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Adolescent PCOS (Myth Buster)

Oct 15 | 2:30 PM

PCOS is the modern epidemic, and there are numerous fallacies surrounding it. Only overweight females are prone to PCOS, only women with irregular menstrual cycles have PCOS, cystic acne is associated with PCOS, and so on. There are several misconceptions about the symptoms, diagnosis, and treatment options. Lets break that bubble and introduce some novel ideas into regular practice.

[Music] um a very good evening to everyone present here i am dr naveda from netflix and on behalf of team netflix i would like to wish you all a very happy the sarah we are glad that you could all be here on a festive evening to join us on this myth busting session on adolescent pcos we have with us tonight uh dr munshal pandya assistant professor at amc met medical college and the path and he's also the honorary secretary of antibiotic obstetrics and gynecological society thank you so much thank you so much for the kind introduction and uh team netflix for this opportunity of sharing my views on adolescent pcos uh honestly this is a topic which is still in the gray zone uh there are times when we keep on changing with definitions and all the criteria with regards to this particular uh you know it is still something we need to explore and uh we need to bridge it enough to conclude or jump onto this particular diagnosis so as we know uh polycystic ovarian syndrome previously it was known as polycystic ovarian disease and now syndrome because it is uh you know a lot of symptoms and a lot of clinical features getting into one particular uh zone that is pcos it does uh the communist endocrinopathy with regards to the females of reproductive age group that is like five to seven percent of females of this particular age group would suffer from pcos so it revolves around basically three uh three particular zones that is like androgen excess that may be clinical or biochemical then overlated dysfunction that might be reflected in form of menstrual irregularities and ultrasonographic feature of polycystic ovarian morphology with regards to hydrolysis and pcos there are basically two things androgen excess and menstrual irregularities the zone of pcom that is polycystic ovarian morphology on sonography is something which is not reliable with regards to this particular age group or adolescent people so this particular zone of sonography would be differed in the absence of other clinical features that cannot be used alone or even in the combination if the other two symptoms are not significant so uh the diagnosis as we discussed would depend on androgen access that might be clinical that is like herculism and acne unresponsive to topical management now this is particularly important because acne is much more common in this particular age group and hirsutism it is not common but still this particular two things need to be unresponsive with regards to topical management biochemical androgen excess that is like total and free testosterone levels need to be in higher range with regards to this particular female zone overlapping dysfunction uh if we can see various criteria the one which i got onto is consecutive menstrual interval more than 90 days even in the first year of menarche but for all practical purposes at least we need to wait up to two years after anarchy to conclude this particular criteria menstrual interval consistently less than 21 days or more than 45 days after two years of managing so spare those two years after menarche before jumping onto diagnosis of menstrual irregularity and lack of menstruation by the age of 15th here or at least two to three years after this that is breast development so if we keep on you know looking at it from this particular stringent criteria these are liberal enough before initiating any unnecessary medication or treatment with regards to menstrual irregularity to make it simple again this is a kind of revision if the menarche is that within one year of menarche illegal menstrual cycles may be considered normal up to one to three years the cycle has to be less than 21 days or more than 45 days after three years less than 21 days or more than 35 days or less than eight cycles per year as a whole and more than one year after minority more than 90 days cycle for any one cycle so basically we need to keep in mind this particular criteria before jumping onto diagnosis or before getting worried about the patients or itself so uh this particular table reflects the evolution of the criteria starting with 1990 they say the clinical hyperendrogenism oligomenorrhea and polycystic morphology on sonography all three criteria must be present to keep it uh you know pco to extend the diagnosis to pcos in 2003 rotterdam had uh another criteria when clinical hyperandrogenism has to be there then oligohydrogenesis and then polycystic ovarian morphology any two criteria out of this three will be stamped as pcos one more one more criteria released in 2009 that is uh a epcos society that is androgen uh that is androgen access pco society which had hyper androgenism as a one of the most criteria and any of the criteria from oligomenorrhea or bcom on ultrasonography so this would stamp it as pcos in the most recent criteria so basically what we talked about uh about physiological um you know menstrual irregularity it is also known as physiologic adolescent and evolution now initial cycles after puberty may be endovillatory and that might lead to the sponsor irregularity as well as the premenopausal zone is also having invulnetary cycles so we need to keep those things in mind so this is known as physiologic adolescent and ovulation we cannot directly jump on to us irregularities within at least two years after menopause and uh pcos is basically as said is a diagnosis of exclusion for which referral to the specialist is tibetan and we need to rule out other conditions of hyper androgenism like non-classic congenital adrenal hyperplasia hyperprolactinemia endogenous cushing syndrome thyroid disorders and other viralizing ovarian or adrenal tumors so it is a diagnosis of exclusion [Music] over in volume uh again this is a particularly of importance that after menarche at least one to four years is a zone where ovarian volume will be of maximum size so enlargement of ovary needs not to be taken uh you know as a literal meaning of pcos when we see sonography you know reports they keep on saying that ovaries are enlarged all vertices take clinical correlation required so we are the clinicians we need to uh you know decide upon whether it is a diagnosis of pcos or it is a normal physiological thing which is to be expected at least from one to four years after menarche the follicle number and volume would be having uh you know great overlap with regards to pcos as well as non-pcos patients so we need again justifying the point that ultrasonographic picture of pcos is not of that importance with regards to diagnosis acne is common in this particular teenage group so uh again if it is unresponsive to topical treatment it is it goes in favor of clinical hyperandrogenism herculism would require a lot of years uh before getting executed or you know before appearing clinically so that is of importance and significance it does not physiologically hyper androgenemia uh needs to be backed up with uh blood levels or biochemical levels of androgen and the more it is the most important and the most useful diagnostic criteria for adolescent pcos so this is of importance biochemical hyper androgenism and even presence of our citizen so persistent hyper androgenism can be there in case of premature pibargi so premature prabanki is something where cubic hair appears or starts appear at around 8 years which is not normal so we need to take history as well with regards to this particular cases of query pc or suspicious uh of having vcos so these are the normal uh changes at the time of puberty the gnrh release would attain the pulsatile frequency at particular frequency or the pulse frequency gnrh release would induce or instigate keyboard particularly to release lh and fsh now this particular lh would have its effect on thicker cells of ovary which would release androstenarion in response fsh would work on granulosa cells of ovary which would have aromatization of androstenedione which would convert it into estradiol now this is normal physiological cycle with regards to adrenal glands there will be increasing androgenesis dhea that is dihydro epi androstenedione and the hydroelectrostrain indian sulfate which would lead to growth of pubic and anxiety hair and normally physiologically acne as well so this is normal physiological cycle at around puberty what happens in pcos so what is the inciting event that may not be known the exact etiology is not known but the cycle is known now there will be increased pulse frequency of gnrh we know that physiologically gan rh has to be released in pulsatile manner for having its impact on pituitary if it is not pulsating it will not have any impact on pituitary this is known in physiology now this frequency will be increased leading to more of lh release that will induce more of thicker cells would lead to more of andro standardium release that is androgen lesser fsh release would lead to lesser aromatization of enduro stenarium so more of androgen will be free there and less of androgen will be converted to estradiol and that less of estradiol would be having impaired follicular development which will be responsible for menstrual irregularity or oligomenorrhea as we can see so basically there will be more of androgen production and less of it getting converted to estradiol now this particular more of androgen would interfere with the negative feedback of hypothalamic sensitivity with regards to ovarian negative feedback so lesser sensitivity with regards to negative feedback again vicious cycle of more secretion or more perceptive frequency of gnrh and that will having that will keep on running and running and running and that would lead to pcos and its clinical implications with regards to insulin it is uh one more villain adding to this particular cycle insulin augments ovarian response to lh and it increases this regulated situation from category so it is more of a villain instigating more of vicious cycle now this increased gnrh pulse frequency is resistant to suppression by progesterone we know that for the regularity of cycle we give protostrone and it doesn't work we give estrogen plus protostrong uh other way we call it progesterone challenge trees and estrogen and progesterone challenge trace but this particular frequency is not responding to progesterone it is highly associated with hyper androgenism and increased ovarian volume in response with regards to monarchy the pcos girls who are obese would have early menopause and the thin girls or the lean pcos females would be having later monarchy so this particular thing needs to be kept in mind it is not for differentiating pcos females it is about expecting what is normal for pcos in obese and non-obvious or lean pcos patients because lean pcos patients are always there it is not something but we keep on saying that obese only obese females would be having or obese girls would be having pcos there are lean pcos cases um clinically and a laboratory diagnosis was made with regards to sonography there are basic two terminologies we need to keep in mind one is polycystic ovary and the other is multicystic ovary when there is sonographic report we keep on looking at there are multiple follicles in favor of multicystic worry clinical correlation required so multicystic ovaries would be having cysts a size at least one or more cyst of more than 10 millimeter with regards to polycystic the follicle size or the follicle size cannot exceed more than 10 mm that is one basic difference the other one is with regards to polycystic the stromal content is more in those ovaries while in multisystic the stromal content is normal stroma is not increased so these are two basic difference the third one as they say the polycystic one would be having uh its arrangement uh in necklace pattern or more of periphery or the cortex of the worry multisystem would be more of uh you know medullary arrangement but again that is not much specific we need to keep in mind the size and the stromal content in mind before jumping on to you know converting that multisystem into polycystic and starting with the management no that needs not to be done the metabolic risk involved with this particular pcos would be acanthosis and chronical obesity are suggestive or reflective of insulin resistance one third of adolescent pcos would be having metabolic syndrome metabolic syndrome we know that two are more of four criteria like obesity hypertension lipidemia and hyperglycemia so this is metabolic syndrome and one third of adolescent pcos would be having metabolic syndrome which is a sign to be worried for for the patient abdominal obesity uh there are chances of greater metabolic syndrome when there is abdominal obesity and that is why the screening of metabolic syndrome needs to be done at regular interval so that we can timely manage that particular syndrome uh this particular table uh suggests you know uh the criteria for metabolic syndrome and neurologists any three of the five criteria out of uh you know would be present would lead to diagnosis of metabolic syndromic adolescence blood glucose level more than 100 milligram per deciliter that is random blood glucose level hdl cholesterol less than 40 milligram per deciliter triglycerides more than 110 milligram per deciliter and waste circumference and blood pressure more than or equal to 90th percentile for that particular age and sex this five criteria are there any three out of five would lead to diagnosis of metabolic syndrome in adolescence this is a vicious cycle of metabolic syndrome hyper androgenemia is the core problem here it leads to various effects on ovary and other issues and that's that particular cycle would lead to as discussed obesity hypertension more of insulin resistance and this lepidemia so we need to keep in mind this particular cycle and we need to break this particular cycle for having um you know optimal health outcome with regards to patient now what what if the patients are you know presenting with pco like pcos like symptoms we need to rule out other problems so to complete the list of laboratory investigations we need to have tsh to rule our thyroid prolactin now we need to know that there are two or three readings of prolactin that our laboratory needs to take before jumping onto diagnosis of hypertrophy anemia because it is a kind of hormone which would reflect the stress just like tsh and previously it was thought that psh needs to be done in a fasting state no now it can be done at um you know normal non-fasting state as well dhes and total and free testosterone level to diagnose the biochemical hyperandrogenism or anything other than pcos leading to hyper androgenism 17 hydroxy proton for a ch congenital hyperplasia of adrenal tissue ultrasound of ovaries uh then fsh lh and estradiol once pcos has been confirmed the fasting into our ogtt for ruling out development of type 2 diabetes mellitus lipid panel and fasting insulin needs to be done for diagnosing or for concluding or evaluating the hyper insulinemia or incident resistance so how would a girl of adolescent age group would present she would present mainly with the constants having menstrual irregularity and physical findings of acne or parasitism harsutism definitely an abnormal finding that needs to be worked properly but acne may be common but acne associated with menstrual irregularity needs to be taken seriously with regards to hyper androgenism and electronic medical record documentation now every consultation would have been having laptop or you know pc so we can take photographs of those patients at initial visit and regular interval with regards to evaluation of the management that we are doing with regards to this particular case so we need to have uh images at the baseline and during follow-up visits after informing the patient so this is a good and uh particular medical degree safe as well as well as uh you know satisfying on the side of patient for us to explain uh this is modified pheromone gallows code more than actually uh you know eight would be having hyper is about clinical hyper androgenism various sites like upper lip chin neck upper chest lower chest uh upper arm lower arm back and pubic region needs to be evaluated and the scoring can be you know charted accordingly and the total score needs to be done so this is particularly of importance with regards to how citizen uh we know uh i think uh uh many of us would know this particular lady her name is harnam uh she lives in uh uk and around uh in 2014 uh at the age of 24 she came out publicly with regards to this heart citizen she was tired of you know removing those hairs and in 2016 she was uh you know award against in a smoke upward with regards to a female having uh you know the highest length of bed but uh uh this is uh of significance i put this particular slide because uh you know if even if diagnosed with pcos we need to have courage for for getting ourselves treated for getting our patients um you know treated properly but at the same time not having lowered self-esteem or not getting into depression because it is nowadays uh you know epidemic of depression we keep on talking about depression because just because some uh xyz actors talked about it it is not a style it is a it is something that where everybody goes through it but we need to deal it correctly that can be done easily you know so uh we get we can get inspired out of those cases so these are uh laboratory investigations we talked about because we need to step diagnosis of pcos and we need to rule out other conditions so free and total testosterone and dhes would rule out ovarian and adrenal androgenic tumors morning 17 hydroxyl proton called congenital adrenal hyperplasia and lhfsh ratio now this is amazing uh important because we keep on writing or prescribing lh and fsh on third day of menses after withdrawal in these cases if it is more than two is to one we constantly jump onto pcos but no uh various studies have shown that it may indicate it is not conclusive of pcos and even in its absence that might be possibility of easiness so it is not confirmative it may help us to jump onto that particular diagnosis so the management is required basically for uh patient education we need to educate the patient we need to tell her that what is going wrong and what is not actually going wrong we need to have a healthy lifestyle healthy lifestyle we all are aware you know we call it uh we need to avoid fast food we need to have exercise just because that person is doing exercise and that is why we start doing it it is wrong notion we need to do it for our body for our body and for ourselves so healthy lifestyle needs to be followed an emotional well-being we need to have a circle you know when we were kids and in school we had uh better friends then we made friends in college and even in practice so those school friends were you know having no motive of friendship they were actually pure friends we need to have such friends and if we do not have it we have parents even though we have studied you know a lot of books we are studying a lot of books and uh medical sciences that our parents might not not have gone through still they are better cushion uh you know as compared to any other question in the society so just keep your mind uh open just keep your eyes and ears open and just keep yourself open uh towards whom uh you know uh who are trustworthy not not towards whom who can actually misuse your details but that doesn't shouldn't make you you know doubtful with regards to this particular sharing zone but yeah keep yourself open to your close ones and then a lot of things would make sense and a lot of support will come on its own so so do not feel good uh do not feel you know superior when you are being that particular support but yeah start expecting support from your trustworthy people and do not miss an opportunity of being a support for somebody else so the goals of managing this first particular cases would be management of menstrual irregularity which is bothersome as well uh reducing the horcidism and acne reducing diabetes and it's you know preventing the development of it reducing cardiovascular risk in case uh the longer zone of pcos would lead to you know more risk of cardiovascular zone reducing endocrine endometrial endocrine it's a mistake reducing endometrial carcinoma risk and improving quality of life and improving or preserving the fertility so the uniform agreement with regards to management of adolescent pcos lifestyle changes being the first line management nothing else needs to be done first lifestyle management nothing else needs to be started no pharmacological you know uh therapy needs to be started so what are lifestyle changes these are like uh diet exercise and weight loss those three are particularly of importance and uh suggested and backed up by all the global societies weight loss would actually be the single manual like releasing the androgen production improving insulin sensitivity and reducing cardiovascular risk so weight loss is something which would uh start the zone and exercise would maintain that particular healthy zone so exercise does improve hyperlipidemia beneficial effect on metabolic and anthropometric and cardiorespiratory fitness so weight loss exercise and proper dietary control or regulatory control would help in managing most of the adolescent pcos cases we know we know not to jump onto pharmacologic therapy with regards to improvement in this particular zone so dairy products what would be your ideal you know weight and we can uh evaluate ourselves we can guide our patients with regards to dietary regulations like uh the portions would be covering the fruits and grains and vegetables and proteins no not more of fat not more of carbohydrates and sports person would be having different uh proportions of carbohydrate as well so uh recently we had concept of zero carbohydrate diet and more of keto diet and everything but any anybody could choose you know what works for the self or the person so with regards to pharmacotherapy the oc pills and metformin are most commonly used drugs and they do respond well with regards to our citizens and acne as well anti-androgens oral state that is like anti-hunger drug uh popularly known as vitamins and supplements and for acne additional topical and oral medications can be started so osipils uh it is postline pharmacotherapy where estrogen content ethanol estrogen can be around 20 to 30 microgram or even 15 microgram would work that is lower those oral contrasts are pimples possible works best for hercultism and acne nothing else needs to be started in most of the cases basically it interferes with the hypothalamic pituitary ovarian axis it increases sex hormone binding globulin and that is why the free androgen level drops and that is how it works it leads to improvement in unwanted hair growth in at least 50 to 70 percent of perceived females it is the most effective therapy for a citizen transdermal patch is not recommended for females or girls having more than 90 kg of weight because it is it was not found to be effective in that poor weight or obese females insulin sensitivity does not get improved in this particular uh obstacles and estrogen has its own impact on vte as it is said that uh you know ocills and obesity would have ten times more risk of development of venous thromboembolism so this particular thing needs to be kept in mind and we need to keep uh keep in mind the common contraindication and side effects with regards to hospitals and uh 14 years i have written this particular thing because uh there are times when uh adolescent pco of emails go to some other doctors non-gynec or even some doctors they start uh the oc bills directly now this is not recommended at least up to 14 to 16 weeks uh you should not start possible because there will be earlier epic artificial fusion and stunting of growth will be there so we do not want it so oc pills must not be started at least uh you know before 14 to 16 weeks uh 16 years of age so uh 16 years before 16 years just uh let let the you know lifestyle changes flow after 16 if at all needed then only you can start the oral contraceptive pills anti-androgens uh need to be started uh if the oral contraceptive pills for six months have not delivered uh results or else they work well there is no need of anti-androgens even if there is harshed issue and if there is alopecia so alopecia and non-responsiveness after six months of forcibles therapy would lead to addition of anti-androgen nowadays there are all there are oral reciprocals with anti-androgen component so we can use them and we need to keep in mind cultural and social factors so it is not the perception from our side it is actually patience perception of severity which needs to be taken into uh you know consideration before starting this particular therapy so one of them would be spironolactone it is basically competitive androgen receptor antagonist with diuretic action that is potassium sparing typically used along with osiphs not commonly used because it has its own side effect in form of menstrual irregularity and it is territorizing so patient must not get conceived if uh or when on a spiral electrode side effect would be electrolyte disturbance and hyperkalemia the dose is 50 to 200 milligram per day in divided doses and other options like cyproterone acetate glutamine and finasteride but again long-term treatment would lead to hepatotoxicity in this particular case so we need to uh have lefty or liver function taste checked metformin insulin societies are very famous in addition to oscillates it decreases hepatic glucose production and increases peripheral insulin sensitivity it has potential to prevent development of type 2 diabetes mellitus along with this nepademia and which actually stems from insulin resistance now there is one more molecule that is a an acetylcysteine which was found to be superior to metformin in effect as well as side effect profile in one of the you know recent studies published in 2019 so right now metformin is being used properly practically but it may be replaced by an sfl system systemic therapy uh can be you know the therapy which we give can be augmented by topical or mechanical treatments for our citizens like electrolysis laser therapy plucking waxing um appellation depolation they call it in cosmetology language and topical therapy for acne and for acne topical retinic acid and antibiotics can be helpful in addition to oral ones and other hormonal therapy good disturbances we cannot ignore the problems they are facing facing from inside so poor self-esteem and depression needs to be treated uh before you know uh along with uh you know this particular pharmacotherapy and lifestyle changes uh platforming therapy for 90 days was shown to be effective in reducing anxiety and depression in those particular cases and count sailing is of utmost importance uh there are particular zones in our country where counselling is now trend you feel low you just talk with people but it has to be utilized medically it has to be utilized optimally in each and every zone of the country why it has been neglected talking it about is not um you know taboo but again opening up like just for style and showing off is not something recommended as well we need to find the balance and we need to be a good counselor along with being good clinicia vitamins and supplements vitamin d and probiotic were experimented for this patients and they found to be having improved general health and improvement in scores of depression anxiety and stress so this is of great importance it is not having problem or complications or side effects but it is having it is working as a boon without having much of uh hormonal changes significant reduction with protein testosterone carcinoidism and serious protein was noted an increase in antioxidant capacity that is like uh antioxidants uh removal of free radicals vitamin d was beneficial for follicular development of ovary and menstrual regulation and omega-3 fatty acids were found to have short-term beneficial effects for mental health and other inflammatory markers all listed famously known as anti-hunger medication reduced a bait and it might lead to decreased cardiovascular risk and improvement in lipid and glucose profile it was found to be more effective uh having lesser side effect than metformin but again practically metformin has been uh in you know continuation for all practical purposes but this molecules are new on horizon which are long-term considerations the contraception adolescent females who are not married may not be you know jumping on it but yeah and now they have a choice so they can use the contraception of their choice before getting conceived with pcos daughters of females who had pcos were found to have highest amh and lowest fsh having more of follicular numbers and more of ovarian volume as compared to the daughters who of the females who did not have pcos this was particular study because from the initiation or the pre-pubertal phase this ovaries are large enough so this uh our daughters need to be monitored or vigilantly monitored for development of pcos in their own life there was increased glucose stimulated insulin and a consistent phenotype of this particular daughters had pcos like picture but that again would not uh you know help in being confirmative of having pcos in those females so increased pcos uh increased amh level that is anti-molarity and hormone level was associated with increased leptin and other inflammatory markers and increased insulin uh with regards to uh you know in response to glucose pre-preparatory and it appears that girls at risk of pcos based on hereditary have evidence of an increased follicle complement and mild metabolic abnormalities compared to controls so they need to be monitored properly with regards to long-term implications infertility is one of them so again in our country nowadays uh career development has been given priority which is not wrong but yeah at the same time the definition of infertility has changed a lot by definition it is like 12 months of unprotected intercourse not leading to research but nowadays people are getting married late and then they are apprehensive suddenly out of you know nowhere because of societal pressure because of personal pressures of not getting conceived and they suddenly you know consult the fertility experts so we need to you need to actually you know fulfill the criteria of being infertile we think before jumping onto this infertility zone but yeah that might be fertility issue majorly with regards to pcos and obesity and that can be tackled easily by again those previous modalities and if not then they need to be monitored in form of ovulation study and then only you can jump on to starting with uh ovulation induction medications the other one is endometrial carcinoma now again we can uh you know prevent this particular risk by being vigilant and be monitoring them properly uh before getting on to that earlier or later stage of carcinoma you know zone diabetes type 2 diabetes is which are pretty much common to develop in this particular females having pcos for longer duration so again monitoring would be required and thyroid and other metabolic syndrome need to be taken care of so uh take home messages would be pelvic sonography is not must it is not one of the criteria for adolescent pcos at least after uh up till eight hours from the minority one anti-valerian hormone it actually came up uh with a lot of hope that amh would reflect the capacity of fertility but nowadays people are you know there are many more research papers which would indicate amh may indicate it is not something which would conclude the fertility capacity of the ovaries and this particular case adolescent pcos amh is not recommended for diagnosis of pcos exclusion of other disorders would be there before jumping onto diagnosis of pcos screening for anxiety and depression and necessary counseling needs to be done and multidisciplinary approach i'm telling you this because i uh we had a lot of discussion with regards to cosmetologist endocrinologist and gynecologist now these three people need to come under one roof for managing one particular case cosmetologists cannot keep on having lesser removal of hair in the absence of actually finding out the root cause endocrinologist cannot uh you know keep on writing or anti-androgenic uh you know uh medications without explaining the risk of spironolactone and teratogenicity and gynecologists cannot keep up uh you know uh uh on on it on his or her own keep on treating it with oscillos uh uh you know now alone so all the three uh disciplinary uh team needs to uh you know uh come under one roof for managing one particular case of adolescent pcos and we need to have a faith in self in treating physician and uh you know the almighty so just uh remove that particular taboo or eclipse you know we have with regards to adolescent pcos uh and just start you know having open mind with regards to the possibilities with regards to the confirmation and then the proper management of adolescent pcos thank you thank you so much thank you so much sir for that amazing session so how long after initiating uh life lifestyle modifications should we consider oc pills ocps yeah so basically uh uh what is the presenting symptom that matters the most in this particular case whenever we are advising lifestyle modification that means we are not dealing with actual pursuitism apparent personalism so lifestyle motivation is something where uh we can uh you know continue till the person or the patient feels that uh nothing is bothersome no symptom that is bothersome has developed illegal so it is the best part for for uh you know life as a whole if she is uh gradually developing her certainism or any uh bothersome symptom then we can start our siblings till then there is no need of starting any kind of following if she is comfortable with weight loss dietary control and exercise she needs to continue it for future benefits as well not only for bcus so there is no limit to it thank you so much i hope that answers your question we have dr fatima who asked what is the right time to go with test for ultrasound uh basically as uh last slide mentioned that up to eight years postmanaging ultrasound is good fine but then again it is not conclusive uh you cannot stand on the basis of ultrasound that this particular patient is having policies so ultrasound is not a feature to stem adolescent pcos but yeah afterwards if you are dealing with some fertility issues or later on some other issues not responding to medications then it is off road and then we can you know decide upon but honestly speaking there is no need of starting any kind of medication before 18 19 years because you cannot allow the patient to keep on continuing this particular medication for regularization of cycle and other features lifelong we are actually you know uh put in uh handcuffs on them in form of pharmacy and again there are many cases where call me therapy started and after two years or one and a half years some particular thing led to [Music] just lifestyle modification if she is not dealing with fertility issues and she is not you know married even so i don't think anything would require uh ultrasound is not of any help other than radiologist you know uh confusing the gynecologist thank you we have dr seema who's asking what will be the minimum age to diagnose for pcos uh as discussed in various criteria i think up to two years after manatee we should not be diagnosing anything because there are annulatory cycles we are dealing with uh after two years of energy yeah like less than 21 days of cycle consuming cycles or more than 45 days of cycles uh you know from one to three years post-management she has not developed menses that would be the diagnosis where we can make and hyper androgenism particularly the biochemical one the laboratory uh hyper androgenism is the one which has to be you know there before diagnosis so we have quite a few people asking if you can reiterate the difference between pcos and multi-cystic ovaries on ultrasound uh uh i i talked about three points majorly uh one is uh the holy cystic ovaries not having any follicles more than an mm diameter the multicystic one would be having one or more follicles more than 10 mm diameter one the other one is trouble growth will be much more in polycystic ones while multicystic ones would not be having stromal growth that is normal stomach content and third one majorly is polycystic ones would be having necklace arrangement that is like they are arranging the periphery of the ovary while once multicystic will be having cyst in the middle of the ovary or medulla but again that third criteria is not significant but yeah the size of follicle the stromal content are much more important before differentiating or jumping onto pcos um so there's a request for etiology for uh ca endometrium in pcos if you could explain that yeah basically uh uh when we uh discuss about uh cervix it is more of more of children you know giving birth to more of children all of the criteria like hpv infection and everything with regards to endometrium it is uh this hormones continuous presence of estrogen that would lead to more chances of endometrial hyperplasia now with regards to hyperplasia the patient would be having muscular problems then we would have the biopsy if the hyperplasia is having a typical simple or complex one and then accordingly we can judge upon the diagnosis of or the risk development risk for developing endometrial carcinoma so it is a lathe stage we are talking about but yeah before that she will be developing abnormal uterine bleeding aub which would be having proper biopsy before you know removing uterus as it is for endometrial or hysterectomy and that is why there is significant still significance or diagnostic significance of dilation impurities or endometrial biopsy before doing any kind of hysterectomy so aub needs to be having proper biopsy workup which which can have eight ipr or absence of hiv would rule out any um you know possibility of carcinoma but presence of fat appear would uh you know have the risk of developing an universal cause so yeah continuous exposure of vcos and this particular metabolic syndrome would add up to the risk of developing endometrial so we have another question since ultrasound is not conclusive of pcos what is the ultimate diagnostic criteria that the patient needs to fulfill and so then we can start treatment for pcos so uh my my second slide actually had those two important points one is hyperandrogen which may be clinical and biochemical clinical is harassing technique not responding to topical therapy and biochemical that is like increased free and or you know total tests so that is one criteria the other one is over little dysfunction which we discussed uh in detail that construal integrality so these two are the criteria on which actually we need to rely on the diagnosis of hydrolysis and pc first okay um [Music] i think so that's it most of the questions you've already gone over and uh so i think we can conclude the q a oh one second i think dr ankita has put up our question again so yes a 17 year old going on with pcos world cup having anemia is suggested to rule out celiac disease by her gynac so is there any correlation i think i i haven't read anywhere uh the association of celiac diseases with uh pcos no no no so i i don't think it is uh any any way interrelated but yeah i will check it out and [Music] and um thank you so much sir for coming up uh on this platform with a very nice topic which was very relevant to today's day and age with so much of lifestyle modification happening and diet and everything so i think the number of cases of pcos have really gone up so this was a really informative talk for all the residents out there so thank you so much and we hope to have you back on our platform soon sure sure thank you thank you so much netflix team uh actually i find it amazing to have this particular platform where you are trying to you know get to the roots who are actually you know dealing with the bulk of the patients so uh thank you so much thank you so much for thinking out of the box

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Dr. Divyansh Garg & 766 others

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dr. Munjal Pandya

Dr. Munjal Pandya

Hon. Secretary of Ahmedabad Obstetrics and Gynaecological Society | Assistant Professor, AMCMET Medical College, Ahmedabad

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dr. Munjal Pandya

Dr. Munjal Pandya

Hon. Secretary of Ahmedabad Obstetrics and Gy...

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