I. What is polycystic ovarian syndrome (PCOS)?
Polycystic ovarian syndrome (PCOS) is an endocrine and metabolic disorder with a high incidence in the population, accounting for 5-10% of women of reproductive age; The second is the excess of androgens in the patient’s body. The performance of acne, often growing many small pimples, etc. The incidence of acne in PCOS patients reaches 60%, but also hairy, hair heavy, hair distribution has a masculine tendency, hairy phenomenon is not noticed by the patient, so that the beautiful girls upset, suffering from this disease, 40% to 60% of the weight will be overweight, you do not eat and drink but uncontrollably obese, mostly abdominal obesity. Some patients may also exhibit polycystic-like changes in the ovaries bilaterally. Despite the high incidence of PCOS, the public has little knowledge of the disease.
How is PCOS diagnosed?
Because of the highly diverse clinical manifestations of PCOS such as irregular menstruation, hirsutism, obesity, hyperlipidemia, various manifestations of hyperandrogenization, polycystic ovaries, insulin resistance and infertility, most patients only highlight a few of these manifestations, and there is a high degree of variability in performance, so the diagnostic criteria are often not uniform. The diagnosis of PCOS is often not standardized, but there are many overweight women who have menstrual disorders or even menopause and are declared to have PCOS.
①Sporadic ovulation or anovulation;
(2) Clinical manifestations of hyperandrogenism and/or hyperandrogenemia;
(iii) polycystic ovarian changes: ≥12 follicles of 2-9 mm in diameter in one or both ovaries and/or ovarian volume ≥10 ml. Two of the above three criteria were met, and other diseases causing hyperandrogenism such as congenital adrenocortical hyperplasia, Cushing’s syndrome, and androgen-secreting tumors were excluded. Sporadic ovulation or anovulation: manifested by two years of menarche without establishing regular menstruation or amenorrhea (menopause for more than 3 previous menstrual cycles or menstrual cycle ≥ 6 months) or sporadic menstruation (≥ 35 days and ≥ 3 months per year without ovulation). Clinical manifestations of hyperandrogenism: refers to recurrent acne on the forehead, cheeks, nose and jaw and/or coarse, hard hair on the upper lip, jaw, around the areola, and lower abdomen midline. Hyperandrogenemia refers to laboratory tests that find total testosterone, free testosterone, and free testosterone index higher than normal reference values.
Why does PCOS occur?
The cause of PCOS is still unclear, and it is speculated that it may be the result of the interaction between genes and environment. There is a certain family aggregation of these patients, many patients’ fathers have hirsutism, acne, seborrheic dermatitis, early baldness, while mothers and sisters have sparse menstruation and infertility. Environmental factors such as geography, nutrition and lifestyle are also related to PCOS.
Fourth, what are the hazards of PCOS?
The recent harm is easy to attract attention such as abnormal menstruation, especially infertility, as well as the beauty of women concerned about obesity, seat sores and hairy; but the long-term negative impact of PCOS many patients do not pay great attention to or not enough attention: PCOS has a higher chance of hyperlipidemia, hypertension, type II diabetes, myocardial infarction, gestational diabetes, gestational hypertensive disease, some malignant lesions, such as uterine endometrial cancer, etc. Since patients with PCOS often have insulin resistance, a pathophysiological state in which the insulin effector organ or site is insensitive to the physiological effects of insulin. Insulin insensitivity is not only limited to glucose metabolism, but also to lipid metabolism disorders and vascular pathology, which affect the reproductive function of female patients of reproductive age. Therefore, patients are more likely to develop hyperlipidemia, hyperglycemia, obesity and coronary heart disease, infertility, etc. Even after pregnancy, the probability of gestational diabetes and gestational hypertensive disease is significantly higher compared to normal population. Due to long-term anovulation, the ovaries continue to secrete estrogen without progesterone antagonism, resulting in excessive endometrial hyperplasia, which may lead to the occurrence of endometrial cancer in the long run.
V. What tests are usually done after the suspicion or diagnosis of PCOS?
Many patients have asked this question. Generally, we have to do.
① Sex hormone measurement: including FSH, LH, PRL, E2, T, P, etc. PCOS patients can show elevated T (testosterone), abnormally elevated LH/FSH ratio and mildly elevated PRL, etc;
(2) Ultrasound examination: pay attention to the presence of polycystic ovarian changes and ovarian tumors, etc;
③Fasting blood glucose or oral glucose tolerance test: especially for obese patients, to rule out abnormal elevation of blood glucose or even diabetes mellitus;
④Insulin level or insulin release test: to determine whether there is insulin resistance in combination with blood glucose;
⑤ Other: endometrial biopsy is used to rule out the occurrence of endometrial lesions, urinary 17-ketosteroid measurement is used to determine whether hyperandrogenemia originates from the adrenal glands, thyroid function measurement, etc.
VI. How to treat PCOS?
PCOS treatment strategy is individualized according to the pathological aspects of the disease and the patient’s needs, with the goals of regulating the menstrual cycle, anti-kaohsiung, promoting fertility, controlling insulin resistance, and preventing long-term diseases (such as type II diabetes, coronary heart disease, endometrial cancer, etc.).
(1) Treatment of PCOS patients without fertility requirements
1, the purpose of treatment: the immediate goal is to regulate the menstrual cycle, treatment of hirsutism and acne, weight control; long-term goal is to prevent diabetes, protection of the endometrium, prevention of endometrial cancer, prevention of cardiovascular disease.
2.Treatment methods.
① Lifestyle adjustment: including low-calorie diet, exercise, energy-consuming exercise, lifestyle changes, smoking cessation, alcohol cessation, etc. Research shows that: weight reduction can improve insulin resistance and reverse the endocrine disorders of PCOS, so overweight or obese people must lose weight; regulation of diet for abnormal metabolism can change or reduce clinical symptoms and facilitate the treatment of infertility, reducing the risk of diabetes and cardiovascular disease. Reducing body weight by 5% or more in obese patients can change or reduce symptoms of menstrual disorders, hirsutism, acne and facilitate the treatment of infertility. Reducing body weight to the normal range can stop the long-term development of PCOS with adverse consequences such as diabetes, hypertension, hyperlipidemia, and metabolic syndromes such as cardiovascular disease. Therefore, for patients with PCOS, choosing a low-sugar, low-fat diet and increasing exercise to reduce body weight are inexpensive, effective basic and preferred methods.
②Treatment of hyperandrogenism: Various short-acting oral contraceptives are available, and Daing-35 is preferred. Usage: Take 1 tablet daily for 21 days on the 3rd to 5th day of natural menstruation or withdrawal bleeding. Withdrawal bleeding starts about 5 days after stopping the pill, and the pill is restarted on the 5th day of withdrawal bleeding or repeatedly activated after 7 days of stopping the pill. Application can be repeated for at least 3 to 6 months. Application of Daimler-35 can improve hyperandrogenic signs, provide regular menstrual cycles, stop endometrial hyperplasia, and also assist fertility in combination with ovulation-promoting drugs, and in combination with insulin sensitizers for the treatment of obese patients with hyperinsulinemia. Precautions for the application of short-acting oral contraceptives: PCOS patients are a special group of people who often have disorders of glucose and lipid metabolism, so contraindications to oral contraceptives should be excluded before the use of the drug, and changes in blood glucose and lipids should be monitored during the use of the drug. Adolescent girls should give full informed consent before application.
③ Progestin therapy: It is mainly applied to anovulatory patients without obvious clinical and laboratory manifestations of hyperandrogenism and without obvious insulin resistance, who can be treated with regular progestin alone to restore menstruation. Advantages: restoring regular menstruation and protecting the endometrium can reduce the occurrence of endometrial cancer; it can reduce the androgen level to a certain extent. However, progesterone alone cannot change the endocrine status of patients, polycystic ovaries are difficult to improve, and the effect of lowering androgens is weak. Commonly used drugs include Amgen progesterone, progesterone capsules (Yimaxin) and Daphne for 10-14 days per month.
④Treatment of insulin resistance (IR): For patients who are obese or have insulin resistance, metformin treatment can be used. It can enhance insulin sensitivity, improve insulin resistance, and increase sensitivity to clomiphene. Dosage: 500mg twice or three times daily, 1000-1500mg/day for 3-6 months of treatment. Patient compliance is good.
(2) Treatment of patients with PCOS with fertility requirements
1.Treatment aim: to promote ovulation and to obtain normal pregnancy.
2.Treatment method: basic treatment + ovulation treatment
1.Basic treatment: lifestyle modification, treatment of hyperandrogenemia: currently TAIE-35 is preferred, treatment of insulin resistance: metformin is preferred. Same as treatment for PCOS patients without fertility requirements.
2. PCOS – ovulation promotion therapy.
① First-line ovulation treatment clomiphene: 50mg/day for 5 days starting from the 5th day of natural menstruation or withdrawal bleeding, and increase by 50mg/day until 150mg/day per cycle if there is no ovulation. It is not necessary to increase the dose if there is satisfactory ovulation. If the follicular phase is long or the luteal phase is short, it means the dose is insufficient and the dose can be increased appropriately. Basal body temperature should be tested and recorded during the cycle of clomiphene to determine the efficacy of the treatment. If the basal body temperature does not rise, transvaginal ultrasonography can be performed 7-10 days after stopping the drug. If the ovaries have near mature follicles, intramuscular HCG injection can be chosen to induce ovulation. If the amount of clomiphene is increased to 150mg/day for 5 days and still no ovulation, then clomiphene resistance is indicated.
②Second-line ovulation treatment gonadotropin therapy or laparoscopic ovarian perforation
Gonadotropin therapy: common human menopausal gonadotropins (hMG), pure FSH drugs, high purity FSH (HP-FSH), genetically recombinant FSH (r-FSH) (almost LH-free, especially for PCOS patients). It is mainly indicated in patients with clomiphene-resistant infertility, other causes of infertility having been excluded. Note that it should not be applied in patients with elevated blood FSH levels and in the absence of technical conditions for monitoring follicular development and ovulation, as the treatment can be complicated by multiple pregnancies and ovarian hyperstimulation syndrome (OHSS).
Laparoscopic ovarian perforation: mainly used for clomiphene resistance, when laparoscopy of the pelvis is required for other diseases, poor follow-up conditions and monitoring of gonadotropin therapy cannot be performed. Those with body mass index <34, lh>10 mIu/ml and high free testosterone are generally selected for treatment. Indirect regulation of the pituitary-ovarian axis by destroying the androgen-producing interstitium increases the chance of pregnancy by decreasing LH and testosterone levels. The disadvantage is that the duration of action is short and there is a risk of premature ovarian failure.
③ In vitro fertilization-embryo transfer (IVF-ET): For patients who have failed to be treated by the above methods, IVF treatment is recommended.
Whether the patient gets pregnant naturally or through medication to promote ovulation, the child born is no different from a normal person and the parents need not worry.
VII. There are often some difficulties in the treatment process of PCOS patients.
For example, adolescent PCOS patients are often unaware of the risk of potential long-term complications of problems such as hirsutism, acne, obesity, and even menstrual disorders, and patients and parents are less responsive to consultation or treatment. pCOS is an endocrine disorder, the cause of which is not fully understood, and the long-term risks are serious. The current view is that it is a lifelong disease that requires regular monitoring of patients; adjustment of medication according to treatment and the requirements of different ages; and can be costly, time-consuming, and unaffordable for patients and parents. In addition, the current understanding of PCOS is incomplete, and its etiology, endocrine biochemical features, and early diagnosis (even before puberty) are not fully understood; our current therapeutic approach may still be biased or inadequate, lacking sufficient evidence of evidence-based medicine. Therefore, long-term, prudent and closely monitored treatment of patients as well as follow-up is necessary.