pcos诊疗及英文病例问诊

Polycysticovariansyndrome

吉林市中心医院

妇产科

安晓汾JilinCentralHospitalobstetricsandGynecologyCasestudy

_clinicaldialogueCasesummaryA23-year-oldmorbidlyobese,gravida0,whopresentedtothegynecologyofficeforevaluationofirregularmensessincemenarche.Thepatientstatedthatonaverage,shehas1periodevery5-6months.Whensheisonherperiod,shebleedsveryheavily,passinglargeclotswithalotofabdominalcramping.Shealsocomplainedaboutexcessivefacialhair,whichrequireshertoshaveatleastonceseveraldays,andalotofhaironherabdomenanarmsaswell.Shedeniedanychangeinhervoiceorincreaseinthesizeofhermuscles.Shehasbeenmorbidlyobesesinceshewasayoungteenager.Shedeniedanyheadaches,blurredvision,ordischargesfromhernipples.Shealsodeniedanyhyper-orhypothyroidismsymptoms.Shehasneverhadanysurgeryinthepast.Shewasunabletoconceivedespiteoneyearofactivelytrying.Sheisnotcurrentlytakinganymedicationandhasneverusedanyformofcontraception.Medicalhistory1.Hello,MissWang,Nicetomeetyou.HowcanIhelpyoutoday?--Ihaven’thadmyperiodover6monthsandIknowIamnotpregnant,Ijusttookapregnancytestanditwasnegative.

2.Haveyoubeentryingtoconceiveandhowlong？--Yes,aboutoneyear.3.Canyoutellmealittlemoreaboutyourperiods?--MyperiodhasbeenirregularsinceIfirstgotit.Onaverage,Ihave1periodevery5-6months.Whenitdoescome,itflowsveryheavily,passinglargeclots,andhavingalotofcrampingaswell.

4.Normally,howmanydaysdoyourperiodslast?----About6-7days.

5.Doyouhaveanyothermedicalconditionssuchasdiabetesandhighbloodpressure?----No,butmymotherdoeshavediabetes6.Haveyounoticedexcessivehairgrowthanywhereonyourbody?---Yes,onmyface,arm,andmybelly.7.Doyoushave?----Yes,Ihavetoshaveatleastonceeveryseveraldays.

8.Haveyounoticedanychangesonyourvoiceorexcessivehairloss?

?----Idong’tthinkso

.

9.Haveyouanyproblemswithyourthyroidgland?----NotthatIknowof

.10.Haveyoueverexperiencedsomethinglikedryskinfatigue,moodswingsoranydepression

?---No,notreally11.whataboutheadaches,visionchange,ordischargefromyournipples?--no.

12.

Well,let’stalkalittlebitaboutyourweightchangeovertime

?----Ihavebeenoverweightformostofmylife.IwasontheheavysidesinceIwasakidandIgainedanother40to50poundsaftercollege(1pounds=0.45359237kg)

.

13.Haveyoudoneanythingtocontrolyourweight?

?----Iamtryingtoexciseandeathealthy,butIhavn’thadanytypeofsurgeries

.14.

Isthereanythingelsethatyouwouldliketotalkabout?----Notfornow..

15.Verygood,next,wewuldneedtodoaphysicalexaminationincludingpelvic----Alright.Physicalexaminationincludingpelvicexam

Shewasclearlyhirsute(Ferriman-Galloweyscoreof10),especiallyinthechinandmid-abdominalregion.Herbodymassindex(BMI)was31.Herpelvicexaminationwasunremarkable,includingnoevidenceforclitoromegaly,butitwasverydifficulttoappreciateheruterusandadnexasecondarytopatient’sbodyhabitus.Therestofherphysicalexaminationwasunremarkable.ATVUS(transvaginalultrasound)wasperformed,whichrevealedanormalappearinguterus,withanendometrialthicknessof20mmandbilateralnormalovaries

1.

MissWang,basedonyourhistoryandexaminationtoday,youmostlikelyhaveaconditioncalledPCOS,orpolycysticovariansyndrom.----Whatisthat?2.Well,PCOSisaconditionthatcausesirregularmenstrualperiodsbecausemonthlyovulationisnotoccurring.Inaddition,yourlevelsofmalehormones(androgens)areelevated,whichleadstoexcessivehairgrowth.Theovariesmaylooktotallynormalorslightlylargerthannormalovaries,andhavetwicethenumberoffollicles(smallcysts).PCOSiscommon,anditaffectsIin5(20%)ofwomen.

discuss3.WhatcausesPCOS

.

--ThecauseofPCOSremainstobedefined.PCOSsometimesrunsinfamilies.ThesymptomsofPCOSarealsorelatedtoabnormalinsulinlevels.Insulinisahormonethatregulatesthelevelofbloodglucose.ifyouhavePCOS，yourbodymaynotrespondtothehormoneinsulin(knownasinsulinresistance),sothelevelofglucosemaybehigher.Topreventtheglucoselevelsfromincreasing,yourbodyproducesmoreinsulin.Highlevelsofinsulincanleadtoweightgain,irregularperiods,infertilityandhigherlevelsoftestosterone..

4.WhatcouldPCOS

meanstomylong-termhealth?--IfyouhavePCOS,youareatgreaterriskofdevelopingsomelong-termhealthproblemssuchasdiabetes,highbloodpressure,heartdisease,laterinlifeyoucanevendevelopcancerWithfewerperiods(lessthanthreeayear),theendometriumcanovergrowandbecomethicken.Thismayleadtoendometrialhyperplasia,aprecancerouschange,andeventuallycancerinasmallnumberofwomen.Forthisreason,sinceyouhavenothadyourperiodfor5monthsand20cmofendometrialthickness,Iwouldliketorecommendanendometrialbiopsyasournextstep.5.WhatshouldIdotoreducetheriskofdevelopingthoselong–termhealthproblems?

--Ahealthylifestyleincludinghealthybalanceddietandregularexciseswouldbebeneficial.Youshouldaimtokeepyourweightwithinanormalrange(BMIbetween19-25).Thebenefitofweightlossinclude:alowerriskofdevelopinginsulinresistanceanddiabetes;alowerriskofheartproblems;alowerriskofdevelopinguterinecancer;moreregularperiods;anincreasedchanceofbecomingpregnant;reductioninacneanddecreasinghairgrowthovertime.

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5～10％占无排卵性不孕30～60％，有报道达75％国内局部地区小规模流行病学调查，育龄妇女患病率分别为6.46％～7.2％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，SteinandLeventhal

首先描述了PCO,1990年，NIH制定PCOS共识

2003年，ESHRE/ASRMRotterdamPCOS诊断共识2006年，AndrogenExcessSociety(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经典型PCOS未将PCO作为诊断的主要症状NIH:NationalInstitutesofHealth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+or2003年，ESHRE/ASRMRotterdamPCOS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（AndrogenExcessSociety）标准2006年AES（AndrogenExcessSociety）标准高雄＋排卵障碍高雄＋PCO高雄＋排卵障碍＋PCO2010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2～9mm的卵泡≥12个，和/或卵巢体积≥10ml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+or2010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-2BBTB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（sexsualhair）：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PCOPCO不是PCOS妇女所特有正常妊娠妇女卵巢8-25％B超呈现PCO服用避孕药的妇女14％B超呈现