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Decoding Polycystic Ovarian Syndrome (PCOS)
Kanthi Bansal, Pooja Sharma Dimri, Apoorva Pallam Reddy
SECTION 1: BASICS
CHAPTER 1:
Polycystic Ovarian Syndrome —The Mounting Syndrome
INTRODUCTION
HISTORY
STUDIES ON PCOS PREVALENCE IN INDIA (TABLE 1.1)
Metropolitan Cities
REASONS FOR RISING NUMBERS
CHAPTER 2:
Etiology of Polycystic Ovarian Syndrome
INTRODUCTION
ENVIRONMENTAL FACTORS CAUSING POLYCYSTIC OVARIAN SYNDROME
GENETIC ASSOCIATION OF POLYCYSTIC OVARIAN SYNDROME
SUMMARY
SECTION 2: DIAGNOSES
CHAPTER 3:
Diagnosis of Polycystic Ovarian Syndrome
INTRODUCTION
CHARACTERISTIC FEATURES OF POLYCYSTIC OVARIAN SYNDROME
Androgen Excess
Chronic Ovulatory Dysfunction
PCOM on Ultrasound
Revised USG Criteria
DIAGNOSTIC CRITERIA OF PCOS IN REPRODUCTIVE AGE GROUP
National Institute of Health Criterion, 1990
Rotterdam Criteria, 2003
Androgen Excess and PCOS Society, 2006
AE-PCOS Diagnostic Criteria
NIH Evidence-based Methodology Workshop 2012
Phenotypic Approach for PCOS Impact on Metabolic Risks and Reproductive Risks
Characteristic Features of Classic PCOS (Phenotypes A and B)
Characteristic Features of Ovulatory PCOS (Phenotype C)
Characteristic Features of Nonhyperandrogenic PCOS (Phenotype D)
Pitfalls of Phenotype Classification
Ultrasound Features Predictive of Degree of Reproductive and Metabolic Disturbance in PCOS
DIAGNOSIS OF PCOS IN ADOLESCENTS
DIAGNOSTIC CRITERIA OF PCOS IN PERI- AND POSTMENOPAUSAL WOMEN
DIAGNOSIS OF EXCLUSION
Role of AMH in Diagnosing PCOS
CONCLUSION
CHAPTER 4:
Ultrasound in Polycystic Ovarian Syndrome
INTRODUCTION
TECHNIQUES FOR BASELINE SCAN OF OVARIES
ULTRASOUND CRITERIA OF POLYCYSTIC OVARY
OVARIAN VOLUME
Antral Follicle Count
Stromal Abundance
PATHOPHYSIOLOGY AND ULTRASOUND FINDINGS
ASSESSMENT OF STROMAL ABUNDANCE
STROMAL ABUNDANCE AND HORMONAL IMPLICATIONS
ARRANGEMENT OF FOLLICLES
Stromal Vascularity
Stromal Vascularity and Hormonal Implications
Endometrium in Polycystic Ovarian Syndrome
CONCLUSION
SECTION 3: POLYCYSTIC OVARIAN SYNDROME AND FERTILITY
CHAPTER 5:
Infertility in Polycystic Ovarian Syndrome
INTRODUCTION
EPIDEMIOLOGY AND DIAGNOSIS
PATHOPHYSIOLOGY OF PCOS-ASSOCIATED INFERTILITY
ETIOLOGY OF EXCESSIVE FOLLICULAR GROWTH
ETIOLOGY OF FOLLICULAR ARREST
INSULIN RESISTANCE AND HYPERINSULINEMIA
Ovaries and the Effect of Insulin
Gonadotropins and the Effect of Insulin
Insulin, IGF, and Sex Hormone-binding Globulins
Insulin and the Adrenal Glands
Insulin Resistance and Obesity
Insulin Resistance, Glucose Intolerance, and Diabetes Mellitus
DISRUPTION OF HYPOTHALAMIC-PITUITARY-GONADAL AXIS IN PCOS
DEREGULATION OF OVARIAN STEROIDOGENESIS
GENETIC FACTORS IN PCOS
CONCLUSION
CHAPTER 6:
Ovulation Inductions in Polycystic Ovarian Syndrome
INTRODUCTION
HISTORY OF OVARIAN STIMULATION
PATHOPHYSIOLOGY OF OVULATION
MANAGEMENT OF OVULATION INDUCTION
Lifestyle Modification
Counseling
Diet
Exercise
Pharmacotherapy for Weight Loss
Metformin
Thiazolidinediones
Flutamide
Statins
Bariatric Surgery
PRINCIPLES OF OVULATION INDUCTION
OVULATION INDUCTION BY ORAL OVULOGENS
Clomiphene Citrate
Dose
Combination Therapy
Clomiphene Citrate/Gonadotropin
Aromatase Inhibitors
Ovulation Induction by Gonadotropins
Principles of Gonadotropin Therapy
Effective Daily Dose (Threshold Principle)
Latent Phase (FSH Window)
Factors Determining the Dose of Gonadotropins
Different Regimes for Gonadotropin Therapy Used in PCOS
Different Regimes for Gonadotropin Therapy not to be Used in PCOS
Step-up Protocol
Chronic Low Dose Protocol
Recombinant vs hMG
Induced Controlled Ovulation Stimulation (ICOS) for IUI / IVF
Use of GnRH Analog versus Antagonist and Trigger hCG versus Agonist
Adjuvants to Ovarian Stimulation
Metformin
Myo-inositol and D-chiro-inositol
N-Acetylcysteine
Melatonin
Berberine
Combined Oral Contraceptives
Dexamethasone
SURGICAL MANAGEMENT OF OVULATION INDUCTION BY LAPAROSCOPIC OVARIAN DRILLING
Luteal Phase Support
COMPLICATIONS
CONCLUSION
CHAPTER 7:
Assisted Reproductive Technology in Polycystic Ovarian Syndrome
INTRODUCTION
INDICATIONS FOR ART IN PCOS
CHALLENGES IN OVULATION INDUCTION IN PCOS FOR ART
PROTOCOLS FOR STIMULATION
Long Protocol/Agonist Protocol
GnRH Antagonist Protocols
PCOS AND OHSS
ART OUTCOMES IN PCOS
Corrective Strategies to Improve ART Outcome
Weight Reduction
Role of Metformin
Pretreatment with Oral Contraceptive Pills
Role of Laparoscopic Ovarian Drilling
Role of Myoinositol
IN VITRO MATURATION
CONCLUSION
CHAPTER 8:
Complications in Assisted Reproductive Technique
INTRODUCTION
ANESTHESIA-RELATED COMPLICATIONS
PROCEDURE-RELATED COMPLICATIONS
Hemorrhage
Case
Ovarian Torsion
Case
Pelvic Infection
Pelvic Injury
Case
LONG-TERM EFFECTS ON FERTILITY
CONCLUSION
CHAPTER 9:
Embryology in Polycystic Ovarian Syndrome
INTRODUCTION
EXTRAOVARIAN FACTORS
Follicle-stimulating Hormone Deficiency
Hypersecretion of Luteinizing Hormone
Hyperandrogenemia
Hyperinsulinemia
INTRAOVARIAN FACTORS
OOCYTE IN POLYCYSTIC OVARY
Follicle Dynamics and Oocyte Maturity
SPINDLE ASSESSMENT AND REACTIVE OXYGEN SPECIES
MITOCHONDRIAL ASSESSMENT AND METABOLISM
EMBRYO IN POLYCYSTIC OVARY
STRATEGIES FOR MANAGING PCOS IN THE LAB
In Vitro Fertilization vs Intracytoplasmic Sperm Injection
Fresh Transfer vs Freeze All
IN VITRO MATURATION
SECTION 4: AREAS OF CONCERN
CHAPTER 10:
Polycystic Ovarian Syndrome in Lean and Obese Women
INTRODUCTION
CHANGES IN BODY WEIGHT AND MENSTRUATION
NEUROENDOCRINE ABNORMALITIES IN POLYCYSTIC OVARIAN SYNDROME
IMPACT OF OBESITY ON POLYCYSTIC OVARIAN SYNDROME
Polycystic Ovarian Syndrome with Superimposed Obesity
Treatment of Obese Polycystic Ovarian by Insulin-sensitizing Drugs
SUMMARY
CHAPTER 11:
Polycystic Ovarian Syndrome in Adolescents
INTRODUCTION
HISTORY AND PATHOGENESIS (FIG. 11.1)
PATHOGENESIS OF POLYCYSTIC OVARIAN SYNDROME
POLYCYSTIC OVARIAN SYNDROME DIAGNOSIS IN ADULTS
ADOLESCENCE
ADOLESCENTS AND POLYCYSTIC OVARIAN SYNDROME
Diagnosis of Polycystic Ovarian Syndrome in Adolescents
Treatment of Adolescent Polycystic Ovarian Syndrome
PRINCIPLES OF MANAGEMENT
ACTUAL MANAGEMENT PROTOCOLS
Lifestyle Modification and Weight Loss
Insulin-sensitizing Agents
Dose, Duration and Schedule of Metformin Treatment
Side Effects
Combined Estrogen and Progestin Pills/Oral Contraceptive Pills
Composition of Oral Contraceptive Pills with Drospirenone
What is Drosperinine?
Currently Available Progestins and their Androgenic Effects
Advantages of Drospirenone
Contraindications
Combined Estrogen and Progestin Pill/OCP and Metformin
Antiandrogens
Ethinylestradiol with Cyproterone Acetate53-55 with or without Metformin
SUMMARY
CHAPTER 12:
Implications of Polycystic Ovarian Syndrome on Pregnancy
INTRODUCTION
PATHOPHYSIOLOGY OF POLYCYSTIC OVARIAN SYNDROME
POLYCYSTIC OVARIAN SYNDROME AND PREGNANCY
MATERNAL COMPLICATIONS
Subfertility
Spontaneous Abortions
Gestational Diabetes Mellitus
Preeclampsia
FETAL COMPLICATIONS
Lactation Issues
Long-term Fetal Complications
DIET AND MEDICATION CONCERNS IN PCOS PREGNANCY
CONCLUSION
CHAPTER 13:
Psychological and Cognitive Problems in Polycystic Ovarian Syndrome
INTRODUCTION
REDUCED QUALITY OF LIFE INDICATORS
DEPRESSION
BIPOLAR DISORDERS
EATING DISORDERS
ANXIETY AND FEARS
SELF-ESTEEM AND BODY SATISFACTION
POTENTIAL MECHANISMS
MANAGEMENT
SUMMARY
CHAPTER 14:
Long-term Sequel of Polycystic Ovarian Syndrome
INTRODUCTION
METABOLIC DYSFUNCTION IN POLYCYSTIC OVARIAN SYNDROME
Metabolic Syndrome
Insulin Resistance
Etiology of Insulin Resistance
How to Detect Insulin Resistance?
Hyperinsulinemia
Dyslipidemia
Obesity
Type II Diabetes Mellitus
Diagnosis
Oral Glucose Tolerance Test
Obstructive Sleep Apnea
Cardiovascular Risk
Malignancy
PSYCHOLOGICAL FEATURES OF POLYCYSTIC OVARIAN SYNDROME
MANAGEMENT OF LONG-TERM COMPLICATIONS
CHAPTER 15:
Medicolegal Aspects of Polycystic Ovarian Disease
INTRODUCTION
LEGAL IMPLICATIONS
What is Negligence?
Civil Negligence and Criminal Negligence
What are the Litigant Situations?
What Prevents Litigation or Saves a Doctor in Court?
Communication
Documents
CONCLUSION
SECTION 5: MANAGEMENT
CHAPTER 16:
Lifestyle Modifications in Polycystic Ovarian Syndrome
INTRODUCTION
DIAGNOSIS OF POLYCYSTIC OVARIAN SYNDROME
Criteria for Diagnosis of PCOS (2 Out of 3 Must be Present)
Definition of Lifestyle Modification
Obesity and Insulin Resistance
DIET IN POLYCYSTIC OVARIAN SYNDROME
Carbohydrates
Proteins
Lipid Abnormalities in PCOS and Dietary Fat
Dietary Fats and PCOS
Fruits and PCOS
Vegetables and PCOS
Dietary Fibers
Dietary Calcium
Dietary Sodium and PCOS
Behavioral Modification in PCOS Management
Exercise and PCOS Management
EXERCISE RECOMMENDATIONS
CHAPTER 17:
Drilling the Ovaries: What is the Latest Evidence?
INTRODUCTION
MANAGEMENT
When Not to Perform LOD?
TECHNIQUES OF LAPAROSCOPIC OVARIAN SURGERY
Technique of Laparoscopic Ovarian Drilling
Transvaginal Hydrolaparoscopy (THL)
Laser Ovarian Surgery
Mechanism of Action: Laparoscopic Ovarian Drilling
Ovulation and Pregnancy
Miscarriage
Long-term Effects of LOD
LOD and In Vitro Fertilization (IVF)
Repeat Laparoscopic Ovarian Drilling
SAFETY AND COMPLICATIONS
Immediate Complications
Late Complications
ADVANTAGES
CONCLUSION
CHAPTER 18:
Hirsutism
INTRODUCTION
PATHOPHYSIOLOGY
Androgens and Hair Growth
Synthesis of Androgens in Females6
CAUSES OF HIRSUTISM
EVALUATION AND DIAGNOSIS
History and Physical Examination
Laboratory Evaluation
Imaging
MANAGEMENT OF HIRSUTISM
Lifestyle Modification
Cosmetic Procedures
Topical Treatment
Temporary Methods
Permanent Methods
PHARMACOLOGIC INTERVENTION
Oral Contraceptive Pills
Mechanism of Action20,21
Choice of OCPs
Antiandrogens
Insulin-sensitizing Drugs
Gonadotropin-releasing Hormone Agents
Glucocorticoids
CHAPTER 19:
Adjuvants in Polycystic Ovarian Syndrome
INTRODUCTION
RATIONALE FOR USE OF ADJUVANTS
ADJUVANTS USED
Metformin
Metformin versus Placebo
Metformin versus Clomiphene Citrate in Nonobese PCOS
Role of Metformin in CC-Resistant Cases
Metformin versus Laparoscopic Ovarian Drilling
Metformin with Gonadotropins for Ovulation Induction
Metformin in IVF
Metformin Effect on Body Mass Index
Metformin and Miscarriage
Metformin and Gestational Diabetes Mellitus
Effective Dose and Duration
Side Effects
Caution with Metformin
Inositol
N-Acetyl Cysteine (NAC)
Calcium and Vitamin D
Zinc
Folic Acid
Omega-3 Fatty Acids
Chromium Picolate
Melatonin
Dexamethasone
Oral Contraceptive Pills (OCPs)
Statins
Coenzyme Q10 (CoQ10)
CONCLUSION
CHAPTER 20:
Recent Advances in Polycystic Ovarian Syndrome
INTRODUCTION
CLASSIFICATION OF PCOS: IS THERE A NEED FOR A NEW CONSENSUS?
Oligomenorrhea
Hyperandrogenemia
Ultrasonography in PCOS
PCOS Phenotypes
Polycystic Ovarian Morphology
Adolescent PCOS
TREATMENT OF PCOS
Ovulation Induction in PCOS
Metformin—the Rise and Fall
Inositols and PCOS
Estrogen–Progesterone Pills in PCOS
IMPACT ON QUALITY OF LIFE
OBESITY AND ITS IMPACT: ROLE OF BARIATRIC SURGERY IN PCOS
CARDIOVASCULAR HEALTH FACTORS
GENETICS AND PCOS
ANIMAL MODELS OF PCOS
PREGNANCY IN PCOS WOMEN
PCOS AND CANCER
PERIMENOPAUSE AND MENOPAUSE
INDEX
TOC
Index
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