1、Polycystic ovarian syndrome 吉林市中心医院 妇产科 安晓汾Jilin Central Hospital obstetrics and GynecologyCase study_clinical dialogueCase summary A 23-year-old morbidly obese,gravida 0,who presented to the gynecology office for evaluation of irregular menses since menarche.The patient stated that on average,she h
2、as 1 period every 5-6 months.When she is on her period,she bleeds very heavily,passing large clots with a lot of abdominal cramping.She also complained about excessive facial hair,which requires her to shave at least once several days,and a lot of hair on her abdomen an arms as well.She denied any c
3、hange in her voice or increase in the size of her muscles.She has been morbidly obese since she was a young teenager.She denied any headaches,blurred vision,or discharges from her nipples.She also denied any hyper-or hypothyroidism symptoms.She has never had any surgery in the past.She was unable to
4、 conceive despite one year of actively trying.She is not currently taking any medication and has never used any form of contraception.Medical history 1.Hello,Miss Wang,Nice to meet you.How can I help you today?-I havent had my period over 6 months and I know I am not pregnant,I just took a pregnancy
5、 test and it was negative.2.Have you been trying to conceive and how long？-Yes,about one year.3.Can you tell me a little more about your periods?-My period has been irregular since I first got it.On average,I have 1 period every 5-6 months.When it does come,it flows very heavily,passing large clots,
6、and having a lot of cramping as well.4.Normally,how many days do your periods last?-About 6-7days.5.Do you have any other medical conditions such as diabetes and high blood pressure?-No,but my mother does have diabetes 6.Have you noticed excessive hair growth anywhere on your body?-Yes,on my face,ar
7、m,and my belly.7.Do you shave?-Yes,I have to shave at least once every several days.8.Have you noticed any changes on your voice or excessive hair loss?-I dongt think so.9.Have you any problems with your thyroid gland?-Not that I know of.10.Have you ever experienced something like dry skin fatigue,m
8、ood swings or any depression?-No,not really 11.what about headaches,vision change,or discharge from your nipples?-no.12.Well,lets talk a little bit about your weight change over time?-I have been overweight for most of my life.I was on the heavy side since I was a kid and I gained another 40 to 50 p
9、ounds after college(1pounds=0.45359237kg).13.Have you done anything to control your weight?-I am trying to excise and eat healthy,but I havnt had any type of surgeries.14.Is there anything else that you would like to talk about?-Not for now.15.Very good,next,we wuld need to do a physical examination
10、 including pelvic -Alright.Physical examination including pelvic exam She was clearly hirsute(Ferriman-Gallowey score of 10),especially in the chin and mid-abdominal region.Her body mass index(BMI)was 31.Her pelvic examination was unremarkable,including no evidence for clitoromegaly,but it was very
11、difficult to appreciate her uterus and adnexa secondary to patients body habitus.The rest of her physical examination was unremarkable.A TVUS(transvaginal ultrasound)was performed,which revealed a normal appearing uterus,with an endometrial thickness of 20mm and bilateral normal ovaries 1.Miss Wang,
12、based on your history and examination today,you most likely have a condition called PCOS,or polycystic ovarian syndrom.-What is that?2.Well,PCOS is a condition that causes irregular menstrual periods because monthly ovulation is not occurring.In addition,your levels of male hormones(androgens)are el
13、evated,which leads to excessive hair growth.The ovaries may look totally normal or slightly larger than normal ovaries,and have twice the number of follicles(small cysts).PCOS is common,and it affects I in 5(20%)of women.discuss 3.What causes PCOS.-The cause of PCOS remains to be defined.PCOS someti
14、mes runs in families.The symptoms of PCOS are also related to abnormal insulin levels.Insulin is a hormone that regulates the level of blood glucose.if you have PCOS，your body may not respond to the hormone insulin(known as insulin resistance),so the level of glucose may be higher.To prevent the glu
15、cose levels from increasing,your body produces more insulin.High levels of insulin can lead to weight gain,irregular periods,infertility and higher levels of testosterone.4.What could PCOS means to my long-term health?-If you have PCOS,you are at greater risk of developing some long-term health prob
16、lems such as diabetes,high blood pressure,heart disease,later in life youcan even develop cancer With fewer periods(less than three a year),the endometrium can overgrow and become thicken.This may lead to endometrial hyperplasia,a precancerous change,and eventually cancer in a small number of women.
17、For this reason,since you have not had your period for 5months and 20 cm of endometrial thickness,I would like to recommend an endometrial biopsy as our next step.5.What should I do to reduce the risk of developing those long term health problems?-A healthy lifestyle including healthy balanced diet
18、and regular excises would be beneficial.You should aim to keep your weight within a normal range(BMI between 19-25).The benefit of weight loss include:a lower risk of developing insulin resistance and diabetes;a lower risk of heart problems;a lower risk of developing uterine cancer;more regular peri
19、ods;an increased chance of becoming pregnant;reduction in acne and decreasing hair growth over time.异质性 临床表现不同临床表现不同 实验室检查和辅助检查差异很大实验室检查和辅助检查差异很大 不能治愈 遗传性疾病遗传性疾病 需长期用药控制，控制好则与正常人无异需长期用药控制，控制好则与正常人无异 进行性发展 代谢综合征代谢综合征 糖代谢异常导致糖尿病糖代谢异常导致糖尿病 脂代谢异常导致心血管疾病脂代谢异常导致心血管疾病 子宫内膜癌子宫内膜癌 不孕NIH:National Institutes o
20、f Health美国国立卫生研究院经典型月经规律型无高雄型排排经典型月经规律型1.1.高雄排卵障碍高雄排卵障碍2.2.高雄高雄PCOPCO3.3.高雄排卵障碍高雄排卵障碍PCOPCO经典型无高雄型日本日本PCOS诊断标准诊断标准 月经异常（无月经、稀发月经、无排卵周期）LH增高，FSH正常，LH/FSH值上升 超声提示PCO任何一项指标升高均可确诊分类分类 BMIBMI（kg/mkg/m2 2）相关疾病的危险性相关疾病的危险性*体重过低体重过低 18.5 18.5 低（但其他疾病危险性增加）低（但其他疾病危险性增加）正常范围正常范围 18.5-22.9 18.5-22.9 平均水平平均水平超重
21、超重 2323肥胖前期肥胖前期 23-24.9 23-24.9 增加增加I I度肥胖度肥胖 25-29.9 25-29.9 中度增加中度增加IIII度肥胖度肥胖 30 30 重度增加重度增加注：注：*疾病危险：糖尿病，高血压，疾病危险：糖尿病，高血压，CADCAD亚洲成人根据亚洲成人根据BMIBMI对体重的分类对体重的分类 黑棘皮症 病因尚不十分明确，通常认为可能是刺激了表皮内的酪氨酸激酶生长因子受体信号通道。有证据表明胰岛素起了一定的作用，严重的胰岛素抵抗常常合并有黑棘皮病。多发生于皮肤皱褶部位，如颈、腋窝、腹股沟、乳头下、脐窝、肛门外生殖器等处 高雄激素血症的女性黑棘皮病的发生率为5%29
22、%。肥胖与黑棘皮病关系密切，两者呈正相关。皮疹的变化不仅与肥胖程度相关，而且随体重的下降而减轻。对肥胖型黑棘皮病，必须纠正肥胖，积极参加体育锻炼，控制饮食以减肥，随着体重的下降，黑棘皮病也就随之治愈PCOS的干预策略及治疗原则的干预策略及治疗原则 肥胖患者的一线治疗是降体重 无排卵患者应采用孕激素口服或口服避孕药控制月经周期，阻止子宫内膜增生性病变 胰岛素抵抗患者需使用胰岛素增敏剂 降雄激素药物可控制高雄激素体征 助孕干预开始之前应给予降雄、内膜准备及纠正胰岛素抵抗和代谢紊乱的治疗*复方短效口服避孕药，具有抗雄激素效果者更佳 抑制LH分泌，减少雄激素 但停药后雄激素分泌可能再次升高二甲双胍 促进周围组织对葡萄糖的摄取，加强周围组织对胰岛素的敏感性，降低胰岛素、LH 可达到肥胖患者降低体重至正常范围同样的效果 65%恢复规律月经，62%恢复排卵，可能降低流产率 副作用 致畸性：随诊154名母亲患PCOS在妊娠期服用二甲双胍的婴儿没有发现不良反应 恶心和腹泻，餐中服用可减轻，其他还有腹胀、胀气和呕吐 低血糖反应很少发生 罕见但严重的并发症是乳酸酸中毒罗格列酮 噻唑烷二酮类 机理 过氧化物酶增殖活化受体（PPAR ）激动剂 与视黄醇受体结合 调节基因活动 作用 增加脂肪-氧化，促进降脂，预防代谢综合征 成熟脂肪细胞对胰岛素更敏感，改善胰岛素抵抗1234
