whs pr symposium: obesity, reproduction and pcos

8/10/2019 WHS PR Symposium: Obesity, Reproduction and PCOS

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Obesity, Reproduction andPolycystic OvarianSyndrome (PCOS)

Nabal Jose Bracero, M.D., F.A.C.O.G.Reproductive Endocrinolog and !n"ertilit

Assistant #ro"essor

Depart$ent o" Obstetrics and Gnecolog%niversit o" #uerto Rico &c'ool o" Medicine

Medical Director

GENE& "ertilit institute


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Pre-Q1:A patient it! PCOS s!ould !ave an endometrial biopsy per"ormed:

a# $early even i" s!e is !avin% re%ularit!draal menstrual cycles, eit!er due to

ovulation or !ormonal t!erapyb# &" s!e is !avin% "eer t!an ' cycles a year

c# &" s!e is over ' years o" a%e it! re%ularovulatory cycles

d# &" an ultrasound reveals !er endometrium tobe mm in t!ic*ness

e# At least once i" s!e is over + years o" a%eindependent o" !er menstrual cycles


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Pre-Q:

Overei%!t patients it! PCOS s!ould be evaluated "or type &&diabetes mellitus typically usin%:

a# '-!our %lucose tolerance test

b# .astin% blood su%ar

c# .astin% blood su%ar to insulin ratio

d# -!our %lucose tolerance test usin%

%rams o" %lucose solution

e# 1-!our test usin% %rams o" %lucosesolution


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Obesity/Reproduction/PCOS

Repro-duction Obesity

PCOS


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Obesity and Reproduction

( Obesity is de0ned as 2& 3'

( &n t!e 4nited States, t!ere as a 5increase in pre-pre%nancy Obesity "rom

166+ to '#( .astest %roin% !ealt! problem in t!e 4#S#

) '15 o" non-7ispanic !ite omen

) '85 o" 7ispanic omen

) +65 o" non-7ispanic blac* omen

( Associated it! si%ni0cant medical problemsand adverse reproductive outcomes


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Adverse &mpact o" Obesity on

7ealt!

( 9ype && iabetes

( 7ypertension

( Coronary 7eart disease

( yslipidemia

( Sleep apnea

(Increase in

uterine/ovarian/colon/breast ca

( AR;SS 7& ?&9A> S&


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2enstrual isturbances

( &ncreasin% 2& and truncal obesitycorrelates it! menstrual irre%ularities

( Close to 5 o" obese omen !ave

menstrual cycle disturbances( Obesity, menstrual disorders, and

increased aist-to-!ip ratio are t!e mostcommon "eatures o" PCOS

( 7oever, not all omen it! PCOS areobese and not all obese omen !ave PCOS#


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&n"ertility

( 2ay be primarily related to ovulatorydys"unction as opposed to pure !i%! 2&

( RR "or anovulatory in"ertility is 1#' "or

2& +-'1 and # "or 2& 3'1#

( Ovulatory "unction improves a"ter ei%!tloss#

( Conversely, "ecundity don by +5 "oreac! 2& unit above a 2& o" 6 inovulatory obese omen


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Response to .ertility 9reatment

( &ncreased len%t! o" ovarianstimulation "or ovulation induction

( >oer oocyte yield in &?.

( 7i%!er cancellation rates "or poorresponse

( >ar%est study (n@') s!oedloer pre%nancy rates "or obeseomen (OR #-#')

( ;Bects pronounced in &?. scenario


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Adverse ObstetricalOutcomes

( Compared to normal-ei%!t omen, obeseomen !ave a -"old increase ris* o"abortion

( irt! de"ects associated it! 2& 3') ?entral all de"ects OR@'#'

) =eural tube de"ects OR@#

) Cardiac de"ects OR@ #

) 2ultiple anomalies OR@#

( eyond birt! de"ects: .etal ori%ins o" adultdiseaseD !ypot!esis


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Adverse Obstetrical OutcomesAssociated it! Obesity

OR 65 C&

Preeclampsia 4.8 +#+E#+


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Pat!op!ysiolo%y:

Obesity and Reproduction

( ;ndocrine c!an%es caused by abdominalobesity (38cm) result in menstrual cyclec!an%es:) 7i%!er insulin levels

( 2ost pronounced in omen it! PCOS independento" obesity

) >oer S7eptin levels

) 7i%!er


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onFt "or%et t!e ot!er !al"G

( Obese men !ave a '-"old ris* o"abnormal semen analysis comparedto normal ei%!t men#

( 7i%! ratio o" adipocyte perip!eralconversion o" andro%en to estro%ensuppresses %onadotropins and

testosterone( 7i%!er body mass increases

testicular temperature and inHuence

sperm parameters


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9reatment

( ietary and li"estyle c!an%es:) .irst line o" treatment#

) Structured ei%!t loss pro%rams, caloric

restrictions by reducin% -1*cal/day (more important t!an dietarycomposition)@ 1- lbs o" t loss/ee*

) A minimum o" ' minutes o" moderatelyintense eIercise, ' I/ee*


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9reatment

( 2edical 9reatment) .or 2& 3 ' or i" 2& 3 it!

additional morbidity (79=, 2,

dyslipidemia)) Anti-absorptive a%ents (Orlistat),

appetite suppressants (sibutramine),and insulin sensitiJin% a%ents(2et"ormin 1-m%/d)

) ariatric sur%ery "or patients it! 2&3+ or 3' it! co-morbidities#


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PCOS is a Syndrome


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PCOS


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PCOS

( 9!e most common endocrinopat!y inomen (-1 million omen in t!e 4#S#)

( 9!e conver%in% point o" metabolic

alterations, endocrinopat!ies, andreproductive dys"unction#

( ApproIimately 5 o" omen it!

PCOS are clinically obese( ;tiolo%y still elusive since described in

16' (Stein->event!al)


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ConseKuences o" PCOS

( Cosmetic (acne, !irsutism, alopecia)

( 4nopposed estro%en (uterine ca #-"old)

( &n"ertility (ovulatory "actors)

( 2etabolic Syndrome (2etS)L 11I in PCOS

) &ncrease ris* o" C?( Abdominal Obesity

( yslipidemia

( P 31+/6

( &nsulin resistance


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PCOS Symptoms


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e0nition o" PCOS

( 166 =&C7) Clinical or bioc!emical hyperandrogenism

) Oligo- or anovulation

( ' Rotterdam) Added PCO-4S appearance (at least one

ovary 31cm' or 31 antral "ollicles)

) out o" t!e ' above

( &n bot!, must rule out Cus!in%Fs, CA7and Andro%en producin% tumors#


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1 PCOS Consensus


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1 PCOS Consensus


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ia%nosis o" PCOS

( Adolescence) Acne and menstrual irre%ularities are common

) All ' Rotterdam criteria s!ould be present

) &rre%ular cycles "or yrs a"ter menarc!e

( ;t!nic considerations) Asian: loer 2&, milder andro%enic sI

) Sout! Asian: !i%!er 9, 2etS

) A"rican American: 79=, C?

) 7ispanic: 2&, 2etS

) 2iddle ;astern: !irsutism


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;valuation o" PCOS( Anovulation evaluation: 9S7/Prolactin

( 9otal and "ree testosterone

( 7;AS

( 1-!ydroIy-pro%esterone ("ollicular p!ase)

( .astin% %lucose or !r-%m-


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2ana%ement o" PCOS

( Cornerstone o" treatment "oroverei%!t or obese omen it!PCOS, re%ardless o" t!eir desire to

conceive is:

( &ntensive li"estyle modi0cationt!rou%! diet, eIercise and ei%!t

loss( -15 loss o" body ei%!t may lead

to resumption o" normal ovulation


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Mei%!t >oss:2ost iNcult ut 2ost ;NcientG


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2ana%ement o" PCOS

( 7irsutism/Acne/Alopecia) OCPs still best option (?aniKa, >aser, ;-

lysis)

) =o si%ni0cant value to add an anti-andro%en (spironolactone, Hutamide, or0nasteride)

) M!ile anti-andro%ens are eBective,insulin sensitiJin% a%ents are not

) Prolon%ed 3 mos o" treatment reKuired

) =o treatment "or alopecia


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2ana%ement o" PCOS

( 2enstrual &rre%ularities/Cancer Ris*) Overall OCPs outei%! t!e ris*s in most PCOS

patients#( Alternative: cyclic pro%estin#

) =o proo" one OCP is better t!an t!e ot!er) Cycles become more re%ular later in li"eL no

increased ris* "or menopausal omen

) =o a%reement on optimal modality or timin% o"monitorin% "or endometrial !yperplasia/cancer

( >en%t! o" amenorr!ea, bleedin% pattern, ;2t!ic*ness/appearance, a%e

( ' menses per year may be bestpredictor


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2ana%ement o" PCOS

( &n"ertility) OptimiJe !ealt! to reduce


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Post-Q1: A patient it! PCOS s!ould !ave an endometrial biopsyper"ormed:

a# $early even i" s!e is !avin% re%ularit!draal menstrual cycles, eit!er dueto ovulation or !ormonal t!erapy

b# &" s!e is !avin% "eer t!an ' cycles a year

c# &" s!e is over ' years o" a%e it! re%ularovulatory cycles

d# &" an ultrasound reveals !er endometrium

to be mm in t!ic*nesse# At least once i" s!e is over + years o"

a%e independent o" !er menstrual cycles


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Post-Q: Overei%!t patients it! PCOS s!ould beevaluated "or type && diabetes mellitus typically usin%:

a# '-!our %lucose tolerance test

b# .astin% blood su%ar

c# .astin% blood su%ar to insulin ratio

d# -!our %lucose tolerance test usin% %rams o" %lucose solution

e# 1-!our test usin% %rams o" %lucosesolution


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97A=S G

whs pr symposium: obesity, reproduction and pcos

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