Polycystic ovary syndrome (PCOS) is a common clinical condition in gynecological endocrinology and has a large patient population in China.
The etiology of PCOS is still unclear, and the current diagnostic criteria are the expert consensus on the diagnosis and treatment of PCOS issued by the Endocrinology Group of the Obstetrics and Gynecology Branch of the Chinese Medical Association, which is suitable for the current Chinese situation.
A, the diagnosis of PCOS
1, PCOS diagnostic criteria.
1, sporadic ovulation or anovulation: 2-3 years after the establishment of menarche cannot establish regular menstruation; amenorrhea (menopause for more than 3 previous menstrual cycles ≥ 6 months); sporadic menstruation, that is, cycles ≥ 35d and ≥ 3 months per year who do not ovulate; regular menstruation can not be taken as a regular with ovulation;
2, the clinical manifestations of hyperandrogenemia and hyperandrogenemia: seat sores (recurrent seat sores, often located in the forehead, cheeks, nose that is the jaw area), hirsutism (coarse and hard hair on the upper lip, jaw, around the areola, lower abdomen midline and other parts); total testosterone, free testosterone index or free testosterone is higher than the laboratory reference normal value;
(3) polycystic ovarian-like changes: ≥ 12 follicles of 2-9 mm in diameter in one or both ovaries, and/or ovarian volume ≥ 10 ml; (4) two of the above 3 items are met, and other diseases causing elevated androgen levels and other diseases causing ovulation disorders are excluded.
2. Exclusion criteria for the diagnosis of PCOS.
Exclusion criteria are necessary for the diagnosis of PCOS, such as elevated prolactin levels, due to exclusion of pituitary tumors, 20%-35% of patients with PCOS can be accompanied by a mild increase in prolactin; if there is sporadic ovulation or anovulation, follicular estrogen (FSH) and estradiol levels should be measured to exclude premature ovarian failure and central amenorrhea, etc.; thyroid function should be measured to exclude hypothyroidism due to If hyperandrogenemia or obvious clinical manifestations of hyperandrogenism, atypical adrenocortical hyperplasia, Cushing’s syndrome, and androgen-secreting tumors should be excluded.
Second, the treatment of PCOS
(A) Lifestyle adjustment
PCOS patients, regardless of whether they have fertility requirements, should first make lifestyle adjustments, quit smoking and alcohol. Obese patients through a low-calorie diet and energy-consuming exercise, simplified 5% or more of all body weight, can change or reduce menstrual disorders, hairy, seat sores and other symptoms and conducive to the treatment of infertility. Weight loss to normal range. It can improve insulin resistance and organize the adverse consequences of long-term development of PCOS, such as diabetes, hypertension, hyperlipidemia and cardiovascular disease and other metabolic syndromes.
(ii) Adjustment of menstrual cycle
Irregular menstruation in PCOS patients can be manifested as irregular menstrual cycle, scanty menstruation, low volume or amenorrhea, and some bleeding is unpredictable. Adjusting menstrual cycle can protect the endometrium and reduce the occurrence of endometrial cancer.
1.Oral contraceptives: You can choose various short-acting contraceptives, among which progestin, can convert the endometrium, thus reducing the occurrence of endometrial cancer. Conventional usage makes taking 1 tablet daily for 21 days on the 1st-5th day of menstruation or withdrawal bleeding. After 5 d of discontinuation but withdrawal bleeding, the drug can be reintroduced on the 5th day of withdrawal bleeding. It can be repeated for at least 3-6 months. Oral contraceptives can correct hyperandrogenemia and improve the clinical manifestations of elevated androgen levels, as well as effective contraception, improve the state of the endometrium and prevent the occurrence of endometrial cancer.
2.Progestin: For anovulatory patients without obvious clinical and laboratory manifestations of elevated androgen levels and without obvious insulin resistance, regular progestin therapy can be used alone to improve the endometrial state with cyclic withdrawal bleeding. Commonly used progestins include amnestic progesterone, micronized progesterone, dextran, and progesterone. The return usage makes MPA 6mg/d in the second half of menstrual cycle, or micronized progesterone 200mg/d, or dydrogesterone 10-20mg/d, 10d per month, at least once every two months for withdrawal bleeding; progesterone can be injected intramuscularly for 5-7d for withdrawal bleeding, and more than 10d intramuscularly is needed to protect the endometrium if applied for a long time.
Advantages of progesterone.
1.Adjust the menstrual cycle, protect the endometrium and prevent the occurrence of endometrial cancer;
2.It can reduce the androgen level to a certain extent by slowing down the frequency of LH pulse secretion;
3. It is suitable for patients without severe hyperandrogenemia and metabolic disorders.
(C) Treatment of hyperandrogenism
Various short-acting oral contraceptives can be used for the treatment of hyperandrogenemia, with compound cyproterone acetate (Dain-35) being the first choice; it can inhibit high levels of androgen production in follicular membrane cells by suppressing hypothalamic-pituitary LH secretion. Usually seizures need to be treated for 3-6 months, but the symptoms of elevated androgen levels will return after stopping the drug.
(iv) Ovulation promotion therapy
In order to achieve ovulation and normal pregnancy in anovulatory patients, ovulation-promoting treatment is often required.
Clomiphene citrate (, CC):: 50mg/d for 5d starting from the fifth day of natural menstruation or withdrawal (progesterone 20mg, qd, intramuscular injection for 3d) bleeding, and increasing by 50mg/d per cycle until 150mg/d if there is no ovulation; with satisfactory ovulation there is no need to increase the dose, if the long follicular phase or short luteal phase indicates that the dose may be low, the dose can be increased appropriately; efficacy judgment BBT can be tested and recorded, but vaginal or rectal ultrasound can also be used to monitor follicular development in order to prevent excessive follicular growth or to observe the exact efficacy.
Clomiphene citrate has a weak anti-estrogenic effect and can affect the cervical mucus, the mirror should not survive penetration; it can also affect the development of the endometrium at the fallopian tube level, which is not conducive to embryo implantation. Occasionally patients cannot tolerate this drug.
(E) Treatment of insulin resistance
Metformin is indicated for the treatment of patients who are obese or have insulin resistance; metformin improves insulin resistance and prevents metabolic syndrome by enhancing glucose uptake by peripheral tissues, inhibiting hepatic gluconeogenesis and enhancing insulin sensitivity at the post-prandial level, and reducing postprandial insulin secretion.