New guidelines for

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New guidelines for
management of
PCOS
Prof. Aboubakr Elnashar Benha University
Hospital Emailelnashar53_at_hotmail.com
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What are the diagnostic criteria of PCOS?
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European view (Balen,1999) In addition to the
U/S findings of PCOS, one or more of the
following 1. Oligo/amenorrhea with positive
progesterone withdrawal bleeding, 2.
Hirsutism/acne, 3. Obesity, 4. Raised LH/FSH
ratio gt2, or 5. Raised circulating androgens.
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• National Institute of Health (1990)
• Combination of
• Chronic anovulation
• Hyperandrogenism
• In absence of other endocrine disorders.

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Japanese view (Kondoh et al, 1999) 1.Amenorrhea
or oligomenorrhea with or without hirsutism. 2.
LH/FSH ratio gt1. 3. Bilaterally normal or
enlarged ovaries with multiple small cysts as
assessed by U/S
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• It is important to define the syndrome correctly
• -The implications of PCOS
• -It is a potentially dangerous syndrome.
• - Improve the ability to treat PCOS
• The European Society for Human Reproduction and
  Embryology (ESHRE)
• the American Society for Reproductive Medicine
  (ASRM) cosponsored the
• Rotterdam PCOS consensus workshop group

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• 26 well-known international authors revised the
  guidelines for diagnosis and management.
• The revised Guidelines are published in the
  January issue of Fertility Sterility J, 2004

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1. Oilgo- or anovulation
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2. Hyperandrogenism
Clinical Biochemical
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Hirsutism is the best clinical marker of
hyperandrogenism. Acne is a more variable marker
of hyperandrogenism.
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• The best biochemical markers of hyperandrogenism
  are
• free testosterone levels or
• free testosterone index.
• However, not all patients with PCOS have elevated
  circulating androgen levels.
• Routine measurement of androstenedione cannot be
  recommended.
• DHEAS is raised in small fraction of patient with
  PCOS levels

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3. Polycyctic ovary
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Polycystic ovaries 12 or more follicles in each
ovary measuring 2 to 9 mm in diameter and/or have
an increased volume of 10 mL or greater. Only
one ovary meeting these criteria is necessary to
meet the definition. The follicle distribution
increase in stromal echogenecity volume should
be omitted
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4. Exclusion of other etiologies
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• PCOS should be excluded from other disorders in
  which hirsutism and menstrual irregularities are
  prominent, such as
• Congenital adrenal hyperplasia,
• Cushing's syndrome, and
• Androgen-secreting tumors.
• In oilgo/anovulation E2 FSH to exclude
  hypogonadotrophic hypogonadism (central origin of
  ovarian dysfunction)

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• In hyperandrogenic females prolactin to exclude
  hyperprolactinaemia.
• Thyroid disorders in PCOS patients are not more
  common than in other young women, and TSH is
  unnecessary

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5. Insulin resistence
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Insulin resistance decreased insulin-mediated
glucose utilization. occur in up to 50 of
patients with PCOS, so the consensus group
recommends for all PCOS patients. 1. Oral
glucose tolerance tests 2. Evaluated for
metabolic syndrome
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Metabolic syndrome 3 of 5 of the following 1.
Waist circumference gt88cm 2. Triglycerides gt150
mg/dl 3. HDL lt50 mg/dl 4. Blood pressure gt
130/85 5. Fasting Blood glucose 110-126 /or 2-h
glucose 140-199 mg/dl.
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6. Lutenizing hormone
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• LH levels are elevated in 60 women with PCOS.
• LH/FSH ratios can be elevated in up to 95 of
  women with PCOS if women with recent ovulation
  are excluded.
• LH levels are not necessary for clinical
  diagnosis of PCOS.

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1.The clinical implications of this abnormality
are unclear. Although some research has suggested
lower fertility rates and higher miscarriage
rates for women with high LH levels, other
studies have contradicted this data. 2. LH
levels or the administration of exogenous LH
activity do not affect the chances of ovulation
or pregnancy rates using CC or HMG.
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7. Long- term health risks
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PCOS is now recognized as a potentially dangerous
syndrome, mostly due to the risk of diabetes
mellitus. Women with PCOS are at increased (3-7
times) risk of developing type 2 DM. This risk is
increased if the patient has anovulatory vs.
ovulatory PCOS. However, PCOS has not been
definitely linked to an increased risk of
cardiovascular disease, endometrial cancer, or
death.
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So, the Rotterdam criteria for diagnosis of
PCOS 2 of the following 3 manifestations 1.
Irregular or absent ovulation 2. Hyperandrogenism
(clinical or biochemical) /or 3. Polycystic
ovaries. Other conditions with similar signs
must be ruled out.
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• So , Women with regular cycles but with
  hyperandrogenism PCO may have the PCOS.
• Women without hyperandrogenism, but with PCO
  ovarian dysfunction may have PCOS.

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This is by no means a final definition of the
syndrome," says Robert Rebar executive director
of ASRM.
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Ovulation induction in PCOS
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• STEPWISE APPROACH FOR OVULATION INDUCTION IN
  PCOS (ACOG,2002)
• 1. Weigh loss If BMI gt30 K/m2
• 2. Clomiphene citrate (CC).
• 3. CC corticosteroids if DHES gt 2ug/ml
• 4. CC Metformin
• 5. Low dose FSH injection
• 6. Low dose FSH injection Metformin
• 7. Ovarian drilling
• 8. IVF

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Thank you
Prof. Aboubakr Elnashar