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Pcso adolescent: 2020

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Prof Aboubakr Mohamed Elnashar

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Pcso adolescent: 2020

  1. 1. 26/12/1441 1 Adolescent PCOS Prof. Aboubakr Elnashar Benha university, Egypt elnashar53@hotmail.com ABOUBAKR ELNASHAR 26/12/1441 2 CONTENTS 1.DEFINITION 2.PREVALENCE 3.DIAGNOSIS 4.EVALUATION 5.TREATMENT CONCLUSION ABOUBAKR ELNASHAR
  2. 2. 26/12/1441 3 1. DEFINITION Adolescence From Latin adolescere, meaning to grow up Transitional stage of physical and psychological development from puberty to adulthood Adolescents (WHO) Young people between the ages of 10&19 years Adolescent PCOS Unexplained persistent hyperandrogenic anovulation (American Academy of Pediatrics, 2015).ABOUBAKR ELNASHAR 26/12/1441 4 2. PREVALENCE 1.8 and 15 % depending on: diagnostic criteria ethnicity [Li et al, 2013] . Increasing {increasing prevalence of childhood obesity} (Hassan et al, 2007). ABOUBAKR ELNASHAR
  3. 3. 26/12/1441 5 Risk factors  Premature pubarche (before 8 yr old)  Obesity  Family Hx  Ethnicity more common in – African-American ABOUBAKR ELNASHAR 26/12/1441 6 Course: ±Progressive course :full-blown picture of adult PCOS (evidence is contradictory) (Coviello et al, 2006) Risk for progress of adolescent to adult PCOS •Persistent irregular cycles 6 y after menarche (Venturoli et al, 1987) •Persistent anovulatory cycles 3y after menarche (Venturoli et al, 1994) •Increased BMI ABOUBAKR ELNASHAR
  4. 4. 26/12/1441 7  Diagnostic criteria of adult PCOS All criteria require exclusion of other conditions: nonclassic congenital adrenal hyperplasia, hypothyroidism, Cushing syndrome, hyperprolactinemia or androgen producing tumours which can cause a PCOS-like picture. ABOUBAKR ELNASHAR 26/12/1441 8 3. DIAGNOSIS  Specific & very strict criteria: 1. Irregular menstrual cycles plus 2. Hyperandrogenism and/or 3. Hyperandrogenaemia ABOUBAKR ELNASHAR
  5. 5. 26/12/1441 9 1. Irregular menstrual cycles (ESHRE, 2018)  Post menarche:  < 1y: Irregular cycles are normal {pubertal transition}.  > 1 y: 90 days for any one cycle  > 1 to < 3 y: < 21 or > 45 days.  > 3 years: < 21 or > 35 days or < 8 cycles/y.  Primary amenorrhea by age 15 or > 3 years post thelarche (breast development). ABOUBAKR ELNASHAR 26/12/1441 10 2. Hyperandrogenism  Isolated hirsuitism, acne and/or alopecia is not diagnostic criteria (LevelC).  Severe acne:No universally accepted visual assessments for evaluating acne.  Severe or progressive hirsutism (Jeffrey CR, Coffler, 2007; ESHRE, 2018) ABOUBAKR ELNASHAR
  6. 6. 26/12/1441 11  Hirsutism: Modified Ferriman & Gallwey  9 sites assessed (mFG)  ≥ 4 - 6 on mFG depending on ethnicity  > 3 in White and Black women  > 5 in Mongoloid Asian  Perception is more important than severity ABOUBAKR ELNASHAR 26/12/1441 12 Grading scale for female pattern hair loss mild but obvious female pattern hair loss Female androgenic alopecia Frontal and temporal hair loss  Alopecia: Ludwig score Assess severity and distribution ABOUBAKR ELNASHAR
  7. 7. 26/12/1441 13 3. Hyperandrogenaemia (ESHRE, 2018)  If clinical hyperandrogenism is unclear  High quality assays: should be used  liquid chromatography–mass spectrometry(LCMS)/mass spectrometry  Extraction/chromatography immunoassays  Direct FT assays: should not be used. {poor sensitivity, accuracy and precision}.  Radiometric or enzyme-linked assays  DHEAS & androstenedione: limited roleABOUBAKR ELNASHAR 26/12/1441 14  Calculated FT, FAI or bioavilable T is recommended  Use upper limits of reference ranges  Hormonal contraception must be off for 3 months  Normal range: 7-10 ABOUBAKR ELNASHAR
  8. 8. 26/12/1441 15  US criteria:  should not be used < 8 years after menarche {high incidence of multi-follicular ovaries in this life stage} (ESHRE, 2018)  Ovarian volume  >10 cm3 ( AE-PCOS Society, 2014)  >12 ml ( Pediatric society, 2015) ABOUBAKR ELNASHAR 26/12/1441 16 AMH: should not yet be used (ESHRE, 2018) No well-defined cutoffs (Rosenfield et al, 2012). •>4.5 ng/mL: useful as a substitute for ovarian morphology when no accurate ovarian US is available (Dewailly et al, 2011). •6.1ng/mL (Yetim et al, 2016) 7.25 ng/ml (Savas-Erdeve et al, 2016) ABOUBAKR ELNASHAR
  9. 9. 26/12/1441 17  IR, compensatory hyperinsulinemia, or obesity  should not be considered as diagnostic criteria for PCOS in adolescents (Level A). ABOUBAKR ELNASHAR 26/12/1441 18  At risk of PCOS (ESHRE, 2018)  If ONLY irregular cycles OR hyperandrogenism  US is not indicated  Symptomatic treatment  Regular re-evaluations. 1. Menstrual cycle re-evaluation after 3 years post menarche 2. US evaluation after 8 years post menarche. ABOUBAKR ELNASHAR
  10. 10. 26/12/1441 19 4. EVALUATION 1. Cutaneous manifestations Physical examination should document cutaneous manifestations of PCOS:  Terminal hair growth  Acne  Alopecia  Acanthosis nigricans  Skin tags (1+++O). (Endocrine Society Clinical Practice, 2013) ABOUBAKR ELNASHAR 26/12/1441 20 2. Obesity {Increased adiposity, particularly abdominal, is associated with hyperandrogenemia and increased metabolic risk } Screening for increased adiposity, by  BMI calculation  Measurement of WC (1+++O). (Endocrine Society Clinical Practice, 2013) ABOUBAKR ELNASHAR
  11. 11. 26/12/1441 21 3. Depression screening for depression and anxiety by history and, if identified: referral and/or treatment (2++OO). (Endocrine Society Clinical Practice, 2013) ABOUBAKR ELNASHAR 26/12/1441 22 4. Sleep-disordered breathing/obstructive sleep apnea (OSA) screening overweight/obese adolescents for symptoms suggestive of OSA when identified: definitive diagnosis using polysomnography: referred for tt (2++OO). (Endocrine Society Clinical Practice, 2013) ABOUBAKR ELNASHAR
  12. 12. 26/12/1441 23 5. Type 2 diabetes mellitus (T2DM) {they are at high risk for such abnormalities} OGTT HgbA1c: if unable or unwilling to complete OGTT Rescreening: /3–5 y more frequently if: central adiposity substantial weight gain, and/or symptoms of diabetes develop (Endocrine Society Clinical Practice, 2013) ABOUBAKR ELNASHAR 26/12/1441 24 6. Cardiovascular risk screened for CVD risk factors: family history cigarette smoking, IGT/T2DM hypertension dyslipidemia OSA obesity especially increased abdominal adiposity (Endocrine Society Clinical Practice, 2013) ABOUBAKR ELNASHAR
  13. 13. 26/12/1441 25 7. Subclinical hypothyroidism may be concealed ±investigated for autoimmune thyroiditis. (Nezi et al, 2016) ABOUBAKR ELNASHAR 26/12/1441 26 5. TREATMENT (A E PCOS Society; Pediatric endocrine society, 2015) Objectives:  Symptomatic Restoration of body wt Cycle regulation Reducing signs of hyperandrogenism Prophylactic: of long term health hazards.  Infertility  Metabolic syndrome  Obesity  Diabetes  Heart disease. ABOUBAKR ELNASHAR
  14. 14. 26/12/1441 27 At risk:: should be treated (ESHRE/ASRM; 2012, ESHRE, 2018)  Acnae  Obesity  Hirsutism  Irregular menses ABOUBAKR ELNASHAR 26/12/1441 28 I. LIFESTYLE THERAPY  First-line strategy (ESHRE, 2018) Overweight or obese. Wt loss 2-5%   testosterone by 21%: resume regular ovulation in 50% women (McCartney et al, 2009). Calorie-restricted diets No evidence that one type of diet is superior Beneficial for both reproductive & metabolic dysfunction. {obesity during adolescence: an important factor that conditions the evolution of ovarian function ABOUBAKR ELNASHAR
  15. 15. 26/12/1441 29  Anti-obesity medications (ESHRE, 2018)  Can be considered with lifestyle, considering  cost  contraindications  side effects  availability  regulatory status ABOUBAKR ELNASHAR 26/12/1441 30  Exercise (Endocrine Society Clinical Practice, 2013)  improves weight loss  reduces  CV risk factors  diabetes risk  60 mins/d: moderate to vigorous intensity  3 times/w: muscle& bone strengthening(ESHRE, 2018) ABOUBAKR ELNASHAR
  16. 16. 26/12/1441 31  Avoid  Alcohol  Smoking  Psychosocial stressors ABOUBAKR ELNASHAR 26/12/1441 32 In normal-weight girls:  Prevention of wt gain  Monitoring of weight  Increasing physical activity effective in reducing the development of metabolic syndrome (Level C).  Weight loss not supported by RCTs (Level C). ABOUBAKR ELNASHAR
  17. 17. 26/12/1441 33 II. FIRST LINE PHARMACOLOGICAL THERAPY COCP alone (ESHRE, 2018)  Should be considered in adolescents 1. with clear diagnosis of PCOS for management of clinical hyperandrogenism and/or irregular menstrual cycles. 2. who are“at risk” but not yet diagnosed with PCOS, for management of cl hyperandrogenism & irregular menstrual cycles. ABOUBAKR ELNASHAR 26/12/1441 34  WHO Contraindications: 1. History of migraine with aura 2. DVT/pulmonary emboli (PE) 3. Known thrombogenic mutation 4. Multiple risk factors for arterial CVD 5. History of ischemic heart disease or stroke 6. Complicated valvular heart disease, 7. Breast cancer 8. Neuropathy 9. Severe cirrhosis 10.Malignant liver tumoursABOUBAKR ELNASHAR
  18. 18. 26/12/1441 35 BMI: ≤35 kg/m2 with no specific metabolic and/ or CV abnormalities Any type Choice acc to: preferences of the physician and patient specific clinical characteristics of the patient. (Italian society of endocrinology, 2015) ≥35 kg/m2 : COC should be prescribed with caution ≥40 kg/m2: Not used (RCOG, 2011). If contraception is needed: alternative measures, such as progestin-only methods. (Italian society of endocrinology, 2015) ABOUBAKR ELNASHAR 26/12/1441 36  Type:  No COCP preparation is superior  Use lowest effective estrogen dose:  20-30 ug EE or equivalent  COCPs containing  Levonorgestrel  Norethisterone associated with lowest risk of DVT.  Norgestimate ABOUBAKR ELNASHAR
  19. 19. 26/12/1441 37  35 ug EE plus cyproterone acetate Not first line in PCOS (higher DVT risk)  Should only be used when treating  Moderate to severe hirsutism or  Acne  Most androgenic progestin:  Levonorgestrel, norethisterone  Low androgenicity: norgestimate and desogestrel  Progestins with antiandrogenic activity  Drospirenone, CPA, Dienogest ABOUBAKR ELNASHAR 26/12/1441 38 III. Second line pharmacological therapies 1. COCP + Metformin Should be considered in Management of metabolic features Where COCP+ lifestyle does not achieve goals. Could be considered in Adolescent PCOS BMI ≥ 25kg/m2 ABOUBAKR ELNASHAR
  20. 20. 26/12/1441 39 2. COCP + Anti-androgens Can be considered After 6/12 cosmetic treatment+ COCP if they fail to reach hirsutism goals. With androgenic alopecia.  Anti-androgens reduce androgen excess features more than metformin in monotherapy (Level B).  Spironolactone is the most commonly (Level C).  Anti-androgens should only be used when contraceptive measures are guaranteed. ABOUBAKR ELNASHAR 26/12/1441 40 3. Metformin Should be considered in Adolescents with a Clear diagnosis of PCOS or At risk: Symptoms of PCOS before diagnosis is made. Most useful with BMI ≥ 25kg/m2 High risk ethnic groups. ABOUBAKR ELNASHAR
  21. 21. 26/12/1441 41  Metformin does not promote wt loss in obese adolescent PCOS [RCT: Ladson et al, 2011].  2 g daily combined with diet &exercise for 6 months did not induce greater wt loss compared with diet&exercise alone  In overweight or obese adolescents with PCOS: beneficial effects (Level A).  In non-obese adolescents with PCOS and hyperinsulinemia: improves ovulation& testosterone levels (Level B). ABOUBAKR ELNASHAR 26/12/1441 42 Inositol should be considered experimental with emerging evidence of efficacy highlighting the need for further research. (ESHRE, 2018) ABOUBAKR ELNASHAR
  22. 22. 26/12/1441 43 Duration of COCP or metformin Not yet been determined.  until the patient is gynecologically mature (5y postmenarcheal) or  has lost a substantial amount of excess wt. (Rosenfield; 2015) ABOUBAKR ELNASHAR 26/12/1441 44 AntiandrogenMetCOClifestylePCOS +++++++Menstrual Dysfunction ++++++++Hirsutism ++++++++Acne ++++++++Hyperandrogenemia +++obesity ++++++IGT/2DM +Psychological +++: strong evidence +: Low evidence Morris et al, 2016 ABOUBAKR ELNASHAR
  23. 23. 26/12/1441 45 CONCLUSIONS Diagnosis: Early & accurate diagnosis is essential Criteria for the diagnosis differ from those used for adult Irregular menstruation plus Moderate to severe hyperandrogenism and/or hyperandrgemia Exclusion of other causes of hyperandrogenism with menstrual irregularity ABOUBAKR ELNASHAR 26/12/1441 46 Evaluation: Metabolic,CV risks, psychologic, dermatologic,SHT Treatment  Should be individualized depending on: age, symptoms, risk factors & choices  1st line: lifestyle modifications  1st line pharmacological: COCP  2nd line pharmacological:  COCP+ Metformin  COCP+ Antiandrogen  Metformin. ABOUBAKR ELNASHAR
  24. 24. 26/12/1441 47 You can get this lecture from: 1.My scientific page on Face book: Aboubakr Elnashar Lectures. https://www.facebook.com/groups/2277448840913 51/ 2.Slide share web site 3.elnashar53@hotmail.com 4.My clinic: Elthwara St. Mansura ABOUBAKR ELNASHAR
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