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PCOS- long term
management
Dr.Anita mani
Gift IVF center , cochin , India
PCOS- Long Term Management
Dr.Anita mani
Gift IVF center , cochin , India
Prevalence
3 to 20 %
70% undiagnosed
Reproductive Symptoms of PCOS
Reproductive symptoms
Anovulation
Subfertility
Hyperandrogenism
Metabolic sequelae of PCOS
obesity
glucose intolerance
Type 2 Diabetes
Cardiovascular
accidents - stroke, MI
Long term management
Life style changes - Diet, weight loss
Screening for cardiovascular risks
Pharmacological intervention
Surgical intervention - Laparoscopy
obstructive sleep apnoea assessment
Psychological assessment and treatment
Multidisciplinary Team Approach
clinician, dietitian, exercise specialist, counsellor
Multidisciplinary team approach
Clinicians - GP, Endocrinologist, Infertility specialist
Diabetes specialist, Physician, Cardiologist, Surgeon
dietician, exercise specialist
counsellor, psychologist / psychiatrist
Life style changes - Diet & exercise
Life style changes including diet, exercise and weight loss
should precede any pharmacological intervention.
Even a 5% loss of body weight will reduce insulin resistance
and circulating androgens, resulting in spontaneous ovulation
and relief of symptoms.
Behavior change techniques should target optimal weight.
Norman RJ, Davies MJ, Lord J, Moran LJ. The role of lifestyle modification in polycystic ovary syndrome. Trends Endocrinol
Metab. 2002;13(6):251-7.
Diet
A diet low in saturated
fat and high in fibre from
predominantly lowglycaemic-indexcarbohydrate foods is
recommended
Marsh K, Brand-Miller J. The optimal diet for women with polycystic
ovary syndrome? Br J Nutr. 2005;94(2):154-65.
Exercise
Regular exercise (30 minutes of
aerobic exercise/day) has been
shown to decrease central
obesity and increase insulin
sensitivity and is therefore
strongly recommended.
Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT,
Hamalainen H, Ilanne-Parikka P, et al.
Prevention of type 2 diabetes mellitus by
changes in lifestyle among subjects with
impaired glucose tolerance. N Engl J Med.
2001;344(18):1343-50.
Strategies
motivational interviewing
established behaviour techniques
ways to access support to help with weight loss and exercise
establishing self-monitoring (including pedometer use)
time management techniques
relapse prevention techniques
individual tailoring
engaging social support
setting goals
Screening for cardiovascular risks
Women with PCOS should be
screened for cardiovascular risk by
determination of CVD risk factors
(obesity, lack of physical activity,
cigarette smoking, family history of
type II diabetes, dyslipidaemia,
hypertension, impaired glucose
tolerance, type II diabetes)
They should be strongly warned
against smoking.
American College of Obstetrics and Gynecology. ACOG Practice Bulletin
No. 41: Polycystic Ovary Syndrome. Obstetrics & Gynecology. 2002;100(6):1389-402.
Screening for type II diabetes
Women presenting with PCOS who are overweight (body mass index [BMI]
≥ 25 kg/m2) and women with PCOS who are not overweight (BMI < 25
kg/m2), but who have additional risk factors such as advanced age (> 40
years), personal history of gestational diabetes or family history of type II
diabetes, should have a 2-hour post 75 g oral glucose tolerance test
performed.
In women with impaired fasting glucose (fasting plasma glucose level from
6.1 mmol/l to 6.9 mmol/l) or impaired glucose tolerance (plasma glucose of
7.8 mmol/l or more but less than 11.1 mmol/l after a 2-hour oral glucose
tolerance test), an oral glucose tolerance test should be performed
annually.
Protocols for clinicians
Protocols should be
provided to clinicians, to
assess CVD risks
considering obesity,
physical inactivity,
smoking, dyslipidemia,
hypertension, glucose
intolerance and type II
diabetes/family history.
Pharmacological interventions in PCOS
Oligo- or amenorrhoea in women with PCOS may predispose to endometrial hyperplasia
and later carcinoma. It is good practice to recommend treatment with gestogens to
induce a withdrawal bleed at least every 3 to 4 months.
Transvaginal ultrasound should be considered in the absence of withdrawal bleeds or
abnormal uterine bleeding. In PCOS, an endometrial thickness of less than 7 mm is
unlikely to be hyperplasia.
A thickened endometrium or an endometrial polyp should prompt consideration of
endometrial biopsy and/or hysteroscopy.
Hickey M, Higham JM, Fraser I. Progestogens with or without oestrogen for irregular uterine bleeding associated with anovulation. Cochrane
Database Syst Rev 2012;(9):CD001895.
61. McCormick BA,Wilburn RD,Thomas MA,Williams DB, Maxwell R,Aubuchon M. Endometrial thickness predicts endometrial hyperplasia in
patients with polycystic ovary syndrome. Fertil Steril 2011;95:2625–7.
Subfertility
medicines
Ovulation inducing agents like
clomiphene citrate and gonadotrophin
can be used for a limited period of less
than 12 months to achieve fertility.
Insulin-sensitizing agents like metformin does not
seem to have long-term benefits.
Weight reduction drugs reduce
hyperandrogenaemia in selected patients with
morbid obesity only.
Laparoscopic Ovarian Drilling
Laparoscopic ovarian
drilling will induce ovulation
in 60% of the subjects for
20 years.
Gjønnaess H. Ovarian electrocautery in the
treatment of women with polycystic ovary syndrome
(PCOS). Factors affecting the results. Acta Obstet
Gynecol Scand 1994;73:407–12.
Obstructive Sleep Apnea (OSA)
Women diagnosed with PCOS should be asked about the symptoms of
OSA (snoring, daytime fatigue/somnolence) and offered investigation
and treatment if indicated.
Fogel RB, Malhotra A, Pillar G, Pittman SD, Dunaif A, White DP. Increased prevalence of obstructive sleep apnea syndrome in
obese women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2001;86(3):1175-80.
Gopal M, Duntley S, Uhles M, Attarian H. The role of obesity in the increased prevalence of obstructive sleep apnea syndrome in
patients with polycystic ovarian syndrome. Sleep Med. 2002;3(5):401-4.
Psychological assessment and intervention
Every study of PCOS has shown a
higher risk of depression, anxiety and
worsened quality of life in this condition.
Practitioners must investigate the
presence of mental distress and include
treatment of this in the management
plan.
Deeks AA, Gibson-Helm ME, Paul E, Teede HJ. Is having polycystic
ovary syndrome a predictor of poor psychological function including
anxiety and depression? Hum Reprod. 2011;26(6):1399-407.
Bariatric surgery
Bariatric surgery has been shown to be effective in women with PCOS and may be an option for severely obese women
with BMI more than 35, in whom long-term diet-based strategies have failed.
Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724-37.
Escobar-Morreale HF, Botella-Carretero JI, Alvarez-Blasco F, Sancho J, San Millan JL. The polycystic ovary syndrome associated with morbid obesity may resolve after weight loss induced by bariatric surgery. J Clin Endocrinol Metab. 2005;90(12):6364-9.
Prevention of PCOS Sequelae
Creating public health awareness on healthy eating and the
necessity of regular exercise and including the subjects in
the school curriculum is needed.
The government should take steps to bring changes , as
there are huge public health implications due to long term
sequelae of PCOS.
The significance is not just due to morbidity and mortality ,
but also the cost involved. Millions are being spent for the
treatment of PCOS and its consequences like diabetes,
obesity, psychological problems and CVA
“ Why are children obese?
May be its because burgers are $0.99
and salads $4.99 ”
“Success is achieved and
maintained by those who
try and keep trying.”
–W.Clement Stone
Make a change!
Dr.Anita Mani
Infertility surgeon and laparoscopic
surgeon
Articles in news papers and magazines
Practical measures
TV shows
Classes to teenage school children by experts
Medical conferences to educate doctors, paramedics
PCOS awareness associations in every country with regular
activities
Good blogs by experts
Social media postings – targetting next generation possible by
face book , instagram, whats up
Websites for information
Comedy shows , memes with this theme of pcos . Target
population likes humour
Target population
Mothers- include Healthy eating and exercise part
of ANC .
Schools - add these in curriculam,
add cooking classes
Schools – experts can take classes
Schools – to reduce sitting hours , increase
activities
Teenagers – catch them early before it is too late
Target population
Infertile women – they are willing to do anything ,
give them complete care , give information in form
of leaflets , put targets for them to achieve wt loss,
give options to choose treatment (informed
Decision)
Counsell them re Future problems .
Protocols to GP s , clinicians to screen CVD risks
Finance
Unless money is involved, nobody is going to act,
so find sponsorers, pharmaceutical companies may
help as it will be marketing for them.
Companies that sell myo-ionositol, NAC etc will
come forward to sponsor meetings
U tube
Make something creative , that will go viral, like
gangam style
Videos (short) on diet , exercise , glycaemic index,
medical treatments, complications etc on pcos.
We could have recorded and uploaded our talks !
Or take small bits of it .
Governments , Rules
Letter to officials with signature from experts, also
from pcos patients
Repeat several times until they notice.
Find pcos patient in higher govt.ranks , and ask for
help
Book
Write a book for the patients. (not for experts as
they already know . Need to get across to patient)
All of us can contribute chapters and write in simple
language to help PCOS patients.
It is practically possible as we all have enough
material.
Autobiography- living with PCOS.
Camps
Doctors can conduct free screening camps in their
locality to encourage girls to come forward, for the
consultation.
We can convince docs , that they will get patients
in future , so they will have a motive.
We do laparoscopy at reduced rate for Patients
yearly once, at our center
conference
Bring in live testimonial by patient who went thru
the disease, what helped them , who helped them,
how much they understood about the disease,
what is the expectation from medical fraternity
Review on internet
Doctors can get patients to put reviews regarding
the experience in internet about the treatment
Research
More research into psychological problems in teens
and adults with PCOS
Try and integrate natural medicines like ayurveda ,
chinese medicine into research
Research on results of Yoga , thai chi etc on PCOS
Partners experience of living with PCOS women,
QOL.
Lesbian population and PCOS incidence
Thank you very much for listening & trying to make a positive change
Dr.Anita
Mani
mom, sister, cousin and doctor of PCOS patients