pcos诊疗及英文病例问诊.ppt

1、Polycystic ovarian syndrome,吉林市中心医院 妇产科 安晓汾Jilin Central Hospital obstetrics and Gynecology,Case study_clinical dialogue,Case 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,

2、she has 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

3、denied any change 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 pas

4、t. She was unable to 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

5、,I just took a pregnancy 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 ver

6、y heavily, passing large clots, 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 diabetes6. Have you noticed excessive hair growth

7、anywhere on your body? -Yes, on my face, arm, 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.

8、Have you ever experienced something like dry skin fatigue, mood swings or any depression ? -No, not really11. 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.

9、I was on the heavy side since I was a kid and I gained another 40 to 50 pounds 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

10、 talk about? -Not for now. 15. Very good,next ,we wuld need to do a physical examination 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

11、pelvic examination was unremarkable, including no evidence for clitoromegaly, but it was very 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 nor

12、mal appearing uterus, with an endometrial thickness of 20mm and bilateral normal ovaries,1. Miss Wang,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 p

13、eriods because monthly ovulation is not occurring.In addition, your levels of male hormones(androgens) are elevated,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

14、 it affects I in 5(20%)of women.,discuss,3.What causes PCOS . -The cause of PCOS remains to be defined. PCOS sometimes 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 no

15、t respond to the hormone insulin (known as insulin resistance),so the level of glucose may be higher. To prevent the glucose 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.Wh

16、at could PCOS means to my long-term health?-If you have PCOS ,you are at greater risk of developing some long-term health problems 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 a

17、nd become thicken. This may lead to endometrial hyperplasia, a precancerous change, and eventually cancer in a small number of women. 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.,

18、5.What should I do to reduce the risk of developing those long term health problems? -A healthy lifestyle including healthy balanced diet 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 r

19、isk of developing insulin resistance and diabetes;a lower risk of heart problems; a lower risk of developing uterine cancer;more regular periods; an increased chance of becoming pregnant; reduction in acne and decreasing hair growth over time.,多囊卵巢综合征,病因不明诊断标准不统一无确切发病率资料，但有庞大病人群治疗需针对不同需求,多囊卵巢综合征的特点,

20、异质性临床表现不同实验室检查和辅助检查差异很大不能治愈遗传性疾病需长期用药控制，控制好则与正常人无异进行性发展代谢综合征糖代谢异常导致糖尿病脂代谢异常导致心血管疾病子宫内膜癌不孕,PCOS的病因,遗传因素PCOS有家族聚集现象，被推测为一种多基因病目前的候选基因研究涉及胰岛素作用相关基因、高雄激素相关基因和慢性炎症因子等环境因素包括宫内高雄激素、抗癫痫药物、地域、营养和生活方式等，可能是PCOS的危险因素、易患因素、高危因素应进行流调后完善环境与PCOS关系的认识遗传与环境的交互作用,PCOS的确切病因尚不清楚,流行病学,占生育年龄妇女510占无排卵性不孕3060，有报道达75国内局部地区小规

21、模流行病学调查，育龄妇女患病率分别为6.467.2我国尚缺少全国性、大样本、多中心研究,PCOS是育龄妇女最常见的内分泌紊乱性疾病,医生应该做什么？,作出诊断处理患者的问题调整月经抗雄诱导排卵减重将远期风险告诉患者改善胰岛素抵抗的状态保护内膜,PCOS的诊断,1935 年，Stein and Leventhal 首先描述了 PCO, 1990 年，NIH 制定PCOS共识 2003年，ESHRE/ ASRM Rotterdam PCOS诊断共识2006年，Androgen Excess Society (AES)的诊断共识2010年，中华医学会妇产科分会内分泌学组提出专家共识,诊断标准,卵巢多

22、囊改变,排卵障碍,高雄激素血症高雄激素表现,+or,+or,+or,排除标准,+,排除标准,其他高雄激素病因：先天性肾上腺皮质增生、柯兴氏综合征、分泌雄激素的肿瘤等，其他引起排卵障碍的疾病：高泌乳素血症，卵巢早衰和垂体或下丘脑性闭经，以及甲状腺功能异常,卵巢多囊改变,排卵障碍,高雄激素血症高雄激素表现,+,排除标准,+,or,+,or,+,or,1990 年，NIH PCOS共识,经典型PCOS,未将PCO作为诊断的主要症状,NIH:National Institutes of Health美国国立卫生研究院,卵巢多囊改变,排卵障碍,高雄激素血症高雄激素表现,+,排除标准,+,or,+,or,

23、+,or,2003年，ESHRE/ ASRM Rotterdam PCOS诊断共识,经典型,月经规律型,无高雄型,强调排除其他病因为PCOS诊断标准的一项内容,卵巢多囊改变,排卵障碍,高雄激素血症高雄激素表现,+,排除标准,+,or,+,or,+,or,经典型,月经规律型,2006年AES（Androgen Excess Society）标准,2006年AES（Androgen Excess Society）标准,2010年卫生部诊断标准共识,3条中符合2条稀发排卵或无排卵高雄激素的临床表现和/或高雄激素血症卵巢多囊性改变：一侧或双侧卵巢直径29mm的卵泡12个，和/或卵巢体积10ml,卵巢多

24、囊改变,排卵障碍,高雄激素血症高雄激素表现,+,排除标准,+,or,+,or,+,or,2010年卫生部诊断标准共识诊断共识,经典型,无高雄型,日本PCOS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,稀发排卵或无排卵-1,初潮两年未建立规律月经闭经（停经时间超过3个以往月经周期或月经周期6个月）月经稀发（35天及每年3个月不排卵者）,月经规律不能作为判断有排卵的证据,稀发排卵或无排卵-2,BBT B超监测排卵 月经后半期孕酮测定FSH和E2水平正常 排除低促性腺激素性性腺功能减退 排除卵巢早衰,明确是否排卵,高雄激素的临床表现痤疮,

25、是一种慢性毛囊皮脂腺炎症机制：DHT刺激皮脂腺分泌过盛导致皮脂中的游离脂肪酸过高，亚油酸过低；痤疮丙酸菌感染面部、前胸和后背等处连续3月以上多发痤疮,高雄激素的临床表现多毛,主要是性毛增多 性毛（sexsual hair）：对性激素有反应的毛，主要生长于面部、下腹部、大腿前部、胸部、乳房、耻骨区和腋窝等部位发生率：约70%,高雄激素血症,总睾酮：高于实验室参考正常值游离睾酮指数：（FAI）=总睾酮/SHBG浓度100，高于实验室参考正常值游离睾酮：高于实验室参考正常值,任何一项指标升高均可确诊,PCO,PCO不是PCOS妇女所特有正常妊娠妇女卵巢8-25B超呈现PCO服用避孕药的妇女14B超呈

26、现PCO,PCO测量方法,阴道超声较准确早卵泡期 (月经规律者)或无优势卵泡时超声检查卵巢体积计算：0.5长宽厚（ml）卵泡数目测量应包括横面与纵面扫描卵泡直径10mm：横径与纵径的平均数卵巢多囊性改变：一侧或双侧卵巢直径29mm的卵泡12个，和/或卵巢体积10ml,PCO PCOS，PCOS PCO,关于青春期PCOS,青春期多有月经不规律或稀发排卵，并且多数青春期少女会有一过性雄激素升高月经紊乱以及高雄症状的原因可能是由于HPO轴处于发育成熟的过渡阶段，也可能是由于PCOS所导致的因此在青春期不应过度诊断PCOS，但是对于月经紊乱以及高雄症状应积极给予治疗,青春期少女初潮后月经的转归,肥胖

27、的诊断标准,注：*疾病危险：糖尿病，高血压，CAD,亚洲成人根据BMI对体重的分类,中心性肥胖的诊断标准,臀围比（腰围cm/臀围cm，WHR）中心性肥胖的切点：男性0.9，女性0.8,中国预防医学科学院等对11个省市城乡4万余人抽样调查结果,中心性肥胖的诊断标准,腰围 中国肥胖问题工作组表示中心性肥胖的切点： 男性85cm，女性80cm,WHR受腰围及臀围影响，还与体形及身高有关，WHO（1998）认为腰围较WHR更适合于测量中心性肥胖,代谢综合征的诊断标准-1,国际糖尿病联盟代谢综合征的全球共识定义（2005年，柏林）必须条件：中心性肥胖腰围切点如下： 欧裔人：男性 94cm，女性80cm

28、中国人：男性90cm，女性80cm 其他人种：采用种族特异性的腰围切点,代谢综合征的诊断标准-2,另加下列4项中的任意两项：TG升高（1.7mmol/L，150mg/dl），或已接受针对脂质异常的特殊治疗HDL-ch降低（男1.03mmol/L或40mg/dl，女1.29mmol/L或已经接受针对此脂质异常的特殊治疗）血压增高，收缩压130mmHg或舒张压85mmH，或已经被确诊为高血压接受治疗者空腹血糖增高：FPG5.6mmol/L（100mg/dl），或已经被确诊为糖尿病。如果空腹血糖5.6mmol/（100mg/dl），强烈推荐口服葡萄糖耐量试验，但口服葡萄糖耐量试验并非为诊断代谢综合征

29、所必需,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%。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的治疗,调整月经周期,高雄血症及临床表现（痤疮和多毛）的治疗,胰岛素抵抗的治疗,促排卵治疗,生活方式调整,PCO

30、S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,减重前后患者月经及排卵的比较,* 与减重5及10组比较，P0.05,*,*,减重前后三组患者睾酮的比较,*,* 与减重前比较，P0.05,*,减重前后三组患者胰岛素的比较,*,* 与减重前比较，P0.05,控制月经,目的使月经规律保护内膜预防子宫内膜癌方法周期补充孕激素OC,适应证：无明显高雄激素临床和实验室表现，及无明显胰岛素抵抗的无排卵患

31、者,可单独采用定期孕激素治疗，以周期性撤退性出血改善宫内膜状态用法：黄体酮胶囊200mg/日，或地屈孕酮1020mg/日，每月1014天,孕激素,高雄激素血症和高雄激素症状的治疗,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,效果周期性撤退性出血改善宫内膜状态，预防子宫内膜癌的发生纠正高雄激素血症，改善高雄激素的临床表现有效避孕用法自然月经或撤退出血的第15天服用，每日1片，连续服用21日，停药7天后重复启用至少服用36个月，可重复使用,口服避孕药（Oral Contraceptive，OC）,PCOS是系统性代谢疾病，因此在应用口服避孕药期

32、间，应定期监测血脂和血糖的变化，有报道OC可能对糖和脂代谢有不利影响用药前应排除禁忌症青春期应用应充分知情同意,口服避孕药（Oral Contraceptive，OC）,口服避孕药,通过抑制黄体生成素（LH）分泌，减少卵巢源雄激素生成，内含雌激素还有利于升高SHBG，减少游离睾酮的组分采用OC预治疗PCOS患者46个周期减轻临床症状改善异常的血激素相改善卵巢形态及血脂相耐CC患者于停药3个月内促排卵敏感性最高,口服避孕药治疗PCOS的作用点,循环中LH水平,垂体LH合成 ,循环SHBG ,保护子宫内膜,卵巢缩小,循环中雄激素 ,高雄激素体征 ,雄烯二酮，睾酮，DHA, DHAS ,卵巢、肾上腺

33、P450 17，17-20裂介酶 ,EE作用,外周竞争受体,达英35 （环丙孕酮）,游离睾酮 游离E2 ,口服避孕药,炔雌醇,适应证：肥胖或有胰岛素抵抗的患者机制：增强周围组织对葡萄糖的摄入、抑制肝糖产生并在受体后水平增强胰岛素敏感性 用法：500mg，每日2次或3次， 治疗时每36个月复诊B类药，药品说明并未将妊娠后妇女列为适应人群副作用常见胃肠道反应严重的副作用是可能发生肾功能损害和乳酸性酸中毒，须定期复查肾功能,胰岛素抵抗的治疗二甲双胍,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%

34、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,Gleuck， et al,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,一线促排卵治疗克罗米芬（Clomiphene Citrate, CC）二线促排卵治疗促性腺激素腹腔镜下卵巢打孔术（Laparoscopic Ovarian Drilling，LOD ）体外受精-胚胎移植（IVF-ET）未成熟卵母细胞的体外成熟（In vitro maturation， IVM）,促排卵治疗,1,2,3,4,PCOS、不育,排卵因素,卵管、宫腔因素,男方因素,CC 50150mg,LapHys,男方治疗,超重,高雄,减重,达英35,胰岛素抵抗代谢综合症,二甲双胍文迪亚,IVF,CC 50150mg,COH+IUI,IUI,ICSI,+,+,+,+,+,+,