam (2003) criteria
Androgen excess
Ovulatory dysfunction
Polycystic ovaries (USG)
2 out of 3
+ Exclusion of other etiologies
Clinical or biochemical
Oligo- or anovulation
Atleast one ovary with
• 12 follicles 2-9mm
• Volume > 10mL
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 15

16. ES Guidelines for PCOS 2013
1.1 - Diagnosis of PCOS in Adults
• Rotterdam (2003) criteria
• Thyroid disease
• Hyperprolactin
• Nonclassical congenital adrenal hyperplasia
• Cushing’s syndrome
• Acromegaly
• Androgen secreting tumors
• Other causes of amenorrhea
Exclusion of other etiologies
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 16

17. ES Guidelines for PCOS 2013
1.2 - Diagnosis of PCOS in adolescents
• Anovulation and Polycystic ovary NOT reliable
Androgen excess
Persistent oligomenorrhea
Exclusion of other etiologies
+
+
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 17
>2 yrs beyond menarche

18. ES Guidelines for PCOS 2013
1.3 Diagnosis in perimenopause and menopause
• Long term history of oligomenorrhea & hyperandrogenism
• Polycystic ovary – less likely
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 18

19. ES Guidelines for PCOS 2013
2 - Associated comorbidity and Evaluation

20. ES Guidelines for PCOS 2013
2.1 - Documenting cutaneous menifestations
• Hirsutism (Modified Ferriman-Gallwey score)
• Acne
• Adrogenic alopecia (Ludwig score)
• Acanthosis nigricans
• Skin tags
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 20

21. ES Guidelines for PCOS 2013
2.2 - Screening ovulatory status (even in eumenorrheic patients)
• ↑ Risk of anovulation and infertility
• Menstrual history
• Midluteal S. Progesterone
2.3 - Exclude other causes of infertility in couples
• Obesity, Male factor infertility, tubal occlusion
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 21

22. ES Guidelines for PCOS 2013
2.4 - Preconceptual Assessment
• ↑ Risk of pregnancy complications (GDM, Preterm
delivery, Pre-eclampsia)
• BMI, BP, OGTT
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 22

23. ES Guidelines for PCOS 2013
2.5 - No intervention for prevention of PCOS in offspring of
PCOS women
• Inconclusive evidence of intrauterine effects
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 23

24. ES Guidelines for PCOS 2013
2.6 - No routine USG screening for endometrial thickness in
PCOS women without abnormal bleeding
• Poor diagnostic accuracy
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 24

25. ES Guidelines for PCOS 2013
2.7 - Screen for increased adiposity
• Ass. with Hyperandrogenemia and ↑ Metabolic risk
• BMI, Waist circumference
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 25

26. ES Guidelines for PCOS 2013
2.8 - Screen and manage depression and anxiety
2.9 - Screen and manage Obstructive sleep apnea (OSA)
• Polysomnography
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 26

27. ES Guidelines for PCOS 2013
2.10 - Awareness about possibility of NAFLD and NASH (No
screening)
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 27

28. ES Guidelines for PCOS 2013
2.11 - Screen for IGT and T2DM
• OGTT or HbA1c
• Re-screening every 3-5 years
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 28

29. ES Guidelines for PCOS 2013
2.12 - Screen for CVD risk factors
At risk
• Obesity
• Cigarette smoking
• Hypertension
• Dyslipidemia
• Subclinical vascular disease
• Impaired glucose tolerance
• Family history of premature
CVD
High risk
• Metabolic syndrome
• T2DM
• Overt vascular or renal disease,
CVD
• OSA
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 29

30. ES Guidelines for PCOS 2013
3 - Treatment

31. ES Guidelines for PCOS 2013
3.1 - Hormonal contraceptives (HC) – First Line management
for menstrual abnormalities and hirsutism/acne of PCOS
3.2 - Screen for contraindications of HCs
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 31

32. ES Guidelines for PCOS 2013
3.3 - Exercise therapy in management of overweight and
obesity in PCOS
• 30 min moderate to vigorous exercise daily
3.4 - Weight loss strategies for adolescents and those
overweight or obese
• Calorie-restricted diet
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 32

33. ES Guidelines for PCOS 2013
3.5 - Metformin NOT first line management for
• Cutaneous manifestations
• Prevention of pregnancy complications
• Obesity
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 33

34. ES Guidelines for PCOS 2013
3.6 - Metformin to be used in PCOS women if
• T2DM or IGT who fail lifestyle modification
• Menstrual irregularities present and HCs are contraindicated / not
tolerated.
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 34

35. ES Guidelines for PCOS 2013
3.7 - Clomiphene citrate (or Letrozole) as first line treatment
for anovulatory infertility in PCOS
3.8 - Metformin as adjuvant for infertility to prevent Ovarian
hyperstimulation syndrome (OHSS) in women with PCOS
undergoing IVF
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 35

36. ES Guidelines for PCOS 2013
3.9 - Insulin sensitizers e.g. inositols or thiazolidinediones use
NOT recommended
3.10 - Statins only recommended in PCOS if patient meet
current indications for statin therapy.
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 36

37. ES Guidelines for PCOS 2013
3.11 - Treatment of adolescents
• HCs first-line treatment with suspected PCOS
• Lifestyle therapy (calorie-restricted diet and exercise)
also first-line if overweight/obesity
• Metformin use to treat IGT/Metabolic syndrome
• Duration not determined
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 37

38. ES Guidelines for PCOS 2013
3.12 - Start HCs in pre-menarchal girls with
hyperandrogenism and advanced pubertal development
• ≥ Tanner stage IV breast development
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 38

39. Summary
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 39
• Follow Rotterdam criteria in adults
• Difficult diagnosis in adolescents & perimenopausal/menopausal
women
Diagnosis of PCOS

40. Summary
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 40
• Document cutaneous manifestations
• Preconceptual assessment to prevent pregnancy complications
• Look for other causes of infertility in couple
• Screening for anovulation, inc. adiposity, depression, anxiety,
OSA, IGT/T2DM, CVD risk factors
• No screening needed for endometrial cancer, NAFLD, NASH
• No specific intervention to prevent PCOS in offspring
Associated comorbidity and evaluation

41. Summary
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 41
• HCs first line therapy for PCOS in adults, adolescents and pre-
menarchal girls with suspected PCOS
• Lifestyle modifications first line therapy in obese/overweights
• Metformin use recommended only when :
• PCOS with T2DM/IGT who fail lifestyle modifications
• Menstrual irregularity with contraindication for HCs
• Adjuvant therapy to prevent OHSS in PCOS women undergoing
IVF
• In Adolescents to treat IGT/ Metabolic syndrome
Treatment

42. Summary
Wednesday, May 28, 2014 Presentation by : Dr. Jagjit Khosla 42
• Clomiphene citrate or Letrozole first line therapy for anovulatory
infertility in PCOS
• Statins only used if indication for statin therapy present
• Insulin sensitizers e.g. inositols & TZDs not recommended in PCOS
Treatment

43. 28 May 2014 Presenter : Dr. Jagjit Khosla 43
Thank you…