What is polycystic ovary syndrome (PCOS)? Diet, nutrition for polycystic ovary syndrome. Irregular menstruation and endometrial hyperplasia

The female body, due to its characteristics, is susceptible to diseases that are unfamiliar to men. Diseases of the organs of the reproductive system - a profile of gynecology. Polycystic ovary syndrome is one of these diseases, manifested by pronounced external symptoms and has a negative effect on the reproductive function of the female body. Is it possible to recover from this disease and restore the ability to bear and give birth to a child?

Characteristics of PCOS

More than ten percent of women who are of reproductive age - that is, theoretically able to bear and give birth to a child - suffer from polycystic ovary syndrome (PCOS). This is one of the main causes of endocrine infertility - more than 70% of women unable to get pregnant suffer from PCOS.

The essence of the disease is in violation of the correct structure and functional abilities of the ovaries. This condition affects the entire body of a woman in the form of hyperandrogenic syndrome, symptoms of menstrual irregularities and, as a result, infertility.

The definitive etiology of PCOS has not yet been clarified. To date, there are several theories that, to one degree or another, explain the occurrence of ovarian pathology. The main reason is heredity. In the course of numerous studies, it has been confirmed that polycystic ovary syndrome is transmitted through the female line for several generations. Other causal factors are considered to be poor ecology, unfavorable living conditions, emotional stress, background gynecological diseases.

Several pathogenetic mechanisms have been identified that collectively give polycystic ovary syndrome:

Clinical picture and methods of detecting pathology

Symptoms consist of external signs and disorders of the reproductive organs.

There is a change in appearance - male-type symptoms:

rough facial features;
male pattern hair growth;
changing the timbre of the voice;
increased work of the sebaceous glands and the appearance of acne;
more than half of the patients are overweight.

There is a violation of the menstrual cycle - menstruation lasts 1-2 days, the volume of blood secreted is insignificant. Bleeding is possible in the first or second phase of the cycle (dysfunctional). A third of patients have no menstruation (secondary amenorrhea).

All patients have an inability to get pregnant - primary infertility. It is associated with the absence of a dominant follicle and a mature egg. A third of women with PCOS are affected. Cysts form in the mammary gland, resulting in symptoms of painful premenstrual syndrome.

The color of the skin changes - in places of friction, reddish-brown spots of different sizes appear in the skin folds. A special type of obesity is characteristic - central, when fat is deposited mainly in the region of the anterior abdominal wall.

After a physical examination, a blood hormone test is scheduled. There is an increased content of luteinizing hormone and androgens, a decrease in the level of follicle-stimulating hormone. For each hormone, there is the most optimal day of the menstrual cycle, when its study will be most revealing. Luteinizing and follicle-stimulating hormones are best tested on the third day of the cycle, when their concentration in the blood is maximum. To identify insulin resistance, a glucose tolerance test is performed. The study of the content of hormones in the urine is not indicative.

Instrumental research methods are also used. The main one is an ultrasound examination of the ovaries. Criteria on the basis of which a diagnosis of PCOS can be made have been determined:

You can also use a visual method for assessing the state of the ovaries. For this, laparoscopy is used, if necessary, during the study, you can take a piece of the organ. With laparoscopy, you can see enlarged ovaries, their surface is uneven, bumpy. If a woman is worried about acyclic bleeding from the uterus, an endometrial biopsy is prescribed to diagnose hyperplastic processes - polyps, endometriosis, endometrial cancer.

Principles of therapy

Treatment of this disease is laborious, directed at all pathological mechanisms. What are the goals of the treatment:

normalization of the menstrual cycle before ovulation appears;
restoration of reproductive function;
suppression of endometrial hyperplasia;
decrease in external manifestations - decrease in body weight, elimination of hair and acne.

The mainstay of treatment is taking hormonal drugs. Before taking these drugs, it is necessary to normalize body weight and eliminate insulin resistance. For the simultaneous treatment of these manifestations, the drug Metformin is used. This is a tablet preparation from the biguanide group used for the treatment of diabetes mellitus. Metformin stimulates the breakdown of glucose in body tissues. As a result, insulin resistance decreases, excess weight decreases. To achieve a sustainable effect, a course of treatment with Metformin is required for at least six months.

After normalization of metabolic disorders, the normal ovulatory cycle is restored.

For this, a drug called Clomiphene Citrate is used. This drug acts on the principle of feedback. By itself, Clomiphene citrate is an antiestrogen. When it accumulates in the body, it blocks the production of estrogens at all levels of regulation. Abrupt withdrawal of the drug leads to stimulation of the production of gonadotropic hormone, which increases the secretion of estrogen in the ovaries. After this, normal maturation of the follicles is observed, the appearance of a dominant follicle and the release of a mature egg. It will be more effective to prescribe a medication while you are taking Metformin (combination therapy).

After the appearance of a physiological ovulatory cycle, the next stage of therapy begins - the intake of gonadotropins. This method is prescribed for those patients who are planning a pregnancy.

If the patient does not respond to Clomiphene therapy, surgery is used. The methods used in this:

wedge-shaped excision of ovarian tissue;
laser or electrical cauterization - destruction of the stroma;
after surgical treatment, six-month therapy with Metformin is carried out.

For the prevention of recurrence of PCOS, oral contraceptives are prescribed - monophasic microdose (Yarina, Marvelon). To reduce the risk of weight gain while taking contraceptives, a transvaginal system is prescribed - NovaRing (a ring with dosed release of hormones).

After the normalization of menstrual and reproductive function, a woman is able to become pregnant and bear a child. However, polycystic ovary syndrome is prone to recurrence. It is necessary to maintain the correct weight, avoid emotional overload. The woman is assigned a special diet with restriction of carbohydrates. Adequate physical activity is recommended. Periodic courses of physiotherapy are shown. Electrophoresis is applied to the area of the ovaries with the drug Lidaza. It stimulates the hormone-producing function of the organ.

Traditional medicines are ineffective in the fight against PCOS.

Treatment with such methods will not only not bring the desired result, but also aggravate the pathological process.

Polycystic ovary syndrome (PCOS), also known as hyperandrogenic anovulation (HA) or Stein-Leventhal syndrome, is a set of symptoms that is caused by hormonal imbalances in women. Symptoms include irregular or no menstrual periods, menorrhagia, excess body and facial hair, acne, pelvic pain, trouble conceiving, areas of thicker, darker, rough skin. Conditions associated with this syndrome include type 2 diabetes, obesity, obstructive sleep, cardiovascular disease, mood disorders, and endometrial cancer. PCOS is caused by a combination of genetic and environmental factors. Risk factors include obesity, physical inactivity, and having relatives with the condition. Diagnosis is based on the presence of two of the following three signs: lack of ovulation, high androgen levels, and ovarian cysts. Cysts can be detected using ultrasound. Other conditions that contribute to these symptoms include adrenal hyperplasia, hypothyroidism, and hyperprolactinemia. PCOS is not completely cured. Treatment may include lifestyle changes such as weight loss and exercise. Birth control pills can help improve menstrual regularity, hair and acne. Metmorphine and antiandrogens can also help. Other typical acne medications and hair removal methods can also be used. Efforts to improve fertility include weight loss and the use of clomiphene or metmorphine. In vitro fertilization is used by some people when other methods are not effective. PCOS is the most common endocrine disorder among women between the ages of 18 and 44. It affects about 5-10% of women in this age group. It is one of the main causes of fertility problems. The earliest mention of this disease dates back to 1721 in Italy.

Signs and symptoms

The following common PCOS symptoms are distinguished:

Asians affected by SPKS are less likely to develop hirsutism than other ethnic groups.

Causes

PCOS is a heterogeneous disorder with no specific cause that causes it. There is strong evidence that the disease is genetic. Such evidence is familial clustering of cases, a greater likelihood of manifestation of the disease in monozygotic twins compared to dizygotic twins, as well as the heritability of endocrine and metabolic characteristics of PCOS. The genetic component appears to be inherited in an autosomal dominant manner with high genetic penetrance, but with variable expressivity in women; this means that every child has a 50% chance of inheriting a predisposing genetic variant from a parent. The genetic variant can be inherited from the father or mother, and it can also be passed on to sons (in whom it will be asymptomatic or then manifest as early baldness and / or increased hairiness), and to daughters, in whom it will manifest as PCOS. Alleles appear to manifest themselves, at least in the form of increased levels of androgens secreted by ovarian follicle mucosal cells from a woman with alleles. The specific gene affected was not identified. The severity of PCOS symptoms appears to be largely determined by factors such as obesity. SPKS has some aspects of metabolic disorder, as its symptoms are often reversible. Even if we consider the syndrome as a gynecological problem, then it consists of 28 clinical symptoms. Even if we assume that the name itself suggests that the ovaries are the basis of the pathology of the disease, cysts are a symptom, not the cause of the disease. Some PCOS symptoms will persist even when both ovaries are removed; the disease can manifest itself even when cysts are absent. The first description of the disease was carried out in 1935 by Stein and Leventhal; diagnostic criteria, symptoms and causal factors were identified, which became the subject of discussion. Gynecologists often consider the disease as a gynecological problem in which the ovaries are the main organ affected. However, recent studies view the syndrome as a multisystem disorder in which the primary problem is hormonal regulation in the hypothalamus involving multiple organs. The name PCOS is used when there is evidence from an ultrasound examination. PCOS is used when there is a wide range of symptoms, with ovarian cysts occurring in 15% of people. PCOS can be associated or aggravated by exposure during the prenatal period, epigenetic factors, environmental influences (especially in industrial endocrine disorders caused by drugs such as bisphenol A and certain other substances), as well as in the case of an increase in obesity.

Diagnostics

Not every person with PCOS has polycystic ovaries (PCOS), and not every person with ovarian ovaries has PCOS; although organ ultrasound is the main diagnostic tool, it is not the only one. Diagnosis is fairly straightforward using the Rotterdam test, even when the syndrome is associated with a wide range of symptoms.

Definition

Usually two definitions are used:

BOTTOM

In 1990, there was a general consensus between the NIH and the National Institute for Child Health and Human Development, which assumed that a woman had PCOS if she had the following characteristics:

infrequent, irregular ovulation;

signs of excess androgens (clinical or biochemical);

other disorders that can lead to irregular menstruation and hyperandrogenism are excluded.

Rotterdam

In 2003, in Rotterdam, a common opinion was developed by the European Society for Human Reproduction and Embryology and the American Society for Reproductive Medicine, within which, in order to diagnose PCOS, it is necessary that a person shows 2 of 3 symptoms, and they should not be caused by other reasons:

infrequent, irregular ovulation or anovulation;

excess of androgens;

polycystic ovary (as part of a gynecological ultrasound).

The concept developed in Rotterdam is broader, including more women, especially those who do not have an excess of androgens. Critics argue that this finding, from a study of women with androgen excess, may not necessarily be extrapolated to women without androgen excess.

The Androgen Excess and PCOS Society

In 2006, the Androgen Excess and PCOS Society proposed tightening the diagnostic criteria to the following list:

excess of androgens;

infrequent, irregular ovulation or anovulation, or polycystic ovary disease;

exclusion of other causes that lead to excess production of androgens.

Routine diagnostic assessment

Some other blood tests are suggestive but not diagnostic. The ratio of LH (luteinizing hormone) to FSH (follicle-stimulating hormone), when measured in international units, is increased in women with PCOS. The total concentration limit for determining an abnormally high ratio of LH to FSH is 2 to 1 or 3 to 1 when measured on the third day of the menstrual cycle. The clinical picture is not very sensitive; a ratio of 2 to 1 or higher was observed in less than 50% of women with PCOS in one study. Quite often, there is a low level of globulin that binds sex hormones, in particular, in women with obesity or overweight. Anti-Müllerian hormone (AMH) is increased in PCOS and is also one of the diagnostic criteria.

Related conditions

Differential diagnosis

Other causes of irregular or absent menstruation and hirsutism should also be investigated, such as hypothyroidism, congenital adrenal hyperplasia (21-hydroxylase deficiency), Cushing's syndrome, hyperprolactinemia, androgen secretion neoplasms, and other pituitary or adrenal disorders.

Pathogenesis

Polycystic ovaries develop when the ovaries have been stimulated to produce excess amounts of male hormones (androgens), specifically testosterone or one or more of the following (depending on genetic predisposition):

release of excess luteinizing hormone (LH) in the anterior pituitary gland;

excessively high levels of insulin in the blood (hyperinsulinemia) in women whose ovaries are sensitive to this stimulus.

The syndrome acquired this name due to the general manifestation during ultrasound in the form of numerous (poly) ovarian cysts. These "cysts" are immature follicles, not cysts. Follicles develop from primordial follicles, but their development was stopped at an early antral stage due to impaired ovarian function. The follicles can be oriented along the periphery of the ovaries, appearing as a "pearl string" on ultrasound. Women with PCOS experience an increased frequency of hypothalamic GnRH pulses, which in turn leads to an increase in the ratio of LH to FSH. Most people with PCOS are insulin resistant and / or obese. Elevated insulin levels lead to abnormalities in the hypothalamic-pituitary-ovarian axis that cause PCOS. Hyperinsulinemia increases the frequency of impulses of GnRH, LH due to the dominance of FSH, and also increases the production of androgens by the ovaries, reduces the rate of follicle maturation and SHBG binding; all of these steps are involved in the development of PCOS. Insulin resistance is a common manifestation in women with normal body weight and overweight. Adipose tissue contains aromatase, an enzyme that converts androstenedione to estrone and testosterone to estradiol. An excess of adipose tissue in obese women creates the paradox of a simultaneous excess of androgens (which are responsible for hirsutism and masculinization) and estrogens (which FSH inhibits due to negative feedback). PCOS may be associated with chronic inflammation, with some studies showing a correlation of inflammatory mediators with anovulation and other symptoms of PCOS. In addition, there has been a link between PCOS and increased levels of oxidative stress. It has previously been suggested that excess androgen production in PCOS may be caused by decreased serum IGFBP-1, which in turn increases free IGF-1, which stimulates ovarian androgen production, but recent studies have questioned this mechanism. PCOS has also been linked to a specific subgenotype of FMR1. Studies show that women with heterozygous-normal / low FMR1 have polycystic-like symptoms, manifested as overactive follicular activity and ovarian hyperactivity. Transgender men may develop PCOS more often than usual due to increased testosterone if they choose to undergo hormone therapy as part of their gender identity.

Treatment

The main treatments for PCOS include lifestyle changes, medication, and surgery. Treatment goals can be divided into four categories:

Decreased levels of insulin resistance;

Fertility recovery;

Treating hirsutism or acne;

Restoration of regular menstruation and prevention of endometrial hyperplasia and endometrial cancer.

For each of these areas, there is much debate about the optimal treatment. One of the main reasons for this is the lack of large-scale clinical trials comparing different treatments. Small tests tend to be less reliable and therefore lead to conflicting results. General measures that help reduce body weight and insulin resistance can be beneficial for all of these goals, as they are thought to affect the underlying cause. Since PCOS appears to cause significant emotional distress, appropriate support can be helpful.

Diet

Since PCOS is associated with being overweight or obese, successful weight loss is the most effective method of restoring normal ovulation / menstruation, but many women find it difficult to achieve and maintain significant weight loss. A 2013 scientific review showed a link between weight loss and improved rates of conception, menstrual cycle, ovulation, hyperandrogenism, insulin resistance, lipids, quality of life, which are specifically caused by weight loss regardless of dietary changes. However, a low-glycemic diet, with a large proportion of carbohydrates in fruits, vegetables, and whole grains, will increase your regular menstrual cycle compared to a diet that contains macronutrients in a healthy diet. Deficiency can play a role in the development of metabolic syndrome, therefore, treatment of any such type of deficiency is indicated. As of 2012, the effects of dietary supplementation to correct metabolic deficits in people with PCOS have been tested in small, uncontrolled, and non-randomized clinical trials; the results are insufficient to recommend the use of any nutritional supplements.

Medications

Medicines for PCOS include oral contraceptives and metmorphine. Oral contraceptives increase the production of sex hormone binding globulin, which increases free testosterone binding. It helps to reduce the symptoms of hirsutism, which are caused by high testosterone levels, by regulating the return to a normal menstrual cycle. Metmorphine is a drug widely used in type 2 diabetes to reduce insulin resistance and is also used inappropriately (in the UK, USA and European Union) for the treatment of insulin resistance in PCOS. In many cases, metmorphine also supports ovarian function by producing a return to normal ovulation. can be used as an antiandrogenic agent, and topical eflornithine cream can be used to reduce facial hair. A new class of drugs used for insulin resistance, namely thiazolidinediones (glitazones), showed an equivalent effect compared to metmorphine, and metmorphine showed a more favorable side effect profile. In 2004, the United Kingdom's National Institute for Health and Clinical Excellence recommended that women with PCOS and BMIs over 25 should use metmorphine when other therapy had failed. Metmorphine may not be effective for all types of PCOS, so there is controversy over its use as a first-line treatment. Difficulties in conception may also be observed, since PCOS causes ovulation disorders. Drugs that promote fertility include drugs that induce ovulation, namely clomiphene or leuprolide. Metmorphine improves the efficacy of treating poor fertility when used in combination with clomiphene. Metmorphine is safe for use during pregnancy (US Category B). A 2014 review found that metmorphine use did not increase the risk of most birth defects in the fetus during the first trimester.

Infertility

Not all women with PCOS have difficulty conceiving. For those who do face this problem, anovulation or infrequent ovulation is the main cause. Other factors include changes in gonadotropin levels, hyperandrogenism, and hyperinsulinemia. Like women without PCOS, women with PCOS who ovulate may be infertile for other reasons, such as blocked fallopian tubes due to sexually transmitted diseases. For women with overweight and anovulation, as well as with PCOS, weight loss and dietary changes based primarily on a decrease in consumption of simple carbohydrates are associated with the resumption of natural ovulation. For women who, even after losing weight, do not ovulate, first of all, they begin to use drugs to induce ovulation, namely clomiphene citrate and FSH. Metmorphine, a drug used in diabetes, was previously recommended for the treatment of anovulation, but it appears to be less effective than clomiphene. For women who are unresponsive to clomiphene use and diet and lifestyle changes, there are options such as assisted reproductive technologies, which include controlled ovarian hyperstimulation with follicle-stimulating hormone (FSH) injections followed by in vitro fertilization (IVF). Although surgery is not usually done, polycystic ovary disease can be treated with a laparoscopic procedure called “ovarian drilling” (4-10 small follicles are punctured with electrocautery, laser, or biopsy), which often results in spontaneous ovulation or ovulation recurrence after adjuvant treatment with clomiphene or FSH (wedge resection of the ovaries is no longer used due to numerous complications such as adhesions and numerous effective medications). However, there are concerns about the long-term effects of ovarian drilling on ovarian function.

Hirsutism and acne

When necessary (for example, in women of childbearing age who need contraception), standard contraceptive pills are used, which are often effective in reducing hirsutism. Progesterones such as norgestrel and levonorgestrel are not recommended for use due to their androgenic effects. Other drugs with antiandrogenic effects include flutamide, spironolactone, which may help reduce the symptoms of hirsutism. Metmorphine can also reduce the manifestation of hirsutism, possibly by reducing insulin resistance; the substance is often used for conditions such as insulin resistance, diabetes, obesity, which makes it more functional. Eflornithine is a drug that is applied to the skin in the form of a cream, acting directly on the hair follicles, thereby slowing down their growth. It is usually applied to the face. 5-alpha reductase inhibitors (eg, and) can also be used; they work by blocking the conversion of testosterone into (the latter is responsible for changes in hair growth and androgenic acne). Although these substances have shown significant efficacy in clinical trials (in the form of oral contraceptives in 60-100% of people), reducing hair growth may not be sufficient to prevent social embarrassment due to hirsutism or the inconvenience of frequent plucking or shaving. Each person responds differently to treatment. You should usually try other treatments if the previous one doesn't work, as each method is effective for each person to varying degrees.

Irregular menstruation and endometrial hyperplasia

If fertility is not the primary goal, menstruation is usually controlled with the use of birth control pills. The purpose of regulating the menstrual cycle is mainly to convince a woman of her well-being; there are no specific medical requirements for regular menstrual cycles as long as they occur frequently enough. If a regular menstrual cycle is not required, then therapy to treat the irregular cycle is no longer required. Most experts argue that if menstrual bleeding occurs at least every three months, it means that the endometrium (the lining of the uterus) is secreted frequently enough to avoid an increased risk of endometrial abnormalities or cancer. If menstruation occurs less frequently or absent altogether, progesterone replacement therapy is recommended. An alternative is to take progesterone orally at intervals (eg, every three months) to induce predictable menstrual bleeding.

Alternative medicine

There is insufficient evidence to draw conclusions about the effectiveness of D-chiroinositol. Myo-inositol, however, is effective according to a systematic review. There is preliminary data, but not very high quality, regarding the use of acupuncture for PCOS.

Forecast

A diagnosis of PCOS suggests an increased risk of the following conditions:

Early diagnosis and treatment can reduce the risk of certain manifestations, such as type 2 diabetes and cardiovascular disease. The risk of ovarian and breast cancer in general did not show a significant increase.

Epidemiology

The prevalence of PCOS depends on the chosen diagnostic criteria. The World Health Organization estimates that it affects about 116 million women worldwide (2010 data) or 3.4% of all women. One study based on criteria developed in Rotterdam showed that about 18% of women suffered from PCOS, and 70% of them did not know about their diagnosis.

One study from the UK found that lesbians were at higher risk of developing PCOS than heterosexual women. However, two subsequent studies showed that this statement about women with PCOS and sexual orientation was not confirmed. Polycystic ovaries occur in 8-25% of normal women undergoing ultrasound. Polycystic ovaries were also found in 14% of women taking oral contraceptives. Ovarian cysts are also a common side effect of using intrauterine contraceptives (IUDs).

History

This condition was first described in 1935 by American gynecologists Irving F. Stein, Sr. and Michael L. Leventhal, after whom the syndrome was named Stein-Leventhal syndrome. The earliest published description of a person who was later revealed to have PCOS was carried out in 1721 in Italy. In 1844, changes in the ovaries associated with cysts were described.

Names

Other names for this syndrome are: polycystic ovarian disorder, functional ovarian hyperandrogenism, ovarian hyperthecosis, sclerotic ovarian syndrome, and Stein-Leventhal syndrome. The latter is the original name and is still used today; in general, this syndrome is usually applied to women who have the following symptoms together: amenorrhea with infertility, hirsutism, and enlarged polycystic ovaries. The most common names for this syndrome come from simple manifestations within the clinical picture and include the combination "polycystic ovary". Polycystic ovaries have an abnormally large number of developing eggs near their surface, which look like a large number of small cysts or strands of pearls.

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(synonym - polycystic ovary syndrome or PCOS) is a bilateral benign growth inside or outside the ovaries of multiple cystic formations due to a complex of endocrine disorders (dysfunction of the ovaries, thyroid and pancreas, adrenal cortex, pituitary and hypothalamus). Primary polycystic ovary disease can be congenital or occur in adolescence at the stage of the formation of menstrual function. In adulthood, the development of PCOS may be due to chronic endocrine pathology or inflammatory diseases of the female reproductive system.

General information

- the formation and growth of multiple small cysts on the surface of the ovaries due to hormonal disorders in the woman's body. It can be asymptomatic, sometimes it manifests itself as a violation of menstrual function (oligomenorrhea), male-type body hair growth, obesity, and acne. Leads to miscarriage and infertility.

Primary polycystic ovary disease can be congenital or occur in adolescence at the stage of the formation of menstrual function. In adulthood, the development of PCOS may be due to chronic endocrine pathology or inflammatory diseases of the female reproductive system - secondary polycystic ovary disease. The incidence of polycystic ovary disease ranges from 5 to 10% of women in the reproductive phase. The greatest danger of PCOS is as the cause of female infertility in 25% of clinical cases.

PCOS symptoms

A number of disorders that arise in the body with polycystic ovaries allow the woman herself to suspect its development.

Irregularity of the menstrual cycle... Violation of ovulation (more often by the type of anovulation - its complete absence) leads to a change in the menstrual cycle, which manifests itself in long (more than a month) delays or complete absence of menstruation (amenorrhea). Often, such manifestations are found already at the very beginning of the formation of menstrual function in girls in adolescence. In some cases, with polycystic ovaries, long delays in menstruation can alternate with uterine bleeding caused by endometrial hyperplasia (excessive proliferation of the uterine lining).
Increased greasiness of hair and skin, the appearance of blackheads, acne, seborrhea. With polycystic ovaries, they develop as a result of androgen hypersecretion, are permanent, and do not respond to symptomatic therapy.
Obesity... It is manifested by a sharp increase in weight by 10-15 kg. Fat deposits can be distributed according to the universal type (evenly throughout the body) or according to the male type of obesity (mainly deposited in the waist and abdomen). Disorders of lipid and carbohydrate metabolism can lead to the development of type 2 diabetes mellitus.
Increased body hair growth- hirsutism. With PCOS, hair begins to grow in a male pattern on the abdomen, perineum, inner thighs, and legs. On the face, tendrils usually appear above the upper lip.
Drawing pains in the lower abdomen... The pains are chronic and moderate in nature, may radiate to the lower back or pelvic region.
Constancy of basal (rectal) temperature throughout the entire menstrual cycle. In the second phase of the menstrual cycle, there is normally a characteristic jump in basal temperature, which coincides in time with the process of ovulation. The absence of a temperature maximum indicates anovulatory cycle.
Infertility... With PCOS, primary infertility is observed, that is, the absence of a history of pregnancy with regular sexual intercourse without the use of contraception.

Causes of PCOS

The development of polycystic ovary is primarily based on polyendocrine disorders, manifested by dysfunction:

pituitary and hypothalamus (dysregulation of the adrenal glands and ovaries);
adrenal cortex (increased secretion of androgens);
ovaries (irregularity or lack of ovulation, increased secretion of estrogen);
pancreas (increased production of insulin with tissue insensitivity to it).

Violation of hormonal regulation leads to a suspension of the development and maturation of follicles, an increase in the size and compaction of the ovarian capsule, under which multiple cystic growths begin to form from immature follicles. This leads to disorders of ovulation, menstrual function and infertility. Against the background of obesity (and it occurs in women with PCOS in 40% of cases), these processes are even more pronounced. Infectious diseases, stress and even climate change can provoke hormonal disorders.

Complications of PCOS

Polycystic ovary disease, accompanied by hormonal disorders and lack of ovulation, is one of the most common causes of female infertility. A prolonged course of polycystic ovary disease without appropriate treatment significantly increases the chances of developing malignant tumors of the body and cervix, as well as, according to some reports, breast cancer. This risk factor is higher when polycystic ovary disease is combined with obesity and diabetes mellitus. In addition, a violation of lipid-fat metabolism leads to the development of vascular atherosclerosis, myocardial infarction, and stroke. Identifying PCOS at an early stage of development greatly facilitates cure and reduces the risk of developing dire consequences.

Diagnostics

A diagnosis of polycystic ovary syndrome is possible if at least two of the following criteria are met:

ovarian dysfunction, manifested in menstrual irregularities, lack of ovulation (anovulation) and infertility;
hyperandrogenism in women - excessive production of androgens (male sex hormones) in the female body, manifested by increased hair growth (hirsutism), acne (acne), increased skin greasiness and seborrhea;
echoscopic or laparoscopic picture of enlargement and cystic changes in the ovaries.

To confirm these criteria in the diagnosis of PCOS, a number of objective, laboratory and instrumental methods are used:

General examination, which includes an assessment of the body type, the nature of hair growth, the condition of the skin and mucous membranes, palpation of the abdomen, etc.
Gynecological vaginal-abdominal examination on a chair, which allows to identify an increase and hardening of the ovaries on both sides.
Ultrasound of the pelvic organs, in which there is a bilateral enlargement of the ovaries up to 4 cm wide and 5-6 cm long, their dense capsule, the presence of multiple (8 or more) small follicular cysts on the periphery. With dopplerometry, an increase in blood flow in the vessels of the ovaries is recorded.
Determination of the level of hormones in the blood of the pituitary gland, ovaries, adrenal glands: prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), progesterone, estradiol, 17-hydroscyprogesterone, testosterone, androstenedione, cortisol, DEA-Sulfate.
Magnetic resonance imaging (MRI), which allows to exclude tumor lesions of the ovaries.
Study of the level of lipids and lipid fractions to determine lipid metabolism disorders.
Determination of insulin and glucose in the blood, TSH (glucose tolerance test) in order to detect disorders of carbohydrate metabolism.
Laparoscopy confirming bilateral cystic ovarian changes.

PCOS treatment

Treatment of polycystic ovary is aimed at restoring or normalizing ovulation, menstrual and reproductive functions and is carried out by conservative and surgical methods. Conservative treatment of PCOS is carried out with the help of hormonal drugs: antiestrogens, combined oral contraceptives with an antiandrogenic effect (restoration of the menstrual cycle, elimination of hyperandrogenism), gonadotropins (stimulating ovulation).

Women suffering from polycystic ovary disease with obesity should combine physical activity with a certain diet and diet:

limiting the calorie content of food to 1200 - 1800 kcal per day with 5-6 meals a day;
the use of low-calorie foods (fruits, vegetables);
increasing the protein content in the diet (fish, seafood, meat, cottage cheese);
restriction of carbohydrate foods (baked goods, sugar, jam, honey, sugary drinks);
elimination of animal fats and their replacement with vegetable fats. The daily fat intake is not more than 80 g;
exclusion of spices, spices, sauces, smoked and pickled products;
complete elimination of alcohol;
fasting days 2-3 times a week (apple, kefir, cottage cheese, vegetable).

In the absence of a result from the ongoing conservative therapy or the development of endometrial hyperplasia, surgical treatment is performed. As a rule, modern operative gynecology uses less traumatic laparoscopic operations in the treatment of polycystic ovaries. With polycystic ovary, a wedge-shaped resection is performed, i.e., partial removal or cauterization (cauterization) of the affected ovarian tissue. This leads to a decrease in the production of androgens and normalization of ovulation. As a result of surgery, pregnancy occurs in 65% of patients. Unfortunately, the effect of the operation lasts from 1 to 3 years, and then a relapse of polycystic ovary occurs again.

The most favorable period for the onset of pregnancy is the first six months after the operation. At this time, hormones are prescribed that stimulate the maturation of the egg. Reoperations are possible, but they bring less effect. Women operated on for PCOS should be under constant dispensary supervision by a gynecologist.

Forecast and prevention

It is impossible to completely cure PCOS, so the goal of treatment is to create favorable opportunities for pregnancy. When planning pregnancy, women diagnosed with polycystic ovary disease need to undergo treatment to restore and stimulate ovulation. With age, polycystic ovary disease progresses, so the issue of pregnancy should be resolved as early as possible.

As with the prevention of other gynecological diseases, the prevention of PCOS requires regular scheduled consultations with a gynecologist. Polycystic ovary disease, detected in the early phase of development, allows you to start correcting violations in time and avoid dire consequences, including infertility. The prevention of abortion, inflammatory and other diseases leading to dysfunction of the ovaries is of great importance. Mothers of teenage girls should be interested in the "women's" health of their daughters and at the first sign of polycystic ovary disease, immediately take them to a competent specialist.

PCOS is a hormonal disorder that affects the ovaries. As a result, their structure is disrupted and the glands malfunction. In the reproductive age, polycystic ovary syndrome is diagnosed most often. Despite the widespread prevalence of the disease, the causes of its occurrence have not yet been fully understood.

What it is?

PCOS (polycystic ovary syndrome) is a pathology characterized by the formation of multiple cystic cavities in the glands. They may be filled with clotted blood or pus. According to statistics, every fifth woman suffers from the disease.

In gynecology, PCOS is considered a serious problem. This is due to the fact that the majority of patients who see a doctor complain about the inability to get pregnant. This is due to the fact that the enlarged ovaries are the cause of increased production of luteinizing hormone and male sex biologically active substances. The consequence is an increase in estrogen levels and a decrease in progesterone concentration.

The natural results of these processes are the following violations:

there is a malfunction of the ovaries;
their blood supply deteriorates;
vital components do not enter the paired glands in sufficient quantities;
ovulation does not appear;
the endometrium of the uterus thickens;
the menstrual cycle becomes irregular;
uterine bleeding may periodically occur.

In gynecology, PCOS is classified according to several criteria.

By etiology, it can be:

Primary. Another name for the disease is Stein-Leventhal syndrome. Primary polycystic ovary disease can be congenital, or it develops during the formation of the menstrual cycle.
Secondary. In this case, the disease is a consequence of an existing endocrine disease.

By pathogenesis, the syndrome can take the following forms:

Typical, in which the synthesis of male sex hormones is significantly increased.
Central, characterized by rapid weight gain.
Mixed, combining features of both forms.

In addition, it can be of two types. In the first case, the glands increase in size, in the second, they do not.

You need to know that PCOS is a disease that needs to be treated. It significantly reduces the likelihood of pregnancy, but with timely access to a doctor, it is possible to successfully carry and give birth to a child. If you ignore the alarming symptoms, pathology will lead not only to infertility, but also to other serious complications.

Causes

You need to know that PCOS is such an ailment that is a consequence of hormonal imbalance. It, in turn, arises from the production of large amounts of testosterone, which inhibits the ovulation process.

The reasons for this situation may be:

hereditary predisposition;
a state of constant psycho-emotional stress;
depression;
pathology of the organs of the endocrine system;
unsatisfactory environmental conditions in the area of permanent residence;
violation of metabolic processes;
decreased sensitivity of body cells to insulin;
neurohumoral disorders;
chronic infectious diseases;
overweight;
climate change.

Under the influence of one or more of the above factors, the process of development and formation of follicles is inhibited. At the same time, the ovarian capsules thicken and increase in size, under which numerous cystic formations begin to form.

Symptoms

Every woman needs to know that PCOS is a disease that can proceed in different ways. The severity of symptoms depends only on the individual characteristics of the organism. The first signs of PCOS may appear when a pathological process has been developing in the ovaries for a long time. In this regard, most women are not even aware of the presence of polycystic disease and seek medical help if numerous attempts to get pregnant were unsuccessful. In this case, the symptom of polycystic ovary syndrome is infertility.

Also, the following signs may indicate the disease:

violation of the menstrual cycle;
amenorrhea;
increased hair growth on the face, neck, arms;
acne;
baldness;
seborrheic dermatitis;
obesity (body weight increases sharply by 10 kg or more);
uterine bleeding;
increased oily skin and hair;
pain in the lower abdomen, often radiating to the lower back or pelvic region;
rectal body temperature is unchanged throughout the cycle (with ovulation, it should increase).

Important! Most of the above symptoms of polycystic ovary syndrome may not be signs of pathology in women during or before menopause and in girls during adolescence. This is due to the fact that in both cases, the violation of the cycle and the manifestation of excessive production of androgen can be normal physiological conditions.

After examination by a doctor, a diagnosis of PCOS can be made if the symptoms are persistent and persist for a long time after the first menstrual bleeding occurs. For women who are preparing or are in menopause, the likelihood of having the syndrome is extremely high if they have already noticed the signs of the disease at a younger age.

Diagnostics

First of all, the doctor needs to take a thorough history. At the initial admission, he should receive answers to the following questions:

what alarming symptoms are bothering the patient;
body type;
body mass index;
whether the condition of the skin and mucous membranes is disturbed;
type of hair growth.

Then the doctor performs a vaginal examination on a gynecological chair and palpation. This is necessary in order to assess the size and density of the glands.

For an accurate diagnosis, laboratory and instrumental methods for diagnosing polycystic ovary syndrome are prescribed:

A blood test to determine the level of the following hormones: progesterone, prolactin, testosterone, cortisol, FSH, LH, DEA-S, estradiol, androstenedione. They are produced by the adrenal glands, pituitary gland and ovaries.
A blood test to determine the concentration of lipids. This is necessary to identify violations of metabolic processes.
Blood sugar test. Most women with polycystic ovary disease suffer from diabetes or are at risk of developing it. For more accurate information, a glucose tolerance test may be prescribed.
Ultrasound. During the study, the blood flow rate, the size of the ovaries, and the density of the capsules are assessed. The diagnosis of PCOS is confirmed by ultrasound if the specialist has found 25 or more formations, the diameter of which varies between 2-9 mm. In addition, in polycystic disease, the volume of the ovary exceeds 10 ml.
MRI. With its help, the doctor gets the opportunity to find out if the glands are affected by tumors.
Laparoscopy. With PCOS, the method allows you to visually assess the state of the ovaries, which is impossible with a vaginal examination. In addition, the doctor can take a biomaterial for its further analysis.

Blood tests are prescribed for all patients. Based on their results, the most appropriate instrumental diagnostic methods are selected.

Conservative treatment

According to the same medical document, the following stages should be present in the treatment of PCOS:

Weight loss... Fighting obesity involves adjusting the diet and increasing the intensity of physical activity. Also shown is the use of hypoglycemic agents, among which doctors prefer Metformin.
Restoration of ovulation and normalization of the menstrual cycle. For this purpose, drugs are prescribed, the active ingredient of which is clomiphene citrate. The therapy is carried out for 6 cycles. If the drug does not lead to positive results, gonadotropin drugs or GnRH agonists are additionally prescribed. If they also turn out to be ineffective, the patient is shown surgery.
Reducing androgen levels, getting rid of male-pattern hair growth. Therapy involves taking combined oral contraceptives. To get rid of the manifestations of hirsutism (excessive hair growth), the drug "Spironolactone" is usually prescribed. The course of treatment is 6 months. As for COCs, a huge number of names are sold on the pharmaceutical market. The choice of a contraceptive is carried out only by a doctor, taking into account the results of all studies. After discontinuation, the drug should provoke the maturation process of several follicles.

Thus, the tactics of treating PCOS comes down to normalizing the cycle, restoring fertility, eliminating metabolic disorders or reducing their manifestations to a minimum, getting rid of cosmetic defects, and reducing body weight.

Diet

There is no way to get rid of polycystic ovary syndrome permanently. But if it is not periodically treated, health-threatening conditions will develop over time. The patient's diet is of great importance in pathology. In most cases, it is the PCOS diet that can enhance the positive effect of medications, especially if the disease is accompanied by a significant increase in body weight.

Basic nutritional principles for polycystic disease:

The calorie content of the diet should be reduced to 2000 kcal per day. It should not be less than 1200 kcal, as it is dangerous to health. The doctor can calculate the ideal calorie content of the daily diet for the patient using special formulas. She can do this on her own.
You need to eat food that contains an acceptable amount of calories. The basis of the diet should be: fruits, vegetables, lean meats, herbs, fish, dairy products, seafood.
It is necessary to reduce the amount of carbohydrates entering the body. At the same time, you need to increase your intake of food rich in proteins.
It is necessary to reduce the amount of animal fats, replacing them with vegetable ones.
It is necessary to exclude from the diet sweet, salty, smoked, pickled, spicy foods, as well as any alcohol-containing drinks.
It is important to arrange fasting days to cleanse the body 1-2 times a week.

Operative treatment

Currently, the main method of surgical intervention is laparoscopy. This is due to the fact that the method is effective and less traumatic. Its essence is as follows: on the abdominal wall, the doctor makes several incisions (there are usually 3 or 4 of them, the length of each does not exceed 2 cm), through which manipulators of various actions are introduced into the body. During the operation, the surgeon has the ability to swap instruments. The main types of manipulators used in polycystic disease are: a coagulator designed to cauterize blood vessels; forceps required to grasp the gland; endoscopic scissors.

Thus, the surgeon does not carry out any manipulations with his own hands inside the abdominal cavity. Thanks to the camera built into the instrument, the progress of the operation is displayed on the monitor.

The main task of laparoscopy in polycystic ovary syndrome is to restore ovulation. Due to this, the patient gets the opportunity to become pregnant naturally.

The operation can be performed in several ways:

Cauterization... During surgery, the doctor grabs the ovary with forceps. Then, using a laser, he makes incisions on its capsule, the depth of which does not exceed 1 cm. The choice of a place for incisions is not accidental: the surgeon preliminarily examines the gland for the detection of translucent follicles. After laparoscopy, they should mature and release an egg. The operation does not imply significant blood loss, it does not exceed 10 ml.
Wedge resection... After capturing the ovary with forceps, the surgeon coagulates the area to be removed. Then with endoscopic scissors, he cuts out part of the gland and cauterizes the vessels. After that, the edges of the wound are sewn together with one suture.
Decortication... The essence of the method is to remove the dense portion of the capsule with a coagulator.

It is important to know that PCOS is a disease that will constantly recur. On average, after surgery, fertility is restored for 1 year. Further, the capsule begins to thicken again gradually. In this regard, the patient needs to conceive a child as soon as possible after the laparoscopy.

Is it possible to get pregnant with polycystic disease?

It is important to understand that for a successful conception, it is necessary that the ovulation process periodically starts in the woman's body. With PCOS, pregnancy is almost impossible, since a mature egg cannot get out of the gland due to the thickening of the capsule. Gradually, the follicle fills with fluid and a cyst forms from it.

The presence of polycystic disease does not mean that a woman is infertile, but without timely treatment, all chances are almost zero. Over time, the situation is getting worse, since with each cycle the number of cystic formations increases.

The greatest difficulty is the situation in which the ovarian tissue does not react in any way to the action of hormonal drugs. This condition is a consequence of a disturbance in the functioning of receptors. In this case, at the same time as PCOS, the doctor diagnoses ovarian resistance syndrome. In the presence of this ailment, the restoration of ovulation is impossible, since not a single drug, nor surgery will make it possible to achieve positive changes. The only way out for women with pathology is in vitro fertilization. But it requires donor material, since with resistance syndrome it is impossible to obtain eggs suitable for IVF.

If not treated?

Polycystic disease is a consequence of hormonal imbalance, and its course is accompanied by the absence of the ovulation process. If you ignore the alarming symptoms, the disease can trigger the onset of infertility. According to statistics, PCOS is one of the most common reasons why women cannot get pregnant naturally.

In addition, the prolonged course of polycystic ovary syndrome without regular courses of therapy significantly increases the likelihood of developing cancer of the cervix, mammary glands and other organs. The risk of a malignant process increases many times if the patient suffers from diabetes mellitus and obesity.

Also, the following diseases can become complications of PCOS:

atherosclerosis;
myocardial infarction;
stroke.

Timely diagnosis allows you to detect pathology at the earliest stage of its development, due to which the likelihood of dangerous complications is minimized.

Finally

Polycystic ovary syndrome is a serious ailment that not only significantly reduces the quality of life of every woman, but also prevents the desired pregnancy. The main symptoms of the disease are: failure of the menstrual cycle (up to amenorrhea), male-pattern hair growth, acne, seborrhea, pain, increased oily hair and skin. The difficulty of making a diagnosis may lie in the fact that not every patient has several characteristic symptoms at once, some may not have them at all. To diagnose the disease, both laboratory and instrumental methods are used, including: blood tests, ultrasound, MRI, laparoscopy. When the diagnosis is confirmed by the doctor, medications are prescribed, the action of which is aimed at restoring fertility, normalizing the menstrual cycle, and reducing the manifestation of cosmetic defects. If they do not bring the desired effect, surgery is indicated. The operation is performed by the laparoscopic method. After it, the ovulation process is restored and it is important for the patient to become pregnant in the coming months. This is due to the fact that it is impossible to get rid of the disease forever, relapses will periodically occur. Without treatment, it can provoke the appearance of infertility and various malignant processes.

Polycystic ovary syndrome(PCOS) is a pathology of the structure and function of the ovaries, the main criteria of which are chronic anovulation and hyperandrogenism. Frequency PCOS in the structure of endocrine infertility reaches 75%.

Symptoms of Polycystic Ovary Syndrome

Violation of the menstrual cycle of the type of oligo-, amenorrhea. Since the violation of the hormonal function of the ovaries begins from puberty, then the disturbances in the cycle begin from menarche and do not tend to normalize. It should be noted that the age of menarche corresponds to that in the population - 12-13 years (in contrast to adrenal hyperandrogenism in adrenogenital syndrome, when menarche is delayed). In about 10-15% of patients, menstrual irregularities have the character of dysfunctional uterine bleeding against the background of endometrial hyperplastic processes. Therefore, women with PCOS are at risk of developing endometrial adenocarcinoma, fibrocystic breast disease and breast cancer, as well as pregnancy problems.

Anovulatory infertility. Infertility is of a primary nature, in contrast to adrenal hyperandrogenism, in which pregnancy is possible and miscarriage is characteristic.

Hirsutism of varying severity develops gradually from the period of menarche, in contrast to the adrenogenital syndrome, when hirsutism develops up to menarche, from the moment of activation of the hormonal function of the adrenal glands during the period of adrenarche.

Excess body weight is observed in about 70% of women and corresponds to the II-III degree of obesity. Obesity is more often universal in nature, as evidenced by the ratio of waist to thigh volume (W / H) less than 0.85, which characterizes the female type of obesity. The OT / O ratio of more than 0.85 characterizes the cushingoid (male) type of obesity and is less common.

The mammary glands are developed correctly, every third woman has fibrocystic mastopathy, which develops against the background of chronic anovulation and hyperestrogenism.

In recent years, when they began to study the characteristics of metabolism in PCOS, it was found that insulin resistance and compensatory hyperinsulinemia - diabetoid type disorders of carbohydrate and fat metabolism - often take place. Dyslipidemia with a predominance of lipoproteins of the atherogenic complex (cholesterol, triglycerides, LDL and VLDL) is also noted. This, in turn, increases the risk of developing cardiovascular diseases in the second or third decades of life, that is, in the age periods in which these diseases are not characteristic.

Causes of polycystic ovary syndrome

There is still no consensus on the causes of the development of the disease.

PCOS is a multifactorial pathology, possibly genetically determined, in the pathogenesis of which there are central mechanisms of regulation of the gonadotropic function of the pituitary gland from puberty, local ovarian factors, extraovarial endocrine and metabolic disorders that determine the clinical symptoms and morphological changes of the ovaries.

Diagnostics of the polycystic ovary syndrome

Structural changes in the ovaries with this pathology are well studied and are characterized by:

hyperplasia of theca cells with areas of luteinization;

the presence of many cystic-atresing follicles with a diameter of 5-8 mm, located under the capsule in the form of a "necklace";

thickening of the ovarian capsule.

A characteristic history, appearance, and clinical presentation facilitate the diagnosis of PCOS. In a modern clinic, the diagnosis can be made without hormonal studies, although they also have characteristic features.

The diagnosis of polycystic ovaries can be established with transvaginal ultrasound, since clear criteria for the echoscopic picture are described: the volume of the ovaries is more than 9 cm 3, the hyperplastic stroma is 25% of the volume, more than ten atretic follicles with a diameter of up to 10 mm, located on the periphery under the thickened capsule.

The volume of the ovaries is determined by the formula: V = 0.523 (L x Sx H) cm3, where V, L, S, H - respectively the volume, length, width and thickness of the ovary; 0.523 is a constant coefficient. The increase in the volume of the ovaries due to the hyperplastic stroma and the characteristic location of the follicles help to differentiate polycystic ovaries from normal (on the 5-7th day of the cycle) or multifollicular. The latter are characteristic of early puberty, hypogonadotropic amenorrhea, and long-term use of COCs. Multifollicular ovaries are characterized by ultrasound by a small number of follicles with a diameter of 4-10 mm located throughout the ovary, the usual picture of the stroma and, most importantly, a normal ovarian volume (4-8 cm 3).

Thus, ultrasound is a non-invasive, highly informative method that can be considered the "gold standard" in the diagnosis of PCOS.

Hormonal characteristic PCOS. Diagnostic criteria are: an increase in the LH level, an increase in the LH / FSH ratio of more than 2.5, an increase in the level of total and free T with normal levels of DEA-C and 17-ONP.

After a test with dexamethasone, the androgen content decreases slightly, by about 25% (due to the adrenal fraction).

The test with ACTH is negative, which excludes adrenal hyperandrogenism, which is characteristic of adrenogenital syndrome. An increase in insulin levels and a decrease in PSH in the blood were also noted.

Metabolic disorders in PCOS characterized by an increase in triglycerides, LDL, VLDL and a decrease in HDL.

In clinical practice, a simple and accessible method for determining impaired glucose tolerance to insulin is the sugar curve. Blood sugar is determined first on an empty stomach, then within 2 hours after taking 75 g of glucose. If, after 2 hours, the blood sugar level does not return to the initial values, this indicates impaired glucose tolerance, that is, insulin resistance, which requires appropriate treatment.

Endometrial biopsy is indicated for women with acyclic bleeding due to the high frequency of endometrial hyperplastic processes.

Criteria for making a diagnosis PCOS are:

Timely age of menarche;
violation of the menstrual cycle from the period of menarche in the overwhelming majority of cases of the type of oligomenorrhea;
hirsutism and obesity from the menarche period in more than 50% of women;
primary infertility;
chronic anovulation;
an increase in the volume of the ovaries due to the stroma according to transvaginal echography;
an increase in the level of T;
an increase in LH and an LH / FSH ratio> 2.5.

Stages of treatment for polycystic ovary syndrome

As a rule, patients with PCOS go to the doctor with complaints of infertility. Therefore, the goal of treatment is to restore ovulatory cycles.

At PCOS with obesity and with normal body weight, the sequence of therapeutic measures is different.

If you are obese:

The first stage of therapy is the normalization of body weight. A decrease in body weight against the background of a reduction diet leads to the normalization of carbohydrate and fat metabolism. The PCOS diet involves reducing the total caloric intake of food to 2,000 kcal per day, of which 52% are carbohydrates, 16% are proteins and 32% are fats, and saturated fat should be no more than 1/3 of the total amount of fat. An important component of the diet is the restriction of spicy and salty foods and liquids. A very good effect is noted when using fasting days, fasting is not recommended due to the consumption of protein during gluconeogenesis. Increasing physical activity is an important component not only for normalizing body weight, but also for increasing the sensitivity of muscle tissue to insulin. Most importantly, it is necessary to convince the patient of the need to normalize body weight, as the first stage in treatment. PCOS.
The second stage of therapy is drug treatment of metabolic disorders (insulin resistance and hyperinsulinemia) in the absence of the effect of a reduction diet and physical activity. A drug that increases the sensitivity of peripheral tissues to insulin is metformin. Metformin leads to a decrease in peripheral insulin resistance, improving glucose utilization in the liver, muscles and adipose tissue; normalizes blood lipid profile by lowering triglyceride and LDL levels. The drug is prescribed at 1000-1500 mg per day for 3-6 months under the control of a glucose tolerance test.
The third stage of therapy is the stimulation of ovulation after normalization of body weight and with PCOS with normal body weight. Stimulation of ovulation is carried out after excluding tubal and male factors of infertility.

Therapeutic Methods for Stimulating Ovulation in PCOS

After normalization of body weight and PCOS with normal body weight, ovulation stimulation is indicated. Stimulation of ovulation is carried out after excluding tubal and male factors of infertility.

Most doctors start ovulation induction with the use of Clomiphene. It should be noted that the long-used method of stimulating ovulation using estrogen-progestin drugs, based on the rebound effect after their cancellation, has not lost its popularity. In the absence of the effect of therapy with estrogen-gestagens and "Clomiphene", it is recommended to prescribe gonadotropins or surgical stimulation of ovulation.

"Clomiphene" refers to a non-steroidal synthetic estrogen. Its mechanism of action is based on the blockade of estradiol receptors. After the cancellation of "Clomiphene" by the feedback mechanism, there is an increase in the secretion of GnRH, which normalizes the release of LH and FSH and, accordingly, the growth and maturation of follicles in the ovary. Thus, "Clomiphene" does not directly stimulate the ovaries, but acts through the hypothalamic-pituitary system. Stimulation of ovulation with "Clomiphene" begins from the 5th to the 9th day of the menstrual cycle, 50 mg per day. With this regimen, the drug-induced increase in the level of gonadrtropins occurs at a time when the selection of the dominant follicle has already been completed. Earlier administration can stimulate the development of multiple follicles and increase the risk of multiple pregnancies. In the absence of ovulation according to ultrasound and basal temperature, the dose of Clomiphene can be increased in each subsequent cycle by 50 mg, until it reaches 200 mg per day. However, many clinicians believe that if there is no effect when prescribing 100-150 mg of Clomiphene, a further increase in the dose is inappropriate. In the absence of ovulation at the maximum dose for 3 months, the patient can be considered resistant to the drug.

The criteria for the effectiveness of ovulation stimulation are:

Restoration of regular menstrual cycles with hyperthermic basal temperature for 12-14 days;
the level of progesterone in the middle of the second phase of the cycle is 5 ng / ml or more, the preovulatory peak of LH;
Ultrasound signs of ovulation on the 13-15th day of the cycle:
the presence of a dominant follicle with a diameter of at least 18 mm;
the thickness of the endometrium is not less than 8-10 mm.

In the presence of these indicators, it is recommended to administer an ovulatory dose of 7500-10000 IU of human chorionic gonadotropin - hCG ("Profazi", "Horagon", "Pregnil"), after which ovulation is noted in 36-48 hours. When treating with Clomiphene, it should be borne in mind that it has antiestrogenic properties, reduces the amount of cervical mucus ("dry neck"), which prevents the penetration of sperm and inhibits the proliferation of the endometrium and leads to impaired implantation in the case of fertilization of the egg. In order to eliminate these undesirable effects of the drug, it is recommended to take natural estrogens in a dose of 1-2 mg or their synthetic analogs (Microfollin) from the 10th to the 14th day of the cycle after the end of Clomiphene intake to increase the permeability of cervical mucus and endometrial proliferation ...

The frequency of ovulation induction in the treatment of "Clomiphene" is approximately 60-65%, the onset of pregnancy - in 32-35% of cases, the frequency of multiple pregnancies, mainly twins, is 5-6%, the risk of ectopic pregnancy and spontaneous miscarriages is not higher than in population. In the absence of pregnancy against the background of ovulatory cycles, the exclusion of peritoneal factors of infertility during laparoscopy is required.

In case of resistance to "Clomiphene", gonadotropic drugs are prescribed - direct stimulators of ovulation. Human menopausal gonadotropin (hMG) prepared from the urine of postmenopausal women is used. HMG preparations contain LH and FSH, 75 IU each (Pergonal, Menogon, Menopur, etc.). When prescribing gonadotropins, the patient should be informed about the risk of multiple pregnancy, the possible development of ovarian hyperstimulation syndrome, as well as the high cost of treatment. Treatment of polycystic ovary syndrome should be carried out only after excluding the pathology of the uterus and tubes, as well as the male factor of infertility. In the course of treatment, transvaginal ultrasound monitoring of folliculogenesis and the state of the endometrium is mandatory. Ovulation is initiated by a single administration of hCG at a dose of 7500-10000 IU, when there is at least one follicle with a diameter of 17 mm. If more than 2 follicles with a diameter of more than 16 mm or 4 follicles with a diameter of more than 14 mm are detected, the introduction of hCG is undesirable due to the risk of multiple pregnancy.

When ovulation is stimulated by gonadotropins, the pregnancy rate increases to 60%, the risk of multiple pregnancy is 10-25%, ectopic pregnancy is 2.5-6%, spontaneous miscarriages in cycles ending in pregnancy reach 12-30%, ovarian hyperstimulation syndrome is observed in 5 -6% of cases.

Surgical methods for stimulating ovulation in PCOS

In recent years, the surgical method of ovulation stimulation (wedge resection of the ovaries) has been performed laparoscopically, thereby ensuring minimal invasive intervention and reducing the risk of adhesions. In addition, the advantage of laparoscopic resection is the ability to eliminate the often concomitant peritoneal factor of infertility. In addition to wedge resection, during laparoscopy, it is possible to cauterize the ovaries using various types of energy (thermo-, electro-, laser), which is based on the destruction of the stroma with a point electrode. From 15 to 25 punctures are performed in each ovary; the operation is less traumatic and time-consuming compared to wedge resection.

In most cases, in the postoperative period, a menstrual reaction is observed after 3-5 days, and after 2 weeks - ovulation, which is tested by basal temperature. Lack of ovulation within 2-3 cycles requires additional administration of "Clomiphene". As a rule, pregnancy occurs within 6-12 months, and then the frequency of pregnancy decreases. The absence of pregnancy in the presence of ovulatory menstrual cycles dictates the need to exclude the tubal factor of infertility.

The frequency of ovulation induction with any laparoscopic technique is approximately the same and amounts to 84-89%, the onset of pregnancy is observed on average in 72% of cases.

Despite the rather high effect in stimulating ovulation and the onset of pregnancy, most clinicians note a relapse of clinical symptoms after about 5 years. Therefore, after pregnancy and childbirth, prevention of PCOS recurrence is necessary, which is important, given the risk of developing endometrial hyperplastic processes. For this purpose, the most appropriate appointment of COCs, preferably monophasic ("Marvelon", "Femoden", "Diana", "Mersilon", etc.). If COCs are poorly tolerated, which happens with excess body weight, progestogens can be recommended in the second phase of the cycle: "Duphaston" at a dose of 20 mg from the 16th to the 25th day of the cycle.

For women who do not plan to become pregnant, after the first stage of ovulation stimulation with Clomiphene, aimed at identifying the reserve capabilities of the reproductive system, it is also recommended to prescribe COCs or gestagens to regulate the cycle, reduce hirsutism and prevent hyperplastic processes.

Operation technique of wedge-shaped ovarian resection

Indications: sclerocystic ovary syndrome. In this case, the ovaries are enlarged 2-5 times, sometimes less than normal, covered with a dense thick fibrous membrane of a whitish or gray color.

Characteristic features are also the absence of yellow bodies in the ovaries, a very small number of small immature follicles.

In sclerocystic ovary syndrome, despite their large mass, many times greater than the mass of normal ovaries, their hormonal function is often reduced. Clinically, this is often manifested by impaired menstrual function, hypomenstrual syndrome or amenorrhea. In some patients, maturation and rupture of follicles are sometimes observed. In these cases, fertility may not be impaired, although, as a rule, with sclerocystic ovary syndrome, menstrual dysfunction and infertility are observed.

The generally accepted method of surgical treatment of sclerocystic ovary syndrome is a wedge-shaped marginal resection of both ovaries; it is recommended to dissect two thirds of the mass of each ovary.

The operation technique is simple. After laparotomy, first one, then the second ovary is removed from the abdominal cavity. The tubular end of the ovary is stitched (taken on a "holder") for ease of manipulation and the main part of the operation is started.

Holding the ovary with the fingers of the left hand, with the right, a significant part of its tissues is excised along the free edge - from half to two-thirds. This is best done with a scalpel. It should be remembered that if the scalpel blade penetrates very deeply in the direction of the ovarian hilum, then blood vessels may be damaged, the ligation of which causes the development of ischemia of the remaining ovarian tissue. This will immediately adversely affect the results of the operation. If the wound of the ovarian vessels during the operation remains unnoticed, internal bleeding will occur in the postoperative period, to stop which it will inevitably have to be performed relaparotomy and suturing of the bleeding vessels. When suturing the ovary, you should not try to carefully join the edges of the wound.

If they diverge slightly, ovulation will be easier in the future.

After the toilet of the abdominal cavity, they begin to restore the integrity of the anterior abdominal wall by layer-by-layer stitching of the edges of the surgical wound and finally apply an aseptic bandage.

The main points of the operation of the marginal wedge-shaped resection of the ovary after laparotomy are as follows:

Examination of the uterus, both ovaries and fallopian tubes;
stitching the tubular end of each ovary (taking them on "holders");
marginal wedge-shaped resection of two-thirds of the mass of both ovaries with small cystic degeneration due to follicle persistence, or with sclerocystic degeneration of the ovaries (Stein-Leventhal syndrome);
when a tumor is detected during an operation, an excision is performed within the limits of healthy tissues;
piercing or diathermopuncture of persistent follicles;
restoration of the integrity of the ovaries by the imposition of a continuous catgut suture or knotty sutures;
abdominal toilet;
layer-by-layer stitching of an operating wound;
aseptic dressing.

Treatment of hyperplastic processes in PCOS

Treatment of hyperplastic processes of the endometrium (see endometrial hyperplasia, as well as the article on its treatment). Recurrent hyperplastic processes of the endometrium in PCOS are an indication for ovarian resection.

Hirsutism treatment

Treatment of hirsutism is the most difficult task, which is due not only to hypersecretion of androgens, but also their peripheral metabolism.

At the level of the target tissue, in particular the hair follicle, T is converted into active dihydrotestosterone under the influence of the enzyme 5α-reductase. An increase in the fractions of free androgens plays an important role, which aggravates the clinical manifestations of hyperandrogenism.

Treatment of hirsutism involves blocking the action of androgens in various ways:

Inhibition of synthesis in the endocrine glands;
an increase in the concentration of PSG, i.e., a decrease in biologically active androgens;
inhibition of the synthesis of dihydrotestosterone in the target tissue due to inhibition of the activity of the enzyme 5α-reductase;
blockade of androgen receptors at the level of the hair follicle.

Given the role of adipose tissue in the synthesis of androgens, normalization of body weight is an indispensable condition in the treatment of hirsutism in obese women. A clear positive correlation has been shown between androgen levels and body mass index. In addition, given the role of insulin in hyperandrogenism in women with PCOS, insulin resistance therapy is needed.

Combined oral contraceptives are widely used to treat hirsutism, especially in mild forms. The mechanism of action of COCs is based on the suppression of LH synthesis, as well as an increase in the level of PSH, which reduces the concentration of free androgens. The most effective, based on clinical studies, are COCs containing desogestrel, gestodene, norgestimate.

One of the first antiandrogens was cyproterone acetate (Androkur), the mechanism of action of which is based on the blockade of androgen receptors in the target tissue and suppression of gonadotropic secretion. An antiandrogen is also "Diane-35", which combines 2 mg of cyproterone acetate with 35 μg of ethinyl estradiol, which also has a contraceptive effect. Strengthening the antiandrogenic effect of "Diana" can be achieved by the additional appointment of "Androkur" - 25-50 mg from the 5th to the 15th day of the cycle. The duration of treatment is from 6 months to 2 years or more. The drug is well tolerated, from side effects sometimes lethargy, pastiness, mastalgia, weight gain and decreased libido are noted at the beginning of admission.

"Spironolactone" ("Veroshpiron") also has an antiandrogenic effect. Blocks peripheral receptors and the synthesis of androgens in the adrenal glands and ovaries, helps to reduce body weight. With long-term intake of 100 mg per day, there is a decrease in hirsutism. Side effect: weak diuretic effect (in the first 5 days of treatment), lethargy, drowsiness. The duration of treatment is from 6 months to 2 years or more.

Flutamide is a non-steroidal antiandrogen used in the treatment of prostate cancer. The mechanism of action is based mainly on inhibition of hair growth by blockade of receptors and a slight suppression of T synthesis. No side effects were noted. It is prescribed at 250-500 mg per day for 6 months or more. Already after 3 months, a pronounced clinical effect was noted without changing the level of androgens in the blood.

Agonists of gonadotropic releasing hormones (Zoladex, Dipherelin Depot, Buserelin, Decapeptil) are rarely used for the treatment of hirsutism. They can be prescribed for high LH levels. The mechanism of action is based on the blockade of the gonadotropic function of the pituitary gland and, therefore, LH-dependent synthesis of androgens in ovarian theca cells. The disadvantage is the appearance of complaints characteristic of the climacteric syndrome, caused by a sharp decrease in ovarian function. These drugs are rarely used to treat hirsutism.

Medical treatment of hirsutism is not always effective, therefore, various types of hair removal (electro-, laser, chemical and mechanical) are widely used.

Hyperandrogenism and chronic anovulation are observed in endocrine disorders such as adrenogenital syndrome, neuroexchange-endocrine syndrome, Cushing's disease, and hyperprolactinemia. At the same time, morphological changes similar to polycystic ovary syndrome develop in the ovaries, and hyperandrogenism takes place. In such cases, we are talking about the so-called secondary polycystic ovaries and the main principle of treatment is the therapy of the above diseases.