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PCOS

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Photos pics PCOS is a complex, multifactorial syndrome, involving a change in the normal structure of the ovaries, hormonal dysfunction and endocrine infertility. It is incorrect to consider PCOS exclusively as a gynecological pathology, since the origins of its formation are outside the reproductive system - in the cerebral cortex, its first clinical signs always follow systemic neuro-metabolic disturbances. With PCOS, the correct structure and tissue ratio in the ovaries changes, follicles eventually do not reach the necessary maturity and begin reverse development( atresia).

Diagnosis of PCOS occurs in 11% of young women, most( 70%) of them refer to specialists about infertility.

More often PCOS is diagnosed in young girls during active puberty( puberty).If the symptoms of PCOS are correlated with the first menstruation, the disease is considered primary. Uncommon in adult patients diagnosed secondary PCOS, it occurs after a period of normal menstrual function.

The mechanism of PCOS formation is very complex and closely related to the structure and functions of the ovaries. Ovary is a pair of female organs, which is essentially a hormonal gland. You can say that it is thanks to the ovaries that a woman is a woman. There are three most important functions of the ovaries:

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1. The vegetative function, which ensures the transformation of the genital organs during the maturation period in the female. This function is also responsible for the female phenotype - the woman's appearance.

2. Generative( genital), the essence of which is reduced to the reproduction of eggs that are capable of fertilization. Generative activity of the ovaries allows a woman to conceive, endure and bring to light a new life.

3. Hormonal function. Ovaries throughout life constantly synthesize sex hormones - estrogens and progesterone, with their help a normal menstrual cycle is formed and a close connection with all links of the endocrine system of the body.

Each ovary externally resembles a peach bone of 3-4 / 2-2.5 cm in size and 1-1.5 cm in thickness. The right ovary is slightly larger than the left and is consequently heavier. Outer membrane( white) of the ovary is designed to protect it from any negative external influence, therefore it is formed by a dense connective tissue. Under the white membrane in the cortical substance of the ovary occurs the germination and maturation of the sex cells. Immature oocytes are found in follicles - peculiar "bubbles", having an outer capsule and filled with a transparent follicular fluid. To "mature" the egg takes about 14 days( the first, the follicular, the phase of the menstrual cycle), the entire period is accompanied by the secretion of estrogens. Then, after the formation period, the follicle moves to the surface of the ovary, ruptures( ovulation), and releases the egg into the abdominal cavity, where fertilization takes place. From the remnants of the destroyed follicle, a temporary hormonal structure is formed - the yellow body responsible for producing progesterone. If the fertilization of the egg does not occur, it collapses, and the yellow body lives for another 10-12 days( the second, luteal, phase of the cycle), and then menstrual bleeding occurs.

All the above processes in the ovaries occur in a regular, cyclic rhythm and continue until the menopause. The highest regulatory hormonal function of the ovaries is the pituitary and hypothalamus. Hormones of the pituitary gland affect the function of the ovaries. So, in the first phase of the cycle, the follicle stimulating( FSH) is synthesized in the pituitary gland, and the second - luteinizing( LH) hormones. In the follicular phase, FSH controls the development of the egg cell, and for the formation of the yellow body in the second phase of the cycle is responsible for LH.In the middle of the cycle, the symmetrical maximum release of FSH and LH "starts" ovulation.

In PCOS as a result of changes in the structure of the ovaries, the mechanism of physiological ovulation is violated, the menstrual cycle is perverted. Follicles do not reach the proper maturity, but begin to accumulate fluid, turning into small cysts.

As the function of the ovaries is integrated into the work of the whole organism, PCOS practically always accompanies metabolic and endocrine disorders. In addition to infertility and hormonal dysfunction, the disease can be manifested by other, non-gynecological, symptoms: obesity, hirsutism, hypertension, changes in the emotional sphere.

The diagnosis of PCOS must be confirmed by laboratory and instrumental studies, since the disease has symptoms similar to many endocrine and hormonal pathologies.

Treat PCOS is very difficult. The success of conservative therapy depends on the degree of ovarian involvement and the associated neuro-metabolic-endocrine disorders. Surgical techniques are often used to treat infertility, if all other methods of therapy have not been successful.

Causes of PCOS

PCOS remains one of the poorly studied ailments. Since this syndrome is formed with the participation of almost all important systems of the body, its cause can be associated with dysfunction of the endocrine, metabolic, nervous or sexual systems, and therefore, it is incredibly difficult to determine the source of ovarian pathology formation in PCOS.

PCOS in its development overcomes several levels. The pathological process begins to form in the structures of the central nervous system and gradually "descends" to the ovaries. At each level, there are certain violations, namely:

1. The hypothalamus level. The rhythmic release of biologically active substances associated with the pituitary gland is distorted, and the hypothalamus "gives wrong orders" to the pituitary gland.

2. The pituitary level. Receiving the wrong commands from the hypothalamus, the anterior pituitary gland begins to synthesize FSH and LH in the acyclic regime. LH secretion is no longer dependent on the phase of the cycle, the hormone begins to be produced monotonously, so its concentration in the blood remains constantly increased, and the FSH figures correspond to the physiological norm or are somewhat lowered. As a result, the ratio of FSH / LH required for a normal two-phase ovulatory cycle is deformed, and follicular maturation processes are distorted.

3. Ovarian level. What happens in the ovaries, when they get an excess of LH?In the tissues of healthy ovary LH, in addition to participating in the formation of the yellow body, provokes the synthesis of androgens. When their concentration approaches the limits of the physiological norm, the ovaries, according to the feedback mechanism, "inform" about it to the brain, so that the pituitary gland reacts with FSH production. With the participation of follicle-stimulating hormone, the ovaries get rid of excess LH, metabolizing them into estrogens.

With PCOS, the concentrations of LH are so high that the ovaries can not cope with their utilization, as a result, androgens becomes too much. Androgens interfere with the process of folliculogenesis and cause the growth( hyperplasia) of ovarian tissue. Follicles, not reaching the necessary maturity, remain in the unripened state for a long time( persist), and then undergo reverse development and accumulate fluid( cystic atresia).

Cystic follicular atresia is a kind of diagnostic marker of PCOS, it is present in all patients with this syndrome and is the cause of chronic ovulation leading to infertility.

More often PCOS manifests itself in adolescence. Violation of the rhythmic activity of the hypothalamus during sexual formation can lead to an increase in the concentration of growth hormone, which stimulates the synthesis of LH, and therefore provokes hyperandrogenism. Excess androgen negatively affects puberty and causes the appearance of "male" features in the appearance of the girl.

Secondary PCOS is associated with metabolic disorders in patients with a previous normal menstrual function. Among the reasons for its appearance are more often complications of pregnancy and / or childbirth, numerous abortions, psychoemotional shocks, brain injuries, severe infections, intoxications.

In the formation of PCOS there are "guilty" and endocrine disorders. One of the varieties of the syndrome is PCOS( primary or secondary) against a background of pronounced obesity. With obesity in the body( not in the ovaries) an excess of androgens is formed.

Adrenal gland can also be a source of excess androgens; in half of patients with PCOS, adrenal dysfunction is diagnosed and, as a consequence, the increased content of androgens.

In 40-70% of patients, PCOS develops on the basis of insulin resistance( insulin resistance) and hyperinsulinemia. Insulin, being a hormone of the pancreas, is responsible for the metabolism of sugar in the body. In increased concentrations, it increases the secretion of androgens.

The main, pernicious, effect of androgens on the ovaries is the formation of persistent anovulation. Infertility always accompanies a pronounced PCOS.Under the influence of androgens, the ovarian membrane thickens and becomes extremely dense, which prevents the egg from "breaking through" outward. As a result, after each menstrual cycle under the outer membrane in the ovary, there is not a destroyed follicle, which accumulated liquid and turned into a cyst. The longer the patient has PCOS, the more pronounced the cystic transformation of the ovaries. Pregnancy after PCOS is not always possible, its probability directly depends on the nature of structural disorders in the ovaries and the presence of an unfavorable background.

Symptoms and signs of PCOS

The clinical picture of PCOS differs significantly in variety, since the disease is not limited to the gynecological sphere only.

Primary PCOS manifests itself at the beginning of puberty. Menstruation usually comes in a timely manner( 12-13 years), but the cycle is unstable. As a rule, over time, menstrual irregularities are aggravated. First, menstruation irregular with an interval of more than 35 days and little blood loss, and then delays become longer( up to six months) and can result in a complete absence of menstruation( amenorrhea).

Women with secondary PCOS have no violations of menstrual function. Often, the appearance of their first symptoms of the disease is preceded by a period of normal menstrual and genital function.

Depending on the location of PCOS, it is possible to distinguish three clinical forms of the disease:

1. A typical( ovarian) form of PCOS.It is manifested by various kinds of menstrual disorders:

- short and rare monthly( oligomenorrhea) in 70% of cases;

- dysfunctional uterine bleeding( 7-9%);

- primary or secondary long-term( more than half a year) absence of menstruation, secondary amenorrhea( 30%), as a rule, is detected in untreated patients for 30 years and more in combination with obesity, and in women with normal weight it is observed from adolescence.

- gipomunstrualny syndrome: rare, short and sparse monthly.

The second most important symptom is infertility due to persistent anovulation.

At external survey the correct, "female", physique is marked. The leading symptom is bilateral enlargement of the ovaries and their densification upon palpation. Laboratory examination confirms the absence of ovulation and a significant decrease in the concentration of estrogens.

2. PCOS adrenal origin.

Visible signs of virilization are clearly visible. Virilism is the result of disruption of the pituitary gland and is characterized by the appearance in the guise of patient features inherent in man: a decrease in size of the pelvis and the presence of broad shoulders, poorly developed breasts, "greasy" hair( fat seborrhea), hirsutism( hair growth on the forearms, face and legs).

Primary damage to the ovarian hormonal system in combination with hyperandrogenism is always accompanied by manifestations of hypertrichosis - increased growth of individual "core" hair in the nipple, chin, neck and thigh regions.

Menstrual dysfunction manifests itself as oligomenorrhea. It is extremely rare for this form of PCOS can occur pregnancy, but almost always ends with an early spontaneous interruption.

3. PCOS in neuroendocrine syndrome( central origin).

Pathological process starts in the hypothalamus, where under the influence of external or internal provoking factors, there are complex metabolic shifts that affect the secretion of PH in the pituitary gland. This form of PCOS is characterized by:

- Menstruation start at 12-13 years old, have unstable character. Subsequently, oligomenorrhea and dysfunctional bleeding occur against the background of endometrial hyperplasia.

- Diencephalic( hypothalamic) disorders. There are psychoemotional disorders( tearfulness, irritability, bad sleep), increased appetite, neurocirculatory dystonia by hypertonic type.

- Obesity of 3-4 degrees. Excess fat deposits are localized in the area of ​​the shoulder girdle, on the chest and lower abdomen. On the skin there are specific, similar to postpartum, stretching bands( striae), their color varies from pink to white.

- Secondary infertility due to persistent chronic anovulation.

- Moderate hypertrichosis. Appears together with obesity and a disorder of menstrual function.

Obesity is indicated in 80% of patients with PCOS.Therefore, in the physical examination, the body mass index is always determined.

An external manifestation of insulin resistance is excessive pigmentation of the skin folds( groin, armpits and others).

After examining the complaints and external examination of the patient, proceed to a gynecological examination. In all patients, regardless of the form of PCOS, enlarged ovaries are palpable. However, in the presence of severe obesity, palpation of the appendages is difficult.

Laboratory examination includes:

- biochemical blood counts;

- determination of the concentrations of the main hormones( FSH, LH, testosterone, prolactin), the ratio of FSH / LH, the level of hormones of the adrenal glands;

- determination of blood sugar level, detection of insulin resistance by the method of stimulation with glucose;

- lipid profile of blood( especially when obesity is present).

Important information about the condition of the ovaries is provided by ultrasound scanning. The presence of PCOS is said:

- Two-sided symmetrical increase in the size of the ovaries.

- The volume of each ovary exceeds 9 cm³.

- Increase of ovarian density up to 25% of the volume.

- Well-visualized thickening of the ovary capsule( indicates hyperandrogenism).

- Multiple( no less than 10) follicles located on the periphery of the ovaries without signs of ovulation.

- The diameter of neovulated follicles is not less than 8-10 mm.

Based on only ultrasound signs, the diagnosis of PCOS can not be made. It is necessary to take into account all the data collected and carefully analyze them. Therefore, when an expert in ultrasound diagnostics gives a conclusion about the presence of "PCOS signs", one should not accept his verdict for a final diagnosis.

The clinic can be supplemented with other extragenital ailments. So PCOS is often combined with type 2 diabetes, hypertension, atherosclerosis. They require additional examination from related specialists.

Often in the diagnosis of PCOS resort to laparoscopy. Laparoscopy in PCOS allows you to visually assess the condition of the ovaries and surrounding structures. The PCOS is indicated by:

- bilateral ovarian enlargement( 91%);

- smooth, shiny surface, "stretched" on the ovary with varying degrees of vascular pattern( 100%);

- twice the number of small follicles at the onset of maturation or atresia( 100%);

- thickened, very dense ovary capsule( 97%);

- presence of small cysts under the capsule of the ovary( 100);

- in the anterior space there is no free fluid( 85%).

Laparoscopy in PCOS is also prescribed for patients who need an ovarian tissue biopsy. Typically, the procedure is required with frequent acyclic bleeding and endometrial hyperplasia.

Thus, reliable diagnostic criteria for PCOS are:

- timely onset of menstruation;

- menstrual dysfunction( mostly primary), mainly by the type of oligomenorrhoea;

- the first months on the background of hirsutism and obesity in every second patient;

- primary infertility;

- chronic anovulation;

- an increase in the size and volume of the ovaries, confirmed by ultrasound;

- increased concentration of LH;

- high concentration of androgens;

- the ratio of LH / FSH, exceeding 2.5.

How to become pregnant with PCOS

Infertility is the most frequent companion of PCOS and is among the complaints of patients with this syndrome. Almost all variants of PCOS develop on the basis of chronic anovulation and expressed endocrine disorders.

Pregnancy after PCOS in rare cases happens without treatment, but its outcome is not always successful. Therefore, it is not recommended to plan motherhood with such a diagnosis independently. It is necessary to visit a specialist, undergo the required examination and get recommendations.

If the patient is aware that the cause of her infertility is the PCOS, she can "help" the doctor in his treatment, changing some of the usual, but "wrong" aspects of his life. Initially, it is very important to get rid of excess weight, and do it without the participation of "slimming" tablets. Proper nutrition and dosed physical activity, even in a moderate volume, are often able to surprise with the results.

The right life rhythm influences psycho-emotional sphere: full sleep, absence of stresses and overwork.

Treatment of infertility in PCOS requires the patient to have a lot of patience and self-discipline.

If the diagnosis of PCOS is made according to the doctor's conclusion after ultrasound, it should be remembered that it is not final and requires additional examination. Sometimes the presence of cystic changes in the ovaries is not associated with PCOS, although it can also be a source of infertility.

Treatment of PCOS

PCOS is not a disease that can be easily cured. Pathology develops against the background of dysfunction of the most important body systems - hormonal, endocrine, nervous, so several physicians of different specialties often take part in the treatment of this syndrome. Unfortunately, even the most adequate therapy is not always successful. However, this does not mean that there is no need to treat PCOS.Timely correction of systemic disorders can stop the progression of the disease and improve the patient's condition.

If PCOS is not treated, it can lead to serious complications, the most serious of which are:

- Inadvertent infertility;

- diabetes mellitus;

- hypertensive disease;

- increased risk of strokes and heart attacks;

- endometrial cancer due to prolonged hormonal dysfunction;

- complications of pregnancy( if any), threatening the lives of both mother and fetus.

Before choosing a treatment strategy, the severity of the symptoms is assessed, the PCOS form and the presence of complications are determined, and the patient's plans for procreation are explained.

Treatment of PCOS has the following objectives:

- elimination of metabolic disorders and carbohydrate-fat metabolism;

- elimination of hormonal ovarian dysfunction and restoration of a two-phase cycle;

- elimination of hyperplastic changes in the endometrium( if any)

- elimination of clinical manifestations of hyperandrogenia( hirsutism, acne);

- elimination of infertility, if the patient is interested in motherhood.

Initially, a more gentle, conservative method of therapy is almost always chosen. Its ultimate goal is to restore the normal operation of the ovaries, and if the patient is interested in motherhood - the elimination of infertility.

Conservative therapy PCOS has a high chance of success only if the correction of the existing neuro-exchange-endocrine disorders is performed beforehand.

Treatment of PCOS begins with the correction of body weight, to lead to a normal carbohydrate and fat metabolism. The individual way of a food in combination with physical loads is chosen. Unfortunately, patients often do not agree to follow recommendations, and in case of consent they do not always "go to the end", so this stage of therapy becomes more prolonged.

Significant disorders of carbohydrate metabolism are corrected by medicines that lower blood glucose levels. These include Metformin. It is recommended to take the drug no more than two weeks. The drug inhibits the absorption of glucose in the digestive tract and affects the synthesis of glucose by the liver. After a short course of taking Metformin, the blood glucose level is significantly reduced. This drug not only fights against insulin resistance, but also significantly reduces the risk of developing secondary cardiovascular pathologies.

Metabolic disorders are also corrected with antioxidants( Methionine, Ascorbic acid, lipoic acid and the like) and vitamin therapy.

After the conversion of metabolic processes to the physiological norm proceed to conservative treatment of ovarian dysfunction. The second stage of therapy is devoted to the restoration of a two-phase menstrual cycle. If the patient does not want to become pregnant, oral contraceptives with anti-androgenic action are used to treat PCOS.It is desirable to prescribe medications with a low content of estrogens( Yarin, Diane - 35, Jess, Janine).If the androgen level in the patient is too high, the hormonal therapy is strengthened with antiandrogens( Androkur, Veroshpiron).Against the background of a decrease in androgenic influence in patients, the manifestations of hirsutism decrease, acne disappears.

A significant improvement in external data on the background of weight loss and hormone therapy has a beneficial effect on the psycho-emotional state of patients and helps in treatment. Women begin to believe in the success of therapy, their mood improves, the level of confidence in the treating doctor increases.

Any, even the shortest, intake of hormonal means requires careful monitoring by laboratory monitoring and ultrasound.

The second stage of treatment is considered to be successfully completed, if the control examination has confirmed:

- restoration of normal LH / FSH;

- absence of hyperandrogenism;

- a two-phase menstrual cycle( not necessarily ovulatory);

- reduction of the size of the ovaries.

The next stage of conservative treatment is required exclusively for patients with infertility who wish to implement generative function. The goal of therapy is to restore ovulation by artificial stimulation. For this purpose, the drug Clomifen is used. It is believed that against the background of its reception no later than three months, ovulation should be restored. The success of the therapy is assessed using laboratory and ultrasound.

If after the expiration of a three-month period of the desired effect of Clomifene is not observed, it is necessary to decide the question of surgical treatment of infertility. In fact, it is similar to hormone therapy for infertility, since it has the same goal - to stimulate ovulation.

The operation is performed laparoscopically. More often for the treatment of PCOS resort to three operational techniques:

- Vaginal resection of ovarian tissue. Recommended for significantly enlarged ovaries. Excessively large ovary produces many androgens, which prevent ovulation. If the overgrown tissue is resected, the amount of androgens will decrease, and ovulation will occur. It is often necessary to remove up to 2/3 of the volume of ovarian tissue.

- Endothermocoagulation - a point "cauterization" of unwanted zones of the ovary. It is performed on small ovaries.

- Decortication of the ovary. A significantly sclerotized and thickened ovary membrane is removed, and the cystic-modified follicles are pierced.

More often the choice of the operation method in PCOS occurs directly during laparoscopy, when all pathological changes in the ovaries and fallopian tubes are visually assessed. Sometimes during the operation on the ovaries parallel dissection of adhesions is carried out or the patency of the fallopian tubes is restored.

With a favorable outcome, ovulation is restored after six months or a year. If this does not happen, infertility treatment is considered to be unpromising.

It is necessary to pay attention of patients to the fact that PCOS can not be completely cured, nor is it possible to permanently rid the woman of infertility. As a rule, the restoration of a full-fledged ovulatory cycle is of a non-permanent nature and is carried out only to temporarily restore the ability to conceive. After five years, PCOS usually recurs, so patients with this disease should undergo courses of anti-relapse therapy and be regularly monitored.

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