Download Myo-inositol for PCOS

Story of poly
narrated by
Narendra Malhotra
&
Jaideep Malhotra
GLOBAL RAINBOW HEALTH CARE,INDIA
www.rainbowhospitals.org
Declaration of conflicts of interest
Sponsored & Supported by
Background
PCOS is an endocrine system disorder affecting women in
their reproductive years.
Polycystic ovary syndrome (PCOS) is the most common
hormonal disorder among women of reproductive age.
Infertility is one of the most common PCOS symptoms.
Because the symptoms of PCOS are seemingly unrelated to one
another, the condition is often overlooked and undiagnosed.
EPIDEMOLOGY

20-33% of all reproductive age group have PCO

5-10% of all reproductive age group have PCOS

87% of women with oligomennorhea

26% of women with ammenorhoea

50% of them presenting with infertility

50% women with recurrent miscarriages
SYMPTOMS
PCOS is a syndrome disease defined by a collection of signs and symptoms. The
symptoms of PCOS that one patient experiences can be very different from the
symptoms of another patient. If there are two or more of the following symptoms,
then a thorough checkup is needed to determine the PCOS treatment:

Irregular or missing menstrual periods

Infertility

Excess or unwanted body or facial hair growth

Thinning hair on the scalp

Weight problems, often including weight gain around the waist

Skin problems, including skin tags, darkening skin and acne
HEALTH RISKS
There are several health risks associated with PCOS like





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Type 2 diabetes
Infertility
High cholesterol
Elevated lipids
Sleep apnea
Liver disease
Abnormal uterine bleeding
Increased risk of endometrial cancer, gestational diabetes, pregnancyinduced high blood pressure, heart attacks and miscarriage
High blood pressure
Obesity possibly leading to issues with low self-esteem and depression
Metabolic syndrome
Nonalcoholic fatty liver (steatohepatitis)
CAUSES
Probable causes for PCOS

Stress

Diet

Genetics

Pollution

Excess insulin

Low-grade inflammation

Lazy life style and lack of excercises
MECHANISM
for INSULIN RESISTANCE PCOS
Insulin
Resistance
 due to poor diet, lifestyle, genetics etc
High Glucose
High Insulin
High
Androgen
Hair Growth
& Acne
Weight Gain
Low
Ovulation
MECHANISM
for NON INSULIN RESISTANCE PCOS
Pollution (toxicity of xenobiotics) -> affects embryo -> may damage a female
embryo’s ovarian follicles and make them dysfunctional; unable to complete
ovulation or manufacture sufficient progesterone. This damage is not apparent
until after puberty.

Intrauterine exposure with androgenic drugs

And androgenic progesterones are

Likely to be a cause of these genetically

prone female Fetuses developing PCOS
BABY POLY IS BORN
other factors that may contribute to dysfunctional follicles

Stress -> high cortisol levels ; Stress alone can cause anovulatory cycles

Birth control pills -> sometimes normal ovary functions don’t resume after
stopping intake of birth control pills

Medications like Prozac

Low grade inflammation
GENETICS OF PCOS

No karyotypic abnormalities found

Gene studies – Candidate genes involved in
steroid hormone synthesis
carbohydrate metabolism
genes involved in gonadotropic action
Genetics
and
Epigenetics




Underlying genetic factor
Single specific gene not yet
determined
Many candidate genes implicated
Different combinations of multiple
gene polymorphisms and of
environmental factors explain the
heterogeneity of PCOS
CLINICAL MANIFESTATIONS
SYMPTOMS
Obesity(38%)
ASSOCIATED ENDOCRINE
MANIFETATIONS
POSSIBLE LATE SEQUALE
Androgens(29%)
Diabetes mellitus(29%)
Menstrual disturbance(66%)
LH(40%)
Cardiovascular disease
Hyperandrogenism(48%)
LH:FSH ratio
Hyperinsulinemia
Infertility (73% of anovulatory
infertility)
Free estradiol
Low LDL
Asymptomatic(20%)
Fasting insulin
Endometrial carcinoma
Prolactin(27%)
hypertension
Sex hormone binding globulin
DIAGNOSIS
There is no definitive test for PCOS; it depends on the medical history,
symptoms, and tests to rule out other possible conditions. Perform a physical and
pelvic examination to look for signs of PCOS, such as swollen ovaries or a swollen
clitoris.

Blood tests to measure hormone levels are typically ordered, as well as
thyroid function tests to determine how much of the thyroid hormone your
body produces

Fasting glucose tests to measure your blood sugar levels

Lipid level tests to assess the amount of cholesterol in your blood

A vaginal ultrasound

A pelvic laparoscopy
PCOS: Goals

Identify patients with risks for or with diagnosis of PCOS

Assess patients appropriately for PCOS and associated disease states

Prescribe therapy to treat complaints and prevent sequelae
COUNSELING OF A PCOS PATIENT
Endocrine problems
Metabolic problems
Infertility
Risk of OHSS and multiple pregnancy
Pregnancy complications
Long term sequel
MOST IMP- Importance of life style modification
Ms poly is growing
at age 5-7 she is obese and overwt.

She is a nice chubby girl

Oooh how sweeet……

Chubby cheeks

The fat appears to be baby fat

No excercises

Eating whenever and whatever
Over feeding
MISS POLY becomes 15 +
CONCERNS are;

Menstrual irregularities

Obesity

Hirsutism

Acne
PROTOCOLS OF MANAGEMENT IN
ADOLESCENTS
Counselling for weight reduction and life style
modification.
 Carbohydrate and fat restricted diet.
 Diet restriction and exercise is the sheet anchor of
treatment for overweight.
 Low glycemic index diet upto 85% will improve
menstrual cycle regularity and ovulation in about
six months.

PCOS Treatments
Polycystic ovary syndrome treatment starts with a proper diagnosis. Treatments
are then chosen based on a woman's symptoms, age and future pregnancy plans.
Treatment for PCOS may include:

Life style changes

Birth control pills to regulate menstruation

Insulin-sensitizing medications

Ovulation induction to treat infertility

Androgen-blocking medications

Topical anti-hair-growth medications

Other excess hair treatments

Treatments for hair loss

Acne treatments

Removal of other skin problems
OBESITY & PCOS

In a study of obese and non-obese women with PCOS, various
hormones were measured with interesting results. Researchers
measured blood levels of six markers, including estradiol,
testosterone and androstenedione. The average levels of testosterone
and androstenedione in obese PCOS women were significantly higher
than those in non-obese PCOS women. This is yet another indicator
that obesity can contribute significantly to hormone imbalance. PCOS
disappears rapidly in most women when they reduce weight.

It is difficult for most PCOS women to lose weight due to hormone
imbalance.

There are latest weight loss programs which works for PCOS like
iSlimRx, which is a scientifically designed protocol that utilizes a
combination of very specific foods at around 1000-1200 calories per
day and the use of proprietary medicine drops that CHANGE THE WAY
BODY PROCESSES FOOD by detoxifying liver and resetting
"Hypothalamus". The hypothalamus gland moderates the thyroid,
adrenals, fat storage, and more importantly, body's metabolic rate. If
followed, this protocol WORKS.
OBESITY AND PCOS

Associated in 35-60% of cases

Usually android type

Raised weight: hip ratio >0.85

Increased waist circumference >90 cm

Also associated with Insulin Resistance (IR)and Hyperinsulinemia

But PCOS also seen in non obese women.
IMPACT OF OBESITY IN REPRODUCTION
Condition
Associated risks
Mensturation
Ammenorhoea, oligomennorhoea, mennorhagia
Infertility
Anovualtion, poor response to infertility drugs
Miscarriage
Increased rate
Infertility treatment
Increased requirement of oral or injectable ovulation induction
agent
Decreased success rate of IVF
Glucose intolerance
Impaired glucose tolerance, type 2 DM
Pregnancy
Increased PIH, GDM,CS, Downs

Even 7% weight reduction may lead to
spontaneous resumption of menses.

Moderate physical activity, 30-60 minutes per day
should be goal of all patient with adolescent PCOS.
M.O.A:
lowers circulating free androgen and insulin levels.

Increases SHBG, thereby decreases level of free testosterone.
WHY ORAL CONTRACEPTIVE PILLS ?



Estrogenic component of the oral contraceptive
suppresses luteinising hormone and thus reduces
ovarian androgen production.
Estrogen also enhances hepatic production of
SHBG ,thereby the level of free testosterone
declines.
Cyproterone acetate, Drospirenone and
desogestrel can be used in combination with
ethinyl estradiol.
Cyproterone acetate

Competitively inhibits the binding of testosterone and
5α-dihydrotestosterone to the androgen receptor.
Combination of ethinyl estradiol (0.35 µg) and
cyproterone acetate (2mg)
is most
scientific
in
Ideal
for Hirsuit
PCOS.
treating hyperandrogenicity as well as
maintaining the menstrual cyclicity.
Dose 1 tab. daily from D1 to D21 which has to be
repeated cyclically for a period of six months.
also
DROSPIRENONE

Combination of ethinyl estradiol (30 µg) with Drospirenone
(3mg), an analogue of spironolactone with unique
antimineralocorticoid and antiandrogenic action has also
been used.
Ideal for Obese PCOS

Combination of ethinyl estradiol (30 µg) with Desogestrel (20
µg) can also be used.
Case studies of iSlimRx
Name
Doctor
Age
wt.after Total
Starting
program Weight
wt.(kg)
(kg)
lost (kg)
City
Shailaja S
Dr.Ravi Kothari
39yrs
95
86.6
8.4kg
Poona
Sanobar S
Dr.Deepak Patil
18yrs
73.2
62.8
10.4kg Mumbai
Janavi P
Dr.Jatin Shah
26yrs
99.7
93.5
6.2kg
Mumbai
Manju
Dr.Neena Malhotra
31yrs
120
103
17kg
Delhi
Udipi B
Dt.Aparna Karanjakr
37yrs
79.9
70.1
9.8kg
U.K
Ritu G
Dt.Ruby Singh
49yrs
67.1
61.3
5.8kg
Dubai
Pankti V
Dr.Malav Shah
28yrs
79
67.2
11.8kg Ahmedabad
Dhwani M
Dr.Kanti Bansal
25yrs
77
67.3
9.7kg
Ahmedabad
OUR EXPERIENCE
4 PTS IN DELHI AND
AGRA RAINBOW IVF
ARE ON THIS THERAPY
3 HAVE SHOWN SIGNIFICANT
WT LOSS
ONE HAS TO YET REPORT BACK
ONE LOST 15 KGS IN 3 MONTHS
AND IS NOW TAKEN FOR IVF
OTHER DRUGS WHICH CAN BE
ADDITION TO O.C.P.
USED IN
In cases of failure or where there is clinical or
biochemical evidence of gross hyperandrogenicity
or hyperinsulinemia, addition of metformin is
recommended.
 Spironolactone- it has antiandrogenic effects in
doses 100-200 mg daily.
 Finasteride - a competitive inhibitor of Type-2 5a
reductase to treat hirsutism. Dose 1-5 mg/day.

IMPROVEMENT OF HYPERINSULINEMIA BY
INSULIN SENSITIZERS
Directly sensitizing insulin receptors.
 Preventing neoglucogenesis.
 Reducing absorption of glucose from intestine.
 Increasing hepatic synthesis of SHBG level thereby
reducing the level of bioactive free testosterone.

Metformin
Decreases basal hepatic glucose output in patients and lowers fasting
plasma glucose concentration.
 It increases the uptake and oxidation of glucose by
adipose tissue as well as lipogenesis.
 S/E- diarrhoea, nausea, vomiting ,specially
initially.
To avoid them metformin should be taken
with meals and the dose increased gradually.

Decrease in levels of leptin prevents excess
estrogen formation and leads to normal
restoration of HPO axis and hence ovulation.

MetforminDosage
500-1500 mg daily in
divided doses for six to nine months.
OTHER DRUGS WHICH CAN BE USED

Rosiglitazone ,

Pioglitazone,

D chiro inositol,

N acetyl cysteine.

Other combinations
Need a drug to
LIKELY CAUSES
Insulin Resistance
and
Hyperinsulinemia
Low-grade
inflammation
(This can trigger
insulin
resistance)
Heredity
(researchers are
looking into gene
mutations)
Excessive
exposure to
androgens in fetal
life
Insulin Resistance – What is It?
• Inability of insulin to demonstrate its
metabolic actions
• It may be due to:
• Decrease in affinity of insulin
receptors towards insulin
• Impaired signaling inside cell
• Decrease in number of insulin
receptors
Management
The first step in managing polycystic ovary syndrome (PCOS) is getting regular exercise, eating a
healthy diet, and not smoking.
1.
Exercise:
Bharadvajasana
Running/Jogging
Butterfly pose
Chakki Chalanasana
Management
2. Nutrition:
The ideal diet plan for women with PCOS should compose of balanced
meals including carbohydrates, proteins and fats
Eat small meals at regular intervals and avoid large meals which would
result in rise in blood glucose levels
Consume fruits, vegetables, beans, legumes, whole grains, fish, lean
meats, nuts and seeds
Limit sugars and enriched carbohydrates
Limit salt intake
Avoid saturated fats
Myo-inositol for PCOS
Myo-inositol has shown promising results in studies of women with PCOS. It works
by helping body to manage its use of insulin, restore balance to hormones,
improve egg quality and help to regulate menses. It also aids in balancing
appetite and moves fat from liver, which is beneficial to women who suffer from
PCOS and are overweight because of it.
How Does Myo-inositol for PCOS Work?

Many women with PCOS struggle with insulin resistance. Inositol naturally
made by the body is actually an important messenger molecule in insulin
signaling.

Insulin in the blood stream binds to receptors on cell walls, which sets off a
biochemical cascade that leads to glucose being taken in and used by cells.
Inositol is part of this reaction.

Women with PCOS excrete inositol so quickly that they often do not have
enough inositol to support this reaction, causing insulin resistance.
Supplementing with inositol thus can reduce insulin resistance and improve
the way glucose is used in the body.
Role of Inositol Derivatives in PCOS
 INOSITOL
is a polyalcohol
 Is
a key messenger in the
insulin signalling pathway
 Deficiency
of inositol may be
linked to insulin resistance
Isabella R and Raffone E. Journal of Ovarian Research 2012, 5:14.
MI+DCI: CLINICAL EFFICACY
•
MI+DCI synergistically improve insulin resistance, reduce
hyperandrogenism and to induce ovulation in PCOS vs. MI
alone in women with PCOS.
•
Improved LDL, HDL, and triglyceride levels vs. baseline
values
•
Duration of therapy evaluated in the studies: 6 months.
•
DOSAGE REGIMEN: 550 mg of MI+13.8 mg of DCI (40:1 ratio)
in soft gel capsule form twice a day.
Nordio M, Proietti E. Eur Rev Med Pharmacol Sci. 2012; 16(5): 575-81.
BENEFITS OF MYO-INOSITOL

restores normal ovulatory activity

increases fertilization rate

prevents spina bifida birth defect

lowers free testosterone (research has shown up to a 73% reduction)

lowers total testosterone (as much as 65% reduction)

lowers LH (as much as 55% reduction)

lowers insulin response after meals (as much as 62% reduction)

lowers DHEA-S (as much as 49% reduction)

increases SHBG (as much as 92% increase)

lowers androstenedione (as much as 27% reduction)

lowers triglycerides (as much as 51% reduction)

lowers blood pressure (minor decrease)

increases peak progesterone (129% increase in one study)
PROTISOL
PROTEIN + INOSITOL SUPPLEMENT

One of the major reason for PCOS is poor diet.

Most Indian diets are low in Protein.

Taking Protein supplements, especially plant protein, benefits those
suffering from PCOS.

PROTISOL is a unique blend of high quality imported pea protein and
Inositols (Myo-Inositol & D-Chiro-inositol in ratio of 40:1).

Each dosage of 20 gm contains 2 gm of Inositols. 2 doses a day meets
the recommended daily dosage of 4 gm of Inositols.
PCOS is associated with low 25-hydroxyvitamin D
[25(OH)D] levels
Increased insulin
resistance, and obesity
Increased androgen levels
Low vitamin D in
PCOS
Poor follicle maturation
Menstrual irregularity
Poor oocyte quality
MENSTRUAL IRREGULARITIES

Mostly managed by OCP

MPA 10 mg/day or micronized progesterone 300 mg at bedtime for 10 - 14 days
effective in Rx of abnormal bleeding.

If
oligomenorrhoea and amenorrhoea does not respond to oral
contraceptives and antiandrogen combinations, insulin sensitizing agents
have to be added.
A lean PCOS may also have insulin resistance and therefore if they do not
respond to oral contraceptive dose, insulin sensitizing drug has to be
added.

COSMETIC TREATMENT

Antiandrogens used in PCOS will prevent further
hair growth but the hair which have already grown have to be
treated by epilation,
waxing, by electrolysis or laser
treatments.

Acne may require oral antibiotics like
erythromycin and isotretinoin ointment.

Acne also gets cleared in 6-9 months by use of oral
contraceptive pills containing cyproterone acetate.
Excessive Hair
Mechanical method
Laser
Waxing
Shaving
Management
3. Dealing with acne:
Acne and oily skin are primarily the result of
hormonal disorders caused by androgens (male
hormones).
Wash face twice daily
Use hypoallergenic products and mild soaps whenever possible
Clean your bed sheets, especially your pillowcase weekly
Avoid foods that are high in sugar or fried
RESPONSE TO TREATMENT IS ASSESSED BY

Resumption of menstrual cyclicity.

Reduction in features of hyperandrogenicity.

Improvement of biochemical parameters like reduction of free serum testosterone and
normalization of fasting glucose insulin ratio.
Different clinical situations

Newly married not wanting conception

Married wanting conception

Married has one child wants spacing

Secondary infertility

Newer concepts in medical management
Managing Mature PCOs.
•Developed
from articles publish from 1966 to 2006.
The Metabolic Syndrome:
WHO criteria
IGT/IFG or
type 2 diabetes
Central Obesity
BMI > 30 kg/m²
Insulin resistance
(glucose uptake below
lowest quartile)
METABOLIC SYNDROME
Microalbuminuria
UAE  20 µg min
Blood pressure
 160/90 mmHg
Triglycerides
&  HDL-Ch
> 150 mg/dl
< 35 mg/dl
Alberti & Zimmet WHO 1998 Diabetic Medicine.
CONCLUSION

Enigmatic,lesser understood

Diagnosis can be tricky

Management is age and need oriented

Lifestyle modification is the crux.

Fertility can be difficult.

Prevention of longterm implications should be kept in mind
These module have been created with the help of all my friends at FOGSI who have devoted precious
time to send certain messages relevant for our day to day practice.
My special thanks to:
Dr.Sanjay Gupte
Dr. C.N. Purandare
Dr.Roza Olyai
Dr.Rishma Pai
Dr.Pratap Kumar
Dr. Richa Singh
Dr.P.K.Sekharan
Dr.Sujata kar
Dr.R.N.Goel
Dr.Tushar Kar
Dr.Anupam Gupta
Dr.P.K. Shah
Dr.Mandakini Parihar
Dr.Abha Majumdar
Dr.Sudha Prasad
Dr.Maninder Ahuja
Dr.Nalini Mahajan
Dr. Girija Wagh
Dr.Sunita Tandulwadkar Dr.Shanta Kumari
Dr.Laxmi Shrikhande
THANK YOU
CONGRATULATIOSN UP
HARYANA&DELHI ISAR FOR THIS
WONDERFUL 3 DAYS