Rashmi Kudesia MD MSc Icahn School of Medicine at Mount Sinai November 18 2015 Objectives To highlight the dilemmas in PCOS management in the primary care setting To address barriers ID: 775775
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Prevention & Management of PCOS
Rashmi Kudesia, M.D. M.Sc.Icahn School of Medicine at Mount SinaiNovember 18, 2015
Slide2Objectives
To highlight the dilemmas in PCOS management in the primary care settingTo address barriers to comprehensive PCOS care for the female through the lifecourse
Slide3PCOS Lifecourse
Slide4Management of PCOS
Most important goalsAvoiding over- and under-diagnosisCounselingPrioritize specific aspects affecting health and quality of life for each individualOptimize fertility and pregnancy (prevention)Minimize cardiometabolic sequelae
Slide5Diagnosis
Dilemma 1: What are the best diagnostic criteria?NIHRotterdamAndrogen Excess
Slide6Diagnosis – Dilemma 1
Common PitfallsNot adhering to strict criteriaGestalt impressionsApplying sonographic criteriaFailure to recognize lean PCOS womenFailure to recognize racial & ethnic variations in phenotype and risk profile
Slide7Diagnosis
Dilemma 2: What is the best approach to the child or adolescent with suspected PCOS?Pubertal symptoms overlap with PCOS criteriaIrregular menstruationAcneWeight gain
Slide8Diagnosis – Dilemma 2
Common Pitfalls:Labeling an adolescent too earlyAnd yet: failure to identify a child who has multiple risk factorsIn a girl with suspected PCOS, failure to identify risk and provide counseling regarding:How the diagnosis might be confirmedBroad strokes of what diagnosis would meanAllay concerns and provide reassurance
Slide9Diagnosis – Dilemma 2
Routine fertility counseling for adolescentsTeens with PCOS have greater fertility concerns than peers without PCOS
Slide10Counseling
Dilemma 3: What are the most salient points in patient counseling once the diagnosis is established?The quality of PCOS care provided is largely determined by the quality of patient counseling
Slide11Counseling
Common Pitfalls:Only addressing patient’s acute concernsFailure to counter misinformation from non-medical sourcesFailure to explain which medications address which aspects of PCOS management
Slide12Lifelong Management
Dilemma 4: In the era of personalized medicine, how best can one individualize PCOS care?OR, how can one take a patient-centered approach to the care of PCOS women?
Slide13Lifelong Management
PCOSQ Questionnaire* helps identify which domains are most affecting current QOLEmotionsBody hairWeightInfertilityMenstrual problems*Cronin et al JCEM 1998
Slide14Lifelong Management
Consensus Guidelines from Endocrine Society (2010):All PCOS women be assessed for CVD riskBP, waist circumference & BMI at every visitComplete lipid profile (target LDL)Reassess every 2 years or sooner if weight gain2h 75g OGTT in women with BMI>30 or in lean women with age>40, h/o GDM, FH of T2DMReassess every 2 years or sooner if new risk factorsA1c has promiseAssessment for depression, anxiety, QOL
Slide15Lifelong Management
Common Pitfalls:Failure to recognize shifting prioritiesDiscomfort with lifestyle counselingTime limitationsFailure to emphasize or provide multi-disciplinary care with a team-based approach:NutritionExerciseBariatric surgeryEndocrinology & cardiology
Slide16Lifelong Management
Common Pitfalls:Over-reliance on metformin
Slide17Lifelong Management
Potential roles of metformin:A meta-analysis of 31 trials concluded that metformin increases insulin sensitivity up to 20%, decreases weight and BMI by 3–5%, decreases fasting glucose by about 5%, and increases HDL-cholesterol and decreases triglycerides by approximately 10% in patients Weight loss enhances the effects of metforminAppears to decrease levels of C-reactive protein (low level chronic inflammation)May improve vascular endothelial function and coronary flow rate
Slide18Lifelong Management
Common Pitfalls:Over-reliance on metforminSpecific Indications for its usage:Prevent or slow progression to type 2 DM and long-term risks for cardiovascular disease) Women with IGT or DM, those with evidence of severe insulin resistance (acanthosis nigricans) and women having features of metabolic syndrome (central obesity, HTN, dyslipidemia)Does not replace lifestyle modifications!
Slide19Lifelong Management
Dilemma 5: How best to optimize fertility and pregnancy?Is there potential for prevention in the next generation?
Slide20Lifelong Management
Common Pitfalls:Failure to optimize health prior to conceptionRequires a detailed planFailure to select the most effective fertility treatmentClomiphene more effective (22.5%) than metformin monotherapy (7.2%) for live birth (Legro et al, NEJM 2007)PPCOS II demonstrated a rate ratio for live birth 1.44 [95% CI 1.1,1.9] with letrozole rather than clomiphene (Legro et al, NEJM 2014)Avoiding gonadotropins in non-IVF settings
Slide21Lifelong Management
Common Pitfalls:Failure to provide preemptive counseling regarding the elevated risks to PCOS women:Excessive pregnancy weight gainGestational diabetesGestational hypertension/preeclampsiaPreterm laborIncreased C-section rateAbnormal birthweight and impact on ultimate cardiometabolic health of their child
Slide22Lifelong Management
Dilemma 6: How best to mitigate cardiometabolic sequelae for the woman with PCOS?What do we know about the risk?
Slide23Lifelong Management
The impact of PCOS by time of menopausal transition is still poorly understood, however:*Kudesia et al Semin Repro Med 2014
Slide24Lifelong Management
Thus, the overarching goals could be:Stave off development of cardiometabolic co-morbidities in middle ageEmphasize lifestyle modificationPrevent or treat obesitySuch that, PCOS women enter post-menopause at similar risks to non-PCOS women
Slide25Conclusions
The comprehensive management of PCOS requires:A patient-centered approachSignificant time dedicated to thorough education and counselingA network of referrals and local resourcesRemaining up-to-date on newest advances in the literatureImprovement in health of the PCOS woman in pregnancy could help “prevent” disease in the next generation