Expert consensus: Polycystic ovary syndrome (PCOS) is a common gynecologic endocrine disorder with a large patient population in China. The etiology of PCOS is still unclear, the diagnostic criteria are not uniform, the use of therapeutic drugs is confusing, and there is a lack of reasonable prevention and treatment measures for long-term complications, therefore, it is urgent to develop norms for diagnosis and treatment. The Endocrinology Group of the Obstetrics and Gynecology Branch of the Chinese Medical Association held an expanded meeting of gynecologic endocrinologists in Chongqing on November 18, 2006, and after a lively discussion, the meeting reached a preliminary expert consensus on the diagnosis and treatment of PCOS in China. On November 24, 2007, the Endocrinology Group of the Obstetrics and Gynecology Branch of the Chinese Medical Association held an expert meeting in Sanya, Hainan, to answer questions about the diagnosis and treatment of PCOS. I. Overview of PCOS PCOS accounts for 5% to 10% of women of reproductive age (the exact prevalence is not yet reported in China) and 30% to 60% of patients with anovulatory infertility. The exact cause of PCOS is still unclear, but some studies suggest that it may be caused by the interaction of certain genetic and environmental factors. 1, genetic factors: PCOS has a family aggregation phenomenon, is presumed to be a polygenic disease, the current candidate gene research involves insulin action-related genes, high androgen-related genes and chronic inflammatory factors. 2, environmental factors: intrauterine hyperandrogenism, antiepileptic drugs, geography, nutrition and lifestyle may be risk factors, predisposing factors or high-risk factors for PCOS, and epidemiological investigation is still needed to improve the understanding of the relationship between environment and PCOS. Second, the diagnosis of PCOS at this stage recommended in 2003 the European Society of Human Reproduction and Embryology and the American Society of Reproductive Medicine expert meeting recommended criteria for use in China, pending the preliminary results of domestic epidemiological surveys and related research in China, and then discretion whether to amend this diagnostic criteria. 1. Diagnostic criteria for PCOS: (1) sporadic ovulation or anovulation; (2) clinical manifestations of hyperandrogenemia 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 three, and exclusion of other causes of elevated androgen levels: congenital adrenocortical hyperplasia, Cushing’s syndrome, androgen-secreting tumors, and other diseases causing ovulation disorders such as hyperprolactinemia, premature ovarian failure and pituitary or hypothalamic amenorrhea, and abnormal thyroid function. 2. Judgment of criteria: (1) sparse ovulation or anovulation: (1) Judgment criteria: 2-3 years after menarche, regular menstruation cannot be established; amenorrhea (menopause for more than 3 previous menstrual cycles or ≥ 6 months); sparse menstruation, i.e., those with ≥ 35 d cycles and ≥ 3 months per year without ovulation (WHO Class II anovulation); (2) regular menstruation does not serve as evidence to judge ovulation; (3) basal body temperature (BBT) (3) Basal body temperature (BBT), ultrasound monitoring of ovulation, and progesterone measurement in the second half of menstruation can help determine whether ovulation is present; (2) Clinical manifestations of elevated androgen levels: acne (recurrent acne, often located on the forehead, cheeks, nose and jaw), hirsutism (coarse, hard hair on the upper lip, jaw, around the areola, and in the midline of the lower abdomen) (3) Biochemical indicators of elevated androgen levels: total testosterone, free testosterone index or free testosterone above the laboratory reference normal value; (4) Diagnostic criteria for polycystic ovaries (PCO): ≥ 12 follicles of 2-9 mm diameter in one or both ovaries, and/or ovarian volume ≥ 10 ml. 3. Exclusion criteria for the diagnosis of PCOS: Exclusion criteria are mandatory for the diagnosis of PCOS, such as If there is sporadic ovulation or anovulation, follicle stimulating hormone (FSH) and estradiol levels should be measured to exclude premature ovarian failure and central amenorrhea; thyroid function should be measured to exclude sporadic menstruation due to hypothyroidism; if hyperandrogenemia or obvious hyper If hyperandrogenemia or obvious clinical manifestations of hyperandrogenism, atypical adrenocortical hyperplasia (NCAH), Cushing’s syndrome, and androgen-secreting ovarian tumors should be excluded. 4. Diagnostic criteria for adolescent PCOS: Due to the difficulty in identifying the difference between the physiological state and the PCOS state, and the lack of evidence of evidence-based medicine, there is a lack of uniform diagnostic criteria. Third, the comorbidity of PCOS PCOS is often accompanied by obesity, metabolic syndrome and insulin resistance. Fourth, the treatment of PCOS PCOS patients regardless of whether they have fertility requirements, the first should be lifestyle adjustments, quit smoking, quit drinking. Obese patients through a low-calorie diet and energy-consuming exercise, reduce the total weight of 5% or more, you can change or reduce menstrual disorders, hairy, acne and other symptoms and conducive to the treatment of infertility. Reducing body weight to the normal range can improve insulin resistance and stop the long-term development of PCOS with adverse consequences such as diabetes, hypertension, hyperlipidemia and cardiovascular disease and other metabolic syndromes. (A) Adjustment of menstrual cycle PCOS patients’ irregular menstruation can be manifested as irregular menstrual cycle, scanty menstruation, low volume or amenorrhea, and some bleeding is unpredictable. Adjusting menstrual cycle can protect the endometrium and reduce the occurrence of endometrial cancer. 1.Oral contraceptive pills: You can choose various short-acting oral contraceptive pills, in which progestin, can convert the endometrium, thus reducing the occurrence of endometrial cancer. Conventional usage is to take 1 tablet daily for 21 days on the 1st to 5th day of natural menstruation or withdrawal bleeding. Withdrawal bleeding starts about 5 d after discontinuation and the dose is restarted on the 5th day of withdrawal bleeding. Or repeat initiation after 7 d of discontinuation. May be repeated for at least 3-6 months. Oral contraceptives can correct hyperandrogenemia and improve the clinical manifestations of elevated androgen levels; they can also provide effective contraception, and cyclic withdrawal bleeding can also improve the state of the endometrium and prevent the development of endometrial cancer. However, special attention should be paid to the following: PCOS patients are a special group of people who often have disorders of glucose and lipid metabolism, and changes in blood glucose and lipids should be monitored during the drug use; in addition, for adolescent girls, full informed consent should be given before applying oral contraceptives; contraindications to oral contraceptives should be excluded before taking the drug. 2.Progestin: For anovulatory patients with no obvious clinical and laboratory manifestations of elevated androgen levels and no obvious insulin resistance, regular progestin therapy can be used alone to improve the endometrial status with cyclic withdrawal bleeding. The commonly used progestins are medroxyprogesterone (MPA), micronized progesterone (other names: Kine), dydrogesterone (other names: Duffetone), and progesterone. Conventional usage is MPA 6 mg/d, or Kinen 200 mg/d, or dydrogesterone 10-20 mg/d in the second half of the menstrual cycle for 10 d per month, with withdrawal bleeding at least once every two months; progesterone can be injected intramuscularly for 5-7 d for withdrawal bleeding, and still needs to be injected intramuscularly for more than 10 d to protect the endometrium if applied for a long time. The advantages of using progesterone are (1) adjusting the menstrual cycle, protecting the endometrium and preventing the occurrence of endometrial cancer; (2) possibly reducing androgen levels to some extent by slowing down the frequency of luteinizing hormone (LH) pulse secretion; (3) suitable for patients without severe hyperandrogenemia and metabolic disorders. (2) High various short-acting oral contraceptives can be used for the treatment of hyperandrogenemia, with cyproterone acetate (other name: daing-35) being the first choice; it can inhibit high levels of androgen production in follicular membrane cells by suppressing hypothalamic-pituitary LH secretion. Usually acne needs to be treated for 3 months and hirsutism needs to be treated for 6 months, but the symptoms of elevated androgen levels will return after stopping the drug. (iii) Treatment of insulin resistance Metformin is indicated for the treatment of patients who are obese or have insulin resistance; Metformin improves insulin resistance and prevents the development of metabolic syndrome by enhancing glucose uptake by peripheral tissues, inhibiting hepatic gluconeogenesis and enhancing insulin sensitivity at the post-receptor level, and reducing postprandial insulin secretion. The routine usage is: 500 mg 2-3 times a day. The treatment should be followed up every 3-6 months for the recovery of menstruation and ovulation, any adverse effects and rechecking of serum insulin. If menstruation does not resume, additional progestin must still be used to regulate menstruation. Metformin is a class B drug, and the drug description does not include post-pregnancy women as an indication group. Whether to continue its use after pregnancy should be decided carefully according to the patient’s specific situation and the endocrinologist’s advice. The most common side effects of metformin are gastrointestinal reactions, such as bloating, nausea, vomiting and diarrhea, which are dose-dependent and can be reduced by gradually increasing to the full dose over 2-3 weeks and by taking the drug with meals. Serious side effects are possible renal impairment and lactic acidosis. Renal function must be reviewed regularly. (iv) Ovulation promotion therapy is often required to promote ovulation and normal pregnancy in patients with anovulation. (1) Clomiphene citrate (CC): 50 mg/d for 5 d starting from the 5th day of natural menstruation or withdrawal (progesterone 20 mg once daily for 3 d) and increasing by 50 mg/d per cycle until 150 mg/d in the absence of ovulation; no need to increase the dose in the presence of satisfactory ovulation. If the follicular phase is long or the luteal phase is short, the dose may be low and may be increased; efficacy may be determined by testing and recording BBT, but follicular development may also be monitored by transvaginal or rectal ultrasound to prevent excessive follicular growth or to observe exact efficacy. Clomiphene citrate has a weak anti-estrogenic effect and can affect the cervical mucus, making it inappropriate for sperm to survive and penetrate; it can also affect the peristalsis of the fallopian tubes and the development of the endometrium, which is not conducive to embryo implantation. Occasionally, patients cannot tolerate this drug. Second-line ovulation treatment: (1) Gonadotropins: The commonly used gonadotropins are human menopausal gonadotropin (hMG), high-purity FSH (HP-FSH) and recombinant FSH (r-FSH). It is indicated for patients with anovulatory infertility resistant to clomiphene citrate (other causes of infertility have been excluded); hospitals with technical conditions for pelvic ultrasound and estrogen monitoring and for the treatment of ovarian hyperstimulation syndrome (OHSS) and fetal reduction techniques; contraindications include: elevated blood FSH levels suggestive of ovarian anovulation; hospitals without technical conditions for monitoring follicular development and ovulation. Dosage: low-dose progressive FSH regimen and tapering regimen. Complications of gonadotropin use include: multiple pregnancy, OHSS; therefore, repeated ultrasound and estrogen monitoring are required during the use of gonadotropin. The literature reports that the likelihood of multiple pregnancy and OHSS is greatly increased when there are 4 or more follicles >16 mm in diameter, and the cycle should be cancelled. (2) Laparoscopic ovarian drilling (LOD): It is mainly used for patients who are clomiphene citrate resistant, require laparoscopic examination of the pelvis due to other diseases, have poor follow-up conditions and cannot be monitored with gonadotropin therapy, and it is recommended to select patients with body mass index (BMI) ≤ 34 kg/m2, LH > 10 U/L and high free testosterone The pro-ovulatory mechanism of LOD is to destroy the androgen-producing ovarian mesenchyme and indirectly regulate the pituitary-ovarian axis, resulting in a decrease in serum LH and testosterone levels, increasing the chance of pregnancy and possibly reducing the risk of miscarriage. possible problems with LOD include ineffective treatment, pelvic adhesions, and low ovarian function. (v) In vitro fertilization-embryo transfer 1. Indications: Patients who have failed ovulation promotion by the above methods. 2. Mechanism: through gonadotropin-releasing hormone descending regulation of the pituitary gland, inhibition of endogenous FSH and LH secretion, reduction of the adverse effects of high levels of LH, improvement of the ovarian response to hMG or FSH, 3. The solution is either to transfer the embryos after fertilization without high estrogen levels in the current cycle, to freeze and preserve them for transfer in the next natural cycle or to perform in vitro maturation (IVM) of immature oocytes.