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[Applause] Yes ma'am.
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Screen visible? Visible. Okay, okay. Right. So after the initial interruptions, now we are on topic. Polycystic Ovarian Syndrome, a clinician's perspective. So, syndrome, what we have to see, how we have to categorize the patient, and how we have to approach based on those categories. Because everyone considers polycystic ovarian syndrome a single disease. We need to evolve. We need to make some subtle changes in the management depending upon the state and stage of the disease, without always needing to. So, based on that, I'm just, I have made my presentation, and I'll be, um, dealing in the coming slides. So, already I have said on the day that in the evidence-based methodology workshop on Polycystic Syndrome by the Royal College of Obstetricians and Gynecologists, they have the word PCOS is a distraction and is an impediment to progress. It causes confusion and is a barrier to effective education of clinicians and communication with the public. As we think about clinicians, you see, so that is why it's a distraction. The name focuses poly only based on morphology, which is neither necessary nor sufficient to diagnose the syndrome.
So, generally, what is polycystic ovarian syndrome? By now, everyone would have known that, okay. Currently, the leading cause of menstrual complication in women. It is characterized by clinical biochemical hyperandrogenism, ovulation abnormalities, and presence of large polycystic ovaries on ultrasound. Generally, PCOS or biochemical hyperandrogenism, ovulation abnormalities, either anovulation or oligo-ovulation. Anovulation means completely there is no ovulation. Oligo-ovulation is reduced frequency of ovulation. Presence of enlarged or polycystic ovaries in ultrasound. Either enlarged ovaries or either polycystic ovaries. So, this is the broad umbrella term, right? Diagnosis. This is the criteria. There are three, three domains. Any two out of the following three is needed to diagnose. Rotterdam criteria. You see, oligo-ovulation and anovulation. I, what I said earlier, oligo-ovulation, reduced frequency of ovulation. Cycles less than six per year, you call it as oligo-ovulation. Anovulation is that their ovulation frequency is, so it should be very clear. PCOS, polycystic ovaries, treatment always differs. Coming slides, I'll be talking.
So, clinical features. Features. Generally, just a minute. What kind of features you are about to receive in case of reduced frequency of cycles? Reduced frequency cycle is less than six per year. Another, if there is a persistent absence of menstruation for six months. Six months or more. So, three months or six months, both we call as amenorrhea. Based on cycle irregularity and cycle regularity. Cycle interval greater than 35 days, less than six months, reduced cycle frequency, less than six cycles per year. Menstrual irregularity. So, that is the reason for PCOS. Why there is infertility in PCOS? It is either due to anovulation or due to reduced follicular quality. Quality is reduced. Patients are predisposed for, um, miscarriages. Third, as you all know, this is associated with obesity. You can see there is an obesity associated with PCOS. Due to endocrine dysfunctions, there is associated acanthosis nigricans. Skin symptom. On skin symptom, there is, um, thickening, thickening of skin around the nape of the neck that you could see. Thickening of skin. It is a sign of insulin resistance. Hyperandrogenism. I already said clinical and biochemical. Androgen levels elevated. What we see. Similarly, it stimulates the hair follicles. That is the reason for hirsutism. That is facial hair growth, chin, jaw, lips. Alopecia. Alopecia is hair loss. Male pattern hair loss. That is also seen associated with hyperandrogenic features in PCOS phenotypes. This is very important. You can see it is androgen excess. Dysfunction. Hyperandrogenism. Androgen excess plus androgen excess.
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Polycystic ovaries without androgen dysfunction. PCOS dysfunction. Treatment response. Androgen. Third, it can take time to correct. Those endocrine abnormalities in PCOS. You know that this is very important. Free androgen index. 3:1, 3:1. Very important. So, there can be elevated. Hyperandrogenism. Excess androgens. Micro androgens. Androgens. Anti-estrogen. This sex hormone binding globulin will bind with all those androgens. All those androgens. Testosterone is binded by sex hormone binding globulin. Once sex hormone binding globulin levels are low, there will be free androgens. Androgen circulation. So, it can bring about a lot of tissue level changes. Changes. Developing mildly elevated prolactin. These are all due to endocrine dysfunctions. Elevated fasting insulin. As I already said, is always associated with PCOS. Abnormal glucose tolerance. 30% of PCOS have normal periods. Even instead of polycystic ovarian morphology. So, you have conditions where in new course, they may develop this, um, abnormality in ovulation. So, 30% have normal periods. 70% have hirsutism. 70% have hirsutism. So, it is a very dominant androgenic feature. 40% suffer from infertility. Not all suffer from infertility. Only a fraction of people suffer from infertility. So, generally, people presenting as infertility because it is not completely. 73% have spontaneous abortion. You can see if they are fertile, you can see there are a lot of spontaneous abortions in case of this. So, we need to prevent secondary.
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Prevention. Always when we treat a case of PCOS, we should always keep in mind what we can do to treat or prevent the spontaneous abortion. That should be, that will prevent. Right. Secondary prevention. 15 to 30% of adult persons with PCOS. 15 to 30% of persons with PCOS. 85 to 90% of women with PCOS have hirsutism. So, this is a dominant sign which we can. Treating amenorrhea in PCOS is quite difficult. Managing hirsutism is more easier. Hyperandrogenism.
So, these are the risk factors. Etiology. How to consider etiology and risk factors? Modern. You know that it runs in families. Genetic influence. It is prevalence in first-degree relatives. First-degree relatives, parents, sisters, siblings. History of weight gain predisposes to PCOS. Healthy lifestyle. Reduce body weight. Abdominal fat. Reduce testosterone. Improve insulin resistance. And healthy lifestyle. Reduce body weight. Lifestyle. Relatives. All those pathologies. So, unhealthy lifestyles. All those things. Prevalence. Very based etiology. PCOS can be described as oligogenic disorder. Couple of genes are associated. Incidental environmental factors are implicated. Okay. Always when any genetic disorders, environmental factors. Inactivity, infectious agents, toxins. Establishment of disease. So, we cannot think on risk factors in children. High birth weight girls born to overweight mothers. Obesity syndromes. Acanthosis nigricans in children. Metabolic syndrome. They all run as risk factors for PCOS. Insulin resistance. And hyperandrogenism.
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Although the demonstration of insulin resistance is not required to make the diagnosis of PCOS, it is clear that hyperinsulinemia. Insulin is even in the absence of obesity. Ratio of fasting blood glucose by fasting insulin level. It should be less than 4.5. So, insulin level, fasting insulin, blood glucose. Run into diabetes in later ages. Impaired glucose tolerance. In one year, 2% becomes type two diabetes. By the second year, it's very, very common that PCOS people can run into diabetes or glucose. Impaired glucose tolerance. 30 to 40% PCOS have impaired glucose. 7.5 to 10% have type two diabetes. These are all epidemiological status. Whenever we are trying to deal a case of PCOS, you should, you should start preventing management for this glucose. They, you should include it into your prescriptions. Metabolic syndrome. Already I said. Waist circumference greater than 88 cm. Abnormal lipid profiles like triglycerides. Abnormal blood pressure. Impaired fasting glucose. Abnormal metabolic markers. Okay. These are very closely associated in cases of PCOS. PCOS, metabolic syndrome.
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USG criteria for polycystic ovaries. USG. You can see that there is peripherally arranged follicles in a necklace. Almost greater than 12 follicles. You can see. It is a very important finding. Ovarian volume. Volume greater than 10 cc. Hormone profile. Unruptured follicles. 20 to 30% of normal women have long-term consequences.
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Term. Go. Endometrial cancer. Cancer. Endometrial. Cancer. Anti-progesterone. Anti-progesterone. Breast cancer. Estrogen. Long-term. So, generally. Months. 12 months. Status. Insulin resistance. Dyslipidemia. Metabolic syndrome. How? Ovarian function. It is nothing but act of menstruation or act of reproduction. Ovulation functions. Endometrial cycle. Ovarian cycle. And follicular function. They are finely coordinated functions. For a well-coordinated. For proper and well-coordinated function of the ovaries. Is essential for the normal release of hormones. All syndromes. FSH. FSH helps in follicular maturation and steroid synthesis. LH. LH helps in fatty composition. Ovulation function. Ovulation plays a very important role in the performance of all physiological functions and maintenance of homeostasis through estrogen formation. Induces follicular development. Initial formation from. Helps the maturation of follicle and also stimulating locally. Forms follicular maturation. Growth for complete maturation of follicle and further helping ovulation. This can be taken as an initial part. Initial part of formation is very essential for complete maturation. So, again, I say that. FSH plays a dominant role in the complete ovarian maturation and subsequent ovulation and corpus luteum maintenance. Compared to LH. For complete ovulation, it happens only with appropriate stimulation of LH through resumption of meiosis and androgen production from theca interna. Example. Estrogen is very essential for development. Follicles has both the component of theca and granulosa. But granulosa doesn't take part in fertilization. Follicular development coordinates all the metabolic processes which take place during steroidogenesis. Ovulation. Very vital. Regulates the functions of local agents and thereby coordinates all autocrine.
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Hello. Hello. Dr. Hello. Hello. Anyone? Am I audible? Can anyone put in chat box? Right. I, I'll proceed. I'll proceed. Okay. Thank you. Does the positive feedback? Positive. Hence, disturbances in FSH functions can lead to dysfunctions in PCOS and related to androgen. And lead to altered HPA axis. A minute. Okay. Androgenic follicular fluid causes follicular AR and defective aromatization function. Androgen formation. Androgen. Granulosa.
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Diffuse AR. AR. What I was trying to say, I was trying to say that this to AR conversion is ovulation. And that is helped by LH. Called LH. And under the support of FSH. Supported by local. That is what is initially. Second. So, said to be due to.
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Abnormal status of infertility. Reduced habits of exercise. Supports it. Supports or directly is localized by PCOS. And.
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Adipose accumulation causes insulin resistance.
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Dominance. White enlarged appearance. Accumulation. Abnormal lipids. Abnormal. Abnormal.
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Growth. El. Is considered as in F.
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Insulin resistance. En.
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Hormones. Hyper. Management. Management. Reversal.
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Increased patient already.
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Hyperestrogenism. PCOS. Enlarged ovaries. Hyper. Aarch. Work. IND. 18-year-old college student with history of irregular cycles since one year, duration of 8 months. Our height is 162 cm. PCOS. PA. Responds. IND. Next. Early stage. Days. Simple. Prop. For. M. Doctor. M. Hello. Right.
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Optimum. For 23-year-old married since two years, housewife, staying together with regular unproven. Haven't conceived yet and is very anxious. Periods are irregular, once a month. Infertility is.
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Initial. Patient. C. Heavy bleeding with large blood clots.
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Hyperestrogenism. Increased volume. Unruptured. Man. Known.
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Respond. INF.
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Dysfunction. Continued sweets completely. Sugar. Fruits completely. Completely. Oils completely. Fatless. Warm water. Example. Condition.
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Conditions. Okay. So, if at all any, any left off questions. Thank you for patient listening. Thank you for the opportunity. Thank you. Thank you. Do you have any options in the chat box for questions?
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Response.
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Patient secret. ML. Okay. Thank you. Endometrial thick. Hormonal. Hormonal. H. Okay. Thank you. In completely. Sub. EX. S%.
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Okay. Thank you, sir. Next question. Menopause.
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Adult. Okay. Okay, sir. P.
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Condition.
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Insulin. Okay. Uh, ovarian.
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Treat. Okay. Uh, how to prevent spontaneous abortion?
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Optimum. Condition. Hormonal. Okay, sir. 16-year-old girl having hypothyroidism, taken medicine, thyroxine and aminoglutethimide for six months. Height 149 cm, weight 70 kg. What are the medicines given for her? 16-year-old girl having hypo, medicine and six months, height 150, weight 70 kg. What are the. Okay. Okay, thank you, sir. How can we manage insulin resistance? Or will it get corrected when we do other treatments? Definitely, definitely. Both ways. You see, once you correct, optimize. Direct opposite. Lifestyle. Okay. 60 mm thickness. Endometrium thick. M. Okay. Hormonal imbalance. Once treated, all symptoms. PCOS treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. 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Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. Symptoms. PCOS. Treated patients. Hormone. Hormone. Ovulation. 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