PCOS: Long Term Sequelae

PCOS: Long Term Sequelae
By
Mohammad Emam
Prof. OB & GYN
Mansoura Faculty of Medicine
Mansoura Integrated Fertility Center
EGYPT 2009

PCOS: An Epidemic
• An epidemic in developing countries (ED & PCOS!!!).
• About 20% of reproductive age women demostrate the ultrasound picture of polycystic ovaries.
• About 5-10% have clinical or biochemical signs of Anovulation and androgen excess. (These date were collected prior to Rotterdam diagnostic consensus).

PCOS: Cause
• Complex interaction of genetic, epigenetic, metabolic, neurologic and environmental factors.
• PCOS, starts in adolescence but not always diagnosed at that age.

Rationale
women with PCOS cluster risky consquences leading to increased morbidity and mortality.

Rationale
• Long term consquences of this syndrome are forgotten by clinicians.
• Treatment is directed only for symptoms without digging into deeper

Aim
• To highlight to the different clinicians:
• The long-term health consquences of PCOS (other than infertility).
• How to minimize or prevent the development of these consquences.

Methods
• Randomised controlled trials, systematic reviews and meta-analyses in:
The Cochrane Library, RCOG, Medline and PubMed (between 1986 and January 2009).

Long term Consequences of PCOS
• Definite
• Possible
• Controversial

Definite
Long term Consequences of PCOS
• Type 2 diabetes
• Dyslipidemia
• Endometrial cancer.

Possible:
Long term Consequences of PCOS
• Metabolic: Obesity & IR & Ms & Gall bladder disease
• Cerbrovascular disease: Coronary & Cerbral & Hypertension
• Depression & anxiety & loss of self esteem
• Obstructive Sleep Apnea
• Pregnancy complications:
• Gestational Diabetes
• Getational hypertension
Epilespy?!!

Controversial
Long term Consequences of PCOS
• PIH
• Miscarriage
• ovarian cancer
• Breast carcinoma

Prevalence of MS in PCOS
MS is present in 2/3 of the PCOS (2-fold higher than women in the general population).

RCOG GREEN-TOP GUIDELINE
(DECEMBER 2007)

Counseling
• Women diagnosed with PCOS:
• Should be informed of the possible long-term risks.
• Should be advised regarding weight control and exercise (B).

Metabolic consequences of PCOS
• Women presenting with PCOS:
BMI > 30 + age > 40 years + +ve Family history of diabetes.
• Are at increased risk of type 2 diabetes and should be offered a glucose tolerance test. (B)

PCOS and obstructive sleep apnoea
• Women diagnosed with PCOS should be asked (or their partners) about:
• Snoring and daytime fatigue
• Informed of the possible risks of sleep apnea

PCOS and cardiovascular risk
• Hypertension should be treated.
• Lipid-lowering drugs should only be prescribed by a specialist

PCOS & Pregnancy
• Women should be screened for gestational diabetes
• Before 20 weeks of gestation, with referral to a specialist if diabetes is detected (B).
• Metformin is currently not licensed for use in pregnancy in the UK!!! and is not recommended for use in pregnancy (D) Controversial

Cancer and PCOS
• Amenorrhoeic or severely oligomenorrhoeic women with PCOS should have induced withdrawal bleeding at regular intervals to reduce the risk of developing endometrial hyperplasia (B).
• There is no association with breast or ovarian cancer and no additional surveillance is required (C).

Exercise and weight control
• All overweight PCOS should be provided with dietary and lifestyle advice.

How to minimize or prevent long term consequences?

Concept
• The genetic expression of PCOS can be optimized and modulated by prevention the interactions between genes and epigenetic factors.

1) Early Detection and treatment of PCOS during adolescence.

Screeing for PCOS in Adolescents
• PCOS should be considered when an adolescent presents with:
• Irregular menses, hirsutism, acne, alopecia, central adiposity, AN, and/or hyperinsulinemia

2) Prevention of peripupertal obesity

More than 1 in 4 children is overweight or obese!!

3) The target of ttt should be causative rather than symptomatic

Conclusion
Treating "the whole state" rather than "the disease" should be the principal on dealing with PCOS

Conclusion
Infertility and oligohypomenorhea represent only the tip of the iceberg of PCOS, but the late Sequelae are the hidden serious base

Conclusion
• Management of PCOS should be started by prevention of obesity in peripupertal kids.

Conclusion
• Screening for PCOS in adolescents in mandatory for early diagnosis and minimizing long term Sequelae

Thank you
Prof. Mohammad Emam
Telfax 0020502319922 & 0020502312299
Email: mae335@hotmail.com