M3 India, invited renowned gynaecologist and infertility expert Dr. Hrishikesh Pai to host a webinar for our viewers, offering a perspective on the diagnosis and treatment of PCOS. Dr. Niranjan Chavan, our trusted and constant support, moderated the webinar and the Q&A that followed. Here we give you a transcript of the questions and answers.

Question 1. Can we give a combination of clomiphene and dexamethasone to improve fertility rate?

Dr. Hrishikesh Pai: Normally, it is not considered but the combination can be given for a short term and stopped once ovulation has occurred. However, please note that short term exposure can cause avascular necrosis and nasal bone aplasia in some cases. It is better to inform the patient about the possible side effects and prescribe the medicine after taking their consent.

Question 2. For hirsutism, which one is better- Drospirenone or Cyproterone?

Dr. Hrishikesh Pai: Cyproterone acetate is good; however, many doctors advise patients to wait for one or two months after stopping cyproterone acetate and then start therapy. This is because it gets stored in fat and gets excreted in circulation and cause teratogenicity. If you give the patient an anti-androgen, you must give an oral contraceptive also to prevent pregnancy. Such a combination is commonly used, is also effective but not everyone likes it.

Question 3. For hirsutism in patients who don’t respond to Spironolactone, what is your experience with Flutamide and Finasteride? What should the dosage and duration?

The recommendation at present is an oral contraceptive pill along with laser for one year. If no effect is seen in the patient after a year, one can move on to cyproterone acetate. One can also give finasteride, but at this stage, it would be best to refer the patient to an Endocrinologist.

Question 4. Does depression in young age increase the chances of developing PCOS in the future?

Dr. Hrishikesh Pai: There is no correlation between depression and PCOS, however, yes, a PCOS patient may have depression. There are international guidelines, which puts patients of depression under five distinct categories and sub-categories and it is recommended that we consider these while treating them for PCOS. Such patients have body image issues due to hirsutism and obesity among other problems, hence, having a counsellor for them is also essential.

Question 5. Your last slide mentioned many recommendations, including the prescription of Metformin or Metformin and Myoinositol. For how many days should these be given?

Dr. Hrishikesh Pai: Metformin has been classified as a wonder drug as it helps in longevity, however, you must do a test for creatinine as there is a 1 in 30,000 chance for a patient to have side effects. You should also regularly monitor liver and kidney functions and prescribe supplements as the medicine tends to bring down B12 levels in patients.

Question 6. What should be the course of action if a mature ovum doesn’t rupture despite giving 10,000 IU of HCG?

Dr. Hrishikesh Pai: If you are using clomiphene, you can use clomiphene in association with gonadotropins and then give an HCG trigger or you may give a dual trigger and also try GnRH-agonist with HCG. Alternatively, one may go for IVF. IVF will definitely give faster results than IUI in PCOD patients as the synchronisation between ovulation and the endometrial receptivity is difficult in IUI. However, my advice is to try IUI first and if it doesn’t work, then for faster results, try IVF.

Question 7. Which blood tests are bare minimum requirements for PCOS?

Dr. Hrishikesh Pai: The tests are based on the classifications. You must do tests as per hyper-androgenism classification, pre-testosterone, and testosterone. One needd to differentiate it from the adrenal source, so 17OHP has to be done. As per biochemical classification, LH/FSH ratio and AMH have to be done and to rule out hypothyroid and hypo-prolactemia, TSH and PRL have to be done. To look for metabolic syndromes, one should check the five-parameters. It is also important to rule out insulin resistance. However, about 60% of patients are phenotype type A, where all three parameters are present with metabolic syndrome, so I usually would put them on a regular dose of metformin. If you don’t wish to put them on metformin, you may go for myoinositol, which is a natural product.

Question 8. What is the role of DNC in PCOS?

Dr. Hrishikesh Pai: DNC plays a therapeutic role because you are scraping out the endometrium. My suggestion is to also use a hysteroscope with it as you may otherwise miss out on the small polyps that might be there. Once you remove them, a woman can become pregnant on her own as well. I think every gynaecologist should keep a hysteroscope and use it to check the cavity.

Our viewers, including those who attended the live webinar and others who saw it through different social media platforms, found the information very useful and the presentation made by Dr. Pai, enlightening. Stay tuned for more such webinars on M3 India.

To watch the recorded webinar, click here.

Disclaimer- The views and opinions expressed in this article are those of the speaker's and do not necessarily reflect the official policy or position of M3 India.

Prof. Dr. Hrishikesh Pai is a leading practicing Obstetrician and Gynecology and infertility expert from Mumbai.

Prof. Dr. Niranjan Chavan is the Unit Chief in the Dept. of Obstetrics & Gynaecology, at a prominent Mumbai hospital.