— The danger of polycystic ovaries is not only infertility
In recent years, the number of patients with polycystic ovary syndrome in gynecological endocrine clinics has been increasing. From 2007 to 2011, an epidemiological survey was conducted on 15924 Han Chinese women aged 19-45 years old, and it was found that the prevalence of polycystic ovary syndrome among Han Chinese women was 5.61%, but only 9.61% of the patients were aware that they might be suffering from endocrine or gynecological diseases.
So what kind of disease is polycystic ovary syndrome?
Polycystic ovary syndrome (PCOS) is one of the most common endocrine and metabolic disorders in adolescent and childbearing women and is the main cause of secondary amenorrhea and anovulatory infertility in women of childbearing age. The syndrome was introduced by Stein and Leventhal in 1935 and is characterized by obesity, hirsutism, skin acne, menstrual disorders, infertility, and polycystic ovarian changes, and is named Stein CLeventhal syndrome.
What are the symptoms that indicate polycystic ovary syndrome?
Polycystic ovary syndrome is a complex and difficult condition to diagnose because of the variety of its clinical manifestations. In general, the following are the main symptoms.
1. Loss of normal regularity of menstruation. Patients often have a prolonged menstrual cycle once every few months, which is commonly known as “seasonal menstruation” or even amenorrhea, while some patients have long, lingering periods lasting more than 10-20 days.
2. The manifestation of hyperandrogenism. Some women have excessive hair on their breasts, armpits, and midline areas of the body. Acne, like hirsutism and seborrhea, is a clinical manifestation of excess androgens in the body.
If parents find that their daughter still has scanty menstruation or amenorrhea two or three years after menarche, and hairy upper lip, lower abdomen, inner thighs, etc., they should be highly suspicious of the “alarm” of polycystic ovary syndrome, and should go to the hospital for blood tests to see if the androgen content, insulin, blood sugar and other indicators are over the limit. If a girl still has scanty menstruation or amenorrhea two or three years after her first menstruation, the possibility of polycystic ovary syndrome is more than fifty percent, and she should be diagnosed and treated as soon as possible.
3, polycystic ovaries refers to the morphological changes of the ovaries, which are manifested by the increase of ovarian volume and several immature follicles wrapped around the ovaries in the shape of beads during ultrasound examination, commonly known as the “necklace sign”, which is one of the unique clinical manifestations of polycystic ovary syndrome.
4. Obesity and overweight. Many girls complain that they don’t eat much, but their weight keeps increasing year after year and they have become “fat girls” without realizing it. The prominent feature of Guangdong patients is that they are not fat in appearance, with a body mass index of less than 23, but their waist circumference is thick and their waist-to-hip ratio exceeds the standard. Usually the patient’s waist circumference is greater than 80 cm, waist-hip ratio is greater than 0.85. This intermediate obesity is also known as “male obesity”, the reason is that the patient’s body androgen is too high, resulting in the selective accumulation of fat in the waist abdomen.
5, infertility and repeated miscarriages. Many women in the workplace are troubled by infertility or repeated miscarriages and come to the hospital only to find out that it is polycystic ovary syndrome. Because this disease has ovulation disorders, the chances of pregnancy are reduced compared to normal women, and once pregnant, they are prone to spontaneous miscarriage because of the unique high androgens, high gonadotropins, high insulin levels and abnormal endometrial tolerance.
Because of the complexity of the causes and diversity of the manifestations of PCOS, it is clinically referred to as “polycystic ovary syndrome”.
How to diagnose polycystic ovary syndrome?
How is polycystic ovary syndrome diagnosed? Our current clinical diagnosis of polycystic ovary syndrome is based on the diagnostic criteria proposed by the European Society for Reproductive and Embryological Medicine and the American Society for Reproductive Medicine in Rotterdam in 2003, which are
1. sporadic ovulation and/or anovulation.
2, clinical hyperandrogenism and/or hyperandrogenemia and exclusion of other possible causative factors.
3. bilateral polycystic changes of the ovaries.
The diagnosis can be made by meeting two of the above three criteria and excluding other etiologies of hyperandrogenism. However, some patients are not so typical in clinical practice. Some of them only show irregular menstruation and irregular vaginal bleeding without changes such as ovarian polycystic, acne, hirsutism and obesity, can polycystic ovary syndrome be ruled out? This is not necessarily the case and requires a detailed examination, judgment and screening by a professional gynecologic endocrinologist.
What tests are often needed for patients?
Many patients have doubts when they come to the clinic, why do doctors have to order so many tests and draw so much blood? Because polycystic ovary syndrome is a complex disease with a variety of clinical manifestations, and each patient may behave differently, we have to do relevant tests to rule out congenital adrenal cortical hyperplasia, androgen-secreting ovarian tumors and other conditions and make an accurate diagnosis. Specifically, the following tests are available.
1. Physical examination, including measurement of height, weight, waist circumference, hip circumference, etc., examination of facial and back acne, distribution of body hair and sexual hair, etc., to make a preliminary assessment of whether the patient has any comorbidities.
2. Testing androgen levels is one of the diagnostic criteria for polycystic ovary syndrome. However, it is often seen in clinical practice that androgen tests give “false alarms”. This is related to the current confusion of androgen testing reagents and testing standards. In fact, free testosterone is the biologically active part of the test. Therefore, a high level of total testosterone does not represent the level of free testosterone in the body.
3. “Drinking sugar water” test. 7.5-10% of patients with polycystic ovary syndrome have type 2 diabetes. 20-40% of patients with PCOS develop abnormal glucose tolerance or type 2 diabetes around the age of 40, and their prevalence is significantly higher than that of women of the same age. About a quarter of patients with polycystic ovary syndrome eventually go on to develop metabolic syndrome, with a higher prevalence than in the general population. The “sugar water” test is to understand the patient’s metabolic status and to determine the presence of comorbidities such as diabetes.
It is recommended that patients come for these tests on the 2nd-5th day of their menstrual period, early in the morning, on an empty stomach.
What are the risks of polycystic ovary syndrome?
The most common perception of polycystic ovary syndrome is that it causes poor menstruation, makes you prone to acne and affects pregnancy. In fact, the dangers of polycystic ovary syndrome go far beyond infertility.
In a large retrospective study published in the Journal of Clinical Endocrinology and Metabolism, Australian scholars revealed that patients with polycystic ovary syndrome (PCOS) are at increased risk for other diseases, including cardiovascular disease, metabolic disease, psychological disease, oncological disease, and reproductive abnormalities. The impact of this disease on women’s health is lifelong. Physicians need to take into account the patient’s complaints, but also assess the overall health status, including risk factors for heart disease, stroke and diabetes, even in young patients.
During adolescence and sexual maturity, many complications such as diabetes, fatty liver and hypertension may arise.
Because polycystic ovary syndrome is characterized by both metabolic diseases, it is likely to be combined with many medical conditions such as diabetes. Patients usually have abdominal obesity, mainly manifested as a large waist circumference of more than 2000px, which is actually closely related to insulin resistance. Patients may also have hypertension, fatty liver, coronary heart disease and many other diseases. Therefore, when abnormal insulin secretion and abnormal blood lipids are detected, it is important to treat them actively to avoid complications such as diabetes, fatty liver and hypertension, coronary heart disease, etc.
Infertility and recurrent miscarriages and various pregnancy complications in the reproductive age
Infertility is an important reason for patients with polycystic ovary syndrome at this stage of reproductive age to visit gynecology, including infertility and recurrent miscarriages. Because ovulation is impaired in polycystic ovary syndrome, the chances of pregnancy are reduced compared to normal women, and once pregnant, they are prone to spontaneous abortion due to the characteristic high androgens, high gonadotropins, high insulin levels, and abnormal endometrial tolerance.
Various complications can also occur during pregnancy, such as gestational hypertension, gestational diabetes, and excess amniotic fluid. Therefore, it is important to receive basic treatment before pregnancy to keep weight under control and adjust blood biochemical parameters to near normal. This will reduce the complications during pregnancy for the mother and also reduce the risk of preterm delivery, low birth weight babies, and huge babies, and get a healthy baby. More importantly, it gives the baby a good start in life. In fact, the adverse intrauterine environment caused by maternal hyperglycemia, hyperinsulin and hyperandrogenism has an important impact on the development of adult diseases in the newborn after birth.
Menopause Increased chance of gynecological tumors such as endometrial cancer
It is worth mentioning that the impact of polycystic ovary syndrome on women’s health does not end with the completion of female fertility or menopause; on the contrary, the risk of associated complications is increasing year by year. In addition to the aforementioned medical complications, some female cancers are also at risk, such as breast cancer and endometrial cancer; these are related to the hormonal imbalance of polycystic ovary syndrome. Due to sparse ovulation, the patient’s endometrium is chronically stimulated by a single estrogen and is at high risk for endometrial hyperplasia, and her risk of endometrial cancer is four times higher than that of the general population. We have found that the incidence of endometrial tumors has tended to be younger and not exclusive to older women, with some patients already having endometrial precancerous lesions or even endometrial cancer in their 30s. We have dozens of such patients in our clinic. Because they did not know they had polycystic ovary syndrome before, they did not make reasonable interventions and treatments until they had prolonged irregular vaginal bleeding and came to the hospital for examination, only to discover the lesions, and some of them had not had children yet, which was very difficult for physicians to handle. Therefore, it is clinically necessary to regularly screen women with polycystic ovary syndrome for endometrial cancer, and regular follow-up and monitoring are still needed even after menopause.
Long-term management of polycystic ovary syndrome – “On the persistent battle”
The cause of polycystic ovary syndrome is still unclear, which makes its treatment difficult and requires a “protracted war”. Studies have shown that a 5-10% weight loss in patients with polycystic ovary syndrome can help improve insulin resistance and ovulation. Therefore, it is important to use a combination of lifestyle interventions such as dietary therapy and exercise therapy. Exercise and diet control are effective treatments for polycystic ovary syndrome.
1. Nutritional management and exercise
The general principles of nutrition therapy can be summarized as “balanced diet, total control, reasonable distribution, regular rationing”.
Nutritional therapy requires the selection of a balanced and nutritious diet that is in line with one’s own eating habits; maintaining a reasonable body weight: the goal of weight reduction for overweight/obese patients is to lose 5-10% of body weight within 3-6 months.
Patients are advised to eat a low-salt, low-fat, low-sugar diet and to choose foods containing more soluble plant fiber (coarse grains) in their staple foods, such as buckwheat, oats, millet, corn, etc., and to eat more leafy vegetables. Available buckwheat, oats, millet, barley, adzuki beans, wolfberries, lentils and other appropriate amount of mixed, soaked and cooked as a staple food, cooking methods: cold, hot stir-fry and stew, prohibit frying, deep-frying, baking and other cooking methods. Oil: mainly olive oil and tea oil rich in unsaturated fatty acids; the daily dosage is controlled within 25ml, and the salt dosage is controlled within 4g per day.
Exercise management
The general principle of exercise is: choose moderate, rhythmic, whole-body exercise, and be measured, gradual and persistent.
The time of exercise is recommended to be chosen one hour after breakfast or dinner. Exercise programs can be brisk walking, jogging, cycling, Tai Chi, swimming, playing badminton. Exercise to ensure that there is “quality”, the “quality” of exercise is to achieve the “effective heart rate range” (exercise pulse rate = 170 – age). The “quantity” of exercise is the cumulative time required to achieve an effective heart rate of 20-30 minutes to be effective. The frequency of exercise should be no less than 5 times a week, of course, you can change different forms of exercise, and it is easier to do it in a group.
2.Medication management of polycystic ovary syndrome
(1), control of androgens. The drugs commonly used in the treatment of PCOS are Daimler-35, Mafloquine, and Ursine. Some patients may have doubts, these drugs are contraceptives, why are they used in the treatment of PCOS? Will it affect pregnancy? In fact, oral contraceptives are commonly used in the treatment of PCOS because they regulate the patient’s menstruation as well as reduce androgen levels and improve insulin resistance. Each tablet of TAIE-35 contains 2mg of cyproterone acetate and 35ug of ethinyl estradiol, of which cyproterone acetate is a progestin with anti-androgenic properties. The treatment of PCOS with TAIE-35 can reduce androgens, balance hormone levels in the body, improve the condition of acne and seborrheic dermatitis, and enable patients to have regular menstrual cycles. The results of a clinical trial study indicate that Daimler-35 is the best choice for improving hyperandrogenemia. However, drugs have certain indications and contraindications, so it must be decided by your doctor whether it is appropriate for PCOS patients to take birth control pills and which pills have the best therapeutic effect.
(2), improve insulin resistance and prevent the occurrence of diabetes. For people with prediabetes, metformin is the first drug that has been shown to prevent or delay the onset of diabetes. Studies have confirmed that the incidence of diabetes decreased by 18% over 10 years with metformin intervention therapy. In addition to blood glucose control, metformin has many additional benefits, including: cardiovascular protective effects, improvement of blood lipids, and improvement of fatty liver; new research has found that it also reduces the incidence of endometrial tumors associated with polycystic ovary syndrome. Gastrointestinal reactions are its common side effects, manifesting as nausea, vomiting, and abdominal distension, etc. The side effects disappear in most patients with longer treatment duration. “Start with a small dose and gradually increase the dosage” is an effective way to reduce the initial adverse reactions.