I. The concept of polycystic ovary syndrome (PCOS).
It is a common endocrine metabolic disease in women of reproductive age. It is often characterized by abnormal menstruation, infertility, hyperandrogenism and polycystic ovarian manifestations, and can be accompanied by metabolic abnormalities such as obesity, insulin resistance and dyslipidemia, and is a high risk factor for the development of type 2 diabetes, cardiovascular disease and endometrial cancer, which seriously affects patients’ quality of life.
Second, the concept of polycystic ovaries (PCO).
It is a description of ovarian morphology by ultrasonography. The number of follicles with 2mm-9mm diameter in one or both ovaries is ≥12, or the ovarian volume is ≥10cm3 [ovarian volume is calculated as 0.5×long diameter (cm) × transverse diameter (cm) × anterior-posterior diameter (cm)].
III. Diagnostic basis of polycystic ovary syndrome
Risk factors for polycystic ovary syndrome include the following conditions.
1. type 2 diabetes mellitus.
2, hypertension.
3, obesity.
4, early onset coronary heart disease.
5, Excessive sexual hair.
6, Positive family history of PCOS.
Clinical manifestations of polycystic ovary syndrome
Signs and symptoms.
1. Menstrual abnormalities Sporadic menstruation.
Length of menstrual cycle of 35 days-6 months.
2. Amenorrhea.
Secondary amenorrhea (menopause ≥ 6 months) is common; primary amenorrhea (no first menstruation yet at age 16) is rare.
3. Irregular uterine bleeding.
Irregularity of menstrual cycle or menstrual period or volume.
4. Hyperandrogenic symptoms.
Acne, excessive sexual hair, obesity, acanthosis nigricans.
IV. Diagnosis of polycystic ovary syndrome
Diagnostic steps
1. Medical history inquiry
Patient’s age, reason for consultation, menstrual status, such as abnormal menstruation should be carefully asked whether the type of abnormality is scanty, amenorrhea or irregular bleeding, marital status, current infertility and fertility requirements. Weight change, family history of diabetes, obesity, hypertension, excessive body hair, similar diseases. Previous relevant examination results, treatment measures and effects.
2.Physical examination
Height, weight, blood pressure, breast development, whether there is extrusion of breast milk, distribution of body hair (including axillary hair, pubic hair), whether there is acanthosis nigricans, acne, etc.
3. Gynecological examination.
Vulvar development and clitoral condition, whether the vaginal mucosa is affected by estrogen, the amount of cervical mucus, and whether there are organic diseases in the uterine body and adnexa.
4.Auxiliary and laboratory examinationsAuxiliary and laboratory examinations
5.Serum reproductive hormone concentration measurement (including FSH, LH, PRL, E2, T, P)
(1) Hyperandrogenemia
The serum total testosterone level, which is a routine clinical examination item, has no positive correlation with the degree of clinical Kaohsiung symptoms. The diagnosis of hypertestosterone is determined by our laboratory testing equipment after measuring the local population of women of normal reproductive age.
(2) Blood LH concentration and LH/FSH ratio
PCOS patients with increased blood LH levels and normal or low FSH levels, with LH/FSH ratio >2, are mostly seen in PCOS patients without obesity.
(3) Other
Blood E2 concentrations are often equivalent to mid-follicular phase levels. Some patients with PCOS may present with mildly elevated PRL levels. Occasionally, P concentrations equivalent to luteal phase levels are seen in patients with sporadic menstruation or regular menstruation.
6.Pelvic ultrasound examination
Oral contraceptives should be discontinued for at least 1 month before the ultrasound examination. In patients with regular menstruation, the examination should be performed on day 3 to day 5 of the menstrual cycle. Patients with sporadic ovulation should be retested in the next cycle if the follicle diameter is >10 mm or if the corpus luteum is present. Transrectal ultrasound is an option for those who are not sexually active, and transvaginal ultrasound is an option for other patients.
PCO is not unique to PCOS. PCO can be found in 20-30% of normal women of childbearing age. PCO can also be seen in hypothalamic amenorrhea, hyperprolactinemia and growth hormone tumors.
7.Basal body temperature (BBT) measurement
Patients should test the sublingual body temperature for 5 min every morning immediately after waking up, for at least one menstrual cycle, and record it on the coordinate paper. No activity such as getting up, talking, urinating or defecating, eating or smoking should be performed before the test. Based on the temperature curve, the presence or absence of the corpus luteum and the function of the corpus luteum can be understood, and the date of ovulation can be estimated for early diagnosis of pregnancy. If there is sexual intercourse, cold, late sleep, insomnia, medication, treatment, etc. should be indicated in the comments.
8. Screening for metabolic complications
Fasting blood glucose and 2-hour postprandial blood glucose measurement.
Fasting lipid (triglyceride, HDL cholesterol, LDL cholesterol) measurement. Liver function (ALT, AST), kidney function (BUN, CR).
V. Diagnosis and typing of polycystic ovary syndrome
Suspected PCOS.
Sporadic menstruation or amenorrhea or irregular uterine bleeding is a mandatory condition for diagnosis. In addition, the diagnosis of suspected PCOS can be made if one of the following two items is met.
(1) clinical manifestation of hyperandrogenism or hyperandrogenemia.
(2) Ultrasound demonstration of PCO.
Determining the diagnosis.
The diagnosis of suspected PCOS can only be made after the above mentioned conditions are met and other diseases that may cause hyperandrogenism and ovulation abnormalities are ruled out one by one.
PCOS staging with or without obesity and central obesity. The presence of impaired glucose tolerance, diabetes mellitus, metabolic syndrome.
PCOS can be divided into patients with classical PCOS (abnormal menstruation and hyperandrogenism with or without PCO) and PCOS without hyperandrogenism (abnormal menstruation and PCO only).
Patients with classical PCOS have more severe manifestations of metabolic disorders, while those with non-hyperandrogenic PCOS have less severe manifestations.
Diagnosis of polycystic ovary syndrome requires exclusion of diseases
Thyroid function abnormalities are excluded based on thyroid function measurements and anti-thyroid antibody measurements.
1. Hyperprolactinemia
Diagnosis is based on elevated serum prolactin measurement. MRI of the pituitary gland should be performed to check for occupational lesions and to exclude hyperprolactinemia caused by drugs or hypothyroidism.
2.Late adrenocortical hyperplasia, 21 hydroxylase deficiency
Identify on the basis of blood basal 17α hydroxyprogesterone level and 17α hydroxyprogesterone response after 60 min of stimulation of adrenocortical stimulation.
3.Cushing’s syndrome
The diagnosis is based on the measurement of circadian rhythm of blood cortisol concentration, 24-hour urinary free cortisol, and low-dose dexamethasone suppression test. Primary ovarian hypofunction or premature ovarian failure Differentiate on the basis of elevated blood FSH levels and low E2.
4. Androgen-secreting tumors of the ovary or adrenal glands
Based on clinical manifestations of masculinization, rapid progression, blood testosterone levels of 150ng/dL-200ng/dL or more, and imaging tests showing the presence of occupying lesions in the ovaries or adrenal glands.
5. Functional hypothalamic amenorrhea
Diagnosis based on normal or low serum FSH and LH, E2 equal to or lower than the early follicular phase level, and the absence of hyperandrogenemia.
6.Other
Drug hyperandrogenism must have a history of drug use, a positive family history of idiopathic hirsutism, normal blood testosterone concentration and ovarian ultrasonography.