pcos診療及英文病例問診

1、Polycystic ovarian syndrome,吉林市中心醫(yī)院 婦產(chǎn)科 安曉汾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 offi

2、ce for evaluation of irregular menses since menarche. The patient stated that on average, 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 abdomina

3、l 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 change in her voice or increase in th

4、e 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 h

5、as never had any surgery in the past. 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

6、 Wang,Nice to meet you.How can I help you today?--I haven’t had my period over 6 months and I know I am not pregnant ,I just took a pregnancy test and it was negative. 2. Have you been trying to conceive and how long？

7、--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, passi

8、ng 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?

9、----No,but my mother does have diabetes6. Have you noticed excessive hair growth 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 sever

10、al days.,8. Have you noticed any changes on your voice or excessive hair loss? ? ----I dong’t think so . 9. Have you any problems with your thyroid gland? ----Not that I know of .10. Have you ever exper

11、ienced 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 , let’s talk a little bit abo

12、ut 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 pounds after college(1pounds=0.45359237kg) . 13. Have you do

13、ne anything to control your weight? ? ----I am trying to excise and eat healthy , but I havn’t had any type of surgeries .,14. Is there anything else that you would like to talk about? ----Not for now.. 15. Ver

14、y 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-a

15、bdominal region. Her body mass index(BMI)was 31. Her pelvic examination was unremarkable, including no evidence for clitoromegaly, but it was very difficult to appreciate her uterus and adnexa secondary to patient’s

16、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

17、 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 m

18、enstrual periods 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 th

19、an 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 sometimes runs in f

20、amilies. 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 ins

21、ulin 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

22、 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 problems such as diabetes, high blood pressure, heart

23、 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 event

24、ually 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.,5.What should

25、 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

26、 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 periods

27、; an increased chance of becoming pregnant; reduction in acne and decreasing hair growth over time.,多囊卵巢綜合征,病因不明診斷標準不統(tǒng)一無確切發(fā)病率資料，但有龐大病人群治療需針對不同需求,多囊卵巢綜合征的特點,異質(zhì)性臨床表現(xiàn)不同實驗室檢查和輔助檢查差異很大不能治愈遺傳性疾病需長期用藥控制，控制好則與正常人無異進行性

28、發(fā)展代謝綜合征糖代謝異常導致糖尿病脂代謝異常導致心血管疾病子宮內(nèi)膜癌不孕,PCOS的病因,遺傳因素PCOS有家族聚集現(xiàn)象，被推測為一種多基因病目前的候選基因研究涉及胰島素作用相關基因、高雄激素相關基因和慢性炎癥因子等環(huán)境因素包括宮內(nèi)高雄激素、抗癲癇藥物、地域、營養(yǎng)和生活方式等，可能是PCOS的危險因素、易患因素、高危因素應進行流調(diào)后完善環(huán)境與PCOS關系的認識遺傳與環(huán)境的交互作用,PCOS的確切病因尚不清楚,流行病

29、學,占生育年齡婦女5～10％占無排卵性不孕30～60％，有報道達75％國內(nèi)局部地區(qū)小規(guī)模流行病學調(diào)查，育齡婦女患病率分別為6.46％～7.2％我國尚缺少全國性、大樣本、多中心研究,PCOS是育齡婦女最常見的內(nèi)分泌紊亂性疾病,醫(yī)生應該做什么？,作出診斷處理患者的問題調(diào)整月經(jīng)抗雄誘導排卵減重將遠期風險告訴患者改善胰島素抵抗的狀態(tài)保護內(nèi)膜,,PCOS的診斷,1935 年，Stein and Leventhal 首先描述了

30、 PCO, 1990 年，NIH 制定PCOS共識 2003年，ESHRE/ ASRM Rotterdam PCOS診斷共識2006年，Androgen Excess Society (AES)的診斷共識2010年，中華醫(yī)學會婦產(chǎn)科分會內(nèi)分泌學組提出專家共識,診斷標準,卵巢多囊改變,排卵障礙,高雄激素血癥高雄激素表現(xiàn),+or,+or,+or,排除標準,+,排除標準,其他高雄激素病因：先天性腎上腺皮質(zhì)增生、柯興氏綜合征、

31、分泌雄激素的腫瘤等，其他引起排卵障礙的疾?。焊呙谌樗匮Y，卵巢早衰和垂體或下丘腦性閉經(jīng)，以及甲狀腺功能異常,卵巢多囊改變,排卵障礙,高雄激素血癥高雄激素表現(xiàn),+,排除標準,+,or,+,or,+,or,1990 年，NIH PCOS共識,,,經(jīng)典型PCOS,未將PCO作為診斷的主要癥狀,NIH:National Institutes of Health美國國立衛(wèi)生研究院,卵巢多囊改變,排卵障礙,高雄激素血癥高雄激素表現(xiàn),+,

32、排除標準,+,or,+,or,+,or,2003年，ESHRE/ ASRM Rotterdam PCOS診斷共識,,經(jīng)典型,,月經(jīng)規(guī)律型,,無高雄型,強調(diào)‘排除其他病因’為PCOS診斷標準的一項內(nèi)容,卵巢多囊改變,排卵障礙,高雄激素血癥高雄激素表現(xiàn),+,排除標準,+,or,+,or,+,or,,經(jīng)典型,,月經(jīng)規(guī)律型,2006年AES（Androgen Excess Society）標準,2006年AES（Androgen Exces

33、s Society）標準,,2010年衛(wèi)生部診斷標準共識,3條中符合2條稀發(fā)排卵或無排卵高雄激素的臨床表現(xiàn)和/或高雄激素血癥卵巢多囊性改變：一側(cè)或雙側(cè)卵巢直徑2～9mm的卵泡≥12個，和/或卵巢體積≥10ml,卵巢多囊改變,排卵障礙,高雄激素血癥高雄激素表現(xiàn),+,排除標準,+,or,+,or,+,or,2010年衛(wèi)生部診斷標準共識診斷共識,,經(jīng)典型,,無高雄型,日本PCOS診斷標準,月經(jīng)異常（無月經(jīng)、稀發(fā)月經(jīng)、無排卵周期）L

34、H增高，F(xiàn)SH正常，LH/FSH值上升超聲提示PCO,稀發(fā)排卵或無排卵-1,初潮兩年未建立規(guī)律月經(jīng)閉經(jīng)（停經(jīng)時間超過3個以往月經(jīng)周期或月經(jīng)周期≥6個月）月經(jīng)稀發(fā)（≥35天及每年≥3個月不排卵者）,月經(jīng)規(guī)律不能作為判斷有排卵的證據(jù),稀發(fā)排卵或無排卵-2,BBT B超監(jiān)測排卵 月經(jīng)后半期孕酮測定FSH和E2水平正常 排除低促性腺激素性性腺功能減退 排除卵巢早衰,,明確是否排卵,高雄激素的臨床表現(xiàn)痤瘡,是一

35、種慢性毛囊皮脂腺炎癥機制：DHT刺激皮脂腺分泌過盛導致皮脂中的游離脂肪酸過高，亞油酸過低；痤瘡丙酸菌感染面部、前胸和后背等處連續(xù)3月以上多發(fā)痤瘡,高雄激素的臨床表現(xiàn)多毛,主要是性毛增多 性毛（sexsual hair）：對性激素有反應的毛，主要生長于面部、下腹部、大腿前部、胸部、乳房、恥骨區(qū)和腋窩等部位發(fā)生率：約70%,高雄激素血癥,總睪酮：高于實驗室參考正常值游離睪酮指數(shù)：（FAI）=總睪酮/SHBG濃度×1

36、00，高于實驗室參考正常值游離睪酮：高于實驗室參考正常值,任何一項指標升高均可確診,PCO,PCO不是PCOS婦女所特有正常妊娠婦女卵巢8-25％B超呈現(xiàn)PCO服用避孕藥的婦女14％B超呈現(xiàn)PCO,PCO測量方法,陰道超聲較準確早卵泡期 (月經(jīng)規(guī)律者)或無優(yōu)勢卵泡時超聲檢查卵巢體積計算：0.5×長×寬×厚（ml）卵泡數(shù)目測量應包括橫面與縱面掃描卵泡直徑＜10mm：橫徑與縱徑的平均數(shù)卵巢多囊性

37、改變：一側(cè)或雙側(cè)卵巢直徑2～9mm的卵泡≥12個，和/或卵巢體積≥10ml,PCO ≠ PCOS，PCOS ≠ PCO,關于青春期PCOS,青春期多有月經(jīng)不規(guī)律或稀發(fā)排卵，并且多數(shù)青春期少女會有一過性雄激素升高月經(jīng)紊亂以及高雄癥狀的原因可能是由于HPO軸處于發(fā)育成熟的過渡階段，也可能是由于PCOS所導致的因此在青春期不應過度診斷PCOS，但是對于月經(jīng)紊亂以及高雄癥狀應積極給予治療,青春期少女初潮后月經(jīng)的轉(zhuǎn)歸,肥胖的診斷標準,注：*疾

38、病危險：糖尿病，高血壓，CAD,亞洲成人根據(jù)BMI對體重的分類,中心性肥胖的診斷標準,臀圍比（腰圍cm/臀圍cm，WHR）中心性肥胖的切點：男性≥0.9，女性≥0.8,中國預防醫(yī)學科學院等對11個省市城鄉(xiāng)4萬余人抽樣調(diào)查結(jié)果,中心性肥胖的診斷標準,腰圍 中國肥胖問題工作組表示中心性肥胖的切點： 男性≥85cm，女性≥80cm,,WHR受腰圍及臀圍影響，還與體形及身高有關，WHO（1998）認為腰圍較WHR更適合于測量中心性肥胖,

39、代謝綜合征的診斷標準-1,國際糖尿病聯(lián)盟代謝綜合征的全球共識定義（2005年，柏林）必須條件：中心性肥胖腰圍切點如下：① 歐裔人：男性≥ 94cm，女性≥80cm② 中國人：男性≥90cm，女性≥80cm③ 其他人種：采用種族特異性的腰圍切點,代謝綜合征的診斷標準-2,另加下列4項中的任意兩項：①TG升高（＞1.7mmol/L，＞150mg/dl），或已接受針對脂質(zhì)異常的特殊治療②HDL-ch降低（男＜1.03mmol/L

40、或40mg/dl，女1.29mmol/L或已經(jīng)接受針對此脂質(zhì)異常的特殊治療）③血壓增高，收縮壓≥130mmHg或舒張壓≥85mmH，或已經(jīng)被確診為高血壓接受治療者④空腹血糖增高：FPG≥5.6mmol/L（100mg/dl），或已經(jīng)被確診為糖尿病。如果空腹血糖≥5.6mmol/（100mg/dl），強烈推薦口服葡萄糖耐量試驗，但口服葡萄糖耐量試驗并非為診斷代謝綜合征所必需,黑棘皮癥,病因尚不十分明確，通常認為可能是刺激了表皮內(nèi)的酪氨

41、酸激酶生長因子受體信號通道。有證據(jù)表明胰島素起了一定的作用，嚴重的胰島素抵抗常常合并有黑棘皮病。多發(fā)生于皮膚皺褶部位，如頸、腋窩、腹股溝、乳頭下、臍窩、肛門外生殖器等處高雄激素血癥的女性黑棘皮病的發(fā)生率為5%～29%。肥胖與黑棘皮病關系密切，兩者呈正相關。皮疹的變化不僅與肥胖程度相關，而且隨體重的下降而減輕。對肥胖型黑棘皮病，必須糾正肥胖，積極參加體育鍛煉，控制飲食以減肥，隨著體重的下降，黑棘皮病也就隨之治愈,PCOS的治療,,,

42、調(diào)整月經(jīng)周期,,,高雄血癥及臨床表現(xiàn)（痤瘡和多毛）的治療,,,胰島素抵抗的治療,,,促排卵治療,,,生活方式調(diào)整,PCOS的干預策略及治療原則,肥胖患者的一線治療是降體重無排卵患者應采用孕激素口服或口服避孕藥控制月經(jīng)周期，阻止子宮內(nèi)膜增生性病變胰島素抵抗患者需使用胰島素增敏劑降雄激素藥物可控制高雄激素體征助孕干預開始之前應給予降雄、內(nèi)膜準備及糾正胰島素抵抗和代謝紊亂的治療,減重前后患者月經(jīng)及排卵的比較,* 與減重≤5％及＜10％

43、組比較，P＜0.05,*,*,減重前后三組患者睪酮的比較,*,* 與減重前比較，P＜0.05,*,減重前后三組患者胰島素的比較,*,* 與減重前比較，P＜0.05,控制月經(jīng),目的使月經(jīng)規(guī)律保護內(nèi)膜預防子宮內(nèi)膜癌方法周期補充孕激素OC,適應證：無明顯高雄激素臨床和實驗室表現(xiàn)，及無明顯胰島素抵抗的無排卵患者,可單獨采用定期孕激素治療，以周期性撤退性出血改善宮內(nèi)膜狀態(tài)用法：黃體酮膠囊200mg/日，或地屈孕酮10～20mg/日，

44、每月10～14天,孕激素,高雄激素血癥和高雄激素癥狀的治療,復方短效口服避孕藥，具有抗雄激素效果者更佳抑制LH分泌，減少雄激素但停藥后雄激素分泌可能再次升高,效果周期性撤退性出血改善宮內(nèi)膜狀態(tài)，預防子宮內(nèi)膜癌的發(fā)生糾正高雄激素血癥，改善高雄激素的臨床表現(xiàn)有效避孕用法自然月經(jīng)或撤退出血的第1～5天服用，每日1片，連續(xù)服用21日，停藥7天后重復啟用至少服用3～6個月，可重復使用,口服避孕藥（Oral Contraceptiv

45、e，OC）,PCOS是系統(tǒng)性代謝疾病，因此在應用口服避孕藥期間，應定期監(jiān)測血脂和血糖的變化，有報道OC可能對糖和脂代謝有不利影響用藥前應排除禁忌癥青春期應用應充分知情同意,口服避孕藥（Oral Contraceptive，OC）,口服避孕藥,通過抑制黃體生成素（LH）分泌，減少卵巢源雄激素生成，內(nèi)含雌激素還有利于升高SHBG，減少游離睪酮的組分采用OC預治療PCOS患者4?6個周期減輕臨床癥狀改善異常的血激素相改善卵巢形態(tài)及

46、血脂相耐CC患者于停藥3個月內(nèi)促排卵敏感性最高,口服避孕藥治療PCOS的作用點,循環(huán)中LH水平,垂體LH合成 ?,循環(huán)SHBG ?,保護子宮內(nèi)膜,卵巢縮小,循環(huán)中雄激素 ?,高雄激素體征 ?,雄烯二酮，睪酮，DHA, DHAS ? ?,卵巢、腎上腺P450 17α，17-20裂介酶 ?,,,,＋,EE作用,外周競爭受體,,,,,,,達英35 （環(huán)丙孕酮）,,,游離睪酮 ?游離E2 ?,,,口服避孕藥,,炔雌醇,

47、,適應證：肥胖或有胰島素抵抗的患者機制：增強周圍組織對葡萄糖的攝入、抑制肝糖產(chǎn)生并在受體后水平增強胰島素敏感性 用法：500mg，每日2次或3次， 治療時每3～6個月復診B類藥，藥品說明并未將妊娠后婦女列為適應人群副作用常見胃腸道反應嚴重的副作用是可能發(fā)生腎功能損害和乳酸性酸中毒，須定期復查腎功能,胰島素抵抗的治療－二甲雙胍,二甲雙胍,促進周圍組織對葡萄糖的攝取，加強周圍組織對胰島素的敏感性，降低胰島素、LH可達到肥胖患者

48、降低體重至正常范圍同樣的效果65%恢復規(guī)律月經(jīng)，62%恢復排卵，可能降低流產(chǎn)率副作用致畸性：隨診154名母親患PCOS在妊娠期服用二甲雙胍的嬰兒沒有發(fā)現(xiàn)不良反應惡心和腹瀉，餐中服用可減輕，其他還有腹脹、脹氣和嘔吐低血糖反應很少發(fā)生罕見但嚴重的并發(fā)癥是乳酸酸中毒,Gleuck， et al,羅格列酮,噻唑烷二酮類機理過氧化物酶增殖活化受體?（PPAR ? ）激動劑與視黃醇受體結(jié)合調(diào)節(jié)基因活動作用增加脂肪?-氧化，促

49、進降脂，預防代謝綜合征成熟脂肪細胞對胰島素更敏感，改善胰島素抵抗,一線促排卵治療—克羅米芬（Clomiphene Citrate, CC）二線促排卵治療促性腺激素腹腔鏡下卵巢打孔術（Laparoscopic Ovarian Drilling，LOD ）體外受精-胚胎移植（IVF-ET）未成熟卵母細胞的體外成熟（In vitro maturation， IVM）,,,促排卵治療,,,1,,,2,,,3,,,4,PCOS、不育