Polycystic Ovary Syndrome
Polycystic ovary syndrome is considered to be one of the most common endocrine disorder of fertile women. It affects between 5 and 10% of premenopausal women. Being a chronic condition of anovulatory hyperandrogenism, polycystic ovary syndrome has important clinical consequences on the patients, consequences that include infertility, diabetes, menstrual abnormalities, hirsutism (excessive hair growth), alopecia (hair loss), high risk of endometrial cancer and cardiovascular diseases.
The ovaries are covered by a thick, fibrous capsule, that the ovarian follicle in its growth dose not manage to break. The ovarian follicle is a cavity filled with fluid, in which the ovule is developing and growing throughout the menstrual cycle, so, on 14th day (for a 28 day menstrual cycle) the pressure inside is exceeding the outside pressure and the follicle ruptures, expelling the egg. The phenomenon is called ovulation. In polycystic ovary syndrome, the pressure inside can not brake the capsule and the egg can not be expelled, and for this reason will appear anovulatory menstrual cycles, and therefor will appear infertility. The name of polycystic ovary syndrome comes from the fact that the follicles remain like little cysts (they no longer break) and, over time, they accumulate in the ovary.
Causes of polycystic ovary syndrome:
Polycystic ovary syndrome is now considered a heterogeneous disease in which are included several subpopulations of women, where etiopathogenic elements are different, most likely are multifactorial – genetic abnormalities, environmental, nutritional and hormonal abnormalities, that are inducing the occurrence of hormonal abnormalities that perpetuates in a vicious circle. In the etiology of polycystic ovary syndrome have also been incriminated primary hypothalamic-pituitary disorders, ovarian and adrenal disorders, and more recently insulin resistance with hyperinsulinemia (increased insulin secretion of the pancreas). Hyperinsulinemia is 2-3 times more common in women with polycystic ovary syndrome compared with healthy women, its prevalence is 60-80% in obese patients and 30-50% in normal-weight patients. Thoraco-abdominal distribution of excess body fat is positively correlated with insulin resistance and hyperinsulinism.
Insulin stimulates the ovarian and adrenal secretion of androgen hormones, reduces the hepatic production of SHBG (plasma protein that is caring the androgen hormones), increases the active plasma fraction of androgen hormones, stimulates the activity of 5-alpha-reductase, the enzyme that converts testosterone into dihydrotestosterone, a hormone which has a important role in the growth of ovarian follicles (follicle genesis).
Symptoms of polycystic ovary syndrome:
Due to androgen excess, will appear abnormal hair growth (hirsutism), android fat deposit, predominantly on the abdomen, neck, and face.
Because of the excess estrogen, will appear excess growth of the lining of the endometrium, which will give genital dysfunctional bleeding (outside the menstruation period or prolonged menses), and the accumulation of adipose tissue, which will lead to secondary obesity.
Hirsutism is defined as a excessive hair growth in a woman, in areas where it is usually minimal or absent (upper lip, chin, chest, around the nipple, sacral region, thighs). The hair will have male characters: it is thick, strong, shiny and well lubricated, dark and curly. Hirsutism is present in most, but not all patients with polycystic ovary syndrome. Hirsutism intensity is influenced by many factors including hormonal disturbances, individual features (the number of hair follicles and their sensitivity to androgens) and racial characteristics. Thus, hirsutism was reported in approx 70% of women with polycystic ovary syndrome in Europe and in the U.S.A., and only 10% of women with polycystic ovary syndrome from Eastern countries.
Acne, a relatively common manifestation in women with polycystic ovary syndrome, is affecting the face, back, shoulders and chest area. It is usually associated with comedones and can leave multiple unpleasant scars.
Male pattern alopecia, which consist of diffuse thinning of the head pilosity, more predominantly in the vertex and the deepening of frontal gulfs.
Virilization of the phenotype: in polycystic ovary syndrome can occur skeletal changes (increased biacromial diameter, shoulder width is greater than the hips), muscle development, with increased muscle strength and fat disposition, particularly on the abdomen and not on the buttocks, which is characteristic for women.
Skin virilization: due to the action of androgens, the skin gets a masculine look became thicker, rough, without smoothness and elasticity.
Virilization of the voice: due to hypertrophy of the vocal cords, the voice becomes lower, with serious tones.
Virilization of external genitalia: consist of the hypertrophy of the labia majora and of the clitoris, gaining a scrotal appearance.
Menstrual disorders consist of changes in the menses rhythm (menstruation appear more often), in the duration of menses (reduced or extended) and in the menstrual flow (low or abundant).Menstrual disorders dose not represent a compulsory element in symptoms of polycystic ovary syndrome, because 15-20% of patients with polycystic ovary syndrome have regular menstrual periods. Premenstrual syndrome occurs at a third of women with polycystic ovary syndrome and is consisting of breast congestion, breast pain, flatulence, fluid retention, headache, irritability, depression, phenomena that occur in 7 to 12 days before menses and subside in the first or second day of menses.
Infertility is a consequence of the anovulatory menstrual cycles, pregnancy is initially impossible but fertility declines progressively with age and with the evolution of the disease.
Obesity: excess weight is positively correlated with the signs of hypeandrogenism, with extent of menstrual disorders and with infertility. In women with polycystic ovary syndrome, the obesity is usually moderate, adipose panicle being deposited in about 75% of cases, in thoraco-abdominal region.
Diagnosis of polycystic ovary syndrome:
Diagnosis of polycystic ovary syndrome is based on symptoms and paraclinical investigations, as fallows:
- Specific transabdominal ultrasound image;
- Specific hormonal dosage (high levels of testosterone, resistant cells to the action of insulin, androstenedione, luteinizing hormone, follicle stimulating hormone);
- Laparoscopy (observation of the ovary appearance with a video camera and taking small pieces to be analyzed);
- Physical control for the observation of the pilosity;
- Determination of cholesterol, triglycerides and glucose;
Treatment of polycystic ovary syndrome:
The first step in controlling the polycystic ovary syndrome is adopting a healthy diet and performing regular exercise. If the patient is overweight or obese, only a small weight loss will helpful in establishing a more balanced hormonal secretion and a regular menstrual cycle.
Administration of ovulation inducers is useful in women who are planning to become pregnant.
Surgical interventions for polycystic ovary syndrome may include:Hormonal treatment is indicated whenever there is a deficiency in endocrine component. When a women with polycystic ovary syndrome is not trying to conceive, then she can use contraceptive pills to regulate her menstrual cycle and prevent the incidence of cervical cancer. Hormone therapy can improve the side effects of the diseases, such as acne and hirsutism. Are, also recommended birth control pills, patches and vaginal ring (containing a small dose of hormones). The combination of diuretics like spironolactone with oral contraceptives containing estrogen and progesterone give good results in the treatment of polycystic ovary syndrome.
- Removing a part of the ovary to stimulate fertility, if the woman wants to get pregnant;
- Remove the ovaries if the woman does not want to get pregnant.
Types of surgical interventions:
- Laparoscopic ovarian surgery is a surgical procedure that can trigger ovulation in women with polycystic ovary syndrome who have failed to lose weight and dose not response to fertility medications. Electrocautery or laser are used to destroy portions of the ovaries.
- Bilateral salpingo-oophorectomy and hysterectomy is a surgical procedure which removal of the uterus, fallopian tubes and ovaries.
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