1 00:00:00,400 --> 00:00:02,879 Speaker 1: All right, so let's talk about polycystic overy syndrome before 2 00:00:02,879 --> 00:00:05,040 we get started. As always, thank you so much for 3 00:00:05,080 --> 00:00:07,440 the support, Thank you, thank you so much. All Right, 4 00:00:07,480 --> 00:00:10,839 let's talk about polycystic ovary syndrome or p COS as 5 00:00:10,839 --> 00:00:13,000 I like to call it, So polycystic overy syndrome. The 6 00:00:13,160 --> 00:00:16,320 name quite literally means a syndrome of many cysts of 7 00:00:16,359 --> 00:00:18,440 the ovaries. So you might think that that's all this is, 8 00:00:18,480 --> 00:00:21,199 but in actuality, you don't even need to have polycystic 9 00:00:21,199 --> 00:00:23,760 overies to be diagnosed, and the fluid filled structures in 10 00:00:23,800 --> 00:00:25,879 the ovaries they're not even true cysts, but we'll talk 11 00:00:25,920 --> 00:00:28,160 more about that later. So PCOS is one of the 12 00:00:28,199 --> 00:00:31,519 most common endochronopothies in women of reproductive age. It effects 13 00:00:31,559 --> 00:00:34,280 between six point five and ten percent of all women 14 00:00:34,280 --> 00:00:36,520 of reproductive age. Let's go ahead and get started with 15 00:00:36,520 --> 00:00:40,240 the patho first. So the patho is pretty complex, multifactorial, 16 00:00:40,280 --> 00:00:42,159 there's a lot going on, so we'll keep it focused 17 00:00:42,200 --> 00:00:44,280 on what you need to know. Some key concepts or 18 00:00:44,320 --> 00:00:47,119 trends that we typically see in patients with piacos. So 19 00:00:47,119 --> 00:00:50,759 starting with your LH levels. So PACOS patients have altered 20 00:00:50,880 --> 00:00:55,799 LH levels with relatively higher serum lutinizing hormone concentrations relative 21 00:00:55,840 --> 00:00:59,159 to FSH concentrations. This is just a small component of 22 00:00:59,159 --> 00:01:02,159 the whole picture, but I think is important to understand. 23 00:01:02,399 --> 00:01:04,640 So let's do a quick review of a normal functioning 24 00:01:04,719 --> 00:01:08,840 hypothalamic pituitary ovariant axis. In a normal HPO axis, the 25 00:01:08,920 --> 00:01:13,439 hypothalamus releases GnRH in a pulsatile manner, stimulating the anterior 26 00:01:13,480 --> 00:01:17,159 pituitary to secrete LH and FSH. LH goes down and 27 00:01:17,200 --> 00:01:20,359 acts on the thika cells in the ovary, promoting androgen 28 00:01:20,400 --> 00:01:25,400 production primarily androstendon, while FSH stimulates granulosa cells to produce aromatase. 29 00:01:25,519 --> 00:01:28,879 Romatase is an enzyme that converts these androgens into estrogen, 30 00:01:29,280 --> 00:01:33,120 specifically estradil. So as this process goes on, a dominant 31 00:01:33,200 --> 00:01:37,079 follicle develops. F SH stimulates the follicle to develop. Rising 32 00:01:37,200 --> 00:01:40,439 estrogen levels trigger positive feedback on the pituitary, leading to 33 00:01:40,480 --> 00:01:43,519 a surge in LH, which induces ovulation. Most of this 34 00:01:43,599 --> 00:01:47,519 you probably already know. After ovulation, progesterone from the corpus 35 00:01:47,599 --> 00:01:52,680 lutium provides negative feedback, slowing down GnRH pulses, reducing LH 36 00:01:52,719 --> 00:01:55,640 and FSH secretion to complete the cycle. It's a lot, 37 00:01:55,640 --> 00:01:57,079 but here's the part that you need to know and 38 00:01:57,159 --> 00:01:59,879 p cosse. This balance is disrupted due in part two, 39 00:01:59,879 --> 00:02:03,400 a higher pulsatile frequency of g n rh which LH 40 00:02:03,519 --> 00:02:06,480 is more responsive to, leaving us with excessive amounts of 41 00:02:06,640 --> 00:02:09,800 LH relative to f SH levels. So it means those 42 00:02:09,840 --> 00:02:12,879 thikas cells which are stimulated by LH are now producing 43 00:02:12,919 --> 00:02:16,520 too many androgens and FSH can't keep up to convert them. 44 00:02:16,840 --> 00:02:20,400 These elevated androgen levels, along with the relatively lower f 45 00:02:20,479 --> 00:02:25,879 SH levels, which normally stimulate follicular development, impair normal follicle maturation, 46 00:02:26,159 --> 00:02:30,280 resulting in anovulation and in accumulation of these immature follicles 47 00:02:30,280 --> 00:02:32,759 in the ovary, which lead to the classic appearance we'll 48 00:02:32,800 --> 00:02:36,039 see on ultrasound in some patients. Okay, so remember the 49 00:02:36,120 --> 00:02:39,039 increased LH to FSH ratio. One other part of the 50 00:02:39,039 --> 00:02:41,639 pathway I feel is important to understand is how insulin 51 00:02:41,680 --> 00:02:44,439 resistance plays a role. So fifty to seventy percent of 52 00:02:44,439 --> 00:02:48,919 females with p costs demonstrate clinically measurable insulin resistance, So 53 00:02:48,960 --> 00:02:53,080 we have insulin resistance which leads to compensatory hyper insulinemia. 54 00:02:53,360 --> 00:02:55,719 So high levels of insulin in the body. But what 55 00:02:55,800 --> 00:02:58,319 do high levels of insulin have to do with androgen 56 00:02:58,400 --> 00:03:01,840 excess and ovulatory to spunction. Well more than you'd think, 57 00:03:01,919 --> 00:03:04,680 So besides the obvious regulation of glucose that comes to 58 00:03:04,719 --> 00:03:07,039 mind when thinking of insulin, it does something else when 59 00:03:07,039 --> 00:03:09,479 in high levels, and that is to stimulate the THIKA 60 00:03:09,560 --> 00:03:12,759 cells of the ovaries to produce more androgens. So kind 61 00:03:12,759 --> 00:03:14,360 of like what we were talking about before with the 62 00:03:14,360 --> 00:03:18,479 effect of LH on the ovaries, insulin can stimulate steroidogenesis, 63 00:03:18,520 --> 00:03:21,639 causing those THECA cells to crank out more androgens. And 64 00:03:21,719 --> 00:03:25,039 these increased levels of insulin also inhibit production of something 65 00:03:25,120 --> 00:03:29,360 known as SHBG, sex hormone binding globulin. This is a 66 00:03:29,439 --> 00:03:32,960 transport protein that binds to hormones like testosterone as well 67 00:03:33,000 --> 00:03:35,719 as others, and it regulates their access to certain tissues. 68 00:03:35,919 --> 00:03:39,560 When hormones like testosterone are bound to SHBG, though, and 69 00:03:39,599 --> 00:03:42,240 this is the important part, these hormones are rendered inactive, 70 00:03:42,360 --> 00:03:44,719 meaning they can't do anything. So the fact that these 71 00:03:44,800 --> 00:03:48,520 high insulin levels inhibit production of SHBG means we have 72 00:03:48,680 --> 00:03:51,319 more of those androgens hanging out free in the bloodstream 73 00:03:51,639 --> 00:03:55,000 in their active state, able to unleash their hyper androgenic effects. 74 00:03:55,080 --> 00:03:57,919 High insulin levels even seem to override the ovara's natural 75 00:03:57,960 --> 00:04:02,960 resistance to LH, making them hyperresponsive, driving even more androgen production, 76 00:04:03,360 --> 00:04:05,479 all of which lead to some of the clinical manifestations 77 00:04:05,479 --> 00:04:07,439 will go over all. Right, So that's a lot of info. 78 00:04:07,719 --> 00:04:11,599 May take away. Excess LH relative to FSH, excess insulin 79 00:04:11,639 --> 00:04:14,319 from insulin resistance. Remember those and let's move on to 80 00:04:14,360 --> 00:04:17,639 the clinical manifestations next. So this is a syndrome, so 81 00:04:17,680 --> 00:04:20,439 the clinical presentation can vary from person to person, and 82 00:04:20,480 --> 00:04:26,240 there's many potential clinical manifestations irregular menstrual cycles, hersutism, acne, obesity, 83 00:04:26,319 --> 00:04:30,839 mood disorders, metabolic issues, cardiovascular issues, diabetes. But the two, 84 00:04:31,040 --> 00:04:33,000 the two I want you to remember that are also 85 00:04:33,079 --> 00:04:35,920 part of the diagnostic criteria will go over shortly is 86 00:04:35,959 --> 00:04:40,920 as follows. The first is menstrual dysfunction oligomenareea amenareea. So 87 00:04:41,000 --> 00:04:44,600 women with PA costs will have infrequent or absent menstrual cycles, 88 00:04:44,639 --> 00:04:48,639 which is caused by infrequent or absent ovulation. As a result. 89 00:04:48,720 --> 00:04:52,480 Infertility is a common consequence of these menstrual regularities and 90 00:04:52,600 --> 00:04:55,000 is frequently one of the reasons women with pea costs 91 00:04:55,040 --> 00:04:58,839 will seek medical attention. So remember oligomenarea or amenarea and 92 00:04:58,879 --> 00:05:04,600 the potential for infertil Next, hyper androgenism, hersaitism, acne, female 93 00:05:04,639 --> 00:05:07,639 pattern hair loss. So these are the repercussions of those 94 00:05:07,720 --> 00:05:11,800 excess androgens like testosterone we mentioned earlier. So hersaitism which 95 00:05:11,839 --> 00:05:14,879 is a thick or pigmented body hair also known as 96 00:05:14,959 --> 00:05:17,720 terminal hair and a male distribution pattern. So we can 97 00:05:17,759 --> 00:05:19,839 see dark hair growth on the upper lip, the chin, 98 00:05:19,920 --> 00:05:23,120 around the nipples, the perieriolar surface, as well as the 99 00:05:23,160 --> 00:05:27,079 lower abdomen. The linear alba acne is common as well. 100 00:05:27,120 --> 00:05:29,199 This can be on the face, back, chest as well 101 00:05:29,240 --> 00:05:31,639 as other areas of the body. And then finally, female 102 00:05:31,639 --> 00:05:34,000 pattern hair loss, so these women may start to have 103 00:05:34,079 --> 00:05:37,959 thinning of the hair on their head. This diffuse alopecia. Okay, 104 00:05:38,040 --> 00:05:42,079 So menstrual dysfunction, oligo or a menorrhea, and hyper androgenism. 105 00:05:42,120 --> 00:05:43,839 Now these are the two I want you to focus on, 106 00:05:44,040 --> 00:05:46,399 but of course be aware there are other potential clinical 107 00:05:46,480 --> 00:05:51,120 manifestations metabolic issues like obesity, insulin resistance, but focus on 108 00:05:51,160 --> 00:05:55,279 the menstrual dysfunction, infertility and hyper androgenic features. Let's talk 109 00:05:55,319 --> 00:05:58,639 about diagnosis next. So when we're talking about the diagnosis 110 00:05:58,680 --> 00:06:01,439 of PECOS, there is no no single lab or imaging 111 00:06:01,439 --> 00:06:04,600 study you can do to definitively diagnose this syndrome. So 112 00:06:04,600 --> 00:06:06,800 what we do to make the diagnosis is by using 113 00:06:06,839 --> 00:06:10,000 something known as the Rotterdam criteria. There are a few 114 00:06:10,040 --> 00:06:13,000 different criteria out there, but the Rotterdam criteria is the 115 00:06:13,000 --> 00:06:15,759 one most expert groups use and therefore it's the one 116 00:06:15,800 --> 00:06:18,040 you need to know. So what does the criteria entail? 117 00:06:18,360 --> 00:06:20,240 So to make the diagnosis of PA costs, you need 118 00:06:20,279 --> 00:06:22,040 to have two out of the three based on the 119 00:06:22,079 --> 00:06:26,839 Rotterdam criteria. The first is oligoovulation or anovulation, which will 120 00:06:26,839 --> 00:06:30,199 generally manifest with menstrual regularity like we talked about before, 121 00:06:30,279 --> 00:06:34,160 so infrequent or absent menstrual cycles. The next is clinical 122 00:06:34,240 --> 00:06:38,000 and or biochemical signs of hyper androgenism. So this means 123 00:06:38,079 --> 00:06:42,360 either the patient has clinical signs of hyperandrogenism so hersitism, 124 00:06:42,399 --> 00:06:45,720 actne et cetera. Or they have biochemical signs of hyper 125 00:06:45,800 --> 00:06:49,680 androgenism so you obtain labs and they have elevated testosterone levels. 126 00:06:49,839 --> 00:06:52,079 And then finally, the last criteria, which we haven't talked 127 00:06:52,079 --> 00:06:54,920 too much about yet is the ultrasound defindings. So the 128 00:06:55,079 --> 00:06:59,240 last criteria is polycystic ovaries by ultrasound. So let's talk 129 00:06:59,279 --> 00:07:02,519 about the ultra findings. Like I mentioned before, the fluid 130 00:07:02,519 --> 00:07:04,720 filled structures in the ovary that we see in some 131 00:07:04,800 --> 00:07:07,839 women with PA costs are not cists, but rather these 132 00:07:07,879 --> 00:07:11,519 immature follicles that never developed during those failed ovulation events. 133 00:07:11,639 --> 00:07:14,480 So an ultrasound will see abnormally high numbers of small 134 00:07:14,519 --> 00:07:19,040 follicles within these enlarged sclerotic ovaries. The small follicles are 135 00:07:19,079 --> 00:07:22,120 often located on the periphery of the ovary and sometimes 136 00:07:22,120 --> 00:07:25,079 they'll resemble a string of pearls and you'll sometimes hear 137 00:07:25,120 --> 00:07:28,120 them being referred to as that string of pearl sign 138 00:07:28,160 --> 00:07:31,800 when describing p COS ultrasound findings. So the Rotterdam criteria 139 00:07:31,839 --> 00:07:34,720 states a positive finding on ultrasound is twelve or more 140 00:07:34,759 --> 00:07:37,839 of these small follicles and either ovary measuring two to 141 00:07:37,959 --> 00:07:41,560 nine millimeters in diameter and or increased ovarian volume over 142 00:07:41,639 --> 00:07:44,839 ten mL. Now, there are some groups that suggest revising 143 00:07:44,879 --> 00:07:47,639 this increasing to twenty or more follicles per ovary because 144 00:07:47,639 --> 00:07:51,079 of the improvements and resolution of pelvic ultrasound and the 145 00:07:51,120 --> 00:07:53,720 fact that a percentage of normal cycling women met the 146 00:07:53,759 --> 00:07:56,879 threshold without having PA costs. What that means to you is, 147 00:07:57,079 --> 00:07:59,519 don't memorize these numbers. If they can't agree on the 148 00:07:59,519 --> 00:08:02,279 criteria for the specifics here, they can't expect you to 149 00:08:02,519 --> 00:08:05,160 remember them or memorize that for an exam. So don't 150 00:08:05,160 --> 00:08:07,759 worry so much about the specific number. But keep in mind, 151 00:08:07,759 --> 00:08:11,040 if the question is describing numerous small follicles and a 152 00:08:11,040 --> 00:08:14,319 big old plump ovary, they're probably describing pea cos all right. 153 00:08:14,319 --> 00:08:17,279 So that's the Rotterdam criteria. That's what you need to know. 154 00:08:17,480 --> 00:08:21,879 Irregular ovulation, hyper androgenism, and polycystic ovaries on ultrasound you 155 00:08:21,959 --> 00:08:23,879 need two out of a three, meaning if you have 156 00:08:23,920 --> 00:08:27,199 a patient with irregular mensis and hyper androgenic symptoms, you 157 00:08:27,240 --> 00:08:29,879 don't even need an ultrasound to diagnose. But there is 158 00:08:29,959 --> 00:08:33,000 one last part we're missing, one very important component. Before 159 00:08:33,039 --> 00:08:36,480 you make the diagnosis based on the Rotterdam criteria, you 160 00:08:36,600 --> 00:08:40,799 absolutely have to rule out your differentials. Rotterdam criteria also 161 00:08:40,879 --> 00:08:44,399 require exclusion of other conditions that mimic pea costs, So 162 00:08:45,200 --> 00:08:48,840 peacos has some very sneaky impostors conditions that have many 163 00:08:49,000 --> 00:08:51,720 of the same or in some cases exactly the same 164 00:08:51,720 --> 00:08:54,759 clinical findings. So once you establish a patient fits the 165 00:08:54,879 --> 00:08:57,519 Rotterdam criteria, the next step is to rule out your 166 00:08:57,639 --> 00:09:00,919 very important differentials. Now, there are a number of differentials. 167 00:09:00,960 --> 00:09:03,200 I'm not going to cover every single one, but the 168 00:09:03,200 --> 00:09:04,919 ones you need to know and the ones that will 169 00:09:05,000 --> 00:09:07,879 likely be tested on can all be found in your apartment. 170 00:09:08,279 --> 00:09:11,039 Your apartment as an APT what does that mean? Apartment 171 00:09:11,120 --> 00:09:15,159 APT stands for three important areas and those are adrenal, pituitary, 172 00:09:15,440 --> 00:09:17,799 and thyroid. So these are the differentials to roll out 173 00:09:17,840 --> 00:09:20,200 before making your diagnosis, and they can all be found 174 00:09:20,240 --> 00:09:22,879 in your apartment. So starting with adrenal, the letter A, 175 00:09:23,120 --> 00:09:25,399 what I'm going to cover right now is the most 176 00:09:25,480 --> 00:09:28,639 important differential you need to know, and if they're going 177 00:09:28,639 --> 00:09:30,519 to give you a differential on an exam, it will 178 00:09:30,639 --> 00:09:34,519 very likely be this one. This is known as NCCAH 179 00:09:34,720 --> 00:09:38,240 non classic congenital adrenal hyperplasia. If you want to forget 180 00:09:38,279 --> 00:09:40,279 all of the other differentials, I'm going to go over 181 00:09:40,360 --> 00:09:42,879 and just remember one. This is it. A patient with 182 00:09:43,039 --> 00:09:46,960 NCCAH can present with almost identical signs and symptoms as 183 00:09:46,960 --> 00:09:51,600 those with PECOS hyperindrogenism, olligo, manaia, polycystic overies, So you 184 00:09:51,679 --> 00:09:53,720 don't want to miss this. So to screen for this, 185 00:09:53,960 --> 00:09:57,840 you obtain a serum seventeen hydroxy progesterone, which is also 186 00:09:57,879 --> 00:10:00,480 super high heal to know, I sometimes remember the as 187 00:10:00,519 --> 00:10:04,000 apartment seventeen just to help me remember this screening test 188 00:10:04,039 --> 00:10:06,799 because it's just so popular to be tested on, and 189 00:10:06,840 --> 00:10:09,000 I definitely got a question on this in school, So 190 00:10:09,120 --> 00:10:11,879 please remember this one and then the other. Adrenal differential 191 00:10:11,960 --> 00:10:14,360 is an adrenal tumor, so a patient with an adrenal 192 00:10:14,399 --> 00:10:18,519 androgen secreting tumor or an adrenal cortical carcinoma. These patients 193 00:10:18,559 --> 00:10:22,720 can have clinical and biochemical manifestations of hyper androgenism like 194 00:10:22,799 --> 00:10:26,000 pa COS, but generally more severe. These patients usually have 195 00:10:26,120 --> 00:10:31,320 significant elevation of testosterone and or DHVAS levels way higher 196 00:10:31,360 --> 00:10:34,679 than PECOS patients, and usually will exhibit more severe signs 197 00:10:34,720 --> 00:10:38,559 of hersitism and even signs of virilization things like cliteromegaly, 198 00:10:38,840 --> 00:10:41,720 increased muscle mass, and deepening of the voice, which we 199 00:10:41,759 --> 00:10:44,440 typically don't see in pea COS. Okay, so that's the 200 00:10:44,480 --> 00:10:48,919 a for apartment. Adrenal main takeaway, don't forget NCCAH screened 201 00:10:48,919 --> 00:10:53,120 with the seventeen hydroxy progesterone. Remember your apartment seventeen. Next 202 00:10:53,159 --> 00:10:56,559 letter in the apartment is P which stands for pituitary. Specifically, 203 00:10:56,639 --> 00:11:00,399 we're talking about hyper prolactinemia. So hyperperlactinemia, which is an 204 00:11:00,440 --> 00:11:04,240 elevation of prolactin levels from the pituitary, can lead to infertility, 205 00:11:04,320 --> 00:11:07,159 oligomenarea or a menareea, so this needs to be in 206 00:11:07,200 --> 00:11:09,799 your workup. And then finally, the T stands for thyroid, 207 00:11:10,039 --> 00:11:13,759 so both hypo and hyperthiroidism can also lead to oligomenarea, 208 00:11:13,919 --> 00:11:16,320 so check a TSH as well. There are, of course 209 00:11:16,360 --> 00:11:21,720 other differentials Cushing syndrome, primary ovarian insufficiency, ovarian hyperthiicosis, pregnancy 210 00:11:21,759 --> 00:11:24,480 of course a very important cause of a menarea. But 211 00:11:24,519 --> 00:11:26,720 the ones I highlighted in your apartment those are the 212 00:11:26,759 --> 00:11:29,159 ones to remember as those will likely be tested on again. 213 00:11:29,240 --> 00:11:33,200 Highlighting non classic congenital adrenal hyperplasia, which you screen for 214 00:11:33,279 --> 00:11:36,480 with a seventeen hydroxy progesterone. All right, next, let's talk 215 00:11:36,480 --> 00:11:39,879 about treatment. So treatment for PCOS is targeted at a 216 00:11:39,960 --> 00:11:42,679 number of different areas because of all of the complications 217 00:11:42,720 --> 00:11:48,159 associated with this condition. Remember we have oligomanarea, hyperindrogenism and fertilities, obesity, 218 00:11:48,159 --> 00:11:51,200 insulin resistance, dyslibidemia. So I'm breaking this down to highlight 219 00:11:51,279 --> 00:11:53,799 the essentials. Let's start with what is considered the first 220 00:11:53,840 --> 00:11:56,679 line intervention for many women with peacos, and that is 221 00:11:56,720 --> 00:12:01,480 lifestyle changes diet exercise, weight reduction. Specifically in our overweight 222 00:12:01,600 --> 00:12:04,440 or obese patients with p costs, Diet, exercise and weight 223 00:12:04,480 --> 00:12:08,120 loss are very effective for improving insulin resistance, decreasing the 224 00:12:08,200 --> 00:12:11,399 hyperandrogenic symptoms, and some studies have found that modest weight 225 00:12:11,440 --> 00:12:14,080 loss five to ten percent reduction in body weight may 226 00:12:14,120 --> 00:12:17,799 restore normal ovulatory cycles and improve pregnancy rates. Of course, 227 00:12:17,799 --> 00:12:21,399 this is also beneficial for managing the underlying metabolic abnormalities 228 00:12:21,399 --> 00:12:25,440 we talked about cardiovascular disease, type two diabetes, etc. So 229 00:12:25,480 --> 00:12:27,840 this should be the first step for all overweight and 230 00:12:27,840 --> 00:12:30,440 obese women with PA costs. The next step for treatment 231 00:12:30,480 --> 00:12:33,559 we're going to talk about. Our medications are pharmacologic therapy. 232 00:12:33,679 --> 00:12:36,320 We're going to break this down into two categories, women 233 00:12:36,360 --> 00:12:39,600 pursuing pregnancy and those who are not pursuing pregnancy. So 234 00:12:39,600 --> 00:12:42,399 starting first with women not pursuing pregnancy, a patient who 235 00:12:42,399 --> 00:12:45,200 does not want to get pregnant, who has menstrual dysfunction 236 00:12:45,399 --> 00:12:48,799 and or androgen excess, which medication can we use? So 237 00:12:48,879 --> 00:12:51,519 the first line pharmacotherapy for most women will be with 238 00:12:51,679 --> 00:12:55,159 a combined oral contraceptive or a COC, which is a 239 00:12:55,159 --> 00:12:58,639 combination of estrogen and progestin. So the coeocs have a 240 00:12:58,720 --> 00:13:02,159 number of benefit for women with PCOS. First, they suppress 241 00:13:02,159 --> 00:13:06,799 ovarian androgens, decreasing the hyper androgenic features. Obviously, provide contraception 242 00:13:06,960 --> 00:13:10,840 because even women with oligomenarrhea may still ovulate intermittently lead 243 00:13:10,919 --> 00:13:13,679 to unwanted pregnancy. And then finally, something that we may 244 00:13:13,679 --> 00:13:16,720 not be thinking about, but patients with chronic annovulation like 245 00:13:16,759 --> 00:13:19,639 in PECOS. These patients are at higher risk for endometril 246 00:13:19,720 --> 00:13:23,360 hyperplasia and even endometrial cancer. And that's because we have 247 00:13:23,440 --> 00:13:27,720 this chronic anovulatory state causing the endometrium to be exposed 248 00:13:27,759 --> 00:13:31,000 to estrogen without the balancing effect of progesterone. We call 249 00:13:31,039 --> 00:13:35,000 this unopposed estrogen, and combined oral contraceptives help prevent this 250 00:13:35,080 --> 00:13:38,279 by providing daily progestin, which is a synthetic form of 251 00:13:38,320 --> 00:13:42,399 progesterone which counteracts the proliferative effects of estrogen on the 252 00:13:42,480 --> 00:13:45,799 endometrium and the second part of the combined oral contraceptive, 253 00:13:45,879 --> 00:13:52,000 the estrogen component reduces serum androgen concentrations by increasing SHBG concentration. 254 00:13:52,360 --> 00:13:55,320 Remember SHBG the guy who gives testosterone a big hug 255 00:13:55,360 --> 00:13:57,600 and doesn't let go. So this in turn reduces the 256 00:13:57,639 --> 00:14:01,000 symptoms of acne or hersitism. Binding these in a CEOC 257 00:14:01,120 --> 00:14:04,759 helps you manage both hyper androgenism and menstrual dysfunction, and 258 00:14:04,759 --> 00:14:08,120 that's why these are generally considered first line pharmacologic treatment. Now, 259 00:14:08,120 --> 00:14:10,759 what about a patient with hyperandrogenic symptoms who's been on 260 00:14:10,799 --> 00:14:13,720 a COEC for many months with no improvement. What other 261 00:14:13,759 --> 00:14:16,679 medication do we have in our arsenal specifically for these 262 00:14:16,679 --> 00:14:21,039 persistent hyperandrogenic symptoms. Well, the one you should know is spirinolactone. 263 00:14:21,159 --> 00:14:25,039 Spiralactone is a minerali cordiicoid receptor antagonist, and it is 264 00:14:25,080 --> 00:14:28,600 an effective treatment option for androgen excess as it blocks 265 00:14:28,639 --> 00:14:33,279 androgen receptors and also decreases testosterone production. And spirinalactone falls 266 00:14:33,360 --> 00:14:36,440 under the women not pursuing pregnancy category because you do 267 00:14:36,480 --> 00:14:39,000 not want to get pregnant while taking this medication as 268 00:14:39,039 --> 00:14:43,039 it can actually feminize male fetuses, preventing development of their genitalia, 269 00:14:43,120 --> 00:14:45,320 so the patient needs to also be on a contraceptive 270 00:14:45,360 --> 00:14:48,200 while taking this medication. There are some other options out there, 271 00:14:48,240 --> 00:14:51,080 such as finess, dride fluta, mind, but spirinalactone is the 272 00:14:51,120 --> 00:14:53,720 preferred agent compared to the other available options due to 273 00:14:53,759 --> 00:14:56,080 its efficacy. All right, next, let's talk about women who 274 00:14:56,120 --> 00:15:00,000 are pursuing pregnancy who are experiencing infertility and require treatment. 275 00:15:00,360 --> 00:15:03,120 So before we go over our meds and ovulatory women 276 00:15:03,159 --> 00:15:05,799 with peacos who are overweight oral beats should attempt to 277 00:15:05,799 --> 00:15:09,639 weight loss prior to initiating ovulation induction therapy. In most cases, 278 00:15:09,919 --> 00:15:12,879 some older women or women whose testing shows diminished ovarian 279 00:15:12,919 --> 00:15:15,519 reserve sometimes they'll go straight to meds, but in general 280 00:15:15,720 --> 00:15:18,799 weight loss for navulatory women who are overweight oral beese 281 00:15:18,879 --> 00:15:22,399 weight loss is recommended first. If lifestyle changes and weight 282 00:15:22,399 --> 00:15:25,279 loss are not effective and medication is needed, the one 283 00:15:25,320 --> 00:15:27,600 you should know is in romatase inhibitor by the name 284 00:15:27,600 --> 00:15:30,840 of lectrisol. Lectrosols should be first line treatment for ovulation 285 00:15:30,960 --> 00:15:34,600 induction in infertile analvieslory women with peacos. Now this has 286 00:15:34,600 --> 00:15:36,960 shifted over the years, as clomaphene used to be first 287 00:15:37,000 --> 00:15:39,240 line by per up to date and the twenty eighteen 288 00:15:39,279 --> 00:15:42,840 International evidence based guidelines, lectrosol is now the first line 289 00:15:42,879 --> 00:15:46,600 treatment option for ovulation induction in women with peacos, Like 290 00:15:46,639 --> 00:15:48,840 a number of pea cost treatments. It's still not FDA 291 00:15:48,840 --> 00:15:51,000 approved for the syndication, so your patients need to be 292 00:15:51,039 --> 00:15:54,200 aware of that, And there are some alternatives clomaphene met foreman, 293 00:15:54,360 --> 00:15:56,639 although both of those are less effective for live birth 294 00:15:56,679 --> 00:15:59,360 rates compared to lectrozol, so I would just focus on 295 00:15:59,440 --> 00:16:02,480 lectrosol after weight loss in women pursuing pregnancy. So how 296 00:16:02,519 --> 00:16:05,440 does letrozol work for ovulation induction? While letrozol is in 297 00:16:05,519 --> 00:16:09,320 aromatase inhibitor. Romatase, as we briefly discussed earlier during the 298 00:16:09,320 --> 00:16:12,960 path or review, is an enzyme that converts androgens into estrogen. 299 00:16:13,200 --> 00:16:16,399 So if we inhibit aromatase, less endrogens are converted to 300 00:16:16,559 --> 00:16:19,039 estrogen and we have much less estrogen in the body. 301 00:16:19,200 --> 00:16:21,919 When we have less estrogen in the body, the hypothalamus 302 00:16:21,960 --> 00:16:24,720 and pituitary sense this say oh, crap we need to 303 00:16:24,720 --> 00:16:27,519 help out, and they produce more FSH, that hormone we 304 00:16:27,559 --> 00:16:30,039 have been lacking because LH took over the show, and 305 00:16:30,080 --> 00:16:33,519 with more FSH we have improved follicular development and improved 306 00:16:33,519 --> 00:16:36,120 ovulatory rates. Those are the mens I think you should know. 307 00:16:36,159 --> 00:16:38,200 There's plenty of others, but the ones I went over 308 00:16:38,279 --> 00:16:40,360 are the most commonly used and the ones you'll likely 309 00:16:40,399 --> 00:16:42,720 get tested on. All right, so that is p COS. 310 00:16:42,759 --> 00:16:44,960 It's a lot, so you probably need a mnemonic. Now, 311 00:16:45,039 --> 00:16:46,720 before I tell you what the mnemonic is, I first 312 00:16:46,759 --> 00:16:48,639 want to be clear. This is just a memory tool. 313 00:16:48,679 --> 00:16:50,759 It's just a way to remember what you need to 314 00:16:50,799 --> 00:16:53,039 know about pa cos. In no way do I intend 315 00:16:53,039 --> 00:16:55,440 for this to be offensive to anyone with PCUS. It's 316 00:16:55,440 --> 00:16:58,080 just a simple little visualization that helped me remember. So 317 00:16:58,159 --> 00:17:00,240 PCUS or pa COS I used to remember in Seat 318 00:17:00,240 --> 00:17:03,600 of Peacos as pea clause. Piacos is pea clause as 319 00:17:03,600 --> 00:17:06,119 in Santa Claus, and Santa Claus contains all of the 320 00:17:06,200 --> 00:17:08,759 high old things you need to know about peacos, including 321 00:17:08,759 --> 00:17:11,960 a Rotterdam criteria and the most important meds. So again, 322 00:17:12,039 --> 00:17:15,240 PACs is now pea clause as in Santa Claus. So 323 00:17:15,319 --> 00:17:17,759 when we visualize our Pea cos Santa Claus, you'll notice 324 00:17:17,799 --> 00:17:20,039 a few things about this version of him. First, in 325 00:17:20,039 --> 00:17:22,240 his right hand, he's holding a ball of lettuce, a 326 00:17:22,319 --> 00:17:24,359 lettuce ball. His left hand, he's holding a bottle of 327 00:17:24,359 --> 00:17:26,559 Coca Cola. On his forehead is a big old pimple 328 00:17:26,559 --> 00:17:29,039 being popped with a spear. He's wearing a pearl necklace 329 00:17:29,240 --> 00:17:31,759 on the wall as a calendar with December twenty fifth circle, 330 00:17:32,039 --> 00:17:34,440 and of course has expected he has a big white beard, 331 00:17:34,480 --> 00:17:36,160 as we've all come to know him for now, what 332 00:17:36,200 --> 00:17:38,920 do all these things represent when it comes to Peacas. First, 333 00:17:38,960 --> 00:17:41,160 that ball of lettuce in his right hand, That lettuce 334 00:17:41,160 --> 00:17:44,319 ball helps remember the first line pharmacologic therapy for patients 335 00:17:44,359 --> 00:17:48,200 pursuing pregnancy letrasol lettuce ball letrasol. And his left hand 336 00:17:48,200 --> 00:17:50,319 holds the clue for first line treatment for women not 337 00:17:50,400 --> 00:17:54,400 pursuing pregnancy, COC's or combined oral contraceptives with the first 338 00:17:54,400 --> 00:17:57,519 three letyers of Coca Cola highlighted coc What about the 339 00:17:57,519 --> 00:17:59,640 big pimple on his forehead being popped by a spear. 340 00:18:00,119 --> 00:18:03,640 Pimple represents your hyper androgenic symptoms like acne and the 341 00:18:03,720 --> 00:18:05,759 spear popping it helps you remember how you treat it 342 00:18:05,799 --> 00:18:10,720 speir in a lactone, spear rhonolacton, speierronolactone. The anti androgen 343 00:18:10,799 --> 00:18:15,480 we used for patients with persistent hyperandrogenic symptoms despite coc monotherapy, 344 00:18:15,799 --> 00:18:17,920 is why beard helps you remember the hersaitism we can 345 00:18:17,920 --> 00:18:20,440 see in patients with peacos. The pearl necklace helps you 346 00:18:20,480 --> 00:18:23,559 remember the string of pearl sign remember those numerous follicles 347 00:18:23,559 --> 00:18:25,960 on the periphery of the ovary. And then the calendar 348 00:18:26,000 --> 00:18:29,119 on the wall shows December twenty fifth circled, symbolizing infrequent 349 00:18:29,160 --> 00:18:31,279 or aps in periods like Sanna who only shows up 350 00:18:31,359 --> 00:18:33,160 once a year in his red suit. So there's a 351 00:18:33,200 --> 00:18:34,960 lot to remember in peacos. But I feel like if 352 00:18:34,960 --> 00:18:38,200 you can just remember Sanna and Apartment seventeen cement this 353 00:18:38,400 --> 00:18:40,720 crazy image in your brain, you should be just fine. 354 00:18:40,880 --> 00:18:42,519 Now that we have our mnemonic, let's do a few 355 00:18:42,559 --> 00:18:45,920 quick questions to test your knowledge. Question one, a twenty 356 00:18:46,039 --> 00:18:48,720 nine year old woman presents to the office complaining of 357 00:18:48,759 --> 00:18:52,000 excessive hair growth on her upper lip, chin, lower abdomen, 358 00:18:52,039 --> 00:18:54,920 as well as irregular menstrual cycles. The patient is five 359 00:18:54,960 --> 00:18:57,640 feet five inches tall, weighs one hundred and thirty two pounds, 360 00:18:57,720 --> 00:19:00,440 and has a BMI of twenty two. On physical examination, 361 00:19:00,519 --> 00:19:02,480 there is terminal hair noted on the face and along 362 00:19:02,519 --> 00:19:05,200 the line alba of the lower abdomen. She's not currently 363 00:19:05,200 --> 00:19:08,480 taking any medications, denies any known medical conditions, and is 364 00:19:08,480 --> 00:19:10,720 not planning on pregnancy at any point in the near future. 365 00:19:11,000 --> 00:19:13,920 She's interested in starting a medication to address the persistent 366 00:19:13,960 --> 00:19:16,200 hair growth on her face and abdomen and the absence 367 00:19:16,200 --> 00:19:18,920 of contraindications. Which of the following would be the most 368 00:19:18,920 --> 00:19:22,240 appropriate next step in management for the likely diagnosis A 369 00:19:22,559 --> 00:19:28,720 letrazol B spirriinalactone C met foreman D combined oral contraceptive 370 00:19:29,119 --> 00:19:38,480 or E lifestyle changes, diet, exercise, weight reduction. So the 371 00:19:38,519 --> 00:19:42,240 correct answer is D combined oral contraceptive. So why is 372 00:19:42,240 --> 00:19:44,079 that the correct answer? So we have a twenty nine 373 00:19:44,119 --> 00:19:47,480 year old female presenting with hersaitism or regular metro cycles 374 00:19:47,720 --> 00:19:50,599 based on the Rotterdam criteria. She has pics. Of course, 375 00:19:50,640 --> 00:19:52,960 to definitively say that full work up to roll out 376 00:19:53,000 --> 00:19:55,119 your differentials would be needed, but that's not what this 377 00:19:55,200 --> 00:19:58,160 question is asking. It's asking based on the likely diagnosis 378 00:19:58,200 --> 00:20:00,599 which treatment are you going to recommend to her hyper 379 00:20:00,640 --> 00:20:03,160 androgenic symptoms? So we know the medication we're going to 380 00:20:03,200 --> 00:20:06,519 prescribe as a coc or combined oral contraceptive. Remember that 381 00:20:06,559 --> 00:20:08,920 bottle of Coca Cola and Santa's left hand. Now, what 382 00:20:08,960 --> 00:20:11,720 about the other options? While letrozol would not be appropriate, 383 00:20:11,799 --> 00:20:15,240 this medication is used for ovulation induction in women pursuing pregnancy. 384 00:20:15,480 --> 00:20:18,599 Spirinalactone could be used as an adjunct therapy for persistent 385 00:20:18,640 --> 00:20:22,400 hyperandrogenic symptoms, but it's generally not first line met foreman 386 00:20:22,480 --> 00:20:24,880 which at one time was used pretty frequently for peacs, 387 00:20:25,240 --> 00:20:27,880 is no longer recommended for hersaitism per the twenty eighteen 388 00:20:27,960 --> 00:20:30,680 Endercin Society guidelines, as it has been found to provide 389 00:20:30,680 --> 00:20:33,359 little or no benefit. And then finally, lifestyle would have 390 00:20:33,400 --> 00:20:36,000 been appropriate if this patient was overweight or obese, but 391 00:20:36,119 --> 00:20:39,240 this patient as a normal BMI of twenty two. Question two. 392 00:20:39,440 --> 00:20:41,480 A twenty six year old woman presents to the clinic 393 00:20:41,519 --> 00:20:44,759 with concerns about difficulty becoming pregnant. She and her partner 394 00:20:44,839 --> 00:20:47,720 have been trying to conceive for several months without success. 395 00:20:48,000 --> 00:20:50,279 She reports only one to two menstrual cycles over the 396 00:20:50,319 --> 00:20:53,039 past year. It's not on any medications and has no 397 00:20:53,119 --> 00:20:57,119 significant past medical history. Physical examination reveals hersatism on the 398 00:20:57,160 --> 00:20:59,960 upper lip and lower abdomen. Her height is five foot four, 399 00:21:00,079 --> 00:21:03,000 weight is two hundred pounds BMI thirty four point three. 400 00:21:03,319 --> 00:21:07,240 A transvaginal ultrasound reveals enlarged ovaries with multiple small follicles 401 00:21:07,319 --> 00:21:10,440 arranged peripherally. Differentials will rule DOWNT and the patient was 402 00:21:10,480 --> 00:21:13,200 diagnosed with PCOS. Which of the following is the most 403 00:21:13,240 --> 00:21:18,160 appropriate first step in managing her infertility? A clomiphene citrate, 404 00:21:18,680 --> 00:21:25,240 B letrasol, C met foreman D spirrinalactone E lifestyle change 405 00:21:25,319 --> 00:21:32,440 weight loss, So that is going to be E weight loss. 406 00:21:32,599 --> 00:21:34,960 So this patient has a BMI of thirty four point three, 407 00:21:35,079 --> 00:21:38,079 so she is classified as obese and for younger women 408 00:21:38,119 --> 00:21:42,160 with PCOS and inovulatory infertility, attempts at weight loss should 409 00:21:42,160 --> 00:21:44,920 be attempted first. In those with obesity. If this does 410 00:21:44,960 --> 00:21:49,119 not restore ovulatory cycles, ovulation induction is attempted next, usually 411 00:21:49,119 --> 00:21:52,519 with letrasol. Question three. A twenty five year old woman 412 00:21:52,519 --> 00:21:55,519 presents to the clinic after noticing increasing facial hair growth 413 00:21:55,680 --> 00:21:58,480 acne in irregular menstrual cycles over the past year. She 414 00:21:58,519 --> 00:22:01,160 reports that her periods now occur every two to three months. 415 00:22:01,319 --> 00:22:04,200 After researching the line, she believes she has polycystic ovary 416 00:22:04,200 --> 00:22:06,920 syndrome and requests treatment to help regulate her cycles and 417 00:22:06,960 --> 00:22:10,279 reduce the hair growth. She's otherwise healthy. Not taking any medication, 418 00:22:10,400 --> 00:22:14,599 denies galactoria, headaches, visual changes, heater, cold intolerance, or fatigue. 419 00:22:14,839 --> 00:22:19,119 Physical examination confirms hersaitism and reveals no other abnormalities. BMI 420 00:22:19,240 --> 00:22:21,599 is twenty seven. Which of the following is the most 421 00:22:21,680 --> 00:22:25,279 appropriate next step in management of this patient. A initiate 422 00:22:25,319 --> 00:22:29,279 treatment with combined oral contraceptives. B prescribes sphere and lactone 423 00:22:29,279 --> 00:22:33,680 for hersuitism, C refer for laser hair removal. D conduct 424 00:22:33,680 --> 00:22:37,119 a diagnostic workup to exclude other causes of hyper androgenism 425 00:22:37,160 --> 00:22:41,400 and oligomenerrhea. Or E suggests lifestyle changes diet and exercise. 426 00:22:45,039 --> 00:22:47,799 So the correct answer is D conduct a diagnostic workup 427 00:22:47,839 --> 00:22:51,759 to exclude other causes of hyper androgenism and oligomenarhea. While 428 00:22:51,759 --> 00:22:53,880 all of these are decent answers and may all be 429 00:22:54,000 --> 00:22:56,240 adequate treatment options at some point in the future for 430 00:22:56,319 --> 00:22:58,880 this patient. The first step before initiating any form of 431 00:22:58,880 --> 00:23:01,359 treatment for a patient with the expected PACs is the 432 00:23:01,400 --> 00:23:04,079 first ensured that they have piacos. And while she has 433 00:23:04,119 --> 00:23:07,480 some convincing symptoms based on the Rotterdam criteria, we can't 434 00:23:07,519 --> 00:23:11,200 forget that Rotterdam criteria also requires exclusion of other conditions 435 00:23:11,240 --> 00:23:14,240 that mimic PACs before making the diagnosis. So we need 436 00:23:14,279 --> 00:23:16,640 to roll out our differentials to ensure we are treating 437 00:23:16,680 --> 00:23:18,559 the right thing. So start in the apartment for those 438 00:23:18,599 --> 00:23:24,119 differentials APT, adrenal, pituitary, thyroid, among others. Question four, a 439 00:23:24,200 --> 00:23:27,000 twenty nine year old woman with PCUS wishes to conceive. 440 00:23:27,359 --> 00:23:30,000 Over the past six months, she has attempted lifestyle modification, 441 00:23:30,319 --> 00:23:34,079 including dietary changes, increase physical activity, and has achieved modest 442 00:23:34,160 --> 00:23:37,000 weight loss. Despite these efforts, he continues to experience and 443 00:23:37,119 --> 00:23:40,599 ovulatory cycles. According to current evidence, which is the most 444 00:23:40,640 --> 00:23:43,759 appropriate first line treatment option for ovulation induction for this 445 00:23:43,920 --> 00:23:49,160 patient A chlomiphene citrate, b letrazol, C met foreman D, 446 00:23:49,400 --> 00:23:57,480 gonadotropins E laparoscopic ovarian drilling. So the correct answer is 447 00:23:57,519 --> 00:24:00,599 going to be b letrozol. So remember, let's tresol your 448 00:24:00,680 --> 00:24:02,920 lettuce ball in Santa's right hand is the first line 449 00:24:02,960 --> 00:24:07,119 ovulation induction agent over klomaphene citrate Answer A and met 450 00:24:07,160 --> 00:24:09,960 format Answer C, which are both less effective for live 451 00:24:10,039 --> 00:24:13,279 birth rates than electrosol and the other two options gonadotropins. 452 00:24:13,519 --> 00:24:17,799 Exogenous gonadotropin regimens are complex and expensive and considered second line, 453 00:24:18,000 --> 00:24:20,960 and of course laparoscopic ovarian drilling also referred to as 454 00:24:21,119 --> 00:24:25,759 ovarian diathermy or electrocoagulation. This is a surgical option, meaning 455 00:24:25,799 --> 00:24:28,519 more invasive, and would generally only be utilize after the 456 00:24:28,559 --> 00:24:31,480 patient has tried and failed pharmacotherapy. All right, So that 457 00:24:31,720 --> 00:24:34,039 was picos. I hope that was helpful. Thank you so 458 00:24:34,119 --> 00:24:35,599 much for the support of the and best of luck 459 00:24:35,640 --> 00:24:36,039 in school.