Polycystic ovary syndrome (PCOS) is an endocrine disorder in which reproductive dysfunction coexists with glucose metabolism abnormalities, and persistent anovulation, androgen excess and insulin resistance are important features.
PCOS not only affects the reproductive health and quality of life of patients because of irregular menstruation, infertility, gestational diabetes, obesity and acne, but also its abnormal endocrine and metabolic environment makes these patients more susceptible to endometrial cancer, hypertension, hypertension and hypertension. The risk of endometrial cancer, hypertension, hyperlipidemia and cardiovascular accidents also increases significantly, which also causes great psychological pressure to patients.
Early diagnosis and treatment are crucial for patients with polycystic ovary syndrome, and the Rotterdam criteria were proposed in 2003.
1. Sporadic ovulation or anovulation;
2. Clinical manifestations of hyperandrogenism and/or hyperandrogenemia;
3, polycystic ovarian changes: ultrasound suggests ≥12 follicles of 2-9 mm in diameter in one or both ovaries, and/or ovarian volume ≥10 ml;
4. 2 out of 3 items and exclude other hyperandrogenic etiologies, such as congenital adrenocortical hyperplasia, Cushing’s syndrome, androgen-secreting tumors. For PCOS patients without fertility needs, the main treatment is to lower androgen and regulate menstruation, while for PCOS patients with fertility needs, the treatment principle is to help pregnancy and raise bubbles.
I. Lifestyle adjustment
Mainly for diet control, exercise and lifestyle changes, quit smoking, alcohol, and avoid hair products. Through lifestyle adjustment, weight reduction can increase insulin sensitivity, reduce insulin and testosterone levels, thus restoring ovulation and fertility functions and stopping the long-term development of PCOS with adverse consequences such as diabetes, hypertension, hyperlipidemia and cardiovascular disease and other metabolic syndromes. The main reason for the higher rate of infertility and spontaneous abortion in PCOS patients than in healthy women is the high levels of luteinizing hormone, insulin, androgens and fibrinogen activation inhibitor-1.
Numerous studies have demonstrated that simple obesity, or even slight overweight (30 > BMI > 25), can also result in reduced fertility. The coexistence of obesity and PCOS worsens the situation, and Lintsen et al. reported that when undergoing in vitro fertilization, obese PCOS patients are less responsive to clomiphene and gonadotropin-releasing hormone, often requiring higher doses of drugs to induce ovulation; and have low oocyte production, delayed follicular development, low conception rates, and high abortion rates. In the case of obese women with PCOS, a combination of “diet + exercise + behavior” has become the primary treatment strategy for weight loss.
The purpose of diet therapy is to control the total caloric intake of the body by reducing the calories in food in order to reduce weight. It advocates a low-calorie diet, high-fiber diet, high polyunsaturated fatty acid diet, high-protein diet, and abstain from smoking, alcohol, and hairy substances (shrimp, crab, dog meat, leek, carp, carp, lettuce, bamboo shoots, pig’s feet, chicken, pumpkin, etc.). Moderate, regular and long-term aerobic exercise is the best choice for obese patients to reduce weight. 45min of oxygen-consuming exercise can improve insulin resistance through a series of effects such as improving glycogen synthesis in the liver, upregulating the expression of skeletal muscle glucose transporter protein and increasing the phosphorylation of insulin receptors.
It can be seen that enhancing exercise is an effective measure to improve insulin sensitivity in all insulin resistant individuals. Behavioral therapy emphasizes on the comprehensive understanding of the problems of diet and exercise behavior of obese patients, and starts from lifestyle intervention to fundamentally promote obese patients to change the bad habits closely related to the occurrence and development of obesity, so as to prevent and control obesity, achieve the purpose of weight reduction, and maintain the effect of weight reduction.
Second, drug treatment
1.Oral contraceptive pill
Estrogen and progestin combined cycle therapy, progestin through negative feedback inhibit pituitary LH abnormal high secretion, reduce ovarian production of androgens, and can directly act on the endometrium, inhibit endometrial hyperplasia and regulate the menstrual cycle; estrogen can promote the liver to produce sex hormone binding globulin, resulting in the reduction of free testosterone. And the combination of estrogen and progestin therapy effectively reduces the growth of new hair and acne formation. Currently, the main clinical application is ethinyl estradiol cyproterone tablets (Daing 35), which are started on the fifth day of menstruation and renewed for 21 days, and the course of treatment is usually 3-6 months and can be repeated. This drug treatment method is only for infertile patients.
2.Androgen-reducing drugs
Spironolactone
Spironolactone is an aldosterone antagonist, which can inhibit 5-a reductase activity. High-dose application has a moderate anti-androgenic effect, and its effect of controlling hirsutism is more obvious than that of oral short contraceptives, which can promote each other and be used simultaneously with oral contraceptives. It is generally well tolerated and occasionally causes fatigue, postural hypotension, dizziness, and may lead to menstrual irregularities when given in high doses alone.
Metformin
Metformin is a biguanide hypoglycemic agent that inhibits hepatic glucose production, reduces intestinal glucose uptake, increases insulin sensitivity and lowers insulin levels in peripheral tissues, alters the effect of insulin on ovarian androgen synthesis, promotes follicular membrane cell proliferation and endometrial growth, and may improve ovulation, menstruation, and reduce body weight. The starting dose (500mg/day) is taken between meals and increased by 500mg per week, with a target dose of 1500 to 2550mg/day. A growing body of data supports its safety throughout pregnancy and results in a significant reduction in the incidence of gestational diabetes.
Glucocorticosteroids
For polycystic ovary syndrome in which the excess androgens are of adrenal origin, or of mixed adrenal and ovarian origin. The commonly used drug is dexamethasone, 0,25mg orally every night, which can effectively inhibit the concentration of dehydroepiandrosterone sulfate.
3.Ovulation induction
For PCOS patients with fertility requirements, ovulation induction therapy can be performed after basic treatment such as lifestyle adjustment, anti-androgen and improvement of insulin resistance.
3.Surgical treatment
Laparoscopic ovarian perforation (LOD), which is performed under direct laparoscopic view using electrocoagulation or laser to make holes on the ovarian surface, usually about 4-10 holes per ovary, with a depth of 4-10 mm. it is currently believed that the mechanism of LOD for Pc0S is similar to that of ovarian wedge resection, by destroying part of the ovarian tissue, reducing ovarian-derived androgen secretion, ameliorating the adverse effects of the hyperandrogenic environment in the ovary on follicle growth. At the same time, the reduction in the conversion of peripheral androgens to estrogens and the decrease in peripheral blood estrogens leads to a weakening of the negative feedback effect of estrogens and a rise in FSH through the regulation of the hypothalamic-pituitary-gonadal axis.
In this way, the follicles are recruited, grow, mature and finally ovulate through the local and organismal environment of the ovaries. A slight decrease in ovarian reserve function in patients with PCOS after laparoscopic bilateral LOD does not usually lead to the development of POF. The long-term effects on the ovarian reserve function of patients need to be further investigated.