Polycystic ovary syndrome (PCOS) is a common endocrine syndrome in women of childbearing age. The exact prevalence of PCOS is not known, but is generally about 1%-4% in women, and has been estimated to be about 3.5%-7.5% in women of reproductive age since the 1980s due to improved morphology and hormone measurement techniques, and about 22% by random ultrasound scan. The census is about 22%. Yang Guoqing, Department of Endocrinology, Beijing 301 Hospital
The etiology of PCOS is unclear. It is generally believed to be related to hypothalamic-pituitary-ovarian axis malfunction, adrenal dysfunction, genetics, metabolism and other factors. A small number of patients with PCOS have sex chromosome or autosomal abnormalities and some have a family history.The pathogenesis of PCOS is complex, but the following facts have been confirmed.
(i) High LH with normal or low levels of FSH.
(ii) Increased androgens.
③Constant estrogen levels (higher E1 than E2).
④Insulin resistance (hyperinsulinemia). most patients with PCOS have varying degrees of insulin resistance and hyperinsulinemia, regardless of obesity.
⑤ PCOS with obesity (BMI ≥ 25) accounted for 20% to 60%. Body fat distribution was not uniform.
⑥Ovarian histomorphology with multiple cystic follicles and interstitial hyperplasia.
The main clinical manifestations include
(i) Menstrual disorders: scanty menstruation, amenorrhea, and in a few cases, functional uterine bleeding. Most often occurring in adolescence, as a continuation of irregular menstruation after menarche, sometimes accompanied by dysmenorrhea.
②Hirsutism: due to androgen elevation, it can be seen that the hair on the upper lip, jaw, chest, back, middle of the lower abdomen, both sides of the upper thighs and the perianal area are thickened and increased, but the degree of hairiness is not proportional to the androgen level. It may be accompanied by acne, excessive sebum secretion on the face, low and coarse voice, enlarged clitoris, throat knot and other masculine signs.
(iii) Obesity and infertility. The body weight is more than 20%, and the body mass index ≥25 accounts for 30%~60%. Obesity is mostly concentrated in the upper body, with waist/hip ratio > 0.85. It mostly starts from adolescence and gradually increases with age. Due to long-term non-ovulation, patients are mostly combined with infertility, sometimes with episodic ovulation or miscarriage, with an incidence of up to 74%.
④ Enlarged ovaries.
⑤ All patients present with good estrogen action. On examination, a high amount of cervical mucus is seen. Continuous, large amounts of estrogen action can result in excessive endometrial hyperplasia, atypical hyperplasia, and even carcinogenesis. Therefore, PCOS should be suspected based on irregular, scanty and/or amenorrheic menstruation for many years after menarche, along with obesity and hirsutism, and infertility after marriage, etc. Typical cases have all the above-mentioned symptoms and signs.
Atypical cases may present as.
(1) Simple amenorrhea without obesity, hirsutism and ovarian enlargement, excluding various other diseases, but a positive progesterone test should still be considered as PCOS.
② Ovulatory dysfunctional bleeding.
③Menstrual abnormalities combined with hirsutism.
④Menstrual abnormalities with masculine symptoms without obvious obesity.
⑤ dysfunctional uterine bleeding with infertility, etc.
Laboratory tests include.
①Blood LH to FSH ratio and concentration are abnormal, with acyclic secretion, most patients have increased LH, while FSH is equivalent to early follicular phase level, LH/FSH ≥ 2.5~3.
(ii) Excessive androgens, testosterone, androstenedione, DHEA and DHEAS levels can be increased.
③Estrone and estrogen abnormalities, constant estrogen levels without normal menstrual cycle changes.
④basal body temperature measurement to determine the presence or absence of ovulation.
⑤ Ultrasound examination of the ovaries.
Due to the heterogeneity of the disease, the diagnostic criteria have not been unified. Most scholars have established the diagnosis of this disorder based on pubertal onset, abnormal menstruation and ovulation, hirsutism, elevated blood LH and/or LH/FSH ratio, combined with an excessive level of one androgen, signs of polycystic ovaries on ultrasonography and exclusion of other similar diseases. The diagnostic criteria for PCOS have been proposed as.
(1) sporadic ovulation or anovulation.
(2) Clinical manifestations of hyperandrogenism and/or hyperandrogenemia.
(3) polycystic ovarian changes: ≥12 follicles of 2-9 mm in diameter in one or both ovaries and/or ovarian volume ≥10 ml.
(4) Two of the above 3 criteria are met and other hyperandrogenic etiologies are excluded: congenital adrenocortical hyperplasia, Cushing’s syndrome, androgen-secreting tumors, and other disorders causing ovulatory disturbances such as hyperprolactinemia, premature ovarian failure and pituitary or hypothalamic amenorrhea, and thyroid dysfunction.
The treatment of PCOS patients should be pharmacological, surgical or other treatments depending on the prominent clinical symptoms and signs, age and fertility requirements of the patient.
(1) Obesity and insulin resistance. Increase exercise to reduce body weight, correct the endocrine metabolic disorders aggravated by obesity, and reduce insulin resistance and hyperinsulinemia. Weight loss can restore ovulation in some obese PCOS patients and prevent the occurrence of type 2 diabetes and cardiovascular disease. Metformin 1.5~2.5g/day with or without diabetes can be used. Insulin sensitizers (thiazolidinedione) may be more suitable for patients with PCOS who are hyperinsulinemic and can be treated long-term.
(ii) Pharmacological induction of ovulation. Clomiphene (clomiphene), clomiphene (clomiphene) in combination with chorionic gonadotropin (HCG), glucocorticoids in combination with clomiphene (clomiphene), human menopausal gonadotropin (HMG), gonadotropin-releasing hormone (GnRH), FSH, bromocriptine.
(iii) Bilateral ovarian wedge resection.
④Hirsutism treatment. It can be cut off regularly or applied with “hair loss agent”, avoid plucking to prevent stimulation of excessive hair follicle growth, or electrolysis treatment or application of androgen inhibiting drugs.
PCOS is often associated with obesity, metabolic syndrome and insulin resistance. Therefore, the Association for Androgen Excess Disorders (AES) recommends oral glucose tolerance testing in patients with PCOS (both adults and adolescents) to screen for IGT (impaired glucose tolerance) and diabetes mellitus: 1.
1. all patients with PCOS, regardless of BMI, should have a 2-hour OGTT to screen for IGT.
2. PCOS patients with NGT should be re-screened at least every 2 years, with shorter intervals for those with high-risk factors.
3, patients with IGT should be monitored annually for progression to diabetes
4. the main management of patients with PCOS and IGT is lifestyle modification and weight loss in obese individuals
5, insulin sensitizers, such as metformin and thiazolidinediones , should be used in patients with PCOS and IGT.
6, adolescent PCOS patients should repeat OGTT screening for IGT every 2 years, and if IGT develops, active lifestyle modification and treatment with metformin should be performed.