(A) Characteristics of polycystic ovary syndrome
For example, 70% of PCOS patients have polycystic ovarian changes, while 16% to 22% of the normal population also have polycystic ovarian changes, which means that polycystic ovarian syndrome is not equal to polycystic ovarian changes;
2. incurability Polycystic ovary syndrome is a lifelong disease that cannot be cured. Therefore, do not expect to be cured with a few times of medication. When we adjust the menstrual cycle for 3-6 months, we can stop the medication and observe. If the menstruation is still bad, don’t be confused, and the patient should accept the fact that this disease cannot be eliminated and is a lifelong disease;
3. Progressive development of the disease If PCOS is not treated, it will get metabolic disease, cardiovascular disease and endometrial cancer 10 to 20 years earlier than its peers, so it needs to be treated actively.
(B) Causes of polycystic ovary syndrome
It is mainly related to genetic and environmental factors. PCOS is an autosomal dominant disorder in which 50% of her mother and sisters are likely to have the disease. The mother’s irregular menstruation, father’s early baldness, and father’s hypertension are the three major independent genetic factors; followed by father’s diabetes and mother’s hirsutism are also related genetic factors. (ii) Environmental influences: such as high intrauterine androgenic environment, low birth weight children, geographical growth environment, and
(C) Diagnostic criteria for polycystic ovary syndrome
As we all know, we used to use the Rotterdam criteria, two out of three: ① irregular menstruation, sporadic ovulation, ovulation disorders; ② hyperandrogenism or hyperandrogenemia; ③ ultrasound showing polycystic ovarian changes. 2011 our national diagnostic criteria: irregular menstruation, sporadic ovulation, ovulation disorders as a necessary condition for diagnosis (also can be seen that the country attaches importance to fertility and ovulation), the other two choose one. These diagnostic criteria do not include elevated LH as a diagnostic criterion for PCOS. These diagnostic criteria do not include elevated LH as a diagnostic condition because one-third of people with PCOS do not have high LH. This group of patients can affect the amplitude of LH release by reducing it if they are obese and develop leptin resistance or severe insulin resistance, so that the measured LH is not high. If high LH is found in the early follicular phase, careful physical examination and related tests are needed to exclude PCOS.
(D) Clinical manifestations of polycystic ovary syndrome
1. Ovulation disorder It can lead to menstrual irregularities, infertility and endometrial lesions. Menstrual scarcity is defined as menstrual cycle ≥ 35 days, or ≥ 3 months per year without ovulation; amenorrhea is defined as menopause ≥ 6 months, or greater than 3 previous menstrual cycles. By menstruation we mean that there is ovulation in the middle of the menstrual cycle, progesterone is produced, and the endometrium peels off and bleeds under the full transformation of progesterone before it is called menstruation. There are 1% to 3% of people with normal menstruation who are anovulatory. Why can anovulation have regular menstruation? There are four clinical types of bleeding: estrogen withdrawal bleeding, estrogen breakthrough bleeding, progesterone withdrawal bleeding and progesterone breakthrough bleeding. If there is no ovulation but regular menstruation is generally considered to be estrogen withdrawal bleeding, when it is possible for the endometrium to be completely exfoliated and clinically manifested as regular menstruation. Therefore, ovulation can be monitored in patients with suspected ovulation disorders, which can be determined by: basal body temperature monitoring, ultrasound follicle monitoring, and progesterone check 5 to 9 days before the next menstrual period. It is important to emphasize here that ultrasound monitoring of ovulation is the most intuitive. We all know that in 10% of people with normal menstruation, follicular luteinization non-rupture syndrome occurs. Because of luteinization, basal body temperature can be biphasic, and progesterone check 5 to 9 days before menstruation is also relatively high. However, if the follicle does not rupture, the egg cannot be ovulated and conception is not possible. Therefore, ultrasound detection of ovulation is more accurate and most intuitive among the three options.
2. Hyperandrogenemia or clinical manifestations After estrogen and androgen enter the blood, most of them are combined with sex hormone binding proteins and very little is free, while the free hormones are active and the bound hormones are inactive. Take testosterone as an example, 19% of testosterone is combined with albumin after entering the blood, 80% is combined with SHBG, the sex hormone binding protein, and only 1% is free. The androgens measured in clinical tests are total testosterone, while we need to measure free testosterone, but the current technology cannot reach it, so the clinical performance of Kaohsiung is more important than the determination of blood androgen level, and we need to pay attention to the clinical performance of hyperandrogenism. There are 3 main clinical manifestations of hyperandrogenism: ① Hirsutism: Hirsutism refers to the increase of sexual hair, i.e. women grow hair in places where they should not grow hair, such as around the lips, jaw, around the areola, under the umbilicus, on the pubic symphysis, and the root of the thighs, etc.; ② Acne: Acne mostly occurs in the face, forehead, back, etc. for 3 consecutive months; ③ Hyperandrogenic alopecia.
3. polycystic ovarian-like changes The number of follicles with 2-9 mm in one or both ovaries ≥12 or ovarian volume ≥10 cm3 on ultrasound is diagnostic of polycystic ovarian-like changes, which requires ultrasound examination in early follicular phase or in the absence of dominant follicles. If there is a primary follicle larger than 10 mm in diameter or if a corpus luteum is present, it should be evaluated again in the next cycle, preferably with a vaginal ultrasound (rectal ultrasound can be done in unmarried women).
4. metabolic syndrome Patients with PCOS will get metabolic diseases such as hypertension, hyperlipidemia and diabetes 10 to 20 years earlier than their peers. The following to talk about obesity-related issues, polycystic ovary syndrome has 50% of people with obesity, mostly abdominal obesity, that is, apple obesity. Normal female obesity should be pear-shaped obesity, that is, fat is mainly hoarded in the buttocks and thighs, while male obesity is apple-shaped obesity, fat is mainly hoarded in the abdomen. Apple type obesity is very unfavorable to health, because at this time the abdominal organs also have a lot of fat, so very easy to get metabolic diseases. If women lose weight for beauty, men lose weight for health. obesity caused by PCOS is mostly apple obesity, which can cause ① leptin resistance: can directly act on follicles, inhibit follicle development; can make the central GnRH amplitude decrease, thus making LH lower; can inhibit the conversion of androgens to estrogen, thus making androgens higher; can lead to insulin resistance; ② insulin resistance: A: can lower sex hormone binding protein, thus elevating free estrogen and androgen; B: can lower insulin-like growth factor 1 binding protein, thus elevating free insulin-like growth factor 1, thus elevating androgen; C: can act directly on follicular membrane cells, increasing androgen production; D: can act directly on pituitary gland, causing ACTH (adrenocorticotropic hormone) elevated, thus increasing androgens of adrenal origin; E: long-term insulin resistance can lead to hypertension, hyperlipidemia, and atheromatous plaque formation.
5. Endometrial lesions PCOS itself is an ovulation disorder, without ovulation there is no progesterone production and the endometrium is under the effect of single estrogen for a long time will lead to endometrial lesions. In patients with polycystic ovary syndrome, because they often have high androgens and obesity, obese patients have more fat cells and more aromatase, because androgens produce estrogen under the action of aromatase, when PCOS patients have high androgens and more aromatase, more estrone is produced; in addition, because obesity reduces sex hormone binding protein, thus increasing free estrogen, overall The relative increase of estrogen in patients with PCOS amplifies the proliferative effect of estrogen on the endometrium, thus increasing the incidence of endometrial lesions, which is 2.7 times higher in patients with PCOS than in normal subjects.
(E) Diagnostic staging of polycystic ovary syndrome
Patients with PCOS are often divided into 2 categories: one is classical PCOS with abnormal menstruation and hyperandrogenism, with or without ovarian polycystic-like changes; this type has more severe metabolic disorders; the second category is without the manifestation of hyperandrogenism, only abnormal menstruation and ovarian polycystic-like changes; this type has less severe metabolic disorders.
(F) Treatment of polycystic ovary syndrome
1. improve lifestyle, eat less fatty food, strengthen exercise and control weight.
2. Because patients with polycystic ovary syndrome are prone to metabolic diseases and cardiovascular diseases, they need to check relevant tests such as liver function, kidney function, blood lipids, blood glucose, insulin including nail function, etc. If there are problems, they should be treated symptomatically.
PCOS is a disorder of ovulation, without ovulation there is no progesterone production, and the endometrium is under the effect of single estrogen for a long time, which will lead to irregularity.
For your understanding, here are my summary of the types of progestins, which have three main categories.
(1) The first category is the oral progestins: progesterone, dydrogesterone, and methylhydroxyprogesterone. For progestin supplementation, not only must the dose be given in adequate amounts, but the duration of use must also be achieved in order to adequately prevent endometrial cancer. The dose of progestin used (daily endometrial dose of transformation): progesterone 200-300mg/day, medroxyprogesterone 5-10mg/day, and dydrogesterone 10-20mg/day; the time of using progestin: if progestin is used monthly for 7 days the incidence of endometrial cancer is 3%-5%, for 10 days the incidence is 2%, and for more than 12 days the incidence is 0;
(2) The second category is compounded short-acting oral contraceptives: it is a compounded preparation of estrogen and progestin, but the progestin activity is the strongest, and its progestin activity is more than ten times that of estrogen, so it can also be seen as highly effective progestin from another perspective, so it can be used to regulate menstruation;
(3) The third category is the Mannophone ring: the levonorgestrel it contains is also a highly effective progestin, so it can also be used to treat anovulatory abnormal uterine bleeding and protect the endometrium.
PCOS patients can take progestin supplements in the second half of each monthly cycle or for 40 days without a period, after pregnancy has been ruled out. As long as it is ensured that for at least 2 months, the endometrium can be fully transformed by progesterone, it can prevent the occurrence of endometrial lesions (another purpose of relaxing to 40 days is that patients will usually recover on their own by losing weight and improving their lifestyle, and if they already have regular menstruation, they do not need progesterone supplementation); you can also use compounded short-acting oral contraceptives, which can lower androgens in patients with high androgens. It can also protect the endometrium (in the compound short-acting oral contraceptives, ethinyl estradiol can increase the sex hormone binding protein, thus reducing the free androgen; the contraceptives contain highly effective estrogen and progestin, so they can inhibit the gonadal axis, inhibit follicular development and reduce LH, because the follicular membrane cells produce androgens from cholesterol under the action of LH, androgens enter the granulosa cells, and FSH promotes aromatase activity, converting androgens into estrogens. This is the two cell-two gonadotropic theory. Therefore, when LH is lowered with the pill, androgens are also lowered). You can try to stop using the pill for 3 to 6 months for observation, because PCOS is a lifelong disease and cannot be removed from the root, so if menstruation is still disordered, you need to treat with the pill or progestin again.
4. If the patient has fertility requirements, ① If you have metabolic disease, first control your weight, improve your lifestyle and correct the metabolic disease. Because if not corrected well, ovulation promotion is not effective and it is not easy to conceive; even if conception occurs, because these indicators will affect the development of the fertilized egg, so the miscarriage rate is high; even if the early stage is not miscarried, in the middle and late stages of pregnancy, it is very easy to develop gestational hypertension, gestational diabetes and other diseases; so first control weight and correct metabolic diseases before pregnancy; ② For patients with high LH, many studies show that in the early follicular stage (2) For patients with high LH, many studies have shown that in the early follicular stage, normal LH should be less than FSH. perforation; the third line of treatment is assisted reproductive technology.
This patient is 21 years old and has been sexually active without contraception for 1 year without pregnancy. The patient has scanty menstruation and clinical manifestations of hyperandrogenism. Other ovulation disorders and hyperandrogenic diseases are excluded and the current diagnosis is polycystic ovary syndrome.
The first thing to do is to sow the seeds, that is, the sperm and eggs, the follicles should be able to grow and ovulate, and the ovarian function should be checked, and the lover should check the semen. Fallopian tube angiography. Fertility testing should follow a simple to complex, non-invasive to invasive approach. Hysterosalpingogram is invasive, and the conception rate is highest within six months after hysterosalpingogram, so we have to seize this six months to guide pregnancy, so we have to put tubal examination to the last step.
This patient has PCOS with ovulation disorder and a body mass index of 31kg/m2, so the current treatment.
1. lose weight and improve lifestyle;
2. check liver and kidney function, blood lipids, blood sugar, insulin including nail function, etc., if there are problems, treat them symptomatically;
3. During this period, regular supplementation of progesterone to adjust the menstrual cycle and protect the endometrium is sufficient;
4. Wait until all indicators are normal before proceeding to ovulation promotion treatment.