Polycystic ovarian syndrome (PCOS) is a syndrome characterized by hyperandrogenism, ovarian dysfunction, and polycystic ovaries. PCOS can cause a range of metabolic disorders, including an increased risk of diabetes and cardiovascular disease, so these factors need to be taken into account in long-term treatment.
Evaluation of patients with polycystic ovary syndrome
Physical examination
Blood pressure
Body mass index BMI (weight (kg) divided by height (m) squared)
25-30 is considered overweight, >30 is obese
Waist circumference to determine body fat distribution
Waist circumference greater than 35 inches is considered abnormal
The presence of hyperandrogenemia and insulin resistance erythema
Acne, hirsutism, androgenic baldness, acanthosis nigricans
Laboratory tests
Biochemical confirmation of hyperandrogenemia
Total testosterone and sex hormone binding globulin or biologically active free testosterone
Exclusion of other causes of hyperandrogenemia
Elevated levels of thyroid-stimulated hormones (thyroid dysfunction)
Prolactin (hyperprolactinemia)
17-OH progesterone (non-classical congenital adrenal hyperplasia due to 21-hydroxylase deficiency)
Random free level below 4ng/ml or morning fasting level below 2ng/ml
Consider screening for Cushing’s syndrome (Cushing’s syndrome) and other rare conditions such as acromegaly
Evaluation of metabolic abnormalities
2-hour oral glucose tolerance test (fasting glucose below 110mg/dl is normal, 110 to 125mg/dl is impaired fasting glucose, above 126mg/dl is type 2 diabetes), followed by 75g of glucose orally and glucose level measured 2 hours later (below 140mg/dl is normal glucose tolerance, 140-199mg/dl is impaired glucose tolerance, above 200mg/dl for type 2 diabetes)
Fasting lipid and lipoprotein levels (total cholesterol and HDL below 50mg/dl are abnormal, triglycerides above 150mg/dl are abnormal, [LDL is usually calculated using Friedewald’s equation])
Ultrasonography
Diagnosis of polycystic ovaries: greater than or equal to 12 immature follicles of 2 to 9 mm in diameter in one or both ovaries, or an increase in the volume of the ovary (more than 250 px3). If the follicles are larger than 10 mm, a new measurement at the early follicular stage is required to calculate the ovarian volume and area. Polycystic changes in one ovary are diagnostic.
Identification of abnormal endometrium
Other tests to consider
Testing for gonadotropins to determine the cause of amenorrhea
Fasting insulin levels in young women with insulin resistance and erythema of hyperandrogenemia or those undergoing ovulation induction
24-hour urinary free cortisol secretion test or low-dose dexamethasone suppression test in women with delayed onset polycystic ovary syndrome or erythema of Cushing’s syndrome
Etiology
The causative genes associated with PCOS are not known and there are no recommended genetic screening methods. Insulin resistance may be an important cause of PCOS. PCOS may be aggravated by the presence of obesity. However, obesity is not a diagnostic criterion for PCOS, and approximately 20% of patients with PCOS are not obese.
Clinical presentation
PCOS usually presents with menstrual disorders (ranging from amenorrhea to menorrhagia) and infertility.
Skin manifestations, especially symptoms caused by increased peripheral androgens such as hirsutism and acne, and more rarely androgenic baldness, are common in patients with polycystic ovary syndrome. patients with PCOS are at increased risk for insulin resistance and related disorders such as metabolic syndrome, nonalcoholic fatty liver disease, and obesity-related disorders such as sleep apnea. In recent years, awareness of PCOS-related mood disorders and depression has gradually increased.
Precautions and recommended norms in the clinic
In obese women with PCOS, does weight loss improve ovarian function?
Obesity primarily causes fertility and metabolic abnormalities in patients with PCOS. Several studies have shown that weight loss reduces circulating androgen levels improving the main factors of the endocrine syndrome in PCOS patients, leading to the restoration of menstruation. Weight loss has been associated with increased pregnancy rates, reduced hirsutism, and improved blood glucose and lipid levels.
What is the best treatment option for menstrual disorders in women with PCOS without fertility requirements?
Combined hormonal contraceptives
There are many options for treating menstrual problems in PCOS. Combined low-dose hormonal contraceptives are the most commonly used long-term treatment option and are the primary medication recommended for menstrual disorders.
Progestins
No studies have been conducted on the long-term use of methacholine acetate or intermittent oral methacholine acetate for the treatment of hirsutism.
Insulin sensitizers
Drugs initially used to treat type 2 diabetes are also used to treat PCOS. most studies have begun to focus on drugs that improve peripheral insulin sensitivity by lowering circulating insulin levels.
What is the best medical treatment for reducing cardiovascular disease and diabetes in PCOS without fertility requirements?
Lifestyle modifications are the best way to reduce the risk of cardiovascular disease and diabetes. Insulin sensitizers and statins may also be considered.
Lifestyle modifications
There is consensus that increased exercise and dietary modifications can reduce the risk of diabetes in a manner consistent with, if not superior to, medications.
Insulin sensitizers
The Diabetes Prevention Program states that metformin can delay progression to diabetes in high-risk populations (e.g., those with impaired glucose tolerance) and that many glucose-lowering drugs can replicate similar outcomes when used in high-risk populations.
Statins
Another area of growing evidence regarding the cardiovascular disease and endocrine benefits of PCOS is in the use of statins (58). However, their long-term effect on the prevention of cardiovascular disease in young women with PCOS, especially in adolescent women, is unclear.
Combined hormonal contraceptives and progestins
There is no evidence that combined hormonal contraceptives and progestins have side effects that increase the risk of diabetes and cardiovascular disease in PCOS, and therefore, these drugs can be used.
Which method of ovulation induction is effective for women with PCOS who have fertility requirements?
For women with PCOS, there is no evidence-based model to guide the initial and subsequent selection of an ovulation-inducing regimen. The recent joint meeting of the American Society for Reproduction and the European Society for Human Reproduction and Embryology (ASRM/ESHRE) recommended that preconception counseling should emphasize the importance of lifestyle, especially weight loss and exercise, smoking cessation, and alcohol reduction in overweight women before initiating any intervention.
The recommended first-line treatment option to induce ovulation remains the anti-estrogenic drug clomiphene. If pregnancy is not achieved with clomiphene, the recommended second-line options are exogenous use of gonadotropins or laparoscopic ovarian surgery.
Clomiphene
Clomiphene has traditionally been the first-line treatment for anovulatory women, including PCOS, and several multicenter randomized controlled studies have supported clomiphene as a first-line treatment option.
Alternatives to clomiphene are also available, including extended duration of oral dosing, pretreatment with oral contraceptives, and the addition of dexamethasone. In clomiphene-resistant PCOS, the addition of dexamethasone as adjunctive therapy to clomiphene may promote ovulation and pregnancy rates.
Gonadotropins
Gonadotropins are often used to induce ovulation in PCOS that has failed clomiphene treatment.
Ovarian perforation
The value of laparoscopic laser or transthermal ovarian perforation as a primary treatment for women with anovulation or low fertility in PCOS is uncertain, so this is primarily used as second-line therapy.
Aromatase inhibitors
Several small studies have used aromatase inhibitors such as letrozole and anastrozole as first- and second-line treatments for ovulation induction, with results similar to those of clomiphene.