Polycystic ovarian syndrome – an update for GPs (19 June 2024)

Summary

The session conducted by Dr. Samina Ahmed focuses on providing an update for general practitioners about Polycystic Ovarian Syndrome (PCOS). The webinar aims to offer insights into the complexities of diagnosing and managing PCOS, emphasizing the importance of comprehensive care and individualized treatment plans. The discourse covers pathophysiology, diagnostic criteria, treatment modalities, and the importance of lifestyle changes, while also addressing the psychological and reproductive challenges associated with PCOS. Dr. Ahmed also highlights the long-term health risks such as diabetes and cardiovascular issues, emphasizing the need for ongoing monitoring and support for women with PCOS. The session is designed to equip GPs with the necessary knowledge to optimize patient care and outcomes.

Highlights

• Polycystic Ovarian Syndrome (PCOS) is a common yet underdiagnosed condition. 📊
• Diagnosis often involves a combination of clinical evaluations and exclusion of other disorders. 🩺
• Lifestyle management aims at achieving 'SMART' goals (Specific, Measurable, Achievable, Realistic, and Timely). ✅
• PCOS-related infertility can often be managed with lifestyle changes and, if needed, medical interventions. 👶
• Emphasis on psychological support due to prevalent mental health challenges in PCOS patients. 🧠
• Important to provide individualized care and encourage patient education and awareness. 👩‍⚕️
• The session promotes awareness of the long-term impact of PCOS on overall health. 🌍

Key Takeaways

• PCOS requires a holistic approach, considering reproductive, metabolic, and psychological aspects. 🌈
• 50% of women with PCOS are undiagnosed, highlighting a need for awareness. 🚨
• Gaining a thorough understanding of PCOS pathophysiology can aid in better management. 🧠
• Lifestyle changes remain a cornerstone of PCOS management. 🏃‍♀️
• Metformin and hormonal therapies are integral but need personalized administration. 💊
• Shared decision-making is crucial in treating PCOS effectively. 🤝
• Awareness of associated risks like diabetes and cardiovascular issues is essential. ❤️

Overview

PCOS is a multifaceted condition that extends beyond gynecological issues, impacting metabolic, psychological, and cardiovascular health. The session underscores the condition's complexity and the necessity for a holistic management approach to improve patient outcomes. Dr. Samina Ahmed elaborates on the varied presentation of PCOS and the implications it holds for different body systems, reminding GPs of the multidisciplinary care required.

The presentation walks GPs through the updated diagnostic criteria and highlights the ongoing debates in the medical community regarding PCOS management. Dr. Ahmed reviews the latest treatment options, emphasizing the importance of personalized medicine and shared decision-making, especially concerning hormonal therapies and fertility treatments. The talk is peppered with practical tips for implementing effective treatment strategies in everyday practice.

A significant portion of the discussion is dedicated to lifestyle interventions and their efficacy in managing PCOS symptoms. Dr. Ahmed stresses the importance of weight management, diet, and exercise, alongside supporting mental health to enhance the quality of life for those with PCOS. She also emphasizes the potential risks of untreated PCOS, such as type 2 diabetes and cardiovascular diseases, encouraging GPs to adopt proactive monitoring and management strategies.

Chapters

• 00:00 - 01:00: Introduction and Acknowledgement The session is introduced as an update on polycystic ovarian syndrome (PCOS) for General Practitioners (GPs). Joe Silver, a GP advisor at Western Health, introduces Dr. Sam Ahmed, the speaker and a specialist in obstetrics and gynecology from Western Health. The session also involves a contributor named Ion from the Northwest Melbourne Primary Health Network (PHN), who is managing the presentation slides. The session begins with an acknowledgement of the traditional custodians of the land, as is customary in Australian presentations.
• 01:30 - 03:30: Health Pathways Melbourne The chapter begins with an acknowledgment of the traditional custodians of the land where the work takes place, including the Wurundjeri, Boon Wurrung, and Woi Wurrung peoples. Respect is paid to Elders past, present, and emerging, as well as to Aboriginal and Torres Strait Islander participants in the session. Housekeeping notes follow, stating that all participants are muted and should ask questions through the Q&A box.
• 04:00 - 05:00: Dr. Samina's Introduction The chapter titled 'Dr. Samina's Introduction' begins with an announcement regarding the recording of the session. Participants are reassured that they will be sent a link to both the recording and a copy of the slides, thus alleviating the need to take notes hastily. Furthermore, there is a request for participants who might be using someone else's laptop, perhaps with a different name, to inform Evon of their identity via the chat box. This ensures proper identification and communication within the session.
• 05:30 - 16:00: History and Pathophysiology of PCOS The chapter titled 'History and Pathophysiology of PCOS' likely discusses the historical understanding and the pathological underpinnings of polycystic ovarian syndrome (PCOS). The provided transcript suggests an educational session or a talk where participants are informed about resources available for healthcare professionals, particularly GPs, in understanding and managing PCOS. One key resource highlighted is the Health Pathways Melbourne, which offers comprehensive information on various health topics including a specific page dedicated to PCOS. This indicates a focus on providing practical and in-depth knowledge for medical practitioners.
• 16:30 - 26:00: Diagnosis and Clinical Approach Health Pathways Melbourne is a resource created by GP clinical editors, in collaboration with local GPs, hospital specialists, and other experts. It aims to provide evidence-based guidance for general practitioners (GPs). The focus is on minimizing variations in care and offering GPs the necessary information for appropriate referrals.
• 26:30 - 36:00: Psychological Impact and Lifestyle Interventions The chapter discusses the referral systems available in both public and private healthcare sectors, with a focus on the abundance of resources available to General Practitioners (GPs) and patients. It highlights the extensive number of gynecology and women's health pathways, noted as a valuable resource especially for GPs who may not frequently engage with women's health. The chapter encourages those GPs to explore these pathways to enhance their understanding and service delivery in women's health.
• 36:30 - 65:30: Fertility and Pregnancy Considerations The chapter 'Fertility and Pregnancy Considerations' provides guidance on how healthcare professionals can record their continuing professional development (CPD) hours. It emphasizes the importance of logging these hours just like any other professional reading or activity and encourages General Practitioners (GPs) to utilize resources like Health Pathways Melbourne. If access is not already granted, it advises GPs to reach out through their webpage or email to gain access. The chapter ultimately encourages everyone in the profession to register for these resources to enhance their knowledge and professional growth.
• 66:00 - 75:00: Cardiometabolic Risks and Other Considerations The chapter titled 'Cardiometabolic Risks and Other Considerations' provides access information for medical professionals, specifically nurses and hospital specialists. They can access Health Pathways Melbourne and, if interested in further education on polycystic ovary syndrome, visit the Jean Hailes Foundation website, which offers a CPD course.
• 75:30 - 79:30: Conclusion and Q&A The chapter titled 'Conclusion and Q&A' features a discussion led by Dr. Samina Ahed, an obstetrician-gynecologist who completed her training in 2016. She holds positions at Joan Ker Women's and Children's Hospital, the Geelong University Hospital, and also practices privately at St. Vincent Wabby. The talk encourages attendees to engage in further upskilling and enhance their knowledge.

Polycystic ovarian syndrome – an update for GPs (19 June 2024) Transcription

• 00:00 - 00:30 Welcome to our session this evening on polycystic ovarian syndrome an update for GPS I'm Joe silver I'm the GP advisor at Western Health and um we have our speaker tonight is Dr Sam Ahmed um who's one of our Obstetricians and gynecologist from Western Health and behind the scenes we have ion from the Northwest Melbourne phn so next slide please so I'll begin this session with an acknowledgement of country so Northwest Melbourne Primary Health Network and Western Health would
• 00:30 - 01:00 like to acknowledge the traditional custodians of the land on which our work takes place the warry warong people the boonwong people and the Wong people we pay respects to Elders past present and emerging as well as pay respects to any Aboriginal and torist straight Islander people in the session with us today so just a little bit of housekeeping before we start everybody is muted and if you could just ask your questions in the Q&A box we will be
• 01:00 - 01:30 recording the session and um everyone will be sent a link to the recording and a copy of the slides so don't worry if you um you know don't need to worry about snapping away at Samina slides so as you've got a record of them um I could also just check um that if you are on someone else's laptop one of your kids and it's got a funny name when you check your participant details if you could just um uh in the chat box just let Evon know who you are um and we we
• 01:30 - 02:00 will allocate everybody their um appropriate CPD points next slide Sina um for those of you who are aware um Health Pathways Melbourne have a fantastic Suite of um information for GPS on multiple different um topics and there is a polycystic ovarian um syndrome page so this is the PCOS page so lots of information there and next slide s the
• 02:00 - 02:30 um for those of you who may not be aware of Health Pathways Melbourne the pathways are written by GP clinical editors with support from local GPS hospital-based Specialists and other subject matter experts they're a fantastic evidence-based um source for GPS and um the aim is to reduce any variation in care provide information for GPS on how to refer appropriately the information that's required um for
• 02:30 - 03:00 referral into public and private systems um so and there's also a lot of um links to resources for GPS and for patients next so there is a huge number of um gy and Women's Health um Pathways so great resource for GPS especially you know some people who may not do so much um Women's Health um I'd encourage you to have a look there if you spend a bit of time going through the Pathways um
• 03:00 - 03:30 you are able to record your self log your CPD hours as same as you would for any of your um Journal reading or anything else that you do um so a lot of the GPS will have been given access to health Pathways Melbourne but if you don't have access you can log on to their page um send them a message and ask the access or you can email them directly so I'd encourage everybody to get yourself registered so
• 03:30 - 04:00 um you've got access for any of the um nurses or Hospital other Specialists who may be on on for this session then you are also able to have access to health Pathways Melbourne uh if at the end of Sea's session you would like to um do some further upskilling in polycystic over overing syndrome then you can have a look at the um Jean hailes Foundation website so they' got a um CPD course
• 04:00 - 04:30 there that you can um work work your way through and um up do some further upskilling and increase your knowledge so our speaker this evening is Dr Samina ahed Samina is a um obstetrician gynecologist um who completed her training in 2016 she um has appointments at Joan ker Women's and Children's the jalong university hospital and also works priv privately at St Vincent wabby and
• 04:30 - 05:00 sunshine private um she's a sub has a special interest in um fertility and um extensive experience in um all things Women's Health and she has um academic appointments at Deacon uni University of Melbourne is also a supervisor with ransco unlike me semina is multilingual so that's very helpful for our patients out in the west of Melbourne um uh who may need that um Extra Care in their own
• 05:00 - 05:30 language and culture so I'll hand over now to sinina well thanks Jo and Ian for a nice introduction uh good evening everyone I'm Sina as Jo has already introduced I'm one of the gynecologist and fertility specialist um I would like to thank you all for taking time out um of your busy schedules to attend the webinar this evening and now without delay further I will start my talk so as you all know that uh tonight uh
• 05:30 - 06:00 meeting is to get an Insight regarding be cost it's one condition where people always like to agree to disagree over the years these disagreements have continued the criteria for diagnosing keep on changing as well as guidelin so it's kind of a dilemma for us and my presentation tonight is to provide clear information assist my colleagues in decision making and to support optimal patient care so we will obviously try to introduce use are disease um I would
• 06:00 - 06:30 call it a syndrome obviously just like everyone else the pathophysiology behind and try to understand what happens what disrup the two cell two hormone Theory the the associated clinical sequels diagnostic criterias clinical approach and treatment mainly involving share decision making and to Target other approachable smart goals and obviously in the end we will take home some evidence they target targeted approach to manage BOS related
• 06:30 - 07:00 health issues uh for our uh patients the syndrome history goes a long way back but was first described in 1935 by the American gynecologist arving Ain and Michael L other names for the syndrome are polycystic ovary disease functional ovarian hyper endogen ISM ovarian hyper theosis
• 07:00 - 07:30 scor cystic ovary syndrome and 15 de syndrome polycystic ovary syndrome is the most common hetrogeneous endocrine disorder of reproductive age women around the world and is defined by a combination of signs and symptoms of endogen excess and ovarian dysfunction with the clinical manifestations of menstrual irregular orities subfertility
• 07:30 - 08:00 hyper endogen ISM and long-term metabolic syndrome now 50% of women with peos go undiagnosed and it's a big number we actually missed 50% of these women develop type two diabetes before the age of 40 the disease puts a huge cost burden on different Healthcare s systems as you can see it's adding approximately 4.3 ion to American
• 08:00 - 08:30 System affected women have three times increased risk of developing endometrial cancer now the pathophysiology remains unclear genetic basis being suspected including disregulation of sep 11 a gene upregulation of other enzymes in endogen synthesis pathway insulin receptor on chromosomes
• 08:30 - 09:00 19p 13.2 a decrease in sex hormone binding Global other predisposing factors are family history of polycystic ovarian syndrome High maternal Androgen onset of type 1 diabetes metis before monarchy insulin resistance and obesity to under understand the
• 09:00 - 09:30 pathopysiology behind peos it is important to understand the normal autocrine paracrine and endocrine Pathways involved in a normal physiological menstrual cycle as you know every month under the influence of gonadotropins the recruitment of a new Badge of follicles begin so that's the journey every month these follicles go through out of these one follicle will become dominant and mature to undergo
• 09:30 - 10:00 ovulation the second half of the cycle is called ltil phase which is usually fixed and two weeks long during this phase fertilization occurs and if no fertilization then women will get period and the cycle restarts whereas in peos There's A disruption of this normal mechanism and the follicles remain arrested in
• 10:00 - 10:30 metaphase 1 or simply immature and fail to develop into a mature M2 follicle resulting in an ulatory Cycles the alteration is further explained here by two cell two gradot tropen Theory this is I think one of the theories which I really really like to discuss with my you know colle colleagues and students and it explains
• 10:30 - 11:00 the overall pathophysiology so beautifully so now in this flowchart you can see that Aller receptors are overexpressed in thica cells and in normal circumstances will help conversion of cholesterol into endogen precursors which will undergo aromatization in gr granulosa cells to produce estrogen under the influence of FSH now what happens in peos in peos LH
• 11:00 - 11:30 levels are increased relative to FSH levels fular arrest and increased Androgen production in paa cells will occur the most likely cause of an an o n ovulation is an FSH level too low to fully mature the follicles FSH levels may be suppressed by the negative feedback inhibition from the mid folicular estral levels leading to and
• 11:30 - 12:00 ovulation insulin resistance is secondary to matur mutation in insulin resistance Gene leading to altered function and 50 to 70% of the patients have insulin resistance and patients who have the diagnosis of polycystic ovarian syndrome now what this resistance does so insulin resistance causes hyperinsulinemia and it synchronization with L leads to hyper endogen
• 12:00 - 12:30 insulin resistance also inhibits sex hormone binding globulin production which will result in increase free endogens and I will try to cover these you know sequels which are mentioned here in coming up slides but the main sequel of these alterations are psychological Dermatological reproductive metabolic and Lead sequels
• 12:30 - 13:00 this is a flowchart representation of what is leading to peos and the clinical sequels and after going through the pathophysiology and understanding the two cell two hormone Theory I hope it is now a bit easier for you to address the elephant in the room as I said in my introduction earlier peos is the diagnosis of exclusion and is a clinical d d
• 13:00 - 13:30 due to the controversies surrounding the pathophysiology a number of criteria have been suggested and evaluated so far Asia and American Society of Reproductive Medicine rodam criteria from 2003 includes two out of the following oo or anovulation clinical or biochemical science of hyper endogen ISM and polycistic over
• 13:30 - 14:00 pH NIH criteria in 1990 includes both oo ulation and Hyper endogen ISM with exclusion of Related Disorders Androgen xspa 2009 suggested hyper endogen ISM and ovarian dysfunction with exclusion of other endogen excess or Related Disorders Arco and other and most of the international bodies recommends the use
• 14:00 - 14:30 of gradam criteria it's very important not to Mis um mistake pea with other disorders and it's very important to rule out other other Related Disorders so the differential diagnosis are hyperthyroid hyperthyroidism hypothyroidism hyperprolactinemia hypogonadotrophic
• 14:30 - 15:00 hypogonadism primary ovarian failure acrel late onset congenital adrenal hyperplasia endogen secreting ovarian tumor endogen secreting adrenal tuor Cushing syndrome and exogenous Androgen use as far as the investigations are concerned we we usually order FSH and
• 15:00 - 15:30 LH testosterone which should include total and free testosterone as well as free endogen index dehydroepiandosterone thyroid function test serum collectin blood sugar test especially the 2hour glucose tolin test fasting insulin level fasting lipid profile 17 hydroxy Pro hydroxy progesterone cortisol and ultrasound
• 15:30 - 16:00 pelvis and in coming up slides I will justify these investigations reliable assessment of biochemical hyper endogen ism is usually not possible on hormonal contraceptive pills so please consider a withdrawal of greater than or equal to three months before testing to avoid false negative results now as far as the testing for
• 16:00 - 16:30 the hyperandrogenism is concerned total and free testosterone to assess biochemical hyperandrogenism is the key in the diagnosis of peos free testosterone can be estimated by the calculated free endogen index if testosterone or free testosterone is not elevated consider measuring endend and dehydroepiandosterone sulfate DHE EAS but please take into account their
• 16:30 - 17:00 poor specificity and advancing age association with decreasing dhas patients with irregular menstrual cycles and Hyper endogen ISM an amh or antim malarian hormone level is not necessary for peos diagnosis both clinical and biochemical hyper endogen ISM persist in the postmenopausal B with Peak
• 17:00 - 17:30 cause postmenopausal hyper endogen ISM symptoms should be taken care of unless other causes of hyper endogen ISM like endogen secreting tumor Etc have been excluded the features of hyper endogen ISM are usually hottism echin endogenic alopecia and ecosis nitrogens for hottism a modified fman delis score
• 17:30 - 18:00 has been historically used and it depend on ethnicity severity of heroism may vary by the ethnicity but the prevalence of hottism appears similar across ethnicities fan Galway score of greater than or equal to 4 to six indicates his citizen
• 18:00 - 18:30 now I will talk about the poising ovarian morphology on ultrasound and the diagnostic criteria for that a follicle count of greater than 20 greater than or equal to 20 per OV of 2 to 9 mm or ovarian volume 10 cm cube in adults is diagnostic of potic ovarian morphology on ultrasound an ovial volume of greater than or equal to 10 mL or follicle numbers per section greater than 10 greater than than equal to 10 in at least one ovy in adults should be
• 18:30 - 19:00 considered the threshold for polycystic ovarian morphology if using older technology or image quality is insufficient to allow for an accurate accurate assessment of follicle counts throughout the entire OV no definitive criteria to Define polycystic ovian morphology on ultrasound in adolescence H it's hence it's not recommended in presence of mened irregularities and clinical or
• 19:00 - 19:30 biochemical hyper endogen ISM ultrasound is not necessary for peos diagnosis however a scan will identify the complete fos phenotype as far as a clinical approach and treatment is concerned no Universal treatment for Vost is available treatment is individ is individualized and based on women's goal
• 19:30 - 20:00 severity of symptoms sheer decision making and smart goals which are basic which are mainly specific measurable achievable realistic And Timely the modalities include conservative interdisciplinary medical team and surgical in this slide I will discuss the importance of psychological
• 20:00 - 20:30 screening and models of care prevalence screening and management of psychological features and models of care are common an important component of peos women with peos should be asked about their perception of peos related symptoms impact on their quality of life their key concerns and priorities for management High prevalence of moderate severe
• 20:30 - 21:00 depressive symptoms and depression in adults and adolesence with peos is noted and should be screened for by using regionally validated screening tools and reer appropriately screening for mental health disorders compromise assessment for risk factors symptoms and risk of self harm and societal intent
• 21:00 - 21:30 it is very important to address the psychosexual function and Body Image in this particular group of patients permission to discuss psychosexual function should be sought noting that the diagnosis of psychosexual dysfunction requires both low psychosexual function combined with Rel related distress posos can H body image that contributes to AB eating this disorders should be considered in PE cause regardless of
• 21:30 - 22:00 weight especially in the context of weight management and lifestyle interventions if disordered eating or eating disorders are suspected appropriately qualified practitioners including dieticians psychologists and other Alli practitioners should be taken on board now a brief discussion regarding achieving smart goals
• 22:00 - 22:30 smart goals are basically interventions to optimize healthy lifestyle and emotional well-being and be C patience and these are a specific measurable achievable realistic And Timely goals and they have been proven quite beneficial in achieving and retaining required targets the above behavioral strategies include goal setting self- monitoring problem solving assertiveness range tring reinforcing reinforcing changes
• 22:30 - 23:00 and relap prevention it has been observed that goal setting for the weight loss by adopting a smart approach and achievable goals such as 5 to 10% weight loss can yield significant significant clinical Improvement dietary interventions play an important role but there's no evidence to support any one type of diet compensation over another for
• 23:00 - 23:30 anthropometric metabolic hormonal reproductive or psychological out any di composition consistent with healthy eating will have health benefits and professionals should advise sustainable healthy eating to individuals in accordance to their preferences and goals it has been observed that energy deficit of 30% of 500 to 1700 750 good Clow calories per day is found to be quite
• 23:30 - 24:00 effective for weight management anti-obesity medications including litr glutide semaglutide which are both glucagon like peptide one receptor agonis and or listed could be considered in addition to active lifestyle intervention for weight management please ensure concurrent effective contraception is on board in
• 24:00 - 24:30 reproductive age woman as pregnancy safety data is lacking for these agents as far as inoco is concerned the evidence so far suggests limited harm potential for improvement in metabolic measures limited clinical benefits including in ovulation hidm or weight share decision making should include
• 24:30 - 25:00 discussion that regulatory um regulatory status and quality control of inositol in any form can differ inositol alone or in combination with other therapies is a still experimental and benefits and risk currently too uncertain to recommend their use as fertility therapies a specific types doses or combinations of inositol cannot currently be recommended in adults and adolesence with PE due to lack of
• 25:00 - 25:30 quality evidence now a little bit about met forming met forming major effect is to decrease hepatic glucose production leading to reduce insulin secretion met forming should be considered over inositol for htis and Central osity has more gastroint
• 25:30 - 26:00 gastrointestinal side effects that inositol metformin alone should be considered in adults with P cost and a BMI of greater than or equal to 25 for anthropometric and metabolic outcomes including insulin resistance glucose and lipid profiles suggested M daily dose of uh metformin in adults is 2.5 gam and 2 G in adolesence starting with the low dose of 500 mg with a gradual increase over
• 26:00 - 26:30 the weeks off label use can help with oom manoria hottism obesity and prevention of diabetes type two diabetes mtis bariatic and metabolic surgery um could be considered to improve weight loss hypertension diabetes hottism irregular mure Cycles ovulation and pregnancy rates
• 26:30 - 27:00 now how to deal with Hyper endogen ISM which is a as we know that the common sequels of hyper endogen ISM are pism acne endogenic alopecia e and e and ecosis nans self administered and professional cosmetic therapy is first line laser is recommended e Florine cream can be added and may IND uce a more rapid
• 27:00 - 27:30 response as far as the pharmacological therapy is concerned consider if there patient concern or if cosmetic treatment is ineffective or inaccessible or unaffordable should we tra Tri for at least 6 months before making change in dose or medication Primary Therapy is ocp and monitor glucose tolerance in those at risk of diabetes anti- endogen monotherapy for example
• 27:30 - 28:00 electon or cypron acetate should not be used without adequate contraception and for women with contraindication for cocp therapy or when women or when cocp are purly tolerated if cocp is ineffective at you can add anti-androgen to the cocp as a combination therapy esparon necton is widely used and
• 28:00 - 28:30 usually the days which are the doses which are in use are 25 to 100 milligrams per day the lower doses obviously have lower adverse effects cypron acetate at doses greater than or equal to 10 milligrams is not advised due to an increased risk including for men Mena as well fenite has an increased risk of liver toxicity flutamide and
• 28:30 - 29:00 bicalutamide have an increased risk of severe liver toxicity the relatively limited evidence on anti- endogens in peos needs to be appreciated with small number of studies and limited number of participants it is normal to have irregular Cycles in first year post minarchy Lifestyle
• 29:00 - 29:30 Changes especially 5 to 10% of weight loss with a structural exercise can enable a patient to get their M uh irregularities sorted or treated cocp can be used in reproductive age adults with PE cause for the management of irregular menst cycles and hitis ocps mainly decreases L secretion leading to decrease endogen and they
• 29:30 - 30:00 also induce increased hepatic production of sex hormone buring globulin leading to decrease bioavailable testosterone which can cause which can obviously reduce the signs of the clinical seek features of hyper endogen ISM they also help in reduction in adrenal endogen secretion there's no clinical Advantage advantage of using high dose of ethanol estradiol versus low do 35 micrograms of ethany estradiol
• 30:00 - 30:30 plus cypron acet acetate preparations should be considered as second line therapy over the CPS progesterone only oral contraceptives may be considered for endometrial protection now here I want to highlight the importance of shared decision making shared decision making is critical while prescribing cooc to treat peos accurate information and
• 30:30 - 31:00 reassurance on the efficacy and safety of the pin should be provided to improve chances of desired outcome CP can be used in conjunction with metformin and it may be most beneficial in high metabolic risk groups including those with a BMI greater than 30 diabetes risk factors impaired glucose
• 31:00 - 31:30 tolerance or highrisk ethnic groups where CP is contract indicated not accepted or tolerated met forming may be considered for irregular M cycles for hottism other interventions may be needed combination with the cocp metformine may be most beneficial in highrisk metabolics group as I have suggested earlier here I want to address the advantages of drinon over other
• 31:30 - 32:00 progesterone so drinon possess the minoc corticoid and Endo Endo endogenic activities and as a result of which it in counter it counteracts water intervention and Hyper endogen ISM so it is some it is a progesterone which we widely use um to manage our patients um with peos in my upcoming slides I will discuss U
• 32:00 - 32:30 the PE CA and its effect um on pregnancy and fertility pregnant women with peos have an increased risk of high gestational weight gain miscarriage gestational diabetes hypertension in pregnancy and preclampsia Inter utrine growth restriction and small forestation L babies prum delivery C inection and prenatal
• 32:30 - 33:00 depression just to elaborate more these women are at three to four times increased risk of developing gestational diabetes four times gestational hypertension two times preclampsia and approximately 1.9 fold increased chance of preuner which is quite High it is very important to advise these women prenatally about smoking
• 33:00 - 33:30 sensation optimal weight exercise and folate supplementations to avoid these bad outcomes perform glucose toin test antiy early and in second trimester to r l gestational and type two diabetes advice regarding the age related decline infertility to allow optimal timing of Family Planning is crucial I would like to discuss the role of
• 33:30 - 34:00 Metformin in pregnancy as this is something which is being asked quite frequently metomen in pregnant women with pea has not been shown to prevent macrosomia gestational diabetes late miscarriage hypertensive disorders in pregnancy met forming can be considered in some circumstances during pregnancy to reduce the risk of freom birth and excess gestational weight gain women should be informed that long-term
• 34:00 - 34:30 consequences of metformi exposure on the off Spring is unclear and there's a theoretical risk of increased childhood weight though no substantial evidence is available side effects of most of meformin are mostly mild transient GI symptoms and are not worse in pregnancy PE and getting pregnant are very difficult question 70% of peock patient actually
• 34:30 - 35:00 struggle falling pregnant most women with Prost can achieve a natural pregnancy with lifestyle modifications and younger patients can be reassured but approximately 40% of women with pea will need fertility infertility assistance age related fertility discussion and planning is highly important LOL is an aromatase inhibitor which is
• 35:00 - 35:30 proven effective as ovulation inducing agent and being most widely used for this purpose aromitas inator actually prevent the aromitas induced conversion of endogens to estrogen including the ovary this mechanism though not for fully understood but results in increased secretion of FS which is a follicle stimulating Harmon is stimulating ovarian follicle
• 35:30 - 36:00 development and maturation leading to pregnancy Chopin citr citrate which is a selective estrogen receptor modulator or Ser is a competive inhibitor of estrogen binding to receptors in hypothalamus and results in increased gonadotropins and and gonadotropins release influencing follicular growth if we do a comparison between Chopin
• 36:00 - 36:30 citrate and LOL evidence has shown that Leon should be used rather than Chopin citrate in women with peos with an ulat infertility and no other in infertility factors to improve ovulation clinical pregnancy and life birth rates current evidence demonstrates no difference in fetal abnormality rates between Leos a CH fenet rate Ovation
• 36:30 - 37:00 induction or natural conception here I would like to do a comparison between IVF versus ovulation induction IVF can be considered in peos patients with an ovula infertility if first or second line ovulation induction therapies have failed in an OV PE cost IVF is found to be effective risk of multiple pregnancies can be
• 37:00 - 37:30 minimized by performing single EMB transfer women with pea are at increased risk of ovarian hyper stimulation syndrome due to the pathophysiology of the pre-existing syndrome and should be cced prior to starting treatment about the additional risk and options to reduce the risk should be discussed risk of ovarian hypers stimulation syndrome can be reduced by using appropriate dosage of gonadotropins and prompt monitoring in
• 37:30 - 38:00 accordance with their amh BMI age and response to the treatment now here I would like to share some information regarding the state funded public fertility care for the Victorian this program provides two stimulation cycles per person at no cost and use of all Fen embs created minimal cost for medication and screening
• 38:00 - 38:30 test couples must complete screens at GP and attach results to the refer all referals from the Northwest Victoria region sent to the Royal women hospital and they are then triage for the satellite clinic for the northwest region the satellite clinics are mainly join Kaa Sunshine hospital and Northern Hospital the eligibility criteria maximum and age is 42 years at the time of
• 38:30 - 39:00 pment Victorian resident and they should have a Medicare card services which are currently available include fertility assessment and management IVF XC IUI ovulation induction fren EMB transfer donor farm and egg programs and medical fertility preservation planning to be introduced into 2024 and 25 out of which some has been already introduced are alistic
• 39:00 - 39:30 surrogacy program genetic test testing for embryos of embryos for monogenic conditions like PG which is called pttm donor embryo program Services which are not off offered at this stage are elective at freezing but if they have a medical reason they can be offered reversal of sterilization procedures now after discussing indepth fertil
• 39:30 - 40:00 infertility I would like to discuss here some cardiometabolic risk associated with peos as we all know after going through the pathophysiology these patients have an increased risk of cardiometabolic indigenous women have a higher prevalence of these respectiv and are more prone to encounter peos related complications at much younger age than non indigenous
• 40:00 - 40:30 women 75% of lean body women with peos will have insulin resistance and approximately 50% can develop metabolic syndrome as I have discussed earlier the lifestyle changes with greater than of five % weight loss in these patients who
• 40:30 - 41:00 are overweight reduces their diabetes risk by approximately 50 to 60% metformin reduces the risk of Diabetes by approximately 50% in adherent highis groups the pill is indicated for contraception and met forming for diabetes the combined use is supported by evidence and is recommended by the international and National specialist societies and is evidence based to bet insulin resistance and Hyper endogen ISM
• 41:00 - 41:30 in patients with PE few things about obstructive sleep atne the evidence suggests that peos patients have significantly High prevalence of sleep EPA compared to women without peos and it's independent of their BMI peos patients should be assessed for symptoms if present is screened with validated tools or refer to respiratory Physicians or
• 41:30 - 42:00 further for further evaluation burin questionnaire is a validated tool in general population and can be used in peos patients as well formal diagnosis requires a sleep study treatment should be tailored according to individual needs and goals because patients have a higher risk of
• 42:00 - 42:30 developing endometrial hyperplasia and endometrial cancer due to Chronic exposure to unexposed estrogen long longstanding untreated amoria High weight type two diabetes and persistent thickened endometrium are additional to PE cost as risk factors for endometrial hyperplasia and endometrial cancer overall chance of developing endometrial cancer is low therefore routine screening is not recommended in Prost
• 42:30 - 43:00 patients preventive measures including lifestyle modifications cycle regulation and progestogen therapy can reduce the risk when increased endom metal thickness is detected on ultrasound consider a hystological diagnosis in the form of a biopsy now this is my LIF side and I would like to conclude my talk tonight with the
• 43:00 - 43:30 following take-home messages polycistic oance syndrome is one of the most important endocrine disorders that affect females in the reproductive age and may lead to serious complications forther studies are needed to determine the exact ethology of peos methods of prevention and proper management because is an endocrine disorder associated with hormonal and menual
• 43:30 - 44:00 abnormalities it may be associated with short and long-term complications diagnosis involved Clinical Laboratory and radiological methods treatment depends on the need of the patients and the severity of the symptoms treatment can be conservative medical or surgical incorporating Shar decision making and smart approach thank you very much for your time and um
• 44:00 - 44:30 Joe if there are any questions I'm more than happy to answer thanks Samina that was a fantastic overview of um a condition that's very common and I think you know in our GP World um there's lots of um multi-stem disease that goes on and I think it's you know um important that we try and tie it all together and it can be really quite challenging for a lot of patients um you know I think they they get focused on you know the the cycle problems and the heru ism but and and
• 44:30 - 45:00 you know for some of them it's the fertility issues but for us GPS we need to be quite Vigilant about all the other um body impacts on other organ systems yes yes I mean you see the late sequels the metabolic syndrome like when you start as a very young person with peos and you end up with all these complications later in the life you know yeah so it's a lifelong problem I think so it needs to be addressed thank you very much so we've got got a few questions um so first question is does
• 45:00 - 45:30 hormone testing need to be timed in relation to the patient's cycle all right I think that's a very good question and tricky one as well so as we know that patients uh with the peos um they usually have matual irregularity so it's very difficult to time the test according to their Cycles um so my Approach usually in those my Approach and obviously the evidence approach is the same is that that um if you can't predicted Cycles the test can be done any time but if you are um
• 45:30 - 46:00 giving them um like for example uh withdrawal bleed in the form of a primal loot or something just to help them with the period Then they can actually do the test on day two or three of the periods but if they are basically having a period every three months or two months or something like that and they think that they might get a period Then I think day two or three is a better day to perform these tests but if they're not getting periods then I think you can do the test um regardless great thank you um now this is a this is
• 46:00 - 46:30 a tricky one too can polycystic Varian syndrome be diagnosed in girls with primary a Manara oh yes so um as I said I don't know whether um um you were there when I was talking about the Adolescent group so if they have primary imor I think it's very important to rule out other causes like whether is a hypo hypo like hypog gonotrophic hypogonadism or it's
• 46:30 - 47:00 basically a primary ovarian failure um what's their kot type you know what's going on so um I think so we need to rule out a lot of differentials before labeling these patients as because cost especially young girls um with primary amoria so there might be something else going on um but obviously the diagnosis of exclusion so you have to exclude all other related you know differentials before diagnosing them with people cost I have hardly seen anyone with primary manoria being diagnosed with PE cost in
• 47:00 - 47:30 my clinical practice if you have please share the details thank you um so with the patient who has a high BMI um and may well have the pill as is contraindicated so the combined pill can you talk a bit about what you would um use for them for if they wanted to have some you know if they wanted the menstrual cycle or if you wanted to give them some endometrial protection yeah so I think so then in that case we
• 47:30 - 48:00 will come down to Progesterone only options so we have got a wide range of progesterone only options to not only provide them contraception benefit but also uh for their endometrial protection so we have the option of peston O pill um SL which is being marketed um with the brand name of Slender these days it has got rosarin non which is um as I said earlier has got both antioc corticoid and anti endogenic activities so it's basically help with the hottism and and um uh bloating
• 48:00 - 48:30 and all of that so this is one of the pill which is available you can also use microl but microl hasn't been um proven like quite um effective in um High BMI women um we have other options like if we can also go for Implant um and we can also consider Marina for the endometrial protection and contraception all right um can you talk a little bit about um the use of cyclical primolut and some of those women who you know is that an option as
• 48:30 - 49:00 well yeah this is an option as well so um the for endometrial protection we actually recommend at least um six to eight cycles per year so I think six Cycles are adequate so if these patients are not uh these patients are not willing to um or you know we have discussed in depth and detail and they are not willing to start any of these uh other agents for the endomet protection and contraceptive purpose then they can
• 49:00 - 49:30 definitely have a withdrawal be uh but obviously they will they need to see the GPS regularly to get the script maybe every three months or four months so that just to make sure that nothing else is going on and Frankly Speaking I would also recommend ultrasound in this population because there's a possibility of developing endometrial hypoplasia or you know are seeing cystic changes in the lining of the uterus so it's I think it's important to monitor these patients maybe um a early scan should be enough but this is how I think um the
• 49:30 - 50:00 monitoring can be scheduled for this group of patients great thank you um uh so another question about contraception can you please um reiterate your preferred contracep combined oral contraceptive pill for peos and rationale so that's part one and then part two of that question um can you discuss options for patients with migraine can they use progesterone only I think you may have addressed some of that already uh you see uh yeah thank
• 50:00 - 50:30 you very much so I will answer the part one of this question first very good questions um so um as far as my Preferred Choice is concerned the evidence is suggesting there's no difference between the usual you know um pills which are available and um the pills which contain uh you know ceron acetate or some other proest strong um uh to be honest I have I mean all of us know that um some of these pills which are basically which we think are going
• 50:30 - 51:00 to work better for um traditionally are going to work better for because they're basically not on PBS so they it's quite expensive treatment for the patient so I usually start with the normal pills according to the evidence and if the patients are not responding well to those routine uh you know pills which we use then you can move up to um eel or d35 or zo or whatever whatever you think um you know with different type of progesteron and different um usually
• 51:00 - 51:30 between 20 to 35 micrograms of ethanol estol but in my clinical practice I usually start with uh PBS label you know cheap um contraceptive Bill to begin with with lifestyle modifications and most of the times it work but if having trouble then you can actually go for something like 935 or eel MH right thank you I'm sorry there was a Part B as well and the part B was
• 51:30 - 52:00 um please discuss options for patients with migraine I can they use the progesterone only all right yes you see obviously with migraine our Preferred Choice is pestone only but I think it's very important to know the causes behind migraines so I come across a lot of uh women these days who were used to have migraines because um related to work um you know or they had some focal functional cause of those migraines not related to hormones so if that is the case and they haven't had migraines for
• 52:00 - 52:30 a long period of time so I think don't think so there's no harm in triing um the routine you know lowdose um pill for them um I'm I'm talking about lowdose um estrogen containing pill for them to begin with and if they are responding well and the migraines are not coming back that things will just continue with that but but if there was the hormone was related um the migraines were related to a focal cause or which was basically hormonal imbalance or something and they're expecting the it to come back then maybe just avoid it and just do the routine P just on only
• 52:30 - 53:00 contraception of um um method right thank you um now a pregnancy related one how early in a pregnancy should you do a um glucose tolerance test in a patient who's got peos or other women at high risk okay so um usually we actually recommend um peos patients to have when theyy trying to have a baby um mean um uh and I think would request GPS to do a glucose trolin test prenatally but uh if
• 53:00 - 53:30 they have entered pregnancy we usually recommend a pea after 14 uh sorry we recommend a glucose tolerance test after 14 weeks that is the early uh ogtt and then but if you have got a patient who is really high race and you're worried about the um um you know um uh glucose intolerance uh you can do it earlier than earlier in the pregnancy like earlier than 14 weeks that's completely fine but we usually recommend after 14 weeks by the time we see them but in your practice if you're worried the patients have really high respectus high
• 53:30 - 54:00 BMI other things going on you already know that patient is insulin resistant you can do it earlier than that the problem is that that early pregnancy the patients have a lot of hyperemesis they most of the times are unable to tolerate the glucose tolerance test because it involves uh drinking a glucose dring um which they usually warm it out because of the hyperemesis um early pregnancy so yeah we usually recommend it around um 14 weeks of gestation onwards and then we do the second one in um second diester yeah so the 26 week one that
• 54:00 - 54:30 they ordered so yeah it's it's great if um if the GPS are you know doing those maternal referrals and they've got a patient who's higher risk if you know once you know you've done your um first trimester sort of Anup Ploy screen you've got a viable pregnancy then and often then the hyperemesis is settled a bit and if you can get the patient to do a glucose tolerance test and send that in with a referral that's fantastic you'll get ra yeah agree
• 54:30 - 55:00 yeah uh now do the patients with peos have gastrointestinal syndromes and food intolerances do they have increased incident I am not sure about it that they have food uh sorry Joe can you repeat yeah so do they do they have an increased incidence of GI syndromes or food intolerances I'm sure you know there's definitely a group have increased risk of um I guess is sort of some yeah because
• 55:00 - 55:30 I think so they struggle with um you know their um um with the hyperinsulinemia and uh deranged uh liver functions so I will not be surprised if they struggle with you know um uh with these problems but I think it's important to exclude other causes as well thanks um another question um I know that depression is a significant risk also I think seven times or so
• 55:30 - 56:00 compared with other women do you know if the S suicide rates are higher yes to be honest the suicide rates are higher and I think um in my um slide in the slide where I was actually discussing about the psychosexual um uh impact it's mentioned that they have higher um risk of suicidal you know intentions and there's a bit higher risk of um societal attempts and suicide in this particular group because of the body Imaging and
• 56:00 - 56:30 psychosexual impact on overall and over and affecting the overall quality of life thank you um another question you may have answered some of these if a patient has a contra indication for the combined pill what's the next option for a regular cycle yeah you can you can um do a progesteron only method so with the microl loot so yeah so you see there's a difference between microlot and slinder so slinder has drinon which works um
• 56:30 - 57:00 quite similar to Marina so um which is level not just dra um when I usually have a discussion with my patient and that's what where the decision shared decision- making you know actually comes in if they're actually looking forward to regulate the period and to have a regular cycle maybe microl loot is a better option as compared to drinon because with drinon they are going to um have a reduction in the flow and most of the times they like approximately 25 to 30% of the patients stop having behers
• 57:00 - 57:30 just like Marina so uh if this is not their goal they want to have a period Then I think micro um as a progesteron only option as a better option um as compared to all other Prestone only options currently available on in the market thank you um now another question just sorry sorry interrupt here but just keep in mind that High chances of you know uh withdraw uh like um um breakthrough bleeding with my FL with M
• 57:30 - 58:00 yeah yeah yeah and and slender you know unfortunately is more expensive so oh it's expensive you know you just only get one strip um uh and it's I think it's quite expensive um so people I mean I I think if um I mean I usually do slender as a trial so I just asked my patients to start slender um because you know a lot of these women have pychosexual and you know um ADHD and mental health concerns as well and you
• 58:00 - 58:30 know that progesterone can impact um the their their um mood and other stuff so I usually start slender as a try because it's easier to stop um and if the patients are feeling okay with Slender usually um I switch to Marina afterwards if they are okay with that so um yeah because um I've come across and we know that it's quite expensive brand yeah yeah which is an issue isn't it yeah yeah e nor thing cream is it used for
• 58:30 - 59:00 acne hutis or acanthosis Sr or alipa so I guess that's the um is we used to have it in Australia it was called Vana um I don't think it's available anymore but I think you can get it compounded you can get it compounded and um to be honest I I also can't prescribe it uh if I have a patient I us for them to a dermatologist and it's used for hutis yeah yeah okay another question uh is it
• 59:00 - 59:30 better to start treatment with a combined contraceptive pill then later add um metformin if it's necessary is that what if so if you're going to start treatment would you start treatment with um combined contraceptive pill and then consider adding met formin again it depends on you know patients preferences so if a patient uh is looking forward for a
• 59:30 - 60:00 contraception then obviously um and has a BMI of less than 25 like normal BMI patient looking forward for contraception and his sism uh you know um um effective management maybe um we can start with uh the pill which will address both but if they are high BMI and they are not looking forward for contracep ion um planning a baby in near future then maybe I think metformin only
• 60:00 - 60:30 should be your call thank you um another question what time frame after monari can you expect periods to if you've got somebody who's got irregular periods would you then consider investigating for pay costs okay so you see um one year post minarch you don't need to worry about one year post minarch if they have irregular periods is completely fine um 3 years is a long period so if someone is still getting abnormal or irregular periods
• 60:30 - 61:00 for a period approximately um of three years then it's the time to start investigations thank you and I think um Pap going have a look at the the redam um diagnostic criteria has got quite detailed explanation of how to approach the adolescence and um irregular cycles and time frames so and then it has also given a good like you know that if they have they are having um less than eight Cycles in a
• 61:00 - 61:30 year then it's time to start rolling the investigation so the new asherman um aure guidelines aser and asrm as asrm guidelines 2023 are very um you know um are I think very good um uh to address all these you know confusions and controversies yeah step yourself through it don't get sort of too tied up um and and I think um Sandy did you want
• 61:30 - 62:00 to comment on ultrasounds in adolescence looking at per CIS so no so again you know um um in adolesence uh the role is controversial one year till um like post Monarch no role uh when you're starting investigations yeah you can perform because obviously because is the diagnosis of exclusion you don't want to miss um endogen secreting tumor or a ovarian tumor which is called which is secreting Androgen so you want to don't
• 62:00 - 62:30 want to miss out on all all of these things so I think just to complete the the the the the overall um peos phenotype you can include it um but as such there's no role if you have um a clear picture of EOS in front of you yeah but I would still like to do it just to complete yeah the whole picture yeah yeah yeah um another question so jumping around a little bit here um do we have to give
• 62:30 - 63:00 microlot cyclically depending upon what the patient preferences are if they want to have you know period every month obviously they need to continue on with the pill and they when they on the pill they will get a period every month that's usually what we suggest to the patients um but if they want to skip the PS they can skip the sugar pills I guess microl doesn't have the sugar have so they just need to be on on the they just need to continue on they
• 63:00 - 63:30 just need to continue yeah and they may get breakthrough bleeding well at a regular period it's a bit unpredictable list this that's one of the thing which usually um is this is one of the factors which is responsible behind you know discontinuing microl in most of the patients because that breakthrough bleeding is so unpredictable thank you for it um another uh final question here how quickly would you um titr trate up
• 63:30 - 64:00 metformin doses for PE cost um obviously depending on GI symptoms if a patient is tolerating it I understand that maximum dose is 2 and a half grams in adults daily as per your slide also would you split the dose or not during the day so you see I usually um start with 500 milligrams um that's what being recommended and then usually I ask them to start it in the evening uh with some because of the GI effects and um then gradually increase it like maybe I'm
• 64:00 - 64:30 depending upon how the patient is tolerating it um and everyone is different so I usually ask my patients that if you have tolerated 500 milligrams well for a week then increase it to um one gram the following week um most of and it Frankly Speaking depends on what dose your patient is actually um stabilized most of the patients are stabilized on a dose between 1.5 to 2 G so you don't most of the time you're not required to go beyond 2 gam I hardly go
• 64:30 - 65:00 beyond 1.5 G because most of my patients usually respond well somewhere in between 1.5 to two gram so you are evaluating these patients on regular basis so um it is recommended that it is that you can it is advisable that you can go up to um 2.2 or 2.5 gram but in most circumstances you don't need to go that hard and do you use the um slow release formulation or yeah yes yeah it
• 65:00 - 65:30 Exel yeah okay good and I just had another question this is my one um the hipper patients um got peos and they on Metformin and they conceive what should the GP do if that patient presents in their rooms so you know so the you know there's a panic do I stop it or do I leave it on and send the keep tell them to keep going and uh send the referral in yeah you see that that's what I especially address in one of the slides but anyways I'll I'll repeat it again for you so this is a frequently Asked question from DPS you
• 65:30 - 66:00 know and and and especially for with us as well because as fertility speci or or as gynecologists we love metformin you know most of our patients fall pregnant while they are on Metformin so um uh the evidence is actually not uh sufficient enough to tell us or guide us but it's saying I mean the the the disadvantage the theoretical disadvantage of continuing metform is the childhood weight gain and child I
• 66:00 - 66:30 mean the problems with the with the child like the child can get um maybe um excessive weight um and and and things like that um later in their childhood so um usually I'm like the evidence Beyond 12 weeks is definitely missing so we usually don't ask them to continue the metformin throughout the pregnancy which I think would be more problematic but if your patient is on Metformin uh has PE call you have treated them for fertility they fall pregnant while they were on PE cause I think there is no harm in uh
• 66:30 - 67:00 this is coming from me basically it's um because the evidence is really insufficient I don't think so there's no harm in continuing metformin and progesterone um through the 12 weeks of pregnancy and then after that uh obviously you can stop it um um but I think that if they are on Metformin and they have conceived on Metformin and they are already on on progesterone or not depending um I think met forming can be continued at least till you have a dating scan where you have seen the vial
• 67:00 - 67:30 pregnancy then then you can stop yeah and then the decision will be made by specialist talk yeah by Specialists and have you see a lot of patients these days you know um maybe you have come across where endocrinologists have continued metformin through the pregnancy yeah yeah well that's great well thank you SAA for a fantastic session um lots of information there for us all to take home and sort of look at what's happening in our own practice and um continue to um improve care and
• 67:30 - 68:00 option for these patients so thank you for all the work you've done in um PR preparing this session for us and presenting tonight and thanks to Evon um behind the scenes yes thank you yeah and everybody will um receive uh the email with the recordings and please um if you can um provide the feed back to us so I think ion will send out that uh as well
• 68:00 - 68:30 um is there another slide maybe oh actually we have got slides regarding I have got some slides um with references and resources what happened yeah so there's some references and there's actually a lot of references uh and some um resources and then we have got this that's right so um so if you can um provide us feedback for the session that would be fantastic because we always like to know um what people um
• 68:30 - 69:00 you know what education you want um going forward um the uh Women's Health sessions are always popular so that's that's been great um but you know whatever else you you feel that you would need um we can um see what the Specialists we can have available to help us um with our education program so and thank you everybody for giving up your evening thanks sinina and Avon thank you yeah oh I've Lost You
• 69:00 - 69:30 Avon I can still see you on yeah she's talking but I can't hear her okay all right thank you so much for a great session all right okay thanks everyone good night good night good night good night