We would like to introduce polycystic ovary syndrome (PCOS), a common gynecological endocrine disorder in women of reproductive age, and to answer your concerns about diagnosis and medication through this article.
Polycystic ovary syndrome (PCOS) is a gynecologic endocrine and metabolic disease with hyperandrogenism, ovulation disorders and polycystic ovarian changes as the main clinical manifestations, and is one of the main causes of female infertility, accounting for 30%-60% of patients with anovulatory infertility. The exact etiology of PCOS is still unclear, but it is generally believed to be the result of a combination of environmental and genetic factors. Because of the diversity of clinical manifestations of PCOS, its diagnostic criteria are still controversial. The global prevalence of PCOS varies from 4% to 21% depending on the diagnostic criteria, and a large-scale epidemiological survey in China in 2013 showed that according to the Rotterdam criteria established by the European Society of Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) in 2003, the prevalence of PCOS in Han Chinese women of childbearing age in China is 5.6%.
I. Diagnostic criteria of PCOS
Since 1990, three different diagnostic criteria have been introduced internationally. Currently, the Rotterdam criteria developed in 2003 are commonly used in clinical practice. PCOS can be diagnosed after meeting 2 of the following 3 criteria and excluding other diseases that cause similar clinical manifestations.
1. Clinical and/or biochemical manifestations of androgen excess;
2. Sporadic ovulation or anovulation;
3, polycystic change of ovary (PCO): unilateral ovarian volume increase of more than 10mL (excluding cysts and dominant follicles) or unilateral ovary with more than 12 follicles of 2-9mm in diameter.
Second, the diagnosis of hyperandrogenemia clinical symptoms: hirsutism, acne, and androgenetic alopecia.
Among them, people may have a misunderstanding of hirsutism. Hirsutism specifically refers to the masculinization of body hair and the appearance of coarse and hard hair on the upper lip, jaw, and lower abdomen midline. The Ferriman-Gallwey scale (see Figure 1) is used clinically to quantify body hair in patients. It scores the amount of hair in a total of 9 parts of the body, and each part is assigned a score of 0-4 depending on the amount from none to many, and a score of ≥6-8 in 9 parts is diagnosed as hirsutism.
Biochemical indicators: elevated serum total testosterone (TT) or free testosterone (FT). Serum TT levels are mostly used clinically to assess whether a patient has hyperandrogenemia, but this method is currently considered inaccurate. Since testosterone in serum has both free and bound (sex hormone binding protein) states, and it is the free state that is biologically active, it is recommended to measure both TT and sex hormone binding protein (SHBG) by calculating FAI=
TT/SHBG to indirectly determine FT.
Third, sporadic ovulation or anovulation manifested by abnormal menstrual cycle (menstrual cycle <21 days or >35 days).
In hyperandrogenemic patients, a normal menstrual cycle does not mean that they are ovulating normally. Ovulatory dysfunction still occurs in 15-40% of hyperandrogenemic patients with normal menstrual cycles.
Screening for complications
Since PCOS patients are often combined with obesity, insulin resistance, and metabolic disorders, they should be screened for related complications, including.
1, risk factors for cardiometabolic diseases: BMI, abdominal circumference, blood pressure and fasting lipid levels, screening every 2 years;
2, abnormal glucose tolerance and diabetes screening: fasting glucose, oral glucose tolerance test (OGTT), insulin release test (IRT);
3.Other: screening for smoking, obstructive sleep apnea, depression, anxiety and other complications.
V. Treatment of PCOS
The individualized treatment plan is mainly based on the patient’s needs. For women of childbearing age with fertility needs, the treatment of PCOS mainly includes: treatment of hyperandrogenemia, adjustment of menstrual cycle, ovulation treatment, lifestyle adjustment, etc. Commonly used drugs include.
VI. Short-acting oral contraceptives
On the one hand, they can inhibit the secretion of gonadotropins and androgens, reduce the bioavailability of androgens, correct hyperandrogenemia and improve the clinical manifestations of hyperandrogenism such as hirsutism and acne; on the other hand, they can adjust the menstrual cycle and prevent excessive endometrial proliferation.
The most commonly used drugs are Daying 35 and MaFuLong.
Dosage: Generally, starting from the 5th day of menstrual redness, take 1 tablet daily at bedtime for 21 days, and the menstrual flow will usually occur within 7 days after stopping the medication. Usually need to take 3-6 months, during the medication should monitor the changes of blood sugar, blood lipids.
Seven, metformin
Metformin is an insulin sensitizer and is indicated for overweight or obese patients (BMI ≥ 25) with insulin resistance and insignificant weight loss by diet and exercise adjustment. In addition, studies have shown that metformin may help reduce serum testosterone levels and improve ovulatory function. Metformin takes time to achieve its efficacy and is recommended to be used as an adjunctive therapy for more than 3 months.
Conventional usage is: 500
mg 2-3 times a day, with follow-up visits every 3-6 months during treatment for recovery of menstruation and ovulation, for any adverse effects, and to review serum insulin levels. The most common side effects are gastrointestinal reactions, such as bloating, nausea, vomiting and diarrhea, and the symptoms are dose dependent. Start with a small dose (500
mg/day) and gradually increase to the full dose in 2-3 weeks and take the drug with meals can reduce the gastrointestinal reactions.
Metformin is a class B drug and the drug description does not include post-pregnancy women as an indication group. The continued use of metformin during pregnancy in PCOS patients with abnormal glucose tolerance needs to be decided carefully based on the patient’s specific situation and the advice of the endocrinologist. Considering the potential embryotoxicity of metformin, patients are advised to discontinue the drug when the pregnancy test is positive.
VIII. Ovulation-promoting drugs
Clomiphene citrate, 50 mg daily for 5 days starting from the 5th day of menstruation or Letrozole tablets, 5 mg daily for 5 days starting from the 5th day of menstruation.
IX. Weight loss
Some studies have shown that a 5% reduction in body mass can improve symptoms of menstrual cycle disorders and hyperandrogenism and favorably affect the outcome of infertility treatment. Therefore, weight loss should be the first treatment of choice for obese or overweight PCOS patients, as it can effectively improve reproductive and metabolic functions, restore ovulation, and reduce the risk of long-term complications.
PCOS is a chronic disease that affects patients until around the time of menopause, and existing treatments do not fundamentally reverse PCOS, although some exceptions may exist (e.g., obese PCOS patients with persistent weight loss). Although fertility is low in patients with PCOS, there is still a chance of natural conception. Some studies have shown no statistically significant difference in the natural fertility rate of patients with PCOS compared to normal women. Therefore, contraception should still be used in patients of childbearing age who do not have a childbearing requirement.