{"id":410,"date":"2020-08-13T20:26:50","date_gmt":"2020-08-13T20:26:50","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=410"},"modified":"2020-10-20T17:00:45","modified_gmt":"2020-10-20T17:00:45","slug":"amenorrhea-and-hirsuitism","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/basic_obgyn\/advanced-training\/amenorrhea-and-hirsuitism\/","title":{"rendered":"Amenorrhea and Hirsuitism"},"content":{"rendered":"<p><iframe loading=\"lazy\" title=\"vimeo-player\" src=\"https:\/\/player.vimeo.com\/video\/154084423\" width=\"640\" height=\"360\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><span data-mce-type=\"bookmark\" style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" class=\"mce_SELRES_start\">\ufeff<\/span><\/iframe><\/p>\n<p>Duration 16:18<\/p>\n<input type='hidden' bg_collapse_expand='69e9c8515a00b2056481754' value='69e9c8515a00b2056481754'><input type='hidden' id='bg-show-more-text-69e9c8515a00b2056481754' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9c8515a00b2056481754' value='Hide Transcript'><button id='bg-showmore-action-69e9c8515a00b2056481754' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9c8515a00b2056481754' ><\/p>\n<p>APGO OBJECTIVES<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>Define Amenorrhea and Oligomenorrhea<\/li>\n<li>Explain the pathophysiology and identify etiologies of amenorrhea and oligomenorrhea, including possible nutritional causes<\/li>\n<li>Describe associated symptoms and PE findings of amenorrhea<\/li>\n<li>Discuss the steps in the evaluation and initial management of amenorrhea and oligomenorrhea<\/li>\n<li>Describe the consequences of untreated amenorrhea and oligomenorrhea<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong><u>Definitions<\/u><\/strong><\/p>\n<p>Amenorrhea means the absence of menstrual flows. It may be \u201cPrimary\u201d or \u201cSecondary.\u201d<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>Primary amenorrhea means the patient has never had a menstrual flow.<\/li>\n<li>Secondary amenorrhea means that she used to have menstrual flows, but they have stopped.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Normally, in the United States, menstruation will have begun by age 15, and if it hasn\u2019t, that\u2019s defined as primary amenorrhea.<\/p>\n<p>But there are a couple of important additions to that general rule:<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>If a 13 year old has never had a menstrual flow, <strong><u>and has no secondary sexual characteristics<\/u><\/strong>, such as breasts and pubic hair, then we would consider her to have primary amenorrhea.<\/li>\n<li>If a girl of any age hasn\u2019t had a menstrual flow within 5 years of developing secondary sexual characteristics, she is considered to have primary amenorrhea.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Oligomenorrhea means infrequent menstrual flows. If a woman has fewer than 9 cycles per year, she is said to have oligomenorrhea.<\/p>\n<p>Secondary amenorrhea means the absence of menses for at least 3 previous cycles or 6 months.<sup>2 <\/sup>Pregnancy is the single most common cause of secondary amenorrhea.<\/p>\n<p><strong><u>Pathophysiology and Etiologies of Amenorrhea<\/u><\/strong><\/p>\n<p>For normal menstrual function to occur, a succession of properly communicated signals and functional end organs must be present.<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>The hypothalamus must be intact and able to send GnRH signals to the anterior pituitary.<\/li>\n<li>After receipt of this signal, the anterior pituitary must be able to produce and deliver the follicle stimulating hormone and luteinizing hormone messages to the ovary.<\/li>\n<li>The ovary must be normal with an adequate number of follicles, and a uterus must be present with a lining that is capable of responding to the sex hormones created by the ovary.<\/li>\n<li>Finally there should be an unobstructed path for the uterine menstrual blood to be delivered to and through the vagina.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>So when investigating the cause for either primary or secondary amenorrhea, we must consider the possibility of an abnormality in any of these areas critical for normal menstrual function:<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>The Hypothalamus and Central Nervous System<\/li>\n<li>The Anterior Pituitary<\/li>\n<li>The Ovary and<\/li>\n<li>The uterus and genital outflow tract.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong><u>Disorders of the Hypothalamus<\/u><\/strong><\/p>\n<p><strong><em>Functional Hypothalamic Amenorrhea<\/em><\/strong><\/p>\n<p>There are two clinically important disorders of the hypothalamus:<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>Functional Hypothalamic Amenorrhea, and<\/li>\n<li>Kallman Syndrome<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>If energy demand is high (with excessive exercise) or supply is low (eating disorder), the body will favor shifting its resources away from reproduction and towards other critical processes. This is what happens with Functional Hypothalamic Amenorrhea, or FHA.<\/p>\n<p>Extremes of weight, stress, and physical activity are thought to cause reproductive restraint through abnormal secretion of GnRH, as well as increases in CRH and cortisol, which can also inhibit gonadotropin secretion.<\/p>\n<p>Functional hypothalamic amenorrhea (FHA) is a diagnosis of exclusion, but one that should be considered in the setting of a hypogonadal state, normal to low gonadotropin levels, and in the absence of any sellar mass on brain imaging.<\/p>\n<p>The majority of women who suffer from FHA either report frequent or strenuous exercise, rapid weight loss, or are themselves \u226510% below their ideal body weight. If an eating disorder, such as anorexia nervosa or bulimia, is suspected, a multi-disciplinary approach involving a mental health specialist, physician, and nutritionist should be taken.<\/p>\n<p>Not all exercise is the same. Exercise regimens that lead to low body weight, such as running, ballet, ice-skating and gymnastics, are linked to a greater chance for amenorrhea.<\/p>\n<p>The most serious complication of hypothalamic amenorrhea is bone loss, thus a baseline DEXA scan should be considered following diagnosis.<\/p>\n<p>For women with eating disorders, weight gain is critical as hormone therapy alone is not sufficient in restoring bone density.<\/p>\n<p>Women with exercise-induced amenorrhea should be counseled about reducing the intensity, frequency or duration of their exercise regimen to reduce their risk for bone loss and fracture. Hormone therapy can be considered for this group, along with supplemental vitamin D and calcium.<\/p>\n<p><strong><em>Kallman Syndrome<\/em><\/strong><\/p>\n<p>A rare cause of hypothalamic amenorrhea is congenital GnRH deficiency.<\/p>\n<p>Although a number of genetic aberrations have been linked to this disorder, the classic X linked type, which is associated with a mutation in the KAL gene, is associated with a loss of one\u2019s sense of smell.<\/p>\n<p>The KAL gene is responsible for transcribing the anosmin protein, a molecule responsible for the migration of olfactory neurons<em> <strong><u>and<\/u><\/strong><\/em> GnRH neurons from the olfactory placode to the hypothalamus during embryogenesis.<\/p>\n<p>Patients with this condition generally present with delayed puberty and have a family history of the syndrome.<\/p>\n<p>Since adrenarche occurs independent of the maturation of the hypothalamic-pituitary-ovarian access, pubic hair is generally present, while breast development and menstrual flows are absent.<\/p>\n<p>The main laboratory findings are very low or undetectable levels of LH and FSH, low estrogen, a normal karyotype and absence of other causes of amenorrhea.<\/p>\n<p>Although sequencing of the KAL gene may lead to definitive diagnosis, but as there are likely many unknown genetic etiologies for Kallman, a negative result cannot exclude the diagnosis.<\/p>\n<p>Treatment involves hormone therapy for both pubertal initiation and bone protection.<\/p>\n<p><strong><u>Disorders of the Pituitary<\/u><\/strong><\/p>\n<p><strong><em>Elevated Prolactin Levels or Hyperprolactinemia<\/em><\/strong><\/p>\n<p>The important pituitary disorder related to amenorrhea is hyperprolactinemia.<\/p>\n<p>Because prolactin inhibits the GnRH pulse generator, elevations in prolactin can also cause a hypothalamic state.<\/p>\n<p>Patients may present with shortened luteal phase, oligomenorrhea, or amenorrhea, galactorrhea, and occasionally headache or visual changes.<\/p>\n<p>Prior to testing, the patient should be advised to fast, to abstain from intercourse, and to avoid exercise, as these activities can lead to a false positive result.<\/p>\n<p>If persistently elevated prolactin levels are found, the next step is to determine the etiology.\u00a0 Typically, hyperprolactinemia is caused by primary thyroid dysfunction, medications (more often dopamine inhibitors), or prolactin producing pituitary adenomas.\u00a0 Thus, evaluation includes thyroid function testing, review of medications, and a brain MRI.<\/p>\n<p>Correction of the thyroid disorder will lead to restoration of normal prolactin levels and resolution of hyperprolactinemic symptoms.\u00a0 If an anti-psychotic medication is the cause, it is best to coordinate the patient\u2019s care with her primary mental health professional.\u00a0 Strategies may include transitioning the patient to an alternative medication.<\/p>\n<p>Dopamine agonists are the primary treatment for lactotroph adenomas of all sizes, however special attention should be given to women with<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>macroadenomas (greater than 10 millimeters),<\/li>\n<li>tumors that do not reduce in size following normalization of prolactin levels (which may suggest a nonfunctioning adenoma), or<\/li>\n<li>those that rapidly grow and cause significant neurologic deficit (suggesting a malignancy).<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Women should be followed closely with serial prolactin measurements and repeat brain imaging to assure resolution.<\/p>\n<p><strong><u>Disorders of the Ovary<\/u><\/strong><\/p>\n<p><strong><em>Polycystic Ovary Syndrome<\/em><\/strong><\/p>\n<p>Let\u2019s consider some problems with the ovaries that can lead to amenorrhea.<\/p>\n<p>Although listed as a disorder of the ovary, the polycystic ovary syndrome is a complex disorder stemming from abnormal GnRH secretion and leading to intra-ovarian hyperandrogenism and abnormal folliculogenesis.<\/p>\n<p>Cyclical release of LH and FSH from the anterior pituitary stimulates the granulose and thecal cells of the ovary to produce estrogens, androgens and progesterone in varying amounts, leading to ovulation, all in support of the monthly opportunity for a pregnancy.<\/p>\n<p>In PCOS, the normal rise and fall of the gonadotropins doesn\u2019t occur. Because abnormal GnRH pulsatility favors LH release over FSH release, increased thecal androgen production occurs.<\/p>\n<p>Insulin resistance can also contribute to increased ovarian androgen production and hyperandrogenemia as insulin acts synergistically with LH and suppresses hepatic sex hormone binding globulin production.<\/p>\n<p>Elevated local androgen prevents normal folliculogenesis and the result is the appearance of polycystic ovaries on ultrasound.<\/p>\n<p>For the diagnosis of PCOS, the patient should meet two of three of the following conditions, known as the Rotterdam Criteria:<\/p>\n<ol>\n<li style=\"list-style-type: none\">\n<ol>\n<li>Oligo- or anovulation<\/li>\n<li>Clinical and or biochemical evidence of hyperandrogenism and<\/li>\n<li>Ultrasound evidence of polycystic ovaries.<\/li>\n<\/ol>\n<\/li>\n<\/ol>\n<p>The sonographic definition of polycystic ovaries includes the presence on one ovary of at least 12 antral follicles or a total ovarian volume of at least 10 cc.\u00a0 As many as 20% of normal women have this ultrasound finding without having the syndrome.<\/p>\n<p>Patients with PCOS are at risk for insulin resistance, diabetes mellitus, metabolic syndrome, endometrial hyperplasia and cancer, obstructive sleep apnea, and depression.<\/p>\n<p>Because about half of women with PCOS are obese, and because obesity is associated with the long-term cardio-metabolic risks of PCOS, the most important initial and maintenance treatment are the lifestyle changes of a healthy diet and exercise.\u00a0 A 2-5% reduction in weight can reduce metabolic risk and improve reproductive potential.<\/p>\n<p>If fertility is not desired, the progestins found in oral contraceptives, cyclic provera, or the mirena IUD can be used to protect the endometrium from hyperplasia.<\/p>\n<p>In women seeking fertility, ovulation induction agents, such as clomiphene citrate, can be used.<\/p>\n<p>In women complaining of androgen excess (hair and acne) and not currently seeking a pregnancy, oral contraceptive pills can effectively reduce androgens. Anti-androgens can also be used.<\/p>\n<p><strong><em>Gonadal dysgenesis<\/em><\/strong><\/p>\n<p>Structural or numerical sex chromosome abnormalities can cause gonadal dysgenesis, ultimately leading to abnormal gonadal formation and the appearance of \u201cstreak gonads.\u201d<\/p>\n<p>Often this occurs in utero or in the first few years of life, and is the most common cause of primary amenorrhea.<\/p>\n<p>Affected girls usually present with primary amenorrhea or pubertal delay as well as elevated FSH levels and low estradiol levels.\u00a0 As adrenarche is driven by the adrenal gland, which is unaffected, pubic hair may still be present.<\/p>\n<p>The key initial step to determining the cause for ovarian failure in the setting of primary amenorrhea is by obtaining a karyotype.\u00a0 Although 25% of patients will have a normal 46 XX karyotype, Turner syndrome must also be ruled out.<\/p>\n<p><strong>Turner Syndrome<\/strong><\/p>\n<p>Turner syndrome, the most common form of gonadal dysgenesis, is associated with a 45, X karyotype.\u00a0 Physical examination may reveal the classic Turner phenotype, which includes a webbed neck, shield chest, and cubitus valgus.<\/p>\n<p>Because patients with Turner syndrome are at increased risk for coarctation of the aorta, hearing loss, thyroid dysfunction, metabolic syndrome and celiac disease, they should undergo routine surveillance for these conditions.<\/p>\n<p>Treatment is aimed at improving final adult height with growth hormone, as well as initiating puberty and maintaining bone protection with hormone therapy.<\/p>\n<p><strong><em>Premature Ovarian Insufficiency<\/em><\/strong><\/p>\n<p>Cessation of menstrual function, or menopause, normally occurs around age 51, but with premature ovarian insufficiency, it may occur at a much younger age.<\/p>\n<p>The diagnosis of premature ovarian insufficiency involves amenorrhea or menstrual irregularity as well as menopausal levels of follicle stimulating hormone on two different occasions 4-6 weeks apart.<\/p>\n<p>Patients may present with menopausal symptoms, such as hot flushes, vaginal dryness, and menstrual irregularity.\u00a0 Carrier status for fragile X permutation and assessment of thyroid and adrenal autoimmunity should be obtained in addition to a karyotype; a baseline DEXA scan can also be considered.<\/p>\n<p>Similar to young girls with gonadal dysgenesis, treatment is centered around hormone therapy for bone protection.<\/p>\n<p><strong><em>Ovarian Surgery, Chemotherapy, Radiation therapy<\/em><\/strong><\/p>\n<p>Other causes of late gonadal failure include gonadal surgery, or a history of chemotherapy and radiation.<\/p>\n<p>Multiple excision procedures which reduce ovarian stroma, or a prior history of bilateral salpingo-oophorectomy, can lead to amenorrhea and the diagnostic picture appears similar to gonadal failure.<\/p>\n<p>Chemotherapy and pelvic radiation can also lead to a reduction in the number of eggs and subsequently lead to amenorrhea.\u00a0 The effect is largely dependent on the type of agent used, the dose, and duration of treatment.<\/p>\n<p>Although fertility preservation procedures, such as in vitro fetrtilization or oocyte cryopreservation, prior to gonadotoxic therapy can help future fertility, hormone therapy is still required if gonadal failure is encountered.<\/p>\n<p>Importantly, all patients with gonadal failure should be offered emotional support and the option for counseling.<\/p>\n<p><strong><u>Disorders of the Genital Outflow tract<\/u><\/strong><\/p>\n<p>Now, let\u2019s consider disorders of the genital outflow tract.<\/p>\n<p><strong><em>Imperforate Hymen <\/em><\/strong><\/p>\n<p>Girls with imperforate hymen generally present with primary amenorrhea, normal secondary sexual characteristics, and cryptomenorrhea, or cyclic abdominal pain without menses.\u00a0 On examination, a thin, bulging, blue membrane just proximal to the introitus can be seen.\u00a0 Treatment involves surgical correction:\u00a0 generally, a cruciate incision is made in the redundant tissue, which is then excised and the hymeneal ring restored.<\/p>\n<p><strong><em>Transverse Vaginal Septum<\/em><\/strong><\/p>\n<p>A transverse vaginal septum can form if the mullerian ducts improperly fuse during embryogenesis.<\/p>\n<p>This condition is far more rare than imperforate hymen, occurring in 1\/20000-1\/80000 women.<\/p>\n<p>Girls with a transverse vaginal septum typically present with primary amenorrhea, normal secondary sexual characteristics, and cryptomenorrhea.\u00a0 The main difference between this and an imperforate hymen is the physical exam.<\/p>\n<p>Unlike imperforate hymen, girls with transverse vaginal septum have a normal introitus and ruptured hymen, and what appears to be a blind ending vaginal pouch and no visible cervix.\u00a0 A Valsalva maneuver can be helpful in also distinguishing the two, as the introitus distends in those with imperforate hymen but not in those with transverse vaginal septum. \u00a0Pelvic MRI confirms the diagnosis.<\/p>\n<p>Surgical resection is best done by a surgeon with expertise in mullerian anomalies.<\/p>\n<p><strong><em>Mullerian Agenesis (Mayer Rokitansky Juster Hauser Syndrome, MRKH Syndrome)<\/em><\/strong><\/p>\n<p>The most common cause of primary amenorrhea in the presence of normal secondary sexual characteristics is mullerian agenesis, also known as Mayer Rokitansky Kuster Hauser or MRKH syndrome.<\/p>\n<p>In this disorder, all or part of the uterus and vagina are absent and girls present with primary amenorrhea, normal female secondary sexual characteristics, and findings of a blind ending vaginal pouch.<\/p>\n<p>Unlike transverse vaginal septum, these patients do not present with cryptomenorrhea, but like the former a pelvic MRI will make the diagnosis.<\/p>\n<p>A higher risk for urogenital malformation is also associated with the syndrome and should be evaluated once the diagnosis is confirmed.\u00a0 Treatment involves counseling and emotional support along with the creation of a neovagina through successive vaginal dilation or surgical construction.<\/p>\n<p><strong><em>Androgen Insensitivity Syndrome<\/em><\/strong><\/p>\n<p>Complete androgen insensitivity syndrome (or AIS) presents similarly to MRKH syndrome, with normal female secondary sexual characteristics, primary amenorrhea and a blind ending vaginal pouch.\u00a0 However, it is more rare.<\/p>\n<p>In this disorder, genetic males have abnormal androgen receptors, which ultimately leads to an absence of virilization and a female phenotype coupled with scant pubic hair.<\/p>\n<p>Inguinal masses may also be present, representing the underdeveloped testes.\u00a0 Serum androgen levels and a karyotype are key to distinguishing these two diagnoses.<\/p>\n<p>As in the case of MRKH Syndrome, those with AIS will benefit from counseling, social support and consideration of creation of a neovagina.<\/p>\n<p>Unlike MRKH, gonadectomy should be performed following puberty in those with a diagnosis of AIS to avoid the formation of gonadoblastoma.<\/p>\n<p><strong><em>Asherman Syndrome<\/em><\/strong><strong> \u00a0<em>and Cervical Stenosis<\/em> <\/strong><\/p>\n<p>Anatomic defects associated with secondary amenorrhea include cervical stenosis and Asherman syndrome, in which the endometrial cavity is scarred.<\/p>\n<p>Historical clues include a prior history of cervical dysplasia requiring multiple excision procedures or postpartum dilation and curettage in the setting of postpartum hemorrhage.<\/p>\n<p>Generally, a diagnosis can be made using physical exam for the former and saline infusion sonohysterogram for the latter.\u00a0 Treatment usually involves cervical dilation or hysteroscopic lysis of adhesions.<\/p>\n<p><strong><u>Evaluation<\/u><\/strong><\/p>\n<p>In cases of primary amenorrhea, it is important to assess if and at what age other pubertal milestones have been reached, such as breast and pubic hair development.\u00a0 A typical exam should also include Tanner staging of breast development and pubertal hair distribution as well as a pelvic exam.<\/p>\n<p>The most important initial step is to determine if there is any clinical or biochemical evidence of estrogen. This can be done through Tanner staging on physical exam (is there breast development?) or response following a progestin challenge test (does the patient bleed after a short course of progestin therapy?).<\/p>\n<p>We can narrow the differential diagnosis further based on the results of 3 additional blood tests: Follicle Stimulating Hormone (FSH), Leutinizing hormone (LH) and Estradiol, which are helpful in determining the causes for both primary and secondary amenorrhea.\u00a0 The exception to this rule is polycystic ovary syndrome, in which isolated elevations in LH can be seen or a eugonadotropic state can be seen.<\/p>\n<p>The key diagnostic components of an amenorrhea evaluation should include a thorough physical exam along with<\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>Serum Pregnancy Test<\/li>\n<li>Pelvic ultrasound or MRI<\/li>\n<li>Serum FSH, LH, and estradiol<\/li>\n<li>Serum fasting prolactin<\/li>\n<li>Serum TSH and FT4<\/li>\n<li><em>Brain MRI (to rule out hypothalamic or pituitary space occupying lesion, and to rule in functional hypothalamic amenorrhea)<\/em><\/li>\n<li><em>Karyotype (If hypergonadotropic hypogonadism is encountered, or to distinguish between MRKH and AIS)<\/em><\/li>\n<li><em>Total Testosterone levels (To rule in PCOS or AIS)<\/em><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<hr \/>\n<p>References<\/p>\n<p><sup>1<\/sup>Current evaluation of amenorrhea.\u00a0 The Practice Committeee of the American Society for Reproductive Medicine.\u00a0 Fertility and Sterility. 2008. 90(3):S219-S225.<\/p>\n<p><sup>2<\/sup>Fritz M.\u00a0 Clinical Gynecologic Endocrinology and Infertility.\u00a0 Philadelphia: Lippincott Williams &amp; Wilkins, 2011.\u00a0 Print.<\/p>\n<p><sup>3<\/sup>Rotterdam ESHRE\/ASRM-Sponsored PCOS Consensus Workshop Group.\u00a0 Revised 2003 consensus on diagnostic criteria and long term health risks related to polycystic ovary syndrome.\u00a0 Fertil Steril 2004; 1:19-25.<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/U3yHIqx8u4M\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 11:58<\/p>\n<input type='hidden' bg_collapse_expand='69e9c8515a80c0010377639' value='69e9c8515a80c0010377639'><input type='hidden' id='bg-show-more-text-69e9c8515a80c0010377639' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9c8515a80c0010377639' value='Hide Transcript'><button id='bg-showmore-action-69e9c8515a80c0010377639' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfafa;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9c8515a80c0010377639' ><\/p>\n<p>My name is Jason Yeh<br \/>\n00:02<br \/>\nand I&#8217;m in my last year<br \/>\n00:03<br \/>\nof an OBGYN residency<br \/>\n00:04<br \/>\nat Duke University.<br \/>\n00:06<br \/>\nThis talk is an overview<br \/>\n00:07<br \/>\nof PCOS.<br \/>\n00:07<br \/>\n00:11<br \/>\nOur objectives are to understand<br \/>\n00:13<br \/>\nthe history of PCOS.<br \/>\n00:14<br \/>\nAlso, we will talk about how<br \/>\n00:16<br \/>\nthe mechanisms of how PCOS<br \/>\n00:17<br \/>\ndevelops.<br \/>\n00:18<br \/>\nIt will also<br \/>\n00:19<br \/>\nbe important to discuss how<br \/>\n00:20<br \/>\nto work up and treat PCOS<br \/>\n00:22<br \/>\nand its related co-morbidities.<br \/>\n00:23<br \/>\n00:27<br \/>\nPCOS was first characterized<br \/>\n00:29<br \/>\nin 1935 by Dr. Stein<br \/>\n00:30<br \/>\nand Leventhal.<br \/>\n00:32<br \/>\nThey collected a series<br \/>\n00:33<br \/>\nof patients that had<br \/>\n00:33<br \/>\ndemonstrated signs and symptoms<br \/>\n00:35<br \/>\nof hirsutism, obesity,<br \/>\n00:37<br \/>\namenorrhea, and oligomenorrhea.<br \/>\n00:39<br \/>\nThey also had polycystic ovaries<br \/>\n00:41<br \/>\nand because of this it was felt<br \/>\n00:42<br \/>\nthat this was probably the cause<br \/>\n00:44<br \/>\nof their problems.<br \/>\n00:45<br \/>\nIt was later found<br \/>\n00:46<br \/>\nthat these women had<br \/>\n00:47<br \/>\nmenstrual cycles restored<br \/>\n00:48<br \/>\nwith partial ovarian resections,<br \/>\n00:50<br \/>\nand therefore, PCOS really stuck<br \/>\n00:52<br \/>\nas the name and likely cause<br \/>\n00:53<br \/>\nof the disease.<br \/>\n00:54<br \/>\nHowever, since then we&#8217;ve<br \/>\n00:55<br \/>\nrealized that having<br \/>\n00:56<br \/>\npolycystic ovaries<br \/>\n00:58<br \/>\nis not necessary.<br \/>\n00:59<br \/>\nAnd some patients don&#8217;t have<br \/>\n01:00<br \/>\nthe ovarian findings<br \/>\n01:01<br \/>\nbut have everything else.<br \/>\n01:03<br \/>\nTherefore, lots of meetings<br \/>\n01:04<br \/>\nhave been made to secure<br \/>\n01:05<br \/>\na good definition of PCOS.<br \/>\n01:08<br \/>\nIn 1990 the NIH decided that you<br \/>\n01:10<br \/>\nneed all three to diagnose PCOS<br \/>\n01:12<br \/>\nwhich include,<br \/>\n01:13<br \/>\noligoovulation, signs<br \/>\n01:15<br \/>\nand symptoms of androgen excess,<br \/>\n01:18<br \/>\nand you need to exclude<br \/>\n01:19<br \/>\nother things that could cause<br \/>\n01:20<br \/>\nPCOS.<br \/>\n01:21<br \/>\nIn 2003 a meeting in Rotterdam<br \/>\n01:23<br \/>\nsuggests that you need two<br \/>\n01:24<br \/>\nof three things<br \/>\n01:25<br \/>\nto diagnose PCOS.<br \/>\n01:26<br \/>\nThose are,<br \/>\n01:27<br \/>\noligoovulation\/anovulation<br \/>\n01:30<br \/>\nexcess androgen activity,<br \/>\n01:32<br \/>\nor polycystic ovaries<br \/>\n01:33<br \/>\nby ultrasound.<br \/>\n01:35<br \/>\nOf no polycystic ovaries can be<br \/>\n01:36<br \/>\ndiagnosed with 12 or more<br \/>\n01:38<br \/>\nfollicles in one ovary, with<br \/>\n01:39<br \/>\nfollicles ranging anywhere from<br \/>\n01:41<br \/>\n2 to 9 millimeters, and\/or<br \/>\n01:43<br \/>\nan increase of total ovarian<br \/>\n01:44<br \/>\nvolume greater than 10 cc&#8217;s.<br \/>\n01:46<br \/>\n01:49<br \/>\nFirst it&#8217;s important to say<br \/>\n01:50<br \/>\nthat no one is entirely<br \/>\n01:51<br \/>\nclear what starts the PCOS<br \/>\n01:53<br \/>\nprocess.<br \/>\n01:54<br \/>\nBut in order to understand how<br \/>\n01:55<br \/>\nPCOS may come about we<br \/>\n01:57<br \/>\nneed to talk about the two cell<br \/>\n01:58<br \/>\nand two gonadotropin theory.<br \/>\n02:00<br \/>\nThe key players are<br \/>\n02:01<br \/>\nfollicle stimulating hormone,<br \/>\n02:02<br \/>\nFSH, and luteinizing hormone,<br \/>\n02:04<br \/>\nLH, which are released<br \/>\n02:05<br \/>\nfrom the gonadotropes<br \/>\n02:06<br \/>\nin the anterior pituitary<br \/>\n02:08<br \/>\nof the brain.<br \/>\n02:09<br \/>\nImagine a sphere shaped follicle<br \/>\n02:11<br \/>\nwith an outside cell layer<br \/>\n02:12<br \/>\nand an inside cell layer.<br \/>\n02:14<br \/>\nThere is also a basement<br \/>\n02:15<br \/>\nmembrane in between.<br \/>\n02:16<br \/>\nThe cells on the outside<br \/>\n02:18<br \/>\nare the theca cells, which have<br \/>\n02:20<br \/>\nLH receptors.<br \/>\n02:21<br \/>\nThere&#8217;s also another layer<br \/>\n02:22<br \/>\nof cells on the inside<br \/>\n02:23<br \/>\nof the membrane called granulosa<br \/>\n02:24<br \/>\ncells, which have FSH receptors.<br \/>\n02:27<br \/>\nSo the key to understanding this<br \/>\n02:29<br \/>\nis that the two cells work<br \/>\n02:30<br \/>\ntogether to convert cholesterol<br \/>\n02:31<br \/>\nto estrogen. First,<br \/>\n02:33<br \/>\nLH stimulates the theca<br \/>\n02:35<br \/>\ncells, which responds by taking<br \/>\n02:36<br \/>\ncholesterol<br \/>\n02:37<br \/>\nand converts it to androgens,<br \/>\n02:39<br \/>\nspecifically<br \/>\n02:40<br \/>\ntestosterone and<br \/>\n02:40<br \/>\nandrostenedione.<br \/>\n02:42<br \/>\nThere is no significant amount<br \/>\n02:43<br \/>\nof aromatase in the theca cells<br \/>\n02:45<br \/>\nso the process of conversion<br \/>\n02:46<br \/>\nstops at the androgen level.<br \/>\n02:49<br \/>\nThen the antigens are then<br \/>\n02:50<br \/>\nsmall enough to cross<br \/>\n02:52<br \/>\nthe membrane<br \/>\n02:52<br \/>\nand get into the granulosa<br \/>\n02:53<br \/>\ncells.<br \/>\n02:54<br \/>\nThese granulosa cells respond<br \/>\n02:56<br \/>\nto FSH and have lots<br \/>\n02:58<br \/>\nof aromatase, which then allows<br \/>\n03:00<br \/>\nthe conversion of androgen<br \/>\n03:01<br \/>\nto estrogen. So ultimately,<br \/>\n03:03<br \/>\nthe process of converting<br \/>\n03:04<br \/>\ncholesterol to estrogen<br \/>\n03:05<br \/>\nrequires two cells and two<br \/>\n03:07<br \/>\nseparate hormones.<br \/>\n03:08<br \/>\nIf you have a defect<br \/>\n03:09<br \/>\nin either cell, you don&#8217;t have<br \/>\n03:11<br \/>\na balanced process.<br \/>\n03:13<br \/>\nSo now that we&#8217;ve established<br \/>\n03:14<br \/>\nhow the synthesis of androgens<br \/>\n03:16<br \/>\nand estrogens happens<br \/>\n03:17<br \/>\nwe can talk about how PCOS<br \/>\n03:18<br \/>\nstarts.<br \/>\n03:19<br \/>\nNo one really knows what starts<br \/>\n03:20<br \/>\nthe process but it&#8217;s believed<br \/>\n03:22<br \/>\nthat it&#8217;s caused<br \/>\n03:23<br \/>\nby a poor balance of FSH to LH.<br \/>\n03:26<br \/>\nOn one hand, if you have too<br \/>\n03:27<br \/>\nmuch LH secretion<br \/>\n03:29<br \/>\nyou have ovarian theca cells<br \/>\n03:30<br \/>\nstimulated to make androgens.<br \/>\n03:32<br \/>\nLots of LH, therefore, makes<br \/>\n03:34<br \/>\nlots of androgens, and overloads<br \/>\n03:35<br \/>\nthe capacity of the granulosa<br \/>\n03:37<br \/>\ncells<br \/>\n03:37<br \/>\nto aromatize into estrogens.<br \/>\n03:40<br \/>\nOn the other hand, it may also<br \/>\n03:41<br \/>\nbe possible that there is not<br \/>\n03:42<br \/>\nenough FSH and therefore<br \/>\n03:44<br \/>\nyour conversion to estrogen<br \/>\n03:45<br \/>\nis too slow<br \/>\n03:46<br \/>\nand you get a back-up<br \/>\n03:47<br \/>\nand build-up of androgens.<br \/>\n03:48<br \/>\nWhen you don&#8217;t have<br \/>\n03:49<br \/>\nenough estrogen a woman<br \/>\n03:50<br \/>\nmay progress to anovulation,<br \/>\n03:52<br \/>\nwhich<br \/>\n03:52<br \/>\nis an important characteristic<br \/>\n03:54<br \/>\nof PCOS.<br \/>\n03:54<br \/>\n03:58<br \/>\nPCOS is one of the most<br \/>\n03:59<br \/>\ncommon disorders<br \/>\n04:00<br \/>\nin endocrinology.<br \/>\n04:02<br \/>\nIn the USA it affects anywhere<br \/>\n04:03<br \/>\nfrom 4% to 12% of people.<br \/>\n04:05<br \/>\nIn Europe is probably closer<br \/>\n04:06<br \/>\nto 6% to 8%.<br \/>\n04:08<br \/>\nIf you remember the way you<br \/>\n04:09<br \/>\ndiagnose it<br \/>\n04:10<br \/>\nfrom the first slide,<br \/>\n04:11<br \/>\nthere are not a lot<br \/>\n04:12<br \/>\nof specific clinical features.<br \/>\n04:14<br \/>\nThis is meant to provide lots<br \/>\n04:15<br \/>\nof flexibility in the diagnosis,<br \/>\n04:17<br \/>\ntherefore,<br \/>\n04:17<br \/>\nthe physical presentation<br \/>\n04:18<br \/>\nis very varied.<br \/>\n04:20<br \/>\nFor example, if an Asian<br \/>\n04:22<br \/>\nand Caucasian have the same<br \/>\n04:23<br \/>\nhyper androgen levels, the Asian<br \/>\n04:25<br \/>\nwill, overall, have much less<br \/>\n04:27<br \/>\nhair.<br \/>\n04:28<br \/>\nAlso, people think that PCOS<br \/>\n04:29<br \/>\npatients need to be obese<br \/>\n04:31<br \/>\nbut there is also<br \/>\n04:31<br \/>\na non-obese type<br \/>\n04:33<br \/>\nof presentation.<br \/>\n04:34<br \/>\nAlso, the inheritance for PCOS<br \/>\n04:36<br \/>\nis unclear<br \/>\n04:37<br \/>\nbut a few familial studies<br \/>\n04:38<br \/>\nsuggest that it may actually<br \/>\n04:40<br \/>\nbe autosomal dominant.<br \/>\n04:41<br \/>\nUnfortunately, there are<br \/>\n04:42<br \/>\nno specific genes that have been<br \/>\n04:43<br \/>\nidentified that definitely<br \/>\n04:44<br \/>\ncaused PCOS.<br \/>\n04:45<br \/>\n04:49<br \/>\nAlthough people can present<br \/>\n04:50<br \/>\nwith varied symptoms, there&#8217;s<br \/>\n04:51<br \/>\na typical presentation<br \/>\n04:52<br \/>\nfor the average PCOS patient.<br \/>\n04:54<br \/>\nMost patients are obese,<br \/>\n04:56<br \/>\nthey typically have<br \/>\n04:56<br \/>\noligomenorrhea, which means<br \/>\n04:58<br \/>\nbleeding less<br \/>\n04:58<br \/>\nfrequent than the normal woman<br \/>\n05:00<br \/>\nwith a cycle length between 35<br \/>\n05:01<br \/>\ndays and six months.<br \/>\n05:03<br \/>\nThey could also have<br \/>\n05:03<br \/>\nsecondary amenorrhea, which<br \/>\n05:05<br \/>\nis no bleeding for six months.<br \/>\n05:06<br \/>\nThey also have symptoms<br \/>\n05:08<br \/>\nof hyperandrogenism,<br \/>\n05:09<br \/>\nsuch as deepening voice,<br \/>\n05:11<br \/>\nclitoromegaly, acne, and<br \/>\n05:12<br \/>\nabnormal or excessive hair<br \/>\n05:14<br \/>\ngrowth.<br \/>\n05:14<br \/>\n05:17<br \/>\nOnce you&#8217;ve suspected PCOS<br \/>\n05:19<br \/>\nyou need to rule out<br \/>\n05:20<br \/>\nall other diseases that could be<br \/>\n05:21<br \/>\nconfusing and confounding<br \/>\n05:22<br \/>\nthe clinical picture.<br \/>\n05:24<br \/>\nCongenital adrenal hyperplasia<br \/>\n05:25<br \/>\nis a disease where there is<br \/>\n05:27<br \/>\na defective 21-hydroxylase<br \/>\n05:29<br \/>\nenzyme.<br \/>\n05:30<br \/>\nThis deficiency is a defect<br \/>\n05:31<br \/>\nin the steroid hormone pathway.<br \/>\n05:33<br \/>\nSome cases are so severe that it<br \/>\n05:35<br \/>\npresents as a newborn,<br \/>\n05:36<br \/>\nbut when the enzyme is not<br \/>\n05:37<br \/>\nentirely defective,<br \/>\n05:38<br \/>\nand it partially works,<br \/>\n05:39<br \/>\nthe disease can actually present<br \/>\n05:40<br \/>\nlater in life<br \/>\n05:41<br \/>\nin the early reproductive years.<br \/>\n05:43<br \/>\nWhen the enzyme is defective<br \/>\n05:45<br \/>\nsteroid precursors build up.<br \/>\n05:46<br \/>\nSo if you look<br \/>\n05:47<br \/>\nat your steroid hormone pathway,<br \/>\n05:49<br \/>\nthe precursors that build up<br \/>\n05:50<br \/>\nare progesterone,<br \/>\n05:51<br \/>\n17-hydroxypregnenolone,<br \/>\n05:54<br \/>\n17-hydroxyprogesterone.<br \/>\n05:56<br \/>\nBlood levels of 17-OHP<br \/>\n05:58<br \/>\ncan reach up to 10 to 1,000<br \/>\n06:00<br \/>\ntimes the normal concentration.<br \/>\n06:01<br \/>\nThese excess precursors actually<br \/>\n06:03<br \/>\noverload the entire system<br \/>\n06:05<br \/>\nand result<br \/>\n06:05<br \/>\nin excessive synthesis<br \/>\n06:06<br \/>\nof androgens.<br \/>\n06:07<br \/>\nWhen it presents later in life<br \/>\n06:09<br \/>\nthe elevated precursor levels<br \/>\n06:10<br \/>\nare sometimes not<br \/>\n06:11<br \/>\ndetectable until, or unless, you<br \/>\n06:13<br \/>\nrun a cosyntropin or ACTH<br \/>\n06:15<br \/>\nstimulation test.<br \/>\n06:17<br \/>\nCushing syndrome can also result<br \/>\n06:19<br \/>\nin suspected PCOS.<br \/>\n06:21<br \/>\nA common way to test for this<br \/>\n06:23<br \/>\nis to run<br \/>\n06:23<br \/>\na urine-free cortisol level.<br \/>\n06:26<br \/>\nThere are many ways of testing<br \/>\n06:27<br \/>\nfor this but this happens to be<br \/>\n06:28<br \/>\none of the easiest ways.<br \/>\n06:30<br \/>\nHyperprolactinemia needs to be<br \/>\n06:31<br \/>\nruled out as well.<br \/>\n06:32<br \/>\nThis can be accomplished<br \/>\n06:33<br \/>\nwith a fasting prolactin level,<br \/>\n06:35<br \/>\nand if elevated,<br \/>\n06:36<br \/>\nyou&#8217;ll need to look for causes,<br \/>\n06:37<br \/>\nwhich include prolactinomas<br \/>\n06:38<br \/>\nin the brain.<br \/>\n06:39<br \/>\nAndrogen levels also need to be<br \/>\n06:41<br \/>\nchecked to make sure there isn&#8217;t<br \/>\n06:42<br \/>\na tremendous elevation that<br \/>\n06:43<br \/>\nwould suggest<br \/>\n06:44<br \/>\nan androgen secreting tumor.<br \/>\n06:46<br \/>\nNext, the LH and FSH levels<br \/>\n06:48<br \/>\ncould also be checked to rule<br \/>\n06:49<br \/>\nout the possibility<br \/>\n06:50<br \/>\nof premature ovarian failure.<br \/>\n06:52<br \/>\nIn PCOS LH is typically elevated<br \/>\n06:54<br \/>\nbecause most people think<br \/>\n06:55<br \/>\nthat is, again, what causes<br \/>\n06:57<br \/>\nthe excessive theca cell<br \/>\n06:58<br \/>\nstimulation and androgen excess.<br \/>\n07:01<br \/>\nA glucose tolerance test should<br \/>\n07:02<br \/>\nalso be done to look<br \/>\n07:03<br \/>\nfor undiagnosed diabetes,<br \/>\n07:05<br \/>\nbecause a hallmark of PCOS<br \/>\n07:06<br \/>\nis actually insulin resistance.<br \/>\n07:08<br \/>\nAnd levels become very, very<br \/>\n07:10<br \/>\nhigh.<br \/>\n07:10<br \/>\nWomen with PCOS<br \/>\n07:11<br \/>\noften have diabetes as well as<br \/>\n07:14<br \/>\nthe need to be treated<br \/>\n07:15<br \/>\nto prevent all the bad outcomes<br \/>\n07:16<br \/>\nassociated with diabetes,<br \/>\n07:17<br \/>\nsuch as renal disease,<br \/>\n07:19<br \/>\ncardiovascular disease, eye<br \/>\n07:21<br \/>\ndisease, et cetera.<br \/>\n07:22<br \/>\nAlso, imaging studies can also<br \/>\n07:24<br \/>\nbe helpful if there is something<br \/>\n07:25<br \/>\nyou suspect<br \/>\n07:26<br \/>\nor if there is a need to image<br \/>\n07:27<br \/>\nthe uterus<br \/>\n07:28<br \/>\nor ovaries to identify<br \/>\n07:29<br \/>\nany tumors or cysts.<br \/>\n07:30<br \/>\n07:33<br \/>\nSo although there is no cure<br \/>\n07:34<br \/>\nfor PCOS, there are a few very<br \/>\n07:37<br \/>\nimportant goals for treatment.<br \/>\n07:38<br \/>\nWe will talk about how to do<br \/>\n07:40<br \/>\nthis specifically<br \/>\n07:40<br \/>\nin the next slide.<br \/>\n07:41<br \/>\nIn general, though, the goals<br \/>\n07:43<br \/>\nare as follows.<br \/>\n07:44<br \/>\nThe first goal is to prevent<br \/>\n07:45<br \/>\nendometrial cancer.<br \/>\n07:47<br \/>\nNext, a clinician should also<br \/>\n07:48<br \/>\ntry to lower insulin levels<br \/>\n07:49<br \/>\nand either to diagnose<br \/>\n07:51<br \/>\nor prevent diabetes.<br \/>\n07:53<br \/>\nAlso, it is important to give<br \/>\n07:54<br \/>\nthese patients a chance<br \/>\n07:55<br \/>\nfor fertility restoration<br \/>\n07:56<br \/>\nwhen they are ready to start<br \/>\n07:57<br \/>\na family, since infertility is<br \/>\n07:59<br \/>\nvery common among PCOS patients.<br \/>\n08:01<br \/>\nLastly, treatment of hirsutism<br \/>\n08:03<br \/>\nand acne<br \/>\n08:04<br \/>\nis often one of the most<br \/>\n08:05<br \/>\nfrequent complaints that brings<br \/>\n08:06<br \/>\npatients to the clinic to begin<br \/>\n08:07<br \/>\nwith,<br \/>\n08:08<br \/>\nso it&#8217;s important to address<br \/>\n08:09<br \/>\nthis.<br \/>\n08:10<br \/>\n08:13<br \/>\nTreatment of PCOS<br \/>\n08:14<br \/>\nis a multimodal process<br \/>\n08:15<br \/>\nand requires an attack on all<br \/>\n08:17<br \/>\nthe different symptoms<br \/>\n08:18<br \/>\nand disease processes.<br \/>\n08:20<br \/>\nFirst, lifestyle modifications<br \/>\n08:22<br \/>\nis one thing we would recommend<br \/>\n08:23<br \/>\nto many patients.<br \/>\n08:25<br \/>\nPatients are often anovulatory<br \/>\n08:26<br \/>\nbecause of complex interactions<br \/>\n08:28<br \/>\nof insulin and imbalanced<br \/>\n08:29<br \/>\ngonadotropins.<br \/>\n08:31<br \/>\nWhat is interesting<br \/>\n08:31<br \/>\nis that diet and exercise that<br \/>\n08:33<br \/>\nleads to,<br \/>\n08:34<br \/>\neven a modest 5% weight loss,<br \/>\n08:36<br \/>\nis usually enough to resume<br \/>\n08:37<br \/>\nnormal menstrual function.<br \/>\n08:39<br \/>\nThe second<br \/>\n08:40<br \/>\nis endometrial protection.<br \/>\n08:42<br \/>\nThis is very important<br \/>\n08:43<br \/>\nbecause patients who don&#8217;t have<br \/>\n08:44<br \/>\nregular cycles<br \/>\n08:45<br \/>\nare at very high risk<br \/>\n08:46<br \/>\nof developing<br \/>\n08:46<br \/>\nendometrial cancer.<br \/>\n08:48<br \/>\nThe goal is, therefore,<br \/>\n08:49<br \/>\nto resume<br \/>\n08:49<br \/>\nnormal menstrual cycles,<br \/>\n08:51<br \/>\nor at least give<br \/>\n08:52<br \/>\nmedications enough to stabilize<br \/>\n08:54<br \/>\nthe endometrium.<br \/>\n08:55<br \/>\nPCOS is a state<br \/>\n08:56<br \/>\nof excess of estrogen and not<br \/>\n08:57<br \/>\nenough progestins.<br \/>\n08:59<br \/>\nThe endometrium doesn&#8217;t have<br \/>\n09:01<br \/>\na chance to shed monthly,<br \/>\n09:02<br \/>\ntherefore, these patients<br \/>\n09:04<br \/>\nrequire medications to prevent<br \/>\n09:05<br \/>\nendometrial hyperplasia that can<br \/>\n09:07<br \/>\nturn into endometrial cancer.<br \/>\n09:09<br \/>\nThis can be accomplished<br \/>\n09:10<br \/>\nwith oral contraceptives,<br \/>\n09:11<br \/>\nor OCP&#8217;s, progestin only pills,<br \/>\n09:13<br \/>\na progestin secreting IUD,<br \/>\n09:15<br \/>\nprogesterone injections,<br \/>\n09:16<br \/>\net cetera.<br \/>\n09:19<br \/>\nNumber three,<br \/>\n09:19<br \/>\nanother common intervention<br \/>\n09:20<br \/>\nis to give OCP&#8217;s, or<br \/>\n09:21<br \/>\noral contraceptives, for PCOS.<br \/>\n09:23<br \/>\nThis is done because, number<br \/>\n09:24<br \/>\none, it has enough progestin<br \/>\n09:26<br \/>\nto protect the endometrium<br \/>\n09:28<br \/>\nagainst cancer in the future.<br \/>\n09:29<br \/>\nAnd two, OCP&#8217;s increase a sex<br \/>\n09:31<br \/>\nhormone binding globulin which<br \/>\n09:33<br \/>\nthen binds to androgens,<br \/>\n09:34<br \/>\nand overall will decrease<br \/>\n09:35<br \/>\nthe free testosterone levels<br \/>\n09:37<br \/>\nto improve acne and hirsutism.<br \/>\n09:41<br \/>\nNext, when PCOS patients need<br \/>\n09:42<br \/>\nto get pregnant they usually<br \/>\n09:43<br \/>\nrequire help.<br \/>\n09:45<br \/>\nThe most common way of inducing<br \/>\n09:46<br \/>\novulation<br \/>\n09:46<br \/>\nis the use of clomiphene citrate<br \/>\n09:48<br \/>\nand metformin, together.<br \/>\n09:50<br \/>\nThe way this works<br \/>\n09:50<br \/>\nis a bit beyond the scope<br \/>\n09:51<br \/>\nof this talk<br \/>\n09:52<br \/>\nbut if you&#8217;re interested, please<br \/>\n09:53<br \/>\nlook into it<br \/>\n09:53<br \/>\nand see how the medication<br \/>\n09:54<br \/>\nworks.<br \/>\n09:56<br \/>\nHirsutism and acne is treated<br \/>\n09:58<br \/>\nin a variety of ways, none<br \/>\n09:59<br \/>\nof which are permanent.<br \/>\n10:01<br \/>\nWe already talked about how<br \/>\n10:02<br \/>\nOCP&#8217;s work, other treatments<br \/>\n10:03<br \/>\ninclude lasers and electrolysis,<br \/>\n10:06<br \/>\nalso, creams and Retin-A<br \/>\n10:07<br \/>\nare used for acne treatment.<br \/>\n10:10<br \/>\nDiabetes is often<br \/>\n10:11<br \/>\na co-morbid diagnosis with PCOS.<br \/>\n10:13<br \/>\nAnd if you treat it like you<br \/>\n10:15<br \/>\ntreat non-PCOS patients<br \/>\n10:16<br \/>\nthat usually works out pretty<br \/>\n10:17<br \/>\nwell.<br \/>\n10:18<br \/>\nBecause insulin resistance is<br \/>\n10:20<br \/>\na part of the PCOS<br \/>\n10:21<br \/>\npathophysiology, metformin<br \/>\n10:23<br \/>\nis usually first line since it<br \/>\n10:25<br \/>\nincreases insulin sensitivity.<br \/>\n10:27<br \/>\nInsulin regimens are added<br \/>\n10:28<br \/>\nif oral medications are not<br \/>\n10:29<br \/>\nsufficiently effective.<br \/>\n10:31<br \/>\nLastly, an interesting treatment<br \/>\n10:32<br \/>\nis something called ovarian<br \/>\n10:33<br \/>\ndrilling, where you do<br \/>\n10:35<br \/>\nlaparoscopy to poke holes<br \/>\n10:37<br \/>\nin the ovary<br \/>\n10:37<br \/>\nwith electrocautery instruments.<br \/>\n10:40<br \/>\nIt&#8217;s not completely understood<br \/>\n10:41<br \/>\nwhy this works but it&#8217;s done<br \/>\n10:42<br \/>\nwhen PCOS was diagnosed,<br \/>\n10:45<br \/>\nand wedge resections<br \/>\n10:45<br \/>\nof the ovary<br \/>\n10:46<br \/>\nwere done<br \/>\n10:47<br \/>\nfor histologic analysis.<br \/>\n10:48<br \/>\nIt was noted at that time<br \/>\n10:49<br \/>\nthat these women, oftentimes,<br \/>\n10:51<br \/>\nstarted having normal cycles.<br \/>\n10:52<br \/>\nSo ovarian drilling is just<br \/>\n10:54<br \/>\na less morbid, and technically<br \/>\n10:55<br \/>\neasier, version of wedge<br \/>\n10:56<br \/>\nresection.<br \/>\n10:57<br \/>\n11:00<br \/>\nI will conclude this talk<br \/>\n11:01<br \/>\nwith a list of all<br \/>\n11:02<br \/>\nthe associated risks of PCOS<br \/>\n11:04<br \/>\nand why it&#8217;s so important<br \/>\n11:05<br \/>\nthat you need to treat<br \/>\n11:05<br \/>\nthe different aspects of such<br \/>\n11:07<br \/>\na multimodal disease.<br \/>\n11:08<br \/>\nThis slide is pretty<br \/>\n11:09<br \/>\nself-explanatory so there&#8217;s<br \/>\n11:10<br \/>\nno need to talk<br \/>\n11:11<br \/>\nthrough each one.<br \/>\n11:12<br \/>\nBut just know that if PCOS is<br \/>\n11:13<br \/>\nleft untreated<br \/>\n11:14<br \/>\nit can lead to very significant<br \/>\n11:16<br \/>\nmultiorgan system disease.<br \/>\n11:17<br \/>\n11:54<br \/>\nThank you for your attention.<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/hv6g-ZgiEbE\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 8:03<\/p>\n<input type='hidden' bg_collapse_expand='69e9c8515ba653069652876' value='69e9c8515ba653069652876'><input type='hidden' id='bg-show-more-text-69e9c8515ba653069652876' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9c8515ba653069652876' value='Hide Transcript'><button id='bg-showmore-action-69e9c8515ba653069652876' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfcfc;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9c8515ba653069652876' ><\/p>\n<p>hey guys so today I wanted to share my<br \/>\n00:06<br \/>\nPCOS story I believe I started to<br \/>\n00:09<br \/>\nshowing signs of PCOS when I was as<br \/>\n00:13<br \/>\nyoung as seven years old because at that<br \/>\n00:15<br \/>\ntime I had developed body hair armpit<br \/>\n00:18<br \/>\nhair and pubic hair and I noticed that<br \/>\n00:22<br \/>\nmy peers didn&#8217;t so I felt really really<br \/>\n00:24<br \/>\nself-conscious and when I say I had hair<br \/>\n00:26<br \/>\nI don&#8217;t mean like it was just coming in<br \/>\n00:28<br \/>\nI mean like it was full-on bushy but I<br \/>\n00:31<br \/>\nwas so ashamed that I didn&#8217;t tell anyone<br \/>\n00:33<br \/>\nand my mom didn&#8217;t find out until about a<br \/>\n00:35<br \/>\nyear and a half to two years later when<br \/>\n00:37<br \/>\nanother family member saw and it<br \/>\n00:40<br \/>\neventually made its way to my mom and so<br \/>\n00:43<br \/>\nshe decided that she didn&#8217;t want me<br \/>\n00:45<br \/>\nshaving instead she purchased Mayer and<br \/>\n00:47<br \/>\nthat&#8217;s what I used at the age of 10 I<br \/>\n00:50<br \/>\ngot my first period and I don&#8217;t think<br \/>\n00:52<br \/>\nanybody could have prepared me for that<br \/>\n00:55<br \/>\nmoment that was so excruciating and it<br \/>\n00:57<br \/>\nwas so heavy but at the time I didn&#8217;t<br \/>\n00:59<br \/>\nknow it because it was my first period<br \/>\n01:02<br \/>\nand I I didn&#8217;t know how periods were<br \/>\n01:06<br \/>\nsupposed to be or how they were supposed<br \/>\n01:08<br \/>\nto feel after I got my first period it<br \/>\n01:10<br \/>\nwasn&#8217;t showing up every month and when<br \/>\n01:13<br \/>\nit would show up it would last for about<br \/>\n01:15<br \/>\n15 days and it was excruciating I was in<br \/>\n01:19<br \/>\nso much pain I was vomiting I would be<br \/>\n01:24<br \/>\nsent home from school I would stay home<br \/>\n01:26<br \/>\nfrom school I would leave school all the<br \/>\n01:29<br \/>\ntime because of my periods and it really<br \/>\n01:32<br \/>\ninterferes with my life and it made me<br \/>\n01:34<br \/>\nreally self-conscious and then when I<br \/>\n01:38<br \/>\nwas 12 I started developing body hair in<br \/>\n01:43<br \/>\nplaces that women are not supposed to be<br \/>\n01:45<br \/>\nparticularly on my face and I did tell<br \/>\n01:49<br \/>\nmy mom about that but she gonna just<br \/>\n01:51<br \/>\nbrush me off and got me some hair bleach<br \/>\n01:53<br \/>\nand that&#8217;s what I used until I turned 15<br \/>\n01:57<br \/>\nbecause as the years went on the hair<br \/>\n02:01<br \/>\ngot darker and denser and bleaching that<br \/>\n02:05<br \/>\nhair was not gonna hide it from anyone<br \/>\n02:07<br \/>\nin fact I remember being in high school<br \/>\n02:10<br \/>\nand some jerk<br \/>\n02:12<br \/>\nblurted it out in front of everyone and<br \/>\n02:15<br \/>\nat that moment I thought I was hiding it<br \/>\n02:17<br \/>\nso looking back I know I wasn&#8217;t I know<br \/>\n02:20<br \/>\nthat more people saw and I&#8217;m grateful<br \/>\n02:22<br \/>\nthat they didn&#8217;t say anything but it<br \/>\n02:25<br \/>\nreally made me feel bad but I was never<br \/>\n02:29<br \/>\ntaken to the doctor uh when I was<br \/>\n02:31<br \/>\nyounger my periods weren&#8217;t coming every<br \/>\n02:33<br \/>\nmonth I did tell my mom and for some<br \/>\n02:36<br \/>\nreason she thought I was and so she kind<br \/>\n02:37<br \/>\nof again she brushed me off and so I was<br \/>\n02:40<br \/>\nkind of alone in this when I was 15 I<br \/>\n02:43<br \/>\ndecided to get a job and I got my first<br \/>\n02:47<br \/>\njob and with my money I chose to buy wax<br \/>\n02:51<br \/>\nand so I started waxing my face and I<br \/>\n02:54<br \/>\nhated having to do it but I I felt like<br \/>\n02:58<br \/>\nthere was no getting around it because<br \/>\n03:00<br \/>\nyou know nobody&#8217;s gonna take me to the<br \/>\n03:01<br \/>\ndoctor I just have to put up with the<br \/>\n03:04<br \/>\nsymptoms my skin was really bad<br \/>\n03:07<br \/>\nMike&#8217;s again is still back to this day<br \/>\n03:10<br \/>\nand I still have to baby it but I kind<br \/>\n03:14<br \/>\nof thought you know puberty acne and all<br \/>\n03:17<br \/>\nthose hand-in-hand but I was getting<br \/>\n03:18<br \/>\ncystic acne and that was my normal and<br \/>\n03:21<br \/>\nso I just continued using the wax and<br \/>\n03:26<br \/>\nthe acne cream until I could get myself<br \/>\n03:28<br \/>\ninto a doctor and so when I was 18 maybe<br \/>\n03:34<br \/>\nI was 19 I made an appointment and I<br \/>\n03:39<br \/>\ntold the doctor everything and it took<br \/>\n03:42<br \/>\nso much in me to come out and admit and<br \/>\n03:45<br \/>\nto even acknowledge that there&#8217;s<br \/>\n03:47<br \/>\nsomething wrong this is not normal it<br \/>\n03:50<br \/>\ntook everything in me to make that<br \/>\n03:52<br \/>\nappointment because I felt so incredibly<br \/>\n03:55<br \/>\nashamed and growing up I was always told<br \/>\n03:58<br \/>\noh it&#8217;s because you&#8217;re polish you know<br \/>\n04:00<br \/>\nyour dad sided their hairy people and<br \/>\n04:02<br \/>\nbut I never felt like that was the right<br \/>\n04:05<br \/>\nanswer so I went to the doctor and I<br \/>\n04:08<br \/>\ntold her that I was getting really bad<br \/>\n04:10<br \/>\nacne that I was getting cystic acne all<br \/>\n04:12<br \/>\nover my face I told her that I was<br \/>\n04:16<br \/>\ngrowing hair in abnormal places but I<br \/>\n04:18<br \/>\nwas getting my periods every month at<br \/>\n04:21<br \/>\nthat time so she sent me off to go get<br \/>\n04:24<br \/>\nsome blood work done and not my fault of<br \/>\n04:25<br \/>\nappointment<br \/>\n04:26<br \/>\nshe told me that my hormone levels are<br \/>\n04:30<br \/>\nnormal and then it must be because I am<br \/>\n04:32<br \/>\npolish<br \/>\n04:33<br \/>\nI cannot even express how disappointing<br \/>\n04:37<br \/>\nit was to hear that because there are<br \/>\n04:40<br \/>\npeople who are the same ethnicity as me<br \/>\n04:43<br \/>\nand nowhere near as hairy as I am but I<br \/>\n04:47<br \/>\nlet it get to me and I let it go I I<br \/>\n04:49<br \/>\nfelt like well there&#8217;s nothing I can do<br \/>\n04:53<br \/>\nand it wasn&#8217;t until earlier this year<br \/>\n04:56<br \/>\nthat my periods once again stopped<br \/>\n04:58<br \/>\ncoming every month and when they were<br \/>\n05:00<br \/>\ncoming it was awful<br \/>\n05:03<br \/>\nonce again I scheduled an appointment<br \/>\n05:05<br \/>\nand I went to my OB office and I saw<br \/>\n05:10<br \/>\nnurse practitioner and she decided to<br \/>\n05:13<br \/>\nput me on birth control to at least get<br \/>\n05:16<br \/>\na period coming hopefully to kind of<br \/>\n05:19<br \/>\nhelp with the hair growth but she<br \/>\n05:22<br \/>\ninstructed me to go see an internal<br \/>\n05:24<br \/>\nmedicine doctor so that&#8217;s what I did at<br \/>\n05:27<br \/>\nmy first appointment I walked out with<br \/>\n05:31<br \/>\nlike two pages of blood work to get done<br \/>\n05:34<br \/>\nranging from thyroid to hormone to check<br \/>\n05:39<br \/>\nfor diabetes everything so I went and I<br \/>\n05:44<br \/>\ngot that blood work done and when I came<br \/>\n05:47<br \/>\nback to review and when I came back to<br \/>\n05:50<br \/>\nreview the results for that blood work I<br \/>\n05:52<br \/>\nfound out that I had Hashimoto&#8217;s which<br \/>\n05:56<br \/>\nis an autoimmune disease and my<br \/>\n05:59<br \/>\ntestosterone was way too high<br \/>\n06:01<br \/>\non my test zero to ten is normal for a<br \/>\n06:05<br \/>\nwoman mine was seventeen point six which<br \/>\n06:08<br \/>\nis almost double and so we decided to go<br \/>\n06:12<br \/>\nahead and do some further testing so I<br \/>\n06:14<br \/>\ngot a cat scan to look at other other<br \/>\n06:17<br \/>\nthings but for me I wanted to know if I<br \/>\n06:22<br \/>\nhad two cysts on my ovaries and I did so<br \/>\n06:27<br \/>\nI deal with everything so if you&#8217;re on<br \/>\n06:34<br \/>\nthis video you&#8217;re probably familiar with<br \/>\n06:36<br \/>\nthe Rotterdam criteria where you need to<br \/>\n06:39<br \/>\nhave two of the three so<br \/>\n06:40<br \/>\nthumbs that are excess androgen levels<br \/>\n06:43<br \/>\nirregular period and cysts on your<br \/>\n06:48<br \/>\novaries and I have all three so this is<br \/>\n06:52<br \/>\nquite the struggle and that&#8217;s when she<br \/>\n06:55<br \/>\nmy doctor decided to put me on metformin<br \/>\n06:58<br \/>\nso I&#8217;m currently on metformin I&#8217;m hoping<br \/>\n07:00<br \/>\nthat it works I I don&#8217;t know I don&#8217;t<br \/>\n07:06<br \/>\nknow if it&#8217;ll work but I just wish that<br \/>\n07:08<br \/>\nI would have gotten into a doctor a lot<br \/>\n07:09<br \/>\nsooner I wish I had better guidance as a<br \/>\n07:12<br \/>\nchild to to figure out what was wrong<br \/>\n07:17<br \/>\nwith me a lot sooner you know there&#8217;s a<br \/>\n07:19<br \/>\nlot of frustration with that but you<br \/>\n07:23<br \/>\nknow I&#8217;m an adult now and I need to take<br \/>\n07:25<br \/>\ncare of myself so that&#8217;s my story<br \/>\n07:28<br \/>\nI know I&#8217;m not the only one that&#8217;s gone<br \/>\n07:31<br \/>\ndone diagnosed with PCOS for a long time<br \/>\n07:36<br \/>\nI know there were women out there that<br \/>\n07:38<br \/>\nare even now are not diagnosed and I<br \/>\n07:42<br \/>\njust hope that they can find a doctor<br \/>\n07:44<br \/>\nthat will listen to them and who won&#8217;t<br \/>\n07:47<br \/>\njust brush it off anyways so that&#8217;s all<br \/>\n07:52<br \/>\nthat I have for today<br \/>\n07:53<br \/>\nif you have any comments or any<br \/>\n07:55<br \/>\nquestions let me know I would love to<br \/>\n07:58<br \/>\nanswer them and I will see you guys next<br \/>\n08:01<br \/>\nvideo bye<\/p>\n<p><\/div>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/4d824ll1JUM\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 13:47<\/p>\n<hr \/>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>\ufeff Duration 16:18 Duration 11:58 Duration 8:03 Duration 13:47 &nbsp;<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":160,"menu_order":2,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-410","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/410","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/comments?post=410"}],"version-history":[{"count":3,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/410\/revisions"}],"predecessor-version":[{"id":504,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/410\/revisions\/504"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/pages\/160"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/basic_obgyn\/wp-json\/wp\/v2\/media?parent=410"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}