Diagnosis of PCOD | Jindal IVF Chandigarh

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Polycystic Ovary Syndrome Diagnosis

• Umesh N. Jindal
• Jindal IVF Sant Memorial Nursing Home
• Chandigarh

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History

• Described first in 1935
• Histology
• Twice cross-sectional area
• Same number of primordial follicles
• Double the developing and atretic follicles.
• 50 thick tunica
• 4 fold greater number of hilar call nests

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Spectrum of clinical conditions associated with
PCOS
PCOS
Insulin Resistance
Anovulation
MS
Infertility
Obesity
DUB
Diabetes
Cancers
Atherosclerosis
Hirsutism
Hypertension
Acne
Alopecia
CVD
Fatty liver
Sleep Apnea
Depression
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The Root Cause ?
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Functional disorder

• Any chronic anovulatory state will lead to a
  polycystic picture provided HPO axis is intact,
  chronpc estrogenism and / or hyper androgenism
  due to any cause will lead to PCO.

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The steady state
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Hormone Status

• Estradiol fluctuate but remain within normal
  range.
• Increased Estrone peripheral conversion.
• Increased Testosterone
• Increased Androstenedione Ovary, LH
• Increased17-OHP
• Increased DHEA
• Increased DHEA-S Adrenal

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Insulin resistance and PCOS
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Causes of PCOS
Genetic
Gn regulation and action
Weight and energy regulation
PCOS Complex metabolic disorder
Insulin secretion and action
Androgen synthesis and regulation
Environmental
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Pathophysiology

• Complex metabolic disorder
• Functional derangement of follicular development
• Increased estogens and androgens, LH and loss of
  cyclicity due self propogating feed back loop.
• Insulin resistance in 70 .
• Polygenic inheritance.

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Diagnosis of PCOD
Year Proposed by Androgen Ovarian function Ovarian morphology Other cause
1990 NICHD Must Menstrual disorders - Exclusion
2003 Rotterdam ASRM-ESHRE Two of the three Two of the three Two of the three Exclusion
2006 AE-PCOS Must Either of two Either of two Exclusion
Definition Clinical or biochemical Oligo-anovulation PCO on ultrasound Cushings Tumur etc.
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Evaluating Androgen excess

• Clinical Hyperandrogenemia
• Hirsuitism
• 60-70
• More gradual
• Variation with age and ethnicity
• Ferrimen and Gallway score-gt15 severe

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Polycystic Ovarian Morphology

• Early follicular phase(day3-5)
• Oligo/Amenorrhoeic-at random or 3-5 days
• Stromal area/total area ratio and or increased
  
• stromal echogenesity
• The usefullness of 3-D,Doppler or MRI
• (Ultrasound assessment of the polycystic
  ovary-International consensus definition-Human
  reproduction9505-13)

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Evaluating PCOM

• Swanson and Co-Workers-1981
• General population-20-33
• gt 12 follicles at 2 - 9 mm in at least 1 ovary
• Volume gt 10cc
• If a follicle is gt10mm, repeat scan next cycle.
• Transvaginal is preferable
• Does not apply to women on OC pills
• Single ovary-sufficient to diagnose

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PCOM

• PCOM (Polycystic Ovarian Morphology)

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Clinical features

• Obesity-BMIgt25 in 35-50
• Android appearance
• Waist to hip ratio
• Acanthosis Nigricans-Non specific
• HAIR-AN SYNDROME
• Hyperpigmented velvety patch-nape of the
  neck,axilla,inner thigh and vulva

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Biochemical Investigations

• Gonadotrophins-LH/FSH
• Increase in amplitude and frequency of LH
• Elevated in 95
• LH increased in 60-70
• ?Reliability of a single measurement
• Increased LH levels and its treatment-controversia
  l
• Lack on agreement on abnormal result

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Biochemical investigations

• 2 hr GTT-F-110-125mgm/dl
• 2hr-140-199mgm/dl
• With severe stigmata of insulin resistance
• and hyperandrogenemia or undergoing
• ovulation induction
• Fasting insulin-gt25microIU/ml
• Fasting G/I ratio of 4.5 or less
• (Suggested evaluation in
  PCOS-ACOG2009)

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Biochemical investigations

• Tests for metabolic syndrome(Updated adult t/t
  panel lII)
• Cholestrol,LDL
• HDLlt50mgm/dl
• Triglyceridesgt150mgm/dl
• BP-130/85
• F blood glucosegt100mgm/dl
• Waist circumferencegt35 inches
• (Suggested evaluation in
  PCOS-ACOG2009)

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Diagnosis of exclusion

• Hypergonadotrophic hypogonadism
• Hypogonadotropic hypogonadism
• Non classic congenital adrenal hyperplasia
• Suspected PCOS-1-19
• Screening-17OHP-lt200ng/dl,gt500 certain
• ACTH stimulation test-25USP
• 17OHPgt1000
• CUSHING SYNDROME
• 24 hour free cortisol and 17 hydroxysteroids

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Diagnosis of exclusion

• Adrenal and ovarian tumours
• Rapid virilization
• Testosterone gt200ngm/dl
• DHEAS gt700ng/dl
• Imaging techniques
• ? Hyper prolactinamia
• ?Hypothyroidism

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Complete Evaluation

• HISTORY-Menstral disturbances, Hyperandrogenism,
  Infertility, weight gain, Galactorrhoea, Symptoms
  of hypothyroidism, Drug intake, Family history
• Examination-BMI, Type of obesity, Hypertension,
  Hirsuitism, Signs of virilization, Signs of
  Cushings disease, Galactorrhoea, Acanthosis
  nigricans, Abdominal examination, PV /PR
  Examination

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Complete Evaluation

• Free testosterone
• Total testosterone
• DHEAS
• LH/FSH Ratio
• 17OH progesterone
• Test for hyperinsulinemia
• Test for dyslipidemias

• Prolactin
• TSH

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Conclusions

• Early diagnosis and intervention is imperative
• Rotterdam criteria should be used
• Somatic or Lab Hyperandrogenism
• Oligo-anovulation
• Polycystic Ovarian Morphology
• Exclude
• Non-classical 17-hydroxylase deficiency, adrenal
  tumor, Cushings, prolactinemia, thyroid
  disorders, hypothalamic amenorrhea
• Make a diagnosis of PCOS before starting
  treatment

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• Thank You