Diagnostics and treatment of patients with polycystic ovary syndrome
Background. Polycystic ovary syndrome (PCOS) is the most common female endocrinopathy of reproductive age affecting 15–22 % of women according to European standards. It is a multisystem reproductive-metabolic disorder and its diagnostics and treatment remain controversial. Women with PCOS are at increased risk of developing type II diabetes, metabolic syndrome, cardiovascular disease, depression, non-alcoholic fatty liver disease, endometrial hyperplasia and cancer and few other types of carcinoma. Due to all above, early correct diagnosis, treatment and permanent surveillance of PCOS are of great importance. The main difficulty with diagnosis of PCOS was until recently lack of clear diagnostic criteria. In 2003 the European Society for Human Reproduction and Embryology and the American Society for Reproductive Medicine published a definition of PCOS. For a diagnosis of PCOS two of three criteria have to be met: oligo- or chronic anovulation (less than 8 menses per year or menses that occur at intervals greater than 35 days), clinical or biochemical signs of hyperandrogenism (alopecia, hirsutism, seborrhoea, acne, virilism), polycystyc ovaries seen on vaginal ultrasound (VUS) (presence of 12 or more follicles in both ovaries measuring 2–9 mm in diameter and/or ovarian volume larger than 10 cm3 of either or both ovaries). Exclusion of other diseases with similar clinical presentation is necessary. Treatment depends on the age of the patient, predominating clinical signs and aim we try to achieve. First-line treatment for all patients includes life-style changes and weight reduction in obese patients. Management of adolescent patients is aimed at abolishment of menses irregularity and endometrial protection, treatment of hyperandrogenism, obesity, and insulin resistance (IR). In the first-line treatment we also recommend oral hormonal contraceptives (OHC) with non-androgenic gestagens (NG) with or without antiandrogens (AA) and topical dermatological treatment (TDT) if necessary. In the second-line treatment we recommend gestagens combined with AA an insulin sensitizing agents (ISA). Management of patients in reproductive age, who do not want to conceive, is aimed at endometrial protection and treatment of hyperandrogenism, obesity, IR and metabolic risks. In the first-line treatment we also recommend OHC with NG preferably combined with AA. Antiandrogenic effect could be strengthened by adding ISA, which also reduce risks of developing diabetes and cardiovascular disease. In cases of very distinctive hyperandrogenism TDT is possible. To protect endometrium and prevent conception insertion of intrauterine device with levonorgestrel is appropriate. In perimenopause we prescribe low-dosage hormonal replacement therapy. First-line treatment of patients of reproductive age, who want to conceive, is medicamental or surgical induction of ovulation. Clomiphene citrate (CC) is most suitable for medicamental induction of ovulation. Recommended duration of treatment with CC is up to six months. At least in the first cycle of treatment response of ovaries and endometrium with VUS is advisable. If response is satisfactory and a patient did not conceive after six months of treatment an intrauterine insemination is recommendable. In obese women, if treatment with CC is unsuccessful, addition of ISA is recommended. In case of failure of induction of ovulation we proceed as in other patients with whom the next step is treatment with gonadotrophines given by a step-up protocol or ovary electrocoagulation (OEC), if it has not been performed during management of infertility. The latter is advisable first of all for CC resistant women with high LH serum levels. After six unsuccessful months of treatment with gonadotrophines and OEC assisted reproduction techniques are recommended.
Conclusions. Because of its complicated nature management of PCOS remains a challenge. According to most recent guidelines diagnosis of PCOS requires two of three criteria to be met: oligo- or chronic anovulation, clinical or biochemical signs of hyperandrogenism and polycystyc ovaries seen on VUS. Women with PCOS are at increased risk of developing diabetes, cardiovascular disease and certain types of carcinoma. Thus long-term treatment of systemic effects of PCOS is of great importance. The latter also has an important role in treating gynaecological problems because combined treatment together with traditional methods offers even more successful management of patients with PCOS. In the first-line treatment we still recommend life-style changes and weight reduction in obese patients. Further treatment depends on the age, predominating clinical signs and reproductive desires of the patient.
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