Polycystic ovary syndrome (PCOS) is a common gynecologic endocrine disorder with multiple causes and symptoms, mainly follicular development disorders. PCOS accounts for 5% to 10% of women of childbearing age and 30% to 60% of patients with anovulatory infertility, with some reports as high as 75%.
Etiology of PCOS
The exact cause of PCOS is still unclear, and studies have shown that it may be caused by the interaction of certain genes and environmental factors.PCOS has a family aggregation phenomenon, and is currently considered a polygenic genetic disease, although the exact genes are not clear, and may involve insulin action-related genes, high androgen-related genes and chronic inflammatory factors, as a genetic disease, so the disease is It cannot be cured and requires long-term medication to control. Environmental factors including intrauterine hyperandrogenism, antiepileptic drugs, geography, nutrition and lifestyle may be high risk factors for PCOS.
Clinical manifestations of PCOS
PCOS patients have different manifestations, which are different from the traditional somatic diseases that we are familiar with (for example, we are familiar with pneumonia, the common symptoms of pneumonia are chest pain, breath-holding fever, etc., all the clinical manifestations are common to almost all pneumonia patients), the clinical manifestations of PCOS are different, the laboratory tests and auxiliary tests vary greatly, and almost no one clinical manifestation is common to all, which is This is the main reason why there are no uniform diagnostic criteria for PCOS.
1, sporadic ovulation or anovulation: sporadic ovulation is considered as sporadic ovulation if the menstrual cycle is greater than 35 days, anovulation is the absence of menstruation or amenorrhea, but it should be noted that there are individuals who have regular menstruation and still do not ovulate, which requires basal body temperature measurement or follicle monitoring with ultrasound to determine whether there is ovulation.
2. Infertility: Most patients are infertile after marriage, with occasional ovulation or pregnancy.
3. Performance of hyperandrogenism and/or hyperandrogenemia: The performance of hyperandrogenism is mainly acne and hirsutism (characterized by coarse and hard hair on the upper lip, jaw, around the areola, lower abdomen, etc.), coarse skin pores and masculine changes (obvious throat knots, thick voice, thick muscles, etc.); hyperandrogenemia refers to total testosterone, free testosterone index or free testosterone higher than the normal value.
4, overweight or obesity: the internationally used method to determine obesity is body mass index (BMI), that is, weight (kg)/height 2 (m2), BMI <15 for wasting, 15 to 22 for normal, >24 for overweight, >27 for obese.
5, acanthosis nigricans is a skin manifestation of severe insulin resistance. Often, gray-brown, flaky hyperkeratosis of the skin is found in the vulva, groin, under the bottom of the heart, and the back of the neck, where there is frequent movement. This is a skin manifestation unique to patients with severe insulin resistance, but is not seen in all patients with insulin resistance.
6, LH/FSH ratio imbalance: manifested by high LH and FSH equivalent to early follicular levels, LH/FSH ≥ 2 to 3. Sometimes the prolactin level may also be elevated in some patients, but physiological causes should be excluded.
7, insulin resistance: In PCOS, almost all of the distant and are disorders are due to insulin resistance. First of all, the hyperandrogenemia of PCOS causes male-type obesity, and obesity will cause the surrounding tissues to decrease the utilization of insulin and produce resistance to insulin. In addition to obesity causing insulin resistance, there is a unique basis of insulin resistance, and PCOS patients without obesity also have hyperinsulinemia. When insulin resistance gradually aggravated, eventually appear clinical diabetes
8. polycystic ovarian changes: ≥12 follicles (2-9 mm in diameter) in one or both ovaries, and/or ovaries ≥10 ml in diameter.
Finally, it should also be noted that patients with atypical adrenocortical hyperplasia, Cushing’s syndrome and androgen-secreting ovarian tumors may also have hyperandrogenic manifestations or hyperandrogenemia.
Treatment of PCOS
The treatment of PCOS aims to reduce the level of androgens and the intensity of their biological effects on target organs, improve insulin sensitivity in peripheral tissues, restore normal follicular development and ovulation, transform the endometrium under the continuous action of estrogen, and prevent gestational diabetes and gestational hypertension syndrome. Different treatment plans are needed depending on whether the patient has fertility requirements or not.
For patients with fertility requirements: The goal of treatment is to induce ovulation in anovulatory patients and to obtain a normal pregnancy. Assisted reproductive technology is not the first choice. Ovulation promotion may include weight loss, pretreatment with clomiphene, birth control pills, pretreatment with gonadotropins, pretreatment with insulin sensitizers, ovarian wedge resection or perforation, and finally, all ovulation promotion methods may fail with assisted reproductive technology. All such assisted conception measures should be performed using highly individualized protocols.
Weight gain is a very serious problem among patients and can lead to menstrual disorders, infertility, and poor pregnancy outcomes. Weight loss can be effective in improving ovulation and pregnancy rates. The literature reports that a 10-15% weight loss can be effective in improving ovulation rates, self-esteem, and endocrine indicators, all through exercise and diet control.
Oral contraceptives are also used as a pre-treatment for PCOS to control androgen levels. The pills contain two hormones, estrogen and progestin, and most oral contraceptives take ethinyl estradiol, which suppresses circulating LH levels, inhibits pituitary LH synthesis, and increases circulating levels of sex hormone binding proteins. It is different from other oral contraceptives in that it also has a special effect of lowering androgen levels, making it an ideal drug for treating high androgens in PCOS.
After weight loss and androgen lowering treatment, if ovulation has not occurred, ovulation can be promoted with medications, preferably clomiphene orally, and controlled ovulation with gonadotropins if clomiphene is not effective. For controlled ovulation, it often leads to multiple follicle development, increasing the risk of ovarian hyperstimulation syndrome, and the medication is expensive and needs to be monitored closely.
Another method often used to treat anovulation in PCOS is laparoscopic ovarian wedge resection or perforation. Because wedge resection is so damaging to ovarian function, it is rarely used and laparoscopic perforation of the ovaries is now the main technique used. Ovarian perforation can destroy the androgen-producing interstitium of the ovary and indirectly regulate the pituitary-ovarian axis, but since this type of ovarian perforation can also cause damage to the function of the ovary, and there are reports of premature ovarian failure after ovarian perforation, it should be applied with caution and appropriate indications should be selected for the procedure.
For patients with insulin resistance, we can use insulin sensitizers for treatment, and the most commonly used insulin sensitizer is metformin. Metformin can induce ovulation in PCOS patients, and it is more effective when combined with clomiphene.
Assisted reproductive techniques are not needed for most patients with simple PCOS. Pregnancy can be obtained with the above mentioned ovulation methods. A few patients who have been unsuccessful with various ovulation methods (especially when combined with semen abnormalities, cervical problems, and tubal problems) can undergo assisted reproductive treatment such as IVF.
PCOS is a long-term, lifelong disease. Women with PCOS are at high risk for diabetes, hypertension, cardiovascular disease, and endometrial cancer, so even if there is no requirement for fertility, they need long-term medication to control these long-term complications, or they will progress progressively.