Prevention & Management of PCOS - PowerPoint Presentation

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Prevention & Management of PCOS

Rashmi Kudesia, M.D. M.Sc.Icahn School of Medicine at Mount SinaiNovember 18, 2015Slide2

Objectives

To highlight the dilemmas in PCOS management in the primary care settingTo address barriers to comprehensive PCOS care for the female through the

lifecourseSlide3

PCOS Lifecourse Slide4

Management 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 sequelaeSlide5

Diagnosis

Dilemma 1: What are the best diagnostic criteria?NIHRotterdamAndrogen ExcessSlide6

Diagnosis – 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 profileSlide7

Diagnosis

Dilemma 2: What is the best approach to the child or adolescent with suspected PCOS?Pubertal symptoms overlap with PCOS criteriaIrregular menstruationAcneWeight gainSlide8

Diagnosis – 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 reassuranceSlide9

Diagnosis – Dilemma 2

Routine fertility counseling for adolescentsTeens with PCOS have greater fertility concerns than peers without PCOSSlide10

Counseling

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 counselingSlide11

Counseling

Common Pitfalls:Only addressing patient’s acute concernsFailure to counter misinformation from non-medical sourcesFailure to explain which medications address which aspects of PCOS managementSlide12

Lifelong 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?Slide13

Lifelong Management

PCOSQ Questionnaire* helps identify which domains are most affecting current QOLEmotionsBody hairWeightInfertilityMenstrual problems

*Cronin et al JCEM 1998Slide14

Lifelong 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 gain

2h 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, QOLSlide15

Lifelong 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 & cardiologySlide16

Lifelong Management

Common Pitfalls:Over-reliance on metforminSlide17

Lifelong 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 metformin

Appears to decrease levels of C-reactive protein (low level chronic inflammation)May improve vascular endothelial function and coronary flow rateSlide18

Lifelong 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!Slide19

Lifelong Management

Dilemma 5: How best to optimize fertility and pregnancy?Is there potential for prevention in the next generation?Slide20

Lifelong 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 settingsSlide21

Lifelong Management

Common Pitfalls:Failure to provide preemptive counseling regarding the elevated risks to PCOS women:Excessive pregnancy weight gainGestational diabetesGestational hypertension/preeclampsia

Preterm laborIncreased C-section rateAbnormal birthweight and impact on ultimate cardiometabolic health of their childSlide22

Lifelong Management

Dilemma 6: How best to mitigate cardiometabolic sequelae for the woman with PCOS?What do we know about the risk?Slide23

Lifelong Management

The impact of PCOS by time of menopausal transition is still poorly understood, however:*

Kudesia et al Semin Repro Med 2014Slide24

Lifelong Management

Thus, the overarching goals could be:Stave off development of cardiometabolic co-morbidities in middle ageEmphasize lifestyle modificationPrevent or treat obesity

Such that, PCOS women enter post-menopause at similar risks to non-PCOS womenSlide25

Conclusions

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 literature

Improvement in health of the PCOS woman in pregnancy could help “prevent” disease in the next generation