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Essay 216 - PCOS

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		Posted by Srivas P. Fri Jan 5, 2007 04:11 pm
I will tell her that PCOS is a common condition affecting 20% of woman and it tends to run in families. More follicles start to mature each cycle than is normal and all do not end in ovulation and this multi follicle development may cause hormone imbalance leading to anovulation, irregular periods and may have been responsible for her infertility. I will enquire if she has other features like acne, hirsutism, obesity or irregular periods. All women need not have all the symptoms while some may not have any symptom at all. For her infertility, if she is obese, I will tell her the importance of keeping her weight in check as this itself might cause ovulation. She may need ovulation induction drugs to conceive. I will tell her about the various drugs like Clomiphene, gonadotrophins, their effectivity, side effects and also complications like multiple gestation and ovarian hyper stimulation syndrome. She may benefit from insulin sensitizing agents like metformin. I will also tell her about surgical options like ovarian drilling if the medical option fails. She may continue to have irregular and infrequent period and this is by itself not a cause for concern. If she wants regular periods, this can only be regularized by taking combined oral contraceptive pills but in her case ovulation inducing drugs is more appropriate if she would like to conceive. She should in any case have menstrual bleed every 3-4 months because prolonged stimulation by hormone can cause thickening of her womb lining and predispose her to future womb cancer. If she has complains of hirsutism I will tell her about physical methods of hair removal like epilation, waxing, threading, laser for immediate effect along with drugs like cyperoterone , finasteride and Flutamide and topical eflornithine. She would need 6mths of medication to see effect. Weight reduction also contributes to decrease hirsutism. Over long term she is prone to have deranged lipid profile and she has increased liability to get cardio vascular disease. She should have yearly lipid profile done. She has 20% chance of getting diabetes mellitus, more so if she is obese and has family history. So she should get blood sugar done yearly and keep her weight in control. b) If she is obese, weight reduction it self may suffice in inducing ovulation. This is physiological does not involve taking medicines with attendant risks of multiple gestation and OHSS. Also, there is no need for follicular tracking. Added advantage is it may reduce hirsutism. Weight reduction may also reduce her chances of getting GDM in pregnancy. Other non medical option is surgical ovarian drilling. This is done laproscopically after medical methods of induction of ovulation have failed. It is an invasive method , needs expertise and facility for laparoscopy and she runs the risk of complications of laparoscopy like injury to viscera, bowel, blood vessels, risk of laparotomy and very rarely even death (1:12000). Frequent ovarian drilling can cause premature ovarian failure. Advantage over medical method is there are no risks on multiple pregnancy and OHSS where as with clomiphene there is 5% and with gonadotrophin there is 30% risk of multiple gestation. The chances of mild OHSS is nearly 30% with gonadotrophns, with severe OHSS occurring in 5% case and may involve renal, ARDS, thromboembolic complication and rarely even death. Other surgical method like ovarian wedge resection is not advocated now due to increased adhesion formation and no advantage over ovarian drilling. c) Though she has 50-80% chance of having ovulation with drugs, pregnancy rates is only around 40 %. There are no obviously increased risk of congenital anomalies but her chances of miscarriage are increased for causes still uncertain. She also has increased chances of having gestational diabetes mellitus. Rest of pregnancy is likely to be uneventful.
		Posted by neera B. Fri Jan 5, 2007 09:15 pm
I would councel her that 1 in 10 women have polycystic ovarian syndrome(PCOS);a hormonal disorder.I shall reassure her that most women have no problems,though some may require medical treatment depending on their symptoms;surgical treatment is an exception. Some women may have infrequent periods or no periods; not all of these need to be treated. 30-40% of PCOS are obese and benefit by loosing weight.I shall tell her that some women with PCOS may have excessive hair growth or acne,for which effective treatment is available. PCOS may be associated with irregular or absent ovulation. This can cause infertility.Weight loss,medical and sometimes surgical tretments give excellent result. Longterm implications include higher chance of developing high blood pressure,ischemic heart disease,type 2 diabetes mellitus,gestational diabetes,cancer endometrium and ovary.Psychological aspect should be taken into consideration while mentioning the word cancer. Non medical option for obese women is to lose weight by diet and exercises, it is cheap, effective but this does not always succeed in inducing ovulation and further treatment may be needed If there no ovulation with clomifene citrate in 6 months laproscopic ovarian drilling is as effective as gonadotrophins. It is a one time treatment , no follicular trckking is needed, and is cost effective. It lowers the LH level , so miscarriage rate is decreased. However risks of laparoscopy like bowel injury , hemorrhage , and infection exists. It may cause premature ovarian failure or post operavive adhesions. It is contraindicated in cases of cardiopulmonary compromise or extensive intraperitoneal adhesions. I shall reassure her that most pregnancies progress smoothly and deliver normally. But the 1st trimester miscarriage rate is increased with PCOS. I shall tell her that 1 % women in general population have recurrent miscariages ( 3 or more consecutive spontaneous miscarriages ) of which some have PCOS . Gestational diabetes mellitus is increased with its attendant complications like big baby, excessive liquor , hence regular antenatal care is advised.
		Posted by Sreekala S. Fri Jan 5, 2007 10:36 pm
a)I will tell her that PCOS could be the main contributing factor for the infertility. The exact cause of PCOS is not known but it is associated with insulin resistance. I will inform her that chances of conception are lower without any intervention although spontaneous conception can still occur.The chances of fertility can be improved with weight loss by dietary modiciations and exercise. Ovulation inducing drugs may be required to conceive. I will discuss the long term implications of PCOS. I will inform her that women with PCOS are at an increased risk of glucose intolerance and Type 2 Diabetes mellitus later in life, especially if they are obese and have a postive family history. I would therefore advice her to get fasting blood glucose checked along with glucosuria regularly for earlier detection, preferably annually. Abnormal results should be followed by oral glucose tolerance test and if abnormal require appropriate treatment. Women with PCOS are known to have hyperlipidemia which predisposes them to have atherosclerotic conditions like Hypertension and Myocardial infarction. Despite having the risk factors for cardiovascular disease like insulin resistance, hyperandrogenism and obesity, the mortality in women with PCOS is not significantly higher than the general population. I would advice her to have fasting lipid profile checked on a regular basis along with fasting blood sugars, such that earlier interventions can be taken to improve the prognosis. I will discuss the increased risk of endometrial hyperplasia and endometrial malignancy in the presence of oligomenorrhoea (or amenorrhoea) especially if the interval between the menstrual cycles is more than 3 months which is due to unopposed estrogen activity. I would therefore recommend her to have regular induction of withdrawal bleed with cyclical progestogens atleast every 3-4months to reduce the risk of endometrial hyperplasia. Hysteroscopy and endometrial biopsy will be indicated in the presence of persistently thickened endometrium on TVS to detect endometrial hyperplasia. I will tell her that she will not be at an increased risk of breast cancer when compared to the general population and that no additional screening is required over and above that being offered by the national breast screening programme. I will inform that the risk of ovarian malignancy is inconclusive although she may be at an increased risk following use of ovulation inducing drugs. b)Options for her include no intervention, conservative management, medical management and surgical. With no intervention, the chances of pregnancy are fewer although spontaneous conception can still occur. Conservative management involves lifestyle modifications like dietary modification, exercise, cessation of smoking, reducing alcohol and caffeine intake. Weight loss by execise and diet improves the insulin sensitivity, resumes ovulation and improves chances of conception. Also weight loss improves the sensitivity of ovulation inducing drugs. Referral to the dietician is required especially if the woman is obese. This requires a highly motivated patient and may take long time to get the results. There is no clear evidence that diet and exercise improve the long term health in women with PCOS who are non obese, but it is advisable to maintain body weight in the normal range. Surgical ovarian drilling should be considered if conservative and medical management fail. It is known to improve the hormone profile and restore ovulation in about 60% of patients but it is associated with anaesthetic risks, surgical risks like visceral injury, bleeding and infection and can also result in premature ovarian failure due to loss of some ovarian tissue. The advantage is that it can be performed as a day case and tubal patency can be tested at the same time. The conservative and surgical management have the advantage that they are not associated with an increased risk of multiple pregnancy or OHSS and do not need intensive ultrasound monitoring as compared to the medical management. c) I will inform her that she may need ovulation induction drugs to conceive and discuss the possible complications like multiple pregnancy and OHSS. I will inform her that there is an increased risk of spontaneous miscarriage with PCOS. The risk of Glucose intolerance and Gestational diabetes are increased in pregnant women with PCOS especially if they are obese and conceived following treatment with ovulation inducing drugs. I would therefore recommend her to have Oral glucose tolerance test at 24-26 weeks of gestation and if it is abnormal, advice a multidisciplinary team care involving the obstetric and diabetic team. I will inform her that there is an increased risk of fetal macrosomia, congenital anomalies, operative delivery, PPH and infection in the presence of gestatinal diabetes. She will be at an increased risk of Pre- eclampsia, especially if she is obese. I will also discuss the difficulties that may be encountered in antenatal fetal growth monitoring and intrapartum difficulties if she is obese.
		Posted by kiria O. Fri Jan 5, 2007 11:27 pm
polycystic ovary syndrome(PCOS) is very common affect 1 in 5 women and is associated with many health implications including effect in her fertility, causing anovulatory infertility even if she has regular period however this problem can be overcomed by weight reduction in high BMI > 30 or by using ovulation inducing drugs or surgery (ovarian drilling). even if she get pregnant her risk of misscarriage is increased. There are a health risks including type ii diabetes mellitus(DM) and gestational DM, also she is at increased risk of hypertension. Woman should be counslled regarding increased risk of cadiovascular problems and ischemic heart disease due to abnormal lipid profile and presence of hypertension and DM. So,she need to follow healty life style to modify those risks including regular exercises ,stop smoking ,high fiber ,low sugar low fat diet and regular testing by GTT and lipid profile. Other imortant issue need to be discussed is her increased risk of endometrial hyperplasia and endometrial cancer because of high estrogen levels and this risk can be modified by adminstring protective progestagens in form of combined contraceptive pills if she need contraception or she has irrgular period. or mirina if systemic side effects of progestagens is not tolerated. Woman my present with a problem of hirsuitism which has no health risk but causing social implication and should be treated. The none medical options for ovulation induction is weight reduction in women with high BMI >30, this is very effective method associated with spontanous ovulation and improvment in other health risks because its lead to reduce insuline risistance and improve blood sugar level and has no side effects or complication compared to other medical and surgical options. However, weight loss need highly motivated pateint and need support from partener, family and staff. Other life style factors could improve general and reproductive health iclude gave up smoking, alcohol,recreational drugs, regular exercises. Other option is surgical, laproscopic ovarian drilling which is associated with high success rate in inducing ovulation around 90% of women achieve ovulation but effective for one year. So,its should be performed if woman wish prgnancy and performed in women not responding to clomifen citrate (6 cycles) and not associated with increase risk of ovarian hyper stimulation syndrome which is potentially fatal itrogenic conditions associated with use of ovulation inducing drugs mainly gonadotrophins. Laproscopic ovarian drilling is associated with risks of surgical morbidites including blood vessles,bowel injury and anasthetic risks with no fixed way of performing drilling using diathermy or laser. Regarding pregnancy out come, she should know that,she at increased risk of misscarrige although this would depend on a method of ovulation induction. and the rate of misscriage is less in weight reduction option and ovarian drilling option compared to gondotrophins and clomid and this is maybe due to increase level of Lutinising hormon, however woman shoule be reassured that most of women has favorable pregnancy outcome.
		Posted by Badi A. Sat Jan 6, 2007 02:29 am
I\'ll tell the patient that PCOS is a condition in which the ovaries are bigger than average, and the outer surface of the ovary has an abnormally large number of small follicles these follicles remain immature, never growing to full development or ovulating to produce an egg capable of being fertilised. In addition, she does not have regular periods and may go for many weeks without a period. Other features of the condition are excess weight and excess body hair due to hormonal imbalance. In addition, because there is a likelihood of developing diabetes in later life and a slightly higher risk of heart disease, low-fat and low-sugar options should be considered . Weight loss, or maintaining weight below a certain level (BMI 15-25), will have the short-term benefit of increasing the likelihood of successful treatment and the long-term benefits of reducing the risk of diabetes and heart disease. non-medical options for ovulation induction include wieght loss and ovarian dithermy which reduce the amount of androgen leading to resumption of ovulation in up to 80 per cent of women. The risks include those of having a laparoscopy and a theoretical risk of ovarian damage from the diathermy. The benefits include resumption of ovulation with effects lasting six to nine month. patient will have increased risk of early pregnancy loss and if pregnancy advances patient shuold be screened for gestational diabetes and should be regularly seen as being at risk of pregnancy induced hypertension and preterm labour.
		Posted by Yasser S. Sat Jan 6, 2007 03:35 am
She should be told that this is the most likely cause of her infertility because her ovaries contain multiple follicles i.e small sacs containing egg. These follicles do not reach to the stage of maturity to release the egg that could fertilize and result in a pregnancy. As a result these cysts build up in the ovaries and may become enlarged. These follicles produce higher than normal amount of androgens, a male hormone which can result in excessive hair growth on face and body and acne. Research has shown that PCOs may be related to increased production of Insulin in the body which may lead to further health problems. Around 20 in 100 women have PCOs, most women have no symptoms. With this diagnosis of PCOs, along with her difficulty in conceiving, she may become aware of some or all of these symptoms like, more body hair than usual, irregular periods or no periods at all, overweight, acne & excessive hair loss on head. These symptoms may vary in severity. Besides, with PCOs, she has a greater risk of developing long term health problems such as heart problems, diabetes, high blood pressure and cancer of the lining of the womb known as endometrial cancer. She may require modifications in life style to control her weight so as to reduce the risk of most of these problem. She may require blood tests like cholesterol levels, insulin levels & hormones levels to assess the problems in time. Regarding her infertility, she have the options of no management, conservative management and pharmaceutical management. The patients who receive no treatment still have a chance to conceive as they do have random ovulations. Conservative management is modification of life style by diet control and increasing physical activity in order to lose weight. Weight loss is not only good for ovulation but also reduces the risks of long term health problems. The medical management can be with certain tablets used for infertility like clomifene, or injections like gonadotrophins depending on the individual?s response. These treatments carries a risk of multiple pregnancies and over stimulation of the ovaries which can be a significant problem. Her treatment would mainly be based on the symptoms which are bothersome for her. Non medical options for ovulation induction are mainly the modifications in the life style & laproscopic ovarian drilling. Modification in life style are focused for weight loss and is by dietary control and increase in physical exercise. The advantage is that weight loss can induce ovulation thus improving the chances of pregnancy and does not carry any risk of multiple pregnancy and ovarian hyperstimulation. Additionally, weight loss is also good to reduce the long term risks of health hazards mentioned earlier. Laproscopic ovarian drilling, though not recommended as a first line management, can induce ovulation and is out of the risks of multiple gestation and ovarian hyperstimulation. It can bring menstrual regularity and can reduce hirsutism. The risks are related to anesthesia and the procedure itself. Requires a trained personal, risks of injury to the bowel, major vesels, post operative adhesions and might need laparotomy. Ovarian wedge resection was a method used in the past which is now obselete and is replaced by laproscopic ovarian drilling. Regarding the pregnancy outcome, she should be told that if she is going to receive medical treatment for pregnancy, then she has a risk of multiple pregnancies. She would also be at risk of developing ovarian hyperstimulation in early pregnany. Also the patients with PCOs have a higher rate of miscarriage. Her risk of developing pregnancy induced hypertension and Diabetes is higher than a woman of her age. The risk of any interventions during labor and delivery is equal to other women. There?s no increased risk of congenital abnormalities in her baby. She need an early and regular antenatal follow up.
		Posted by Yasser S. Sat Jan 6, 2007 03:40 am
She should be told that this is the most likely cause of her infertility because her ovaries contain multiple follicles i.e small sacs containing egg. These follicles do not reach to the stage of maturity to release the egg that could fertilize and result in a pregnancy. As a result these cysts build up in the ovaries and may become enlarged. These follicles produce higher than normal amount of androgens, a male hormone which can result in excessive hair growth on face and body and acne. Research has shown that PCOs may be related to increased production of Insulin in the body which may lead to further health problems. Around 20 in 100 women have PCOs, most women have no symptoms. With this diagnosis of PCOs, along with her difficulty in conceiving, she may become aware of some or all of these symptoms like, more body hair than usual, irregular periods or no periods at all, overweight, acne & excessive hair loss on head. These symptoms may vary in severity. Besides, with PCOs, she has a greater risk of developing long term health problems such as heart problems, diabetes, high blood pressure and cancer of the lining of the womb known as endometrial cancer. She may require modifications in life style to control her weight so as to reduce the risk of most of these problem. She may require blood tests like cholesterol levels, insulin levels & hormones levels to assess the problems in time. Regarding her infertility, she have the options of no management, conservative management and pharmaceutical management. The patients who receive no treatment still have a chance to conceive as they do have random ovulations. Conservative management is modification of life style by diet control and increasing physical activity in order to lose weight. Weight loss is not only good for ovulation but also reduces the risks of long term health problems. The medical management can be with certain tablets used for infertility like clomifene, or injections like gonadotrophins depending on the individual?s response. These treatments carries a risk of multiple pregnancies and over stimulation of the ovaries which can be a significant problem. Her treatment would mainly be based on the symptoms which are bothersome for her. Non medical options for ovulation induction are mainly the modifications in the life style & laproscopic ovarian drilling. Modification in life style are focused for weight loss and is by dietary control and increase in physical exercise. The advantage is that weight loss can induce ovulation thus improving the chances of pregnancy and does not carry any risk of multiple pregnancy and ovarian hyperstimulation. Additionally, weight loss is also good to reduce the long term risks of health hazards mentioned earlier. Laproscopic ovarian drilling, though not recommended as a first line management, can induce ovulation and is out of the risks of multiple gestation and ovarian hyperstimulation. It can bring menstrual regularity and can reduce hirsutism. The risks are related to anesthesia and the procedure itself. Requires a trained personal, risks of injury to the bowel, major vesels, post operative adhesions and might need laparotomy. Ovarian wedge resection was a method used in the past which is now obselete and is replaced by laproscopic ovarian drilling. Regarding the pregnancy outcome, she should be told that if she is going to receive medical treatment for pregnancy, then she has a risk of multiple pregnancies. She would also be at risk of developing ovarian hyperstimulation in early pregnany. Also the patients with PCOs have a higher rate of miscarriage. Her risk of developing pregnancy induced hypertension and Diabetes is higher than a woman of her age. The risk of any interventions during labor and delivery is equal to other women. There?s no increased risk of congenital abnormalities in her baby. She need an early and regular antenatal follow up.
		Posted by sailaja devi K. Sat Jan 6, 2007 06:55 am
I will expain polycystic ovary syndrome(PCOS) is a condition of harmonal imbalance with anovulatory infertility, infrequent menses,hirsutism.I will tell she needs treatment to correct anovulation , polycystic ovary is associated with metabolic abnormality like Type 2 diabetes ,risk of hyperlipidaemia.I will tell long term health risk associated with this,advice regarding diet & exercise. PCOS is linked to diabetes type 2 .I will check her BMI , enquiry about family history of diabetes as obesity & family history increase the risk of diabetes.I will offer urinanalysis for glucose,fasting bood sugar (FBS), if result is abnormal ,i will offer glucose tolerance test , refer to physician.I will offer annual FBS. PCOS is linked to cardiovascular risk because of obesity hypertension,hyperandrogenemia,hyperinsulinemia.It increases triglycerides,LDL cholesterol so prone for atherosclerosis.I will offer fasting cholesterol ,triglycerides, lipid.Early detection of risk factors helps to alter diet ,life style modifications. PCOS is associated with thickening of endometrial linning , endometrial carcinoma if the cycles were infrequent,so need for withdrawal bleeding once in 3-4 months with drus. Because of above health consequenses i will tell her steps to reduce risk . Diet and exercise to maintain ideal body weight.5 % reduction in weight is associated with restoration of ovulation ,improve pregnancy rates.With diet & exercise blood sugar normalise ,reduce the chance of diaetes. Drugs like insulin sensitisers ( metformin) are used for short term treatment of anovulation , long term treatment to avoid metabolic compicaions is not recommended . Discontinue if conceived , no evidence to support its use in pregnancy. I will expain role of laproscopic ovarian diathermy .Surgery normalises hormone imbalance ,it has long term benefit over and above resumption of ovulation , menses . I will give advice about optimising fertility,written information & information about useful websites covering PCOS .I will refer to physician if FBS ,lipid profile are abnormal. I will advise to see dietician if obese. Non medical options fo ovulation induction are diet ,exercise,laproscopic ovarian diathermy.Diet & exercise are life style modificationsto be followed through out life , it is not a pill.Weight reduction restores ovulation, improves pregnancy rates. Ovarian diathermy is second line therapy if not responding to metformin - clomiphene.Ovarian diathemy normalise serum androgens , sex harmone binding globulin. With regard to pregnancy outcome i will offer early pregnancy screen for gestational diabetes.PCOS before pregnancy is associated with increased incidence of gestational diabetes in pregnancyt If it is abnormal i will offer oral glucose tolerance and reffer to specialized obstetric diabetic service if abnornality is detected. I will advice to correct weight in prepregnancy to reduce obesity related problems PCOS is not direct cause of recurrent pregnancy loss.Correction of raised LH is not going to impove outcome .
		Posted by M M A. Sat Jan 6, 2007 01:34 pm
I explain to her the nature of the syndrome including a collection of different signs and symptoms .,and it is about 20% of the women have polycystic ovaries. I will tell her that the implications vary from no symptoms to the wider health implications of the condition. The health implications may vary from cardiovascular disorders ,which include hypertension and ischaemic heart disease due to abnormal cholesterol metabolism. So, It is important that the patient to reduce cholesterol in her diet and to check her BP regularly , especially if she experience headache ,easy fatiguability and precordial chest pain. The patient is also, at increased risk of type 2 diabetes mellitus. She must therefore be educated on its early symptoms such as polyurea ,polydypsia and polyphagia. I have to tell her that : she must attend her GP for regular urine testing and occasional blood glucose estimation . An important complication of PCOS is the development of endometrial hyperplasia and cancer. I have to be extremely sensitive with her and cautious as she could be unnecessarily alarmed. I have to tell her that irregular periods are a recognized symptom of PCOS and may be also, be a presentation of endometrial cancer . It is important for the patient to visit her GP if unusual vaginal bleeding and , where necessary , ultrasound scan should be performed , and if the endometrium is persistently thickened she must be advised to have endometrial biopsy and hysteroscopy to rule out endometrial hyperplasia.. I have to tell her : To reduce this risk ,she may be offered treatment with progestogen hormones. Obesity is an important sequelae of this condition . If the patient is even not obese , she needs to be counselled about her diet and exercise . These will not only reduce the risk of hypertension and endometrial carcinoma , but will reduce the risks of diabetes. Subfertility may represent a psychological problem , so, she requires sensitive , honest and reassuring discussion.. Psychological support is deemed appropriate and important with this patient. Other symptoms may be present as hirsuitism ,acne , oily skin and temporal baldness should be explained to the patient . The potential problems with the body image should be discussed , using objective methods to quantify .The implications of PCOS this patient will be given by information leaflet about this common endocrinal condition. The non-medical options for ovulation induction are:Firstly( life style change ) . The treatment should firstly include weight loss through group sessions involving exercising and advice on diet for 3 ? 6 months . This programme could acheive ovulation and more pregnancy than weight loss advice alone. Laparoscopic ovarian drilling is the surgical treatment of choice for infertility in the case of polycystic ovaries resistant to clomiphene . There is a considerable reduction in multiple pregnancy rates , hence its sequels are avoided .The risk of ovarian hyperstimulation is removed. It is more cost effective than medical treatment , and it is once only treatment and no intensive monitoring is required . A 12 months cumulative pregnancy rate of 54- 84 % has been reported It leads to ovulation in 90% of the patients with reducing the LH levels ,thereby reducing the subsequent miscarriage rate after conception. It is associated with inherent anaesthetic and surgical risks,including diathermy and laser damage . There is a great risk of periovarian adhesions ,however , there is no evidence of an increased risk of premature menopause. Regarding the implications of pregnancy outcome ,she has a low risk rate of miscarriage after LOD ( about 14% compared to 30-40%) for women treated by hormonal ovulation induction. The risk of multiple pregnancy is increased with hormonal induction of ovulation ,hence,its sequels : problems with prenatal screening, Pregnancy-induced hypertension,antepartum haemorrhage,preterm labour and gestational diabetes.
		Posted by Mary M. Sat Jan 6, 2007 04:55 pm
(a)I will tell her that PCOS is the condition, which is due to harmonal disturbance and it may affect her body image, menstruation,future fertlity and has long term health consequences. These informations are given in non medical language along with written details with addresses of supprt groups & giving her chance to ask the questions. It can lead to abesity & hirsutism and she needs to be careful about diet & daily exercises to keep herself fit .This is very helpful in keeping regular periods & spontanous ovulation. If hirutism develops then Dianette or waxing/bleaching or electrolysis will help. Menstruation could be irregular or very light & occasinal or may leed to ammenorhea.COCP may help to regulate this. If she has infrquent periods then she must have withdrawl bleeds after every 3-6 months to prevent endometrial hyperplsia & future endometrial cancer. Fertility could be normal or it can leed to subfertility. Ovulation induction is required in later case. It can be achieved medically by drugs , surgically by ovarian drilling or by IVF. If it leeds to normal fertiliy & pregnany then there are chances of spontanous miscarriage & gestational diabetes. It has future consequences of cardiovascular problems such as hypertension& NIDDM. She needs to do exercie to keep herself fit & to prevnt those. Sheneeds to go to GP for at least annual check of blood lipids & cholesterol &blood sugar levels. There is possibility of ovarian & endometrial carcinomas which neds future screening by Ultrasound imaging & blod harmonal levels. (b)Non Medical options are weight reeducion if patient is obese. This can achieved by diet & exeercises.There is no risk of side effects or mulltiple pregnancy & it does not need surgical intervention & anaesthesia. Other method is laproscopic ovarian drilling. It has no side effect of medications or multiple pregnancies.It has potential risks of anaethesia & it can lead to adhesion which might effect on future fertility. Anyway it is a successful way of ovulation induction i whom medical induction has failed or contraindicated. (c)Ii can leed to spontanous miscarriage and gestational diabetes and need to check urinary glucoser & blood glucose. If it happened then blood glucose need to be monitored & she might need insulin during gestation. Strict control of blood sugars is mandatory in order to achieve good outcome.
		Posted by Sarwat F. Sat Jan 6, 2007 08:32 pm
I will tell her that polycystic ovary syndrome is a disorder which can cause infertility but there are treatments available for it. There are other manifestations of this disorder which include oligomenorrohea that is irregular periods, infertility, weight gain, hirsutism and acne. It is associated with characteristic finding of 8 to 10 cysts arranged around the periphery in the ovaries on ultrasound examination, hence the name polycystic ovaries. It is caused by hormonal and metabolic changes in the body with increased concentration of certain hormones. This also leads to metabolic changes in the body which can lead to long term complications namely diabetes mellitus, abnormal lipid profile, hypertension, cardiovascular disease and endometrial carcinoma. I will tell her that treatment can be given for short term manifestations of the disease and she will be monitored for long term complications. Non medical options for ovulation induction include weight reduction and surgical options which include laparosopic ovarian drilling. Weight reduction has been found to be associated with improvement in period regulation and ovulation. Ideally a body mass index of between 19 and 25 should be maintained. Laparoscopic ovarian drilling can be done and it is as effective as medical treatment with hormones. However drawbacks include complications associated with anesthesia and laparoscopy. This can include damage to bowel, bladder, blood vessels, haemorrhage, infection and very rarely death. Women with polycystic ovary syndrome have increased risk of miscarriage and abnormal glucose tolerance during pregnancy. Urine should be tested for glucose on each visit and glucose tolerance test done at 26 weeks of gestation. There are no implications for labour and delivery other than in a normal pregnancy.
		Posted by Parveen Q. Sun Jan 7, 2007 12:08 am
Iwill tell her that PCOS is a common endocrine abormality affecting about 5-10% of women intheir reproductive years. Some women will remain asympatamatic, while the rest has varied symptoms like irregular menstruation, anovlatory infertility, obesity, hirsuitism, acne, and male type of baldness. . It has both short term and long term consequences .The pathophysiology is notfully understood, but increase androgen production, , hyper secretion of luteinising hormone, hyperinsulinemia plays an important role. It may run in families. the reason for her infertility could be due to Pcos.The longterm problems associated with Pcos are diabetes mellitus, hypertension, cardiovascular disease, hyperlipedemia, endometrial carcinoma ,and reproductive problems like anovlatory infertility and early misscarriage.Though the mortality with CVS disesae is not increased significantly early detection of abnormal levels by measuring fasting lipid profiles help alleviate the problem.And taking up simple measures like modification in lifestyle like weight reduction and healthy eating can restore ovulation in an obese women .If the interval between her periods are more thn 3months, the chances of endometrial carcinoma increases by 5fold, so she will have take COCP to induce withdrawl bleed and shed the endomtrium, or can use medroxyprogesterone acetate for 5-10days every 1-3 months to induce withdrawl bleeding. There is increase risk of NIDDM , this risk increases if she has a family history, so annual screening can be done. During her drug treatment foe anovlatory infertitily , the chances for OHSS increases and also multiple pregnancy, if she gets pregnant, there is increased risk of early pregnancy loss. 2. The nonmedical options are weight reduction,OVARIAN DRILLING, wedge resection. She will be advised simple measures like modification of life style, by healthy eating, by avidance of excess fat, alcohol, and reglar excercises, and reduction of even 5-10%of body weight in obese ,overweight women , ovlation will be restored in almost all cases. Excercise like swimming , aerobics are beneficial, but just execercise without diet restriction will only reduce the wasit circumference without alteration in the BMI. oVRAIAN DRILLING has replaced wedge resection due to the peritubal and periovarian adhesions associated with the later.. Laproscopic ovarian drilling is less costly, doesn\'t need the USS monitoring which is done for medical treatment by colmiphene or gonadotrophins. theres is no risk of multiple pregnancy or ovarian hyperstimultation.the incidences of misacarriage may be reduced. It reduces the secrection of LH and androgen and the menstrual cycles become regular and a single treatment produces regulary ovulatory cycles for many years. The tubal patency test and pelvic anatomy could be visualised at the same time. But , it has the risk of laproscopic surgency and anasthesia risk, and injury to bowel, bladder, blood vessels can occur. The pregnancy outcome in PCOS is 30-50%will have early pregnancy misscarriage ,also there is increased incidence of gestational diabetes, pregnancy induced hypertension. There is also risk of multiple pregnancy, and due to severe OHSS , the much awaited pregnancy has to terminated sometimes to reduce the maternal morbidity and mortality.
		Posted by Freha Z. Sun Jan 7, 2007 12:29 am
I would inform her that polycystic ovary syndrome is the most common female endocrine abnormality in their reproductive years(20% risk). Exact etiology of PCOS is unknown, but has genetic predisposition interacting with environmental factors(obesity) results in oligomenorrhoea, anovulatory infertility and metabolic disturbances such as hyperandrogenaemia resulting in hirsutism and acne. Furthermore, there are long term implications like development of type-11 Diabetes and endometrial carcinoma due to effect of unopposed estrogen on endometrium therefore progestogen prophylaxis atleast every 3-6 months is recommended. She should be advised Weight reduction if obese and measurement of fasting glucose offered to detect Diabetes. There is alteration in lipid profile which results in higher risk of developing atherosclerotic conditions, hypertension and myocardial infarction however the average mortality from cardiovascular disease is not raised. She should be therefore be offered fasting cholestrol,lipid, triglyceride measurement for early detection. There is also 2.5 fold increase risk of ovarian cancer however risk of postmenopausal breast cancer is not increased therefore do not require surveillance over and above that offered by National Breast Screening Programme. (b)Infertility in PCOS is mainly due to anovulation and treatment is induction of unifollicular ovulation by coservative measures, medical and surgical. Ovulation induction should begin with simple measures like weight reduction and exercise and weight reduction even if moderate obesity(BMI>27Kg/m2). The loss of body weight of 10% may result in return of regular ouulation. Laparoscopic ovarian drilling with diathermy/laser is effective treatment for anovlation in women with clomiphene resistant PCO. It leads to ovulation in 80% patients with normalization of LH concentration and low miscarriage rate. It doesn\'t need intensive follicular monitering that required on gonadotrophin therapy and is therefore suitable for patients living far away from hospital and also in those who require laparoscopic assessment of their pelvis. (c) Patients with PCOS have higher risk of spontaneous miscarriage but risk of congenital anamolies is not increased. There is also increased risk of multiple pregnancy with subsequent increased perinatal mortality and morbidity. Risk of gestational diabetes is higher and more in obese women. Therefore there is need for screening and referral to specialised obstetric diabetic service if abnomality detected. Incidence of pregnancy induced hypertension is also increased which is independent of obesity and gestational diabetes.
		Posted by Randa E. Sun Jan 7, 2007 03:09 am
She should be told that this is the commonest female endocrine abnormality affecting up to 5-10% of women in their reproductive years. It is the presence of multiple cysts in the ovaries, producing excess androgen. It is associated with a cluster of symptoms including amenorrhoea, oligomenorrhoea, infertility, obesity, hirsutism,, and other evidence of androgen excess such as acne, male pattern baldness and acanthosis negricans. She should be told that PCOS has long term risks to health for example in middle age ( 40% risk by age 40), and that an increased body mass, particular truncal obesity and a strong family history of diabetes both contribute to increasing to her risk of developing NIDDM . She should be offered measurements of fasting blood glucose and urinanalysis for glucoseuria, particularly if she is obese to detect diabetes on a regular basis- perhaps annually. She also has a greater risk of developing atherosclerotic conditions, hypertension and MI and measurement of fasting cholesterol, lipids and TGs should be offered. She also has a higher risk of developing endometrial hyperplasia and carcinoma and also and increased risk of ovarian cancer. She must know that some women are at a higher risk of developing psychological problems and these require sensitive, honest and reassuring discussion and referral to a clinical psychologist or psychotherapist as deemed appropriate. Regarding her infertility she should know that she has a choice between conservative, medical and surgical management .The conservative being through weight loss and general modification of lifestyle which might result in restoration of regular ovulation in 10% of women. The medical being through drugs like Clomiphene and Tamoxifen which induce ovulation but carry a higher risk of multiple pregnancy and should only take place with facilities for ovarian monitoring to reduce risks of multiple pregnancy. They also carry higher risks of ovarian cancer . A test for tubal patency and semen analysis should be preformed before ovulation induction is carried out. Gonadotrophins are also an alternative to clomiphene resistant PCOS but their use may be associated with an increased risk of ovarian hyperstimulation. The surgical option is Laproscopic ovarian drilling using laser diathermy. It is free of the risk of multiple pregnancy and does not require u/s follicular tracking and is associated with normalisation of serum androgens and SHBG over many years in 60% of patients, but there is concern that overdrilling may precipitate premature ovarian failure. In Vitro Fertilisation is also occasionally offered to those who fail to conceive with other treatements. If she becomes pregnant she has an increased incidence of multiple pregnancy and gestational diabetes. She should be given an information leaflet to back up the information given and the addresses and names of support groups provided. The non-medical options for ovulation induction are general life modifications like wt. loss and excersice which might often simply restore ovulation and reduce the likilhood of developing NIDDM. Laproscopic ovarian drilling is another option and leads to ovulation in 80% of patients with normalisation of LH concentrations and good pregnancy rates(40-69%) and a low miscarriage rate. It is free of the risks of multiple pregnancy, requires tests for tubal patency . It does not require u/s follicular tracking. It is also associated with normalisation of serum androgen and SHBG over many years in 60% of women. It has now replaced wedged resection which is associated with extensive per-ovarian and tubal adhesions. Its problems is that more research is needed into long term sequel of ovarian damage and so it must be reserved for clomiphene resistant women or those who are unable to attend for u/s follicular tracking. Concerning the implication of pregnancy outcome, if she conceives she has a higher risk of miscarriage because of raised LH levels. If she is induced she has a higher risk of multiple pregnancy with increased perinatal mortality and morbidity.She also has a greater risk of gestational diabetes especially if she is obese and if appropriate she should be refered for management by an obstetrician with special interest in pregnancy and diabetes. There is also an increase in pregnancy induced hypertension with all its complications.
		Posted by Shyamaly S. Sun Jan 7, 2007 09:07 am
A)It should be explained to the patient that polycystic ovarian syndrome (PCOS) is a common metabolic syndrome, which can have both short and long term consequences. It is characterised by having two of the three following criteria: infrequent irregular ovulation; symptoms or blood tests suggesting high levels of androgens; and ovaries with multiple peripheral cysts with a characteristic appearance. It is a familial condition and it can exist without clinical manifestations of the disease, which can express themselves over time The main short term consequence of concern to her is that PCOS may be the reason for her difficulty in conceiving. Strategies to encourage regular ovulation would improve her fertility. PCOS is also associated with insulin resistance, which is exacerbated by obesity. Both weight loss and exercise can reduce this insulin resistance, which can improve fertility as well as reduce long-term complications of the disease. Metformin is a useful for insulin sensitisation and has been shown to improve fertility and maybe shown to improve long-term health. In the long term PCOS is associated with glucose intolerance, which may evolve into Type 2 Diabetes by middle age, dyslipidemias and an increased risk of atherosclerotic disease. It has been recommended that women with PCOS should be assessed regularly for diabetes, lipid profiles and ischemic heart disease in the General practice setting. PCOS is also associated with endometrial cancer because of high levels of endometrial exposure to oestrogens. In order to reduce this risk, she should aim to have at least 4 withdrawal bleeds per year, which may need to be induced with the COC or progestogens. B)These include weight loss, ovarian drilling and ovarian wedge resection. A 10% loss in body weight maybe associated with a return to regular ovulation and regular periods. Although weight loss is not simple, it may be facilitated by the use of exercise, healthy eating strategies and dietetic advice. This method of weight loss avoids the risks associated with medical treatment and surgical risks, as well as helps to modify the risks for long-term morbidity. Surgical treatment includes laparoscopic ovarian drilling. This is not a first line treatment for ovulation induction and has not been compared with medical methods in any trials. It is useful in cases where clomid has not succeeded in inducing ovulation. This method of ovulation induction carries surgical risks of bleeding, infection and damage to visceral organs. It does however allow other causes of infertility to be investigated and treated simultaneously, for example, tubal patency may be assessed, and adhesions may be divided. Ovarian drilling is not associated with the risks of ovarian hyper stimulation and multiple pregnancy and does not require Ultrasound follow up with follicle tracking as medical induction of ovulation necessitates. Wedge resection was a previously widely used form of surgical ovulation induction. It is no longer recommended as it is associated with periovarian and tubal adhesions, which may exacerbate infertility. C) The patient should be informed that she might still conceive spontaneously without assistance. If ovulation induction is required she should be aware that this maybe difficult and require progression through different modalities. It maybe complicated by ovarian hyper stimulation Syndrome which may require hospitalisation. Even if Ovulation induction is successful, the chances of conceiving are 40%, and in the first trimester, likely to be associated with a higher than normal rate of miscarriage. If medical ovulation induction is used there is a higher risk of multiple pregnancy. There is a higher than normal incidence of Gestational Diabetes and Hypertensive disorders, as a result it has been recommended that women with PCOS should be screened for GDM in early pregnancy and vigilance used in monitoring maternal blood pressure. There is no evidence to support an increase in congenital abnormalities or preterm delivery. Overall the outlook for pregnancy is positive.
		Posted by Abi T. Mon Jan 8, 2007 06:49 am
a) I will explain to the patient that PCOS is a common metabolic condition that affects 10% of women and has short term and long term consequences and that this is likely to be the reason for her infertility. The underlying pathology is unknown as yet but there is a familial inheritance. The syndrome is characterized by androgen excess causing excess facial and body hair, acne, alteration in LH/FSH ratio causing irregular and infrequent periods, formation of multiple small follicles on the ovary which are incapable of maturation, hence leading to anovulation and infertility and insulin insensitivity which increases the risk of developing Type 2 DM, obesity and associated risks of ischemic heart disease and hypertension in later life. The increase in circulating estrogens would also increase her risk of developing endometrial carcinoma. Not all women with PCOS will display these signs and symptoms and 2 out of 3 of the above criteria are needed to diagnose the condition. I would explain that although hirsutism and acne can be socially and psychologically distressing, there exists medical and non-medical methods of treating them. it is likely that she may need medical help in conceiving either by medical or surgical methods however spontaneous conception is possible in a small percentage of women. the risks of obesity ,Type 2 DM, coronary heart disease and hypertension can be reduced by modification of diet and lifestyle e.g. healthy eating habits, regular exercise and smoking cessation.Yearly glucose and lipid prolfile monitoring in her 40\'s could be done to identify her risk at that stage and this could be done in the general practice setting. The risk of endometrial CA by unopposed estrogen can be reduced by inducing at least 4 periods a year via the COC or progestogens. I would provide written information by way of leaflets. b) The non-medical methods of ovulation induction include weight reduction and multiple puncture ovarian diathermy. A 10% reduction in weight in itself has been shown to restore regular menses and hence ovulation. This is cheap and effective and should be first line management. Weight and hence lowering of BMI also has other long term benefits in that it reduces surgical risks, problems associated with pregnancy and labour ie. PET/PIH, GDM, dysfunctional labour, operative delivery and reducing risks of developing Type 2 DM and artherosclerotic diseases. Multiple puncture ovarian diathermy is not fisrt line management but has been shown to improve ovulation if clomiphene alone has not acheived this. It also has the added advantage of assessing tubal patency and diagnosing and treating other pelvic causes of infertility eg endometriosis and adhesions. c) Most pregnancies in women with PCOS are uneventful. However there is an increased risk of first trimester miscarriages due to the high LH levels. There is no increased risk of fetal anomalies.There is also a risk of OHSS and multiple pregnancies with ovulation induction. These women are also at an increased risk of developing GDM hence GTT should be done early in pregnancy. They are also at an increased risk of developing PET and PIH hence vigilance is needed to detect and treat these conditions early.
		Posted by Olubunmi O. Wed Jan 10, 2007 03:40 am
I will explain to her that this is a syndrome characterised by absent or infrequent menses in association with excess male type hormone levels and multiple ovarian cysts(at least 12 measuring 5-9mm) or increased ovarian volume found on ultrasound scan. The syndrome is found in 10% of the female population and may have a genetic aetiology as it may be found in other female relatives and expression can be modified by other environmental factors like obesity. There is reversal in the ratio of hormones responsible for regular cycles LH/FSH leading to anovulation and menstral irregularity in the presence of normal oestrogen levels. Although the ovary may contain many follicles, these are immature and ovulation may not occur .I will reassure are that the cysts are benign in nature. She may also have features associated with excess androgen like excess hair, acne, male pattern baldness and acanthosis nigricans. The syndrome is associated with raised fasting insulin levels may also in the long term pedispose her(40% risk) to abnormal glucose metabolism leading to type 2 diabetes before the age of 40 with a positive family history adding to this risk. She may also have raised lipid levels and increased cardiovascular morbidity although mortality is not affected. Other features may include raised prolactin and obesity. The syndrome is also associated with infertility usually secondary to anovulation but there is usually good response to lifestyle, medical and surgical management. There may be an increased risk of ovarian cancer(risk 2.5) especially with ovulation induction. Treatment is usually symptomatic and yearly monitoring of glucose tolerance and Lipid levels is recommended. I will stress the need for regular shedding of the endometrium every 1 to 3 months with the use of progestogens if neccesary if not pregnant as the syndrome is associated with a 5 fold increased risk of endometrial cancer. I will provide leaflets about the condition and details of relevant societies. Follic acid prophylaxis and rubella testing will also be offered. Non medical options for ovulation induction include weight loss if BMI is above 30.Loss of 10% of body weight is associated with spontaneous ovulation and return of fertility without recourse to drugs. There is also improvement in glucose metabolim , hyperinsulinaemia and risk of NIDDM as well as improved physical fitness. Laparoscopic ovarian drilling is reserved for patients with clomiphene resistance. It involves lazer or diathermy of the ovaries at 4 points for 4 seconds at a powerof 4 watts. It is as effective as Gonadotrophin induction with an ovulation rate of 80% and pregnancy rate of 40-69%.There is normalization of LH levels and reduced miscarriage rates(14%).Risk of multiple pregnancy is no higher than normal and there is no need for follicular tracking. Tubal patency can be assessed at the same time and the results are long lasting for 6-12 months. In over 60% the effect lasts for many years. There is an associated morbidity with general anaesthesia and Laparoscopy. There is a risk of perforation of bladder and bowel with cost implication and hospital stay. Wedge resection of the ovary is no longer used due to extensive peritubal and ovarian adhesions. If weight is normal with regular menses and ovulationspontaneous conception may occur Should she succeed in getting pregnant there is a higher risk of miscarriage30-40%,and increased risk of Gestational diabetes. Medical treatment of infertility will involve induction of ovulation with Clomiphene of Gonadotrophins with intensive monitoring.There is increased risk of multiple pregnancy (10% with clomiphene )with its attendant risk of increased morbidity and morality,prematurity and congenital abnormalities. The ovulation rate with clomiphene is 70to 85% with a pregnancy rate of about 40%.Addition of metformin, an insulin sensitizer significantly increases chances of ovulatin and improves glucose metabolism, lipid profile ,and blood pressure but does not help weight loss.Side effects include nausea,vomiting diarrhoea and flatulence but are usually not long lasting. Gonadotrophin may be used if there is no response to clomipene after 6 to 12 months but is associated with higher rates of multiple pregnancy upto 25%and ovarian hyperstimulation syndrome which is more common in cycles when pregnancy has occurred and PCOS patients. I will explain the clinical features and the need for hospital admission if moderate or severe and that the risk of this can be minimised by careful monitoring,use of lowest possible dose and cancellation of cycles.Occasionally,termination of pregnancy may be required. Assisted conception will be considered if above fails and the take home baby rate on average is about 25%