PCOS and Obesity
DUB is better treated by OCPs
Dr. Ritu Joshi
- Senior consultant Fortis escorts Hospital, Jaipur
- Chairperson Family welfare com. FOGSI (2009-2012)
- Vice President FOGSI 2014
Introduction
One of the most common endocrinopathy.
Unknown etiology.
Prevalence in India of 3.7% to 22.5% with 9.13% to 36% adolescents.
Common symptoms range from-
- menstrual disorders
- Infertility
- Hyperandrogenemia
- Metabolic syndrome.
In India rapid increase in prevalence of PCOS is
associated with morbid conditions such as-
- IR
- Excess body fat
- Adverse body fat patterning
- Hypertriglyceridemia
- Obesity related diseases like diabetes, and
cardiovascular diseases.
Category Specific abnormality
Recommended diagnosis NIH Rotterdam
AE-PCOS
Androgen status
Clinical Hyper-AndrogenismBiochemicalhyperandrogenism
Hirsutism, acne, and Central alopeciaIncreased total bioavailability or free serum testosterone level
XX
XX
X
X
XX
XX
Menstrual History
Oligo- or anovulation
Anovulation frequent (<21 d) or infrequent (>55d) bleeding intervals
Mid luteal progesterone test for anovulatorybleeding in women with regular ovulation
XX X XX
Ovarian appearance
Ovarian size/morphology on ultrasound
PCO morphology presence of 12 follicles of 2-9mm dia and/or ovarian vol >10ml without a cyst or dominant follicle >10mm
X X
Diagnostic criteria for PCOS which has been adapted from Legro et al 2013
Malik, et al.: A Consensus Evidence-based Good Clinical Practice Recommendations
Obesity and PCOS
• Obesity has been linked to abnormal function of
the hypothalamic-pituitary-ovarian axis through
multiple mechanisms that contribute to PCOS.
• Obesity is associated with insulin resistance and
compensatory hyperinsulinemia.
• Insulin serves as co-gonadotropin to stimulate
ovarian androgen production.
• Inputs from adipokines such as leptin are key to
controlling ovulatory function.
Effect of obesity in PCOS
Obesity is associated with increased likelyhood of
metabolic sequelae, like glucose intolerance,
dyslipidemia.
Obesity is associated with anovulation and
hyperandrogenemia.
Obesity and DUB• Hyperandrogenism contributes to ovulatory and menstrual
dysfunction.
• Management of hyperandrogenism focuses on treating its clinical consequences.
• OCPs are the first line management for the treatment of menstrual abnormalities.
• They suppress the gonadotropin release and consequently inhibit ovarian androgen secretion in women with PCOS.
• The estrogen in the OCPs also stimulates hepatic production of sex hormone binding globulin (SHBG), which inturnreduces the free fraction of circulating androgens .
Obese adolescent with PCOS
• OCPs are the first line option-
• They regulate the menstrual cycles.
• Lower the risk of endometrial hyperplasia, acne
and hirsutism.
• Act by regulating the GnRh pulses and suppress
FSH and LH resulting in decreased ovarian
stromal proliferation and reducing ovarian
steroidogenesis and androgen production.
• Mechanism of action of OCPs-
• Estrogen increases the production of SHBG
thereby decreasing the circulating free androgens.
• Reduction in adrenal androgen secretion and
inhibiting peripheral conversion of testosterone to
dihydrotestostrone and binding of
dihydrotesterone to androgen receptors.
• Progestogens counteract the unopposed estrogen
thereby reducing endometrial hyperplasia.
Choice of OCP
• Type of estrogen compound used.Most current
OCPs contain 30-35ug of ethinyl estradiol
combined with a progestin with minimal
androgenic activity.
• Choice of progestin compound used.
• Dosage of estrogen and progestin compounds
in combination.
Existing guidelines
ACOG
RCOG
Endocrine society
PCOS Australian alliance
PCOS guideline-GCPR by Indian fertility society
All suggest use of OCPs as the first line
primary treatment option in menstrual
irregularities.
Oral Contraceptives Pills
• Suppress ovarian androgen
• Increase SHBG
• Regular menstrual cyclicity
• Progestin opposition
• Contraception
Oligomenorrhea
• Combination estrogen-progestin pill first line when fertility is not desired• Decrease in LH secretion and decrease in
androgen production
• Increase in hepatic production of sex-hormone binding globulin
• Decreased bioavailablity of testosterone
• Decreased adrenal androgen secretion
• Regular withdrawal bleeds
• Prevention of endometrial hyperplasia
A comparison of various progestins
Progestin Estro-
genic
Anti-
estrogenic
Andro-
genic
Antiandro-
genic
Antimineralo
-corticoid
Progesterone - - - + +
Older
progestins:
MPA
Norethisterone
Levonorgestrel
-
-
-
-
+
+
+
+
+
-
-
-
-
-
-
Newer
progestins:
Desogestrel
Cyproterone
acetate
-
-
-
-
-
-
-
+
-
-
Drospirenone - - - + +
Advantages
• Best for adolescents.
• In adults who do not wish to conceive
• Best for regulating menstrual cycles.
• Simultaneously also treats acne and hirsutism
when present.