Polycystic ovarian syndrome

Polycystic ovarian syndrome

Definition: a syndrome affecting the reproductive, endocrine & metabolic system, characterized by polycystic ovarian morphology with oligo/amenorrhea or hyperandrogenism  hirsutism, alopecia, acne)

Symptoms:

a)      Oligo-amenorrhoeas:- 80% , related to chronic anovulation

b)      Dysfunctional uterine bleeding

c)      Hyperandrogenism:- hirsutism, acne

d)      Subfertility :->75%

e)      Obesity :>40%

f)       Recurrent miscarriage :- >3 early pregnancy losses (50-60%)

g)      Acanthosis nigricans : 2%

h)      Elevated Serum LH      40-51%

i)        Elevated testosterone   29-50%

Diagnosis:

Diagnosis of exclusion of other endocrine disorder(thyroid dysfunction, congenital adrenal hyperplasia, Cushing syndrome, Hyperprolactinoma, androgen secreting tumor).

2003 Rotterdam ESHRE

1)      Oligo or anovulation

2)      Clinical and/or biochemical signs of hyperandrogenism

3)      polycystic ovaries (either 12 or more peripheral follicles or increased ovarian volume (greater than 10 cm3)~string of pearls’ sign~.

Investigation:

1. Thyroid function test
2. Serum Prolactin
3. Free Androgen Index (total testosterone divided by sex hormone binding globulin (SHBG) x 100=free testosterone level).-serum testosterone
4. 17-hydroxyprogesterone  (In cases of clinical evidence of hyperandrogenism and total testosterone greater than 5 nmol/l)-serum d21 progesterone
5. MOGTT

Counsel patients:

Women diagnosed with PCOS should be informed of the possible long-term risks to health that are

associated with their condition (advised weight control and exercise)

Long term complication

1)      Metabolic consequences – diabetes mellitus type 2

Indication for OGTT

-          obese (body mass index greater than 30)

-          strong family history of type 2 diabetes

-           >40 years

-          FBS >5.6mmol/L

2)      PCOS and obstructive sleep apnoea

3)      Infertility

asked about snoring and daytime fatigue/somnolence and the possible risk of sleep apnoea

4)      Cardiovascular risk

5)      PCOS & Pregnancy

Women who have been diagnosed as having PCOS before pregnancy (such as those requiring ovulation induction for conception) should be screened for gestational diabetes before 20  weeks of gestation

6)      Endometrial hyperplasia

Oligo- or amenorrhoea in women with PCOS may predispose to endometrial hyperplasia and later

Carcinoma(Endometrial Carcinoma)

 It is recommend treatment with progestogens to induce a withdrawal bleedat least every 3–4 months.

Treatment

1. Lifestyle modification

-          weight loss through diet and exercise.

-          reduced the risk of diabetes by 58%

2. Medication

-          Insulin-sensitising agents have not been licensed in the UK for use in women who are not diabetic. Although a body of evidence has accumulated demonstrating the safety of these drugs, there is currently no evidence of a long-term benefit for the use of insulin-sensitising agents.

-          Use of weight-reduction drugs may be helpful in reducing insulin resistance through weight loss.

-          Both metformin57–64 and troglitazone65,66 have been shown to have beneficial short-term effects on insulin resistance in women with PCOS who are notdiabetic. There is evidence that metformin may modestly reduce androgen levels by around 11% in women with PCOS compared with placebo

-          Orlistat69 and sibutramine70 have been shown to significantly reduce body weight and hyperandrogenism in women with PCOS. However, the use of sibutramine is not recommended in patients with systolic hypertension.

3. Surgery: ovarian drilling 
4.  cyproterone acetat (OCP), flutamide and 
5.  spironolactone,[antiandrogen)-treatment for acne and hirsutism
6. uterine progestogen device such as the intrauterine system (Mirena) or the progestin implant (Nexplanon)- treat Menstrual irregularity and endometrial hyperplasia
7. clomiphene citrate-promote ovulation for fertility

Prepared by :Dr.Fahmiza
Edited by:Dr Zharif

 OVARIAN DRILLING

Radical Wertheim Hysterectomy With Bilateral Pelvic Lymph Node Dissection and With Extension of the Vagina

Radical Wertheim Hysterectomy With Bilateral Pelvic Lymph Node Dissection and With Extension of the Vagina

Radical Wertheim hysterectomy is performed predominantly for stage IB and early stage IIA carcinoma of the cervix and for stage I carcinoma of the vagina. It is also appropriate for stage II adenocarcinoma of the endometrium (corpus excervicus). The operation essentially includes removal of the uterus, upper vagina, and all the parametrial tissues to the pelvic side wall. The ureter and bladder are dissected free and left intact. 

Reconstruction of the vagina, if necessary, can be achieved by the technique of extension of the vagina, making a pocket out of the vesical peritoneum and the rectal serosa.

Physiologic Changes. Carcinoma of the vagina, cervix, and uterus is removed.

Points of Caution. 

 The major complications of the radical Wertheim hysterectomy are vesicovaginal and ureterovaginal fistulae in approximately 1.5% of patients.

Hemorrhage can be a problem. The danger areas from hemorrhage are the hypogastric vein and its tributaries (internal iliac vein), the vessels in the obturator fossa, and nuisance bleeding from the small vessels located in the tunnel of the ureter.

Postoperative urinary retention with bladder atony is a permanent problem in less than 10% of patients. It comes from the transection of (1) the sympathetic nerves to the bladder in the upper portion of the web and (2) the ureterosacral ligaments.

History:

Ernst Wertheim (February 21, 1864 - February 15, 1920) was an Austrian gynecologist born in Graz.

In 1898, Wertheim performed the first radical abdominal hysterectomy for cervical cancer. This operation involved removal of the uterus, parametrium, tissues surrounding the upper vagina, and pelvic lymph nodes. Afterwards, Wertheim surgery became a fairly common, although risky procedure for cervical cancer. He also did important research of gonorrhea in the female genital tract, and was the first physician to demonstrate the presence of gonococcus in the peritoneum. Wertheim also discovered that gonococcus grows best on a culture of agar mixed with human blood-serum.

  

Articles: weirtheim operation procedure

Operation weirtheim