Polycystic ovary syndrome (PCOS) accounts for 5-10% of women of reproductive age, which means that one out of every 10 to 20 women with menstruation suffers from this disease. It is a common disease that affects the quality of life of women and is more common among obese women, leading to menstrual irregularities, acne, hirsutism, infertility and other related problems, and needs to be treated actively once it is clearly diagnosed.
PCOS is characterized by enlarged polycystic ovaries, as well as prolonged anovulation, varying degrees of high androgen levels and hirsutism, which may be associated with future infertility, endometrial cancer, diabetes, hypertension, hyperlipidemia and coronary heart disease.
Clinical manifestations of polycystic ovary syndrome.
1. Menstrual disorders. This is the most common symptom of polycystic ovary syndrome. The normal menstrual cycle is 21-35 days. If menstruation stops for 6 months or for more than 3 months according to the original menstrual cycle, it is called secondary amenorrhea. Most of the polycystic ovary syndrome is characterized by sparse menstruation and secondary amenorrhea, which is often preceded by sparse or too little menstruation. Some people have regular menstruation but no ovulation, which is called anovulatory menstruation.
2. Infertility. About 75% of patients with polycystic ovary syndrome of reproductive age are infertile due to low ovulation or anovulation. Primary infertility (primary infertility is defined as those who have never been pregnant) is more common. In addition, there is an increased incidence of spontaneous abortion. Infertility and spontaneous abortion are the main reasons for many people to visit the clinic.
3. Hirsutism and acne. Caused by hyperandrogenism, it is the most unique clinical manifestation of polycystic ovary syndrome. It often shows a male type hair distribution, with increased sexual hair as the main cause. The main manifestations are hairy upper lip like beard; increased hair on forearm and calf; dense pubic hair, extending upward to the midline of the abdomen, extending backward to the perianal area, extending to the groin and inner thighs on both sides; occasionally there are long hairs around the areola, etc. About 78% of women with hirsutism are suffering from polycystic ovary syndrome. Oily skin and acne are also common, which is related to the body’s high androgen stimulation sebaceous gland secretion.
4. Obesity. About 50%-70% of women with polycystic ovary syndrome are obese. BMI = weight (kg) / height (m) 2. BMI in our population is normal from 18.5 to 22.9, ≥23 for overweight, ≥25 for obesity. Such as weight 68 kg, height 1.6 m, BMI of 26.6, that is, obesity.
5, acanthosis nigricans sign. Expression for the back of the neck, groin and other places of the skin folds of the skin thickening, appear gray-brown pigmentation. It is related to insulin resistance and is a potential marker of diabetes.
Currently, patients with polycystic ovary syndrome are generally treated with comprehensive therapeutic measures aimed at promoting fertility and preventing distant complications.
1. Lifestyle interventions, i.e. diet control and exercise therapy, are the preferred treatment modalities. Especially in people with combined obesity, weight loss is the basis of all treatment. Scientists have found that patients with polycystic ovary syndrome have 5%-10% weight loss and increased ovulation rate; improved insulin sensitivity, improved hyperinsulinemia and reduced the occurrence of long-term complications. A proper diet and moderate exercise are the safest and cheapest treatments for patients with polycystic ovary syndrome. The dietary principles are low salt (less than 6 g/day), low cholesterol (less than 300 mg/day), low calorie (daily calorie requirement calculated based on daily activity and obesity level), and high fiber (greater than 20 mg/day) diet. Simply put, it means eating more vegetables, fruits, coarse grains, vegetable oils (olive oil is best), and fish, supplemented by small amounts of eggs, meat, nuts, etc. Scientific exercise is another important means of weight loss. It is recommended to choose aerobic exercise, such as jogging, cycling, swimming and so on. Exercise intensity to medium intensity is most appropriate. Each exercise time lasts at least 30 minutes, 3 to 5 times a week. Exercise intensity is generally guided by heart rate, the easiest way to calculate is heart rate at quiet +2O beats/min; or use the age projection method, 170-age (years). Lifestyle changes are the main measure to lose weight and to maintain it. Only when the above treatments are not effective, the use of drugs to reduce weight should be considered.
2. Correcting endocrine disorders: The main thing is to reduce the level of androgens in the body. Da Ying 35 is an oral contraceptive that is taken from the 5th day of menstruation and applied for 21 consecutive days, with the onset of menstruation 3-5 days after stopping the drug. It usually takes 2-3 cycles. Its effective in reducing the level of androgens in the body. In addition, there are also momofolone, glucocorticoids, etc., which have the effect of lowering androgens.
3.Improve insulin resistance:Metformin is preferred. The drug can improve insulin resistance, make the patient’s testosterone level drop, acne decrease and restore ovulation. Commonly used dose of 1500-2000 mg/day, continuous application for 4-6 weeks. It is followed by rosiglitazone and pioglitazone.
4. Ovulation-promoting drug therapy.
(1) Clomiphene (CC): CC has become the drug of choice for ovulation-promoting treatment of PCOS. CC can bind to hypothalamic estrogen receptors so that the sensing of circulating estrogen levels by the central nervous system is blocked and pulsatile GnRH and gonadotropin secretion increases, further causing follicle growth and development.
(2) Gonadotropins (Gn) :In patients with CC resistance, gonadotropins are commonly used ovulation-promoting drugs, including FSH and HMG. Currently, there are various preparations of Gn, such as hMG, urinary FSH and recombinant FSH, but all are applied with the problems of high price, multiple pregnancy and risk of ovarian hyperstimulation syndrome (OHSS).
(3) Letrozole: Ovulation-promoting therapy is a new indication for aromatase inhibitors, a class of drugs previously used mainly in the treatment of breast cancer. They can be applied alone or in combination with FSH. They are mostly applied after the beginning of menstrual cycle or after progesterone withdrawal bleeding, on the 3rd-7th day of menstruation (5 days in total), 2.5-5.0 mg/day, after which the monitoring process is the same as clomiphene.
5.Surgical treatment
(1) Bilateral ovarian wedge resection: The surgery requires removal of 1/3 of the ovarian tissue. 95% of patients have been reported to resume normal menstruation after surgery, and the pregnancy rate can reach 85%, and subsequent reports have confirmed the effectiveness of this method, but the success rate varies greatly. This method is rarely used nowadays precisely because of its greater damage.
(2) Laparoscopic electrocautery or laser perforation of the ovaries The currently preferred surgical treatment is laparoscopic perforation of the ovaries using thermal penetration or laser. The response to postoperative ovulation treatment improves, the rate of multiple pregnancies decreases due to medical intervention, and the incidence of postoperative adhesions is significantly lower compared to ovarian wedge resection. The incidence of premature ovarian failure after surgery has also been reported.
6. Assisted reproductive technology
For patients with PCOS who have ovulated after more than 6 months of standard ovulatory cycles but still have not conceived, or who have not ovulated with multiple pharmacological ovulatory treatments and adjuvant therapy and are desperate for a pregnancy, embryo transfer can be an option for assisted reproduction techniques.
(1) In vitro fertilization technique ( IVF) : For patients with refractory PCOS, IVF-ET is an effective treatment method. However, due to hyperandrogenemia and insulin resistance in PCOS, which cause multiple dysfunctions of the reproductive and endocrine systems, PCOS patients are prone to hyperreactivity of Gn during IVF treatment, resulting in excessive follicle count and high blood E2, which in turn increases the incidence of OHSS
(2) In vitro oocyte maturation (IVM) IVM is a technique that simulates the maturation environment of oocytes in vivo and allows immature oocytes collected from the ovaries to reach final maturation in vitro. the clinical pregnancy rate after IVM transplantation is about 29%.