[醫如往常] Senior Clerkship Day 5: Ob/Gyn PCOS; polycystic ovary syndrome

PCOS; polycystic ovary syndrome
陳教授

Common symptoms & signs

• Obesity (40-60%)
• Acanthosis nigricans 黑黑的

• Mediterranean alopecia
• Acnes (10-25%)

• Infertility (50-80%)
• Hirsutism (30-60%)

• 東方人obesity, hertutism不明顯

Mother to infant effect

• Imperforated hymen
• Ambiguous genitalis

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Diagnosis

Hyperandrogenism

Oligomenorrhea/oligo ovulation: Less than 9 menstrual cycles per year

Polycystic > 12 antral follicles, 一邊就可以

• 1990 NIH 前兩個
• 2003 Rotterdam 三取二, 最常用
• 2009AE- PCOS 第一加上後兩取一

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Ddx

• sertoli leydig cell tumor
• Congenital adrenal hyperplasia, hoarseness
• Cushing syndrome, 最早就要鑒別
• Thyroid
• Hypogonadism, hypo hypo

• Hyperprolactinemia

• Idiopathic hirsutism, familial, 有月經
• WNT4 syndrome, no uterus
• Androgen receptor insensitivity
• Medication

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Biomaker

Free testosterone

Free androgen index (FAI)

FAI(%)=total testosterone / SHBG X 100

LH/FSH>3 現在不用了

Unopposed estrogen

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Prevalence 5-10%

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Pathophysiology

Insulin resistance

Liver SHBG↓

Low grade inflammation

Androgen stimulate early follicle

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Granulosal cell↑

Inhibin B ↑

Anti Mullerian hormone↑ 抑制ovulation

DHEAS dominant

More Acnes

Less obesity

Suppress myostatin

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PTEN, 抑制FSH, 影響AKT活化

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Tx

• ovarian drilling 不會改善代謝
• Life style modification, 減重5%
• Insulin sensitizer, metfomin懷孕可以用 至少半年, ppar gamma agonist
• Low glycemic index food
• ART for 不適合懷孕的人
• Gonadotropin 小心OHSS
• Clomiphene citrate對於想懷孕的人比較好， 75%成功， 六次無效換藥
• Aromatase inhibitor Letrozole更好，不過是off label use, 因為可能增加胎兒CHD

Oral contraceptive pills只能治療normal weight PCOS

胖的增加metabolic syndrome, insulin resistance

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Complications

• Type II DM
• CAD, stroke
• Hypertension
• NAFLD, NASH

The prevalence of metabolic syndrome in young Taiwanese women with PCOS is around 17 %. (reference population is 6% in Taipei). ~ MJ Chen et al, Hum Reprod. 2006 September; 21(9):2266-71

用array CGH 找出高風險病人

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測DHEA, androstenedine做研究

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CRP 預測CVD風險

Endothelium function測carotid flow

Follistatin影響排卵，anti-inflammation

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新發展薏仁

Adlay extract suppress androgen, thecal cell