Being Feminine and Fabulous - PowerPoint Presentation

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Being Feminine and Fabulous The 2015 Guide

2015 Bayer SymposiumFEMBRYO Fertility and Gynaecology ClinicSlide2

Evolution of the Modern WomanSlide3
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Princess

Sugar and Spice

and all things nice

Thank Heaven

for little girlsSlide5

“If Barbie were an actual woman, she would be 5'9" tall, have a 39" bust, an 18" waist, 33" hips and a size 3 shoe," Slayen wrote in the Huffington Post

. "She likely would not menstruate... she'd have to walk on all fours due to her proportions."

BMI - 16Slide6
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OverviewSlide17

Case presentation17 y.o P0 G0 . Amenorrhoea for 5 months. Increasing facial hair and weight gain. Family history of Type 2 DM in mother. Acne vulgaris not responding to topical treatment. B HCG -Question 1:What is your most likely diagnosis?

a. Steroid use b. DM c. Adrenal tumour d. PCOS e. Cushing syndromeSlide18

AnswerQuestion 1:What is your most likely diagnosis? a. Steroid use b. DM

c. Adrenal tumour d. PCOS e. Cushing syndromeAll of the above conditions may however be possible causes and should be on the differential diagnosis listSlide19
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Question 2: What are the long term issues regarding the health of these patients?Endometrial hyperplasia/Ca Adverse pregnancy outcome Infertility

NIDDM CVDa. c. d. and eAll the aboveSlide21

Morbidity1. HyperandrogenismInsulin resistanceAcne vulgaris

Hirsutism2.

If not recognised and treated:

Endometrial hyperplasia/

Ca

Breast abnormalities Infertility NIDDM CVDSlide22

Infertility and PregnancyAnovulatory infertility. 50% primary infertility, 25% secondary infertilityPregnancy complications:

Gestational diabetes, preterm delivery, pregnancy induced hypertension and pre eclampsia. Fetal origins of disease: Barker Hypothesis with an increase in cardiovascular disease related to intra-uterine eventsSlide23

Answer Question 2: What are the long term issues regarding the health of these patients?Endometrial hyperplasia/Ca Adverse pregnancy outcome

Infertility NIDDM CVDa. c. d. and eAll the aboveSlide24
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Acanthosis NigricansSlide26

Question 3: Which of the following are diagnostic factors according to the Rotterdam criteria?Cysts on ultrasound of more than 25 mmAcneShort statureIrregular ovulation

a. and d.b. and d.b. c. and d.Slide27

Diagnosis of PCOSDiagnosis can be made with careful history combined with a targeted laboratory evaluation and exclusion of other underlying conditions.There are several diagnostic guidelines for polycystic ovary syndrome, and although different, each relies on combination of 3 major elements

to make the diagnosis: 1. Ovulatory dysfunction 2. Hyper androgenism (Clinical or biochemical) 3.

Ovarian morphologySlide28
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Poli follicular syndromeSlide30

Radiological criteriaNon specific(23% of normal healthy women has PCO picture).12 or more follicles, 2-9 mm in diameter in each ovary, arranged around a dense stroma or scattered throughout an increased amount of stroma./ increased volume( > 10 ml) in absence of dominant follicle.

Important to differentiate between PCO and PCOS Slide31
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AnswerQuestion 3: Which of the following are diagnostic factors according to the Rotterdam criteria?Cysts on ultrasound of more than 25 mmAcneShort stature

Irregular ovulationa. and d.b. and d.b. c. and d.Slide33

Question 4: Which other conditions must be in the differential diagnosis during the work up?Late onset congenital adrenal hyperplasiaHypothyroidismTumour of OvaryCushing syndromeIntersex

a. b. and d.a. b. c. and d.Slide34

Exclusion of other causesSlide35

Laboratory InvestigationsOrgan targeted assessment 1. Ovary Total and free Test DHEA 2. Adrenal 17 0H

Prog, DHEAS 3. Pituitary LH:FSH 4. Metabolic Insulin;glucose ratio Lipid ProfileSlide36

AnswerQuestion 4: Which other conditions must be in the differential diagnosis during the work up?Late onset congenital adrenal hyperplasiaHypothyroidismTumour of OvaryCushing syndrome

Intersexa. b. and d.a. b. c. and d.Slide37

Goals of treatment1. Short term: Adolescent years. General well being and self esteem with education and support2. Intermediate

: Reproductive years. Fertility and pregnancy management3. Long term: Post reproductive years

. Prevention/management of metabolic syndromeSlide38

Question 5: Which statement is incorrect?Weight loss is the cornerstone of treatment in obese patients.Every woman that is obese does not have PCOS but every PCOS patient is obese.

Calorie restricted diets are superior to other forms of eating plansMetformin is a biguanide that enhances peripheral tissue sensitivity to insulin and inhibits hepatic glucose production.Slide39

Weight reductionCornerstone of available therapy.Diet and lifestyle modifications.No RCT’s to guide but the combination of diet and exercise leads to weight loss with proven cardiovascular and diabetic risk reduction in general.Slide40

Weight lossEvery woman that is obese does not have PCOS and every PCOS patient is not obese!Why weight loss? 1. Decreased aromatization of Androgens to Estrone in adipose tissue

2. Increased SHBG 3. Decreased hyperinsulinaemia: Increased SHBG 4. Positive effect on lipid profile 5. 5-7% weight loss results in >75% ovulation and fertility Slide41

AnswerQuestion 5: Which statement is incorrect?Weight loss is the cornerstone of treatment in obese patients.Every woman that is obese does not have PCOS but

every PCOS patient is obese.Calorie restricted diets are superior to other forms of eating plansMetformin is a biguanide that enhances peripheral tissue sensitivity to insulin and inhibits hepatic glucose production.Slide42

Endocrine Society Clinical Practice Guideline 2013“We suggest that weight loss strategies begin with calorie-restricted diets, with no evidence that one type of diet is superior, for adolescents and women with PCOS who are overweight or obese.”Slide43

Drugs that Improve Insulin SensitivityMetformin is a biguanide that enhances peripheral tissue sensitivity to insulin and

inhibits hepatic glucose production. It reduces glucose uptake and increases glucose utilization by muscle.ESCPG .

Should not be used as first line treatment of cutaneous manifestations, prevention of pregnancy complications or for treatment of obesity.

Suggest Metformin in women with PCOS with T2DM or IGT who fail lifestyle modificationSlide44

Oral ContraceptivesEffective in reducing hyperandrogenic features (alone < 10% effective).Should be used together with an anti- androgen as first line therapy for menstrual abnormalities and hirsutism

/acne.Mechanisms: 1. Decreased LH secretion (Central) 2. Reduces 5 alpha reductase action (Prog) 3. Increases SHBG (Estrogen)3rd Generation

Progestins: less anti Estrogenic, increased SHBG

Reduces ovarian and endometrial cancer.Slide45

SummaryRecognition and early diagnosis in women presenting with PCOS, offers an important opportunity to begin a life-long conversation about prevention and treatment of a condition that has a multi-system impact on affected women.Slide46

Abnormal Uterine BleedingSlide47

Abnormal Uterine BleedingCommon problem in women of all ages.20% of women complain of abnormal menses and constitutes 4% of general practice consultations.Accurate diagnosis forms the cornerstone of successful therapy. Slide48
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Approach according to AgeSlide54

Approach according to SiteSlide55

Approach according to EtiologySlide56

AdolescentCase 1: 13 year old patient with irregular cycles and severe bleeding.Slide57

What is the most likely diagnosis?Slide58

AnswerSlide59

Anovulatory DUB70-80%Cause: Post menarche immature H-H-O axis

Management Exclude: 1.Platelet disorder ITP

2.Coagulation disorder VWF/FVIII 3.Hypothyroidism

4.Bone

marrow

disease:

Leukaemia

/Lymphoma

5.PregnancySlide60

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Reproductive yearsCase 2: 31 year old P0 G0 sexually active patient on COC. Presents with episodes of breakthrough bleeding and post coital bleeding.Slide62

What is the most common reason for abnormal bleeding?Slide63

AnswerSlide64

Management1. Exclude pregnancy2. Clinical examination and Pap smear3. Menstrual calendar4. Pelvic ultrasound to exclude ovarian functional cysts5. If no C/I for COC use or LNG IUS, initiate therapy.6. If already on Rx, change dose of EE, change to triphasic or Estradiol valerate7. If pregnancy wish: Consider ovulation inductionSlide65

Perimenopausal ageCase 3: 49 year old patient with irregular menses and episodes of amenorrhoea for 2 months followed by heavy menstrual flow Slide66

In the perimenopausal patient, anovulatory abn uterine bleeding is still common .However, underlying pathology MUST be excludedPALM COEINUterine:Endocervical and endometrial polyps, fibroids

Ovarian: Functional cystsManagementSame as for reproductive years butexclude pathology of endometrium.If hormonal abnormality: E2 and Prog treatment and reassuranceSlide67

Uterine pathologySlide68
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Postmenopausal ageCase 4: 65 year old postmenopausal patient with sudden onset of bleeding per vagina. HT on Rx.Slide70

Cancer of Endometrium until proven otherwise!Slide71
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SummarySlide75

Contraceptive PearlsSlide76

Question 1: Which of the following conditions are absolute contra indications to the use of COC? a. Age 45-51b. Cholecystitisc. Migraine with aurad. Ulcerative colitis

e. Crohn’s diseaseSlide77

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Answer Question 1a. Age 45-51b. Cholecystitisc. Migraine with aurad. Ulcerative colitis

e. Crohn’s diseaseInflammatory bowel disease and cholecystitis are relative C/IAge alone is NOT a C/ISlide79

Question 2: Which of the benefits of COC are applicable to the patient in age group 45-51?a. Effective contraceptionb. Reduction in heavy menstrual flowc. Protection against ovarian, endometrial and colorectal cancerd. Prevention of bone losse. Answers a. b. df. All of aboveSlide80

Answera. Effective contraceptionb. Reduction in heavy menstrual flowc. Protection against ovarian, endometrial and colorectal cancerd. Prevention of bone losse. Answers a. b. df. All of above

It also reduces vasomotor symptoms.Low dose, <30ug should be used.Only applies to lean, non smoking healthy peri menopausal women.Slide81

Question 3: Which of the following combinations are indicated for hyper-androgenism ( acne/hirsutism)?EE + CPAEE + Drosperinone

Estradiol valerate + dienogestAll of the aboveSlide82

AnswerEE + CPAEE + DrosperinoneEstradiol

valerate + dienogestAll of the aboveThe mechanism of action is an increase in the SHBG production by the liver through EE. This leads to an increase of bound(Inactive) T

and inhibition of peripheral conversion of T to DHT (Activated=active) by progestogen

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Question 4: Which COC decreases libido less than other COC’s?EE + GestodeneEE + DrosperinoneEstradiol

valerate + dienogestEE + DesogestrelSlide84

AnswerEE + GestodeneEE + DrosperinoneEstradiol

valerate + dienogestEE + Desogestrel

It does not increase SHBG, therefore free T not affectedSlide85

Question 5:When can women stop using contraception? Faculty of Sexual &Reproductive Healthcare Clinical GuidelinesAt age 51When early menopause is diagnosed12 months of amenorrhoea if younger than 50

24 months of amenorrhoea if younger than 5024 months of amenorrhoea when older than 50Slide86
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AnswerAt age 51When early menopause is diagnosed12 months of amenorrhoea if younger than 5024 months of amenorrhoea if younger than 50

24 months of amenorrhoea when older than 50Slide89

Gynecology Guidelines for Good PracticeSlide90

Cervical cancer screeningQuestion 1: When should routine screening start and when should it end? United States Task Force on Preventative ScreeningSlide91
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Osteoporosis ScreeningQuestion 2: When should DXA screening start in women?Slide93
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Breast cancer ScreeningQuestion 3: When should Breast Cancer Screening start?Slide95
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BREAST CANCER RISK ASSESSMENTQUESTION 4: Which tool is validated?Slide97
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prophylaxis for BREAST CAQuestion 5: Which women should be offered Prophylaxis?Slide99
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FERTILITYQUESTION 6: When should couples seek expert help?Slide101
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Women <35 years and no pregnancy after 12 months of unprotected intercourseWomen > 35 years should seek expert help after 6 months

Women > 39 years attempting pregnancy should seek immediate helpSlide103

Onco-fertilityQuestion 7: What is onco fertility?Slide104
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“Social Freezing”Question 7: What does social freezing mean?Slide106

Cryopreservation of embryos and mature oocytes, spermSlide107

Thank you for your attentionThe slides are available on www.fembryo.co.za