PCOS - is a complex, multifactorial syndrome, including changes in the normal structure of the ovaries, hormonal endocrine dysfunction and infertility.Incorrectly regarded as PCOS exclusively gynecological diseases, since the origins of its formation are beyond the reproductive system - in the cerebral cortex and its first clinical signs always follow the system neyroobmennymi disorders.If PCOS is changed right structure and the ratio of tissue in the ovaries, as a result of the follicles do not reach the necessary maturity and beginning to reverse the development (atresia).
diagnosis of PCOS appears in 11% of young women, the majority (70%) of these apply to specialists in infertility.
Most PCOS is diagnosed in young girls during puberty active (puberty).If the symptoms of PCOS are related to the first menstrual period, the disease is considered to be primary.Infrequently, adult patients diagnosed with PCOS is secondary, it occurs after a period of normal menstrual function.
PCOS formation mechanism is very complex and is closely related to the structure and function of the ovaries.Ovary - is paired female body is essentially a hormonal gland.We can say that it was thanks to a woman's ovaries is a woman.There are three most important function of the ovaries:
1. autonomic functions, providing conversion of genitalia during maturation in women.Also, this function is responsible for female phenotype - a woman inherent appearance.
2. generative (fertility), the essence of which is to reproduce able to fertilize eggs.Generative activity of the ovaries allows a woman to conceive, bear and to give birth to a new life.
3. hormonal function.Ovaries lifelong constantly synthesize sex hormones - estrogen and progesterone, using them formed a normal menstrual cycle and maintain close contact with all units of the endocrine system.
Each ovary looks like a peach pit size 3-4 / 2-2.5 cm and a thickness of 1-1.5 cm. The right ovary slightly larger and therefore heavier than the left.Outer sheath (tunica) of the ovary is intended to protect it from any negative external influence, so to form a dense connective tissue.Under the tunica in the cortex of the ovary is the emergence and maturation of sex cells.The immature egg follicles are in - a sort of "bubbles", having an outer capsule and filled with clear follicular fluid.For the "older" egg takes about 14 days (the first, the follicular phase of the menstrual cycle), the entire period is accompanied by the secretion of estrogen.Then, after the expiry of the formation, the follicle is moved to the surface of the ovary breaks (ovulation) and release the egg into the abdominal cavity, where fertilization occurs.From the remnants of the destroyed follicle forms a temporary hormonal structure - corpus luteum responsible for the production of progesterone.If fertilization does not occur, it is destroyed, and the corpus luteum lives 10-12 days (second, luteal phase of the cycle), and then comes the menstrual bleeding.
All of the above processes in the ovaries occur in a regular, cyclical rhythm and continue until menopause.Higher hormone regulating ovarian function structures are the pituitary and hypothalamus.Pituitary hormones affect the function of the ovaries.Thus, in the first phase of the cycle, it is synthesized in the pituitary follicle-stimulating hormone (FSH), and the second - luteinizing (LH) hormones.The follicular phase FSH controls the processes of development of the egg, and for the formation of the corpus luteum in the second phase of the cycle corresponds to the LH.In mid-cycle symmetrical emission maximum FSH and LH "triggers" ovulation.
in PCOS as a result of changes in the structure of the ovaries is disturbed physiological mechanism of ovulation, menstruation is perverted.The follicles do not reach the proper maturity, and fluid begins to accumulate, turning into a small cyst.
Since ovarian function is integrated into the whole body, PCOS is almost always accompanied by metabolic and endocrine disorders.In addition to infertility and hormonal dysfunction, the disease can manifest itself and others, neginekologicheskimi symptoms: obesity, hirsutism, hypertension, changes in the emotional sphere.
PCOS diagnosis must be confirmed by lab tests, as the disease has symptoms similar to those of many endocrine and hormonal abnormalities.
Treat PCOS is very difficult.The success of conservative treatment depends on the extent of ovarian and related neuro-metabolic and endocrine disorders.For surgical procedures are turning to fertility treatments when all other therapies have failed.
PCOS is one of the little-known ailments.Since this syndrome is formed with the participation of almost all major systems of the body, the cause may be related to endocrine dysfunction, metabolism, nervous and reproductive systems, and therefore reliably identify the source of the formation of the pathology of the ovaries in PCOS is incredibly difficult.
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 level of the hypothalamus.The rhythmic release of biologically active substances related to the work of the pituitary gland, is distorted, and the hypothalamus, "giving the wrong orders" pituitary.
2. Gipofizalny level.Received an invalid command from the hypothalamus, anterior pituitary begins to synthesize FSH and LH in the acyclic mode.LH secretion is not dependent on the phase of the cycle, the hormone begins to produce a monotone, so its concentration in the blood remains constant increase and the numbers of FSH normal physiological range or slightly reduced.As a result, necessary for normal biphasic ovulatory cycle ratio of FSH / LH is deformed, and the maturation of follicles distorted.
3. Ovarian level.What occurs in the ovaries when it gets to the excess of N?In healthy tissues, ovarian LH, in addition to participating in the formation of the corpus luteum triggers the synthesis of androgens.When the concentration is close to the borders of the physiological norm, ovaries, according to the feedback mechanism, "reports" about her brain to the pituitary FSH production responded.With the participation of the ovaries FSH get rid of excess LH, estrogen metabolizing them.
in PCOS LH concentrations are so high that the ovaries can not cope with their disposal, eventually becomes too much androgen.Androgens interfere in the process of folliculogenesis and cause overgrowth (hyperplasia) of the ovary tissue.Follicles are not reaching the necessary maturity, long-term stay in the immature state (persist), and then regress and accumulate fluid (cystic atresia).
Cystic follicular atresia is a kind of diagnostic marker for PCOS, it is present in all patients with this syndrome is the cause of chronic ovulation leading to infertility.
Most PCOS manifests in adolescence.Violation of the rhythmic activity of the hypothalamus during sexual formation may lead to an increase in the concentration of growth hormone, which stimulates the synthesis of LH, and therefore provokes hyperandrogenism.Excess androgens negative effect on puberty and becomes a cause of the "male" traits in the appearance of the girl.
Secondary PCOS is associated with metabolic disorders in patients with prior normal menstrual function.Among the reasons for its occurrence often appear complications during pregnancy and / or childbirth, numerous abortions, psycho-emotional turmoil, brain trauma, severe infections, intoxication.
in the formation of PCOS are "guilty" and endocrine disorders.One kind of syndrome is a PCOS (primary or secondary) on the background of marked obesity.In obesity the body (not in the ovaries) an excess of androgens.
source of androgen excess can be, and adrenal glands, half of the patients diagnosed with PCOS and adrenal dysfunction, as a consequence, elevated androgens.
have 40-70% of PCOS patients develop on the basis of insulin resistance (insulin resistance) and hyperinsulinemia.Insulin, a hormone being pancreas responsible for the metabolism of sugar in the body.The increased concentrations it increases the secretion of androgens.
Home, detrimental, effects of androgens on the ovaries is the formation of persistent anovulation.Infertility is always accompanied by severe PCOS.Under the influence of androgens shell of the ovary thickens and becomes extremely dense, which prevents the egg "break through" the outside.As a result, after each menstrual cycle under the outer shell of the ovarian follicle is not destroyed, the accumulated fluid and become a cyst.The longer a patient has PCOS, the more pronounced cystic transformation of the ovaries.Pregnancy after PCOS is not always possible, its probability depends on the nature of structural abnormalities in the ovaries and the presence of an unfavorable background.
Symptoms and signs of PCOS
clinical picture of PCOS vary widely, as the disease is not limited to gynecological.
Primary PCOS declares itself at the beginning of puberty.Menstruation usually come in a timely manner (12-13 years), but the cycle of instability.Typically, over time menstrual disorders worse.First, irregular menstruation at an interval greater than 35 days and a minor loss of blood, and then becoming longer delays (up to six months) and may result in the complete absence of menstruation (amenorrhea).
Women with PCOS secondary formation of menstrual disorders were noted.Often the appearance of the first symptoms of the disease is preceded by a period of normal menstrual and fertility.
Depending on the location of PCOS may be divided into three clinical forms of the disease:
1. Typical (ovarian) form of PCOS.Exhibit various kinds of menstrual disorders:
- brief and infrequent periods (oligomenorrhea) in 70% of cases;
- dysfunctional uterine bleeding (7-9%);
- primary or secondary long-term (more than six months), the absence of menstruation, secondary amenorrhea (30%) tend to be detected in untreated patients 30 years or more in combination with obesity and in women of normal weight, she celebrated with youth.
- hypomenstrual syndrome: a rare, short and scanty menses.
second most important symptom is infertility due to anovulation reception.
During external examination the right notes, "feminine" physique.The main symptom is bilateral ovarian enlargement and induration on palpation.Laboratory tests confirmed the absence of ovulation and a significant decrease in the concentration of estrogen.
2. PCOS adrenal origin.
When viewed clearly visible signs of virilization.Virilism is a consequence of malfunction of the pituitary gland and is characterized by the appearance in the guise of patient characteristics inherent in man: reducing the 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 lesion of ovarian hormonal apparatus in combination with hyperandrogenism is always accompanied by manifestations of hypertrichosis - increased growth of certain "core" of hair in the area of the nipple, chin, neck and hips.
Menstrual dysfunction manifested oligomenorrhea.Extremely rare in this form of PCOS pregnancy can occur, but almost always ends in early spontaneous abortion.
3. PCOS neuro syndrome (central origin).
pathological process starts in the hypothalamus, where under the influence of external or internal trigger factors there are complex metabolic changes that affect the secretion of LH in the pituitary gland.This form of PCOS is characterized by:
- Menses start in 12-13 years are unsustainable.In the following appears oligomenorrhea and dysfunctional bleeding on the background of endometrial hyperplasia.
- diencephalic (hypothalamic) disturbances.There are psycho-emotional disorders (tearfulness, irritability, poor sleep), increased appetite, cardiopsychoneurosis of hypertensive type.
- Obesity grade 3-4.Excess fat deposits are located in the shoulder girdle, chest and lower abdomen.On the skin appear specific, similar to postpartum, strip stretching (striae), their color varies from pink to white.
- Secondary infertility due to persistent chronic anovulation.
- Moderate hypertrichosis.Displayed together with obesity and disorders of menstrual function.
Obesity is seen in 80% of patients with PCOS.Therefore, the physical examination always determine body mass index.
external manifestation of insulin resistance is excessive pigmentation of skin folds (groin, armpits, etc.).
After studying the complaints and external examination of the patient, to begin pelvic examination.In all patients, regardless of the form PCOS palpable enlarged ovaries.However, in the presence of gross obesity, palpation appendages difficult.
Laboratory examination includes:
- biochemical blood;
- determining concentrations of the main hormones (FSH, LH, testosterone, prolactin), the ratio of FSH / LH levels of adrenal hormones;
- determine the level of blood sugar, insulin resistance detection method of stimulating glucose;
- blood lipid profile (especially in the presence of obesity).
important information about the state offered an ultrasound scan of the ovaries.The presence of PCOS say:
- Bilateral symmetrical enlargement of the ovaries.
- The volume of each ovary exceed 9sm³.
- Increase the density to 25% of ovarian volume.
- well visualized thickened ovarian capsule (indicating hyperandrogenism).
- placed on the periphery of the ovaries, multiple (at least 10) follicles without evidence of ovulation.
- neovulirovannyh follicle diameter not less than 8-10 mm.
based only on ultrasound diagnosis of PCOS symptoms to put it is impossible.It is necessary to take into account all the data collected and carefully analyzed them.Therefore, when the specialist ultrasound diagnostics determine whether there are "signs of PCOS," accept the verdict of the final diagnosis should not be.
clinic disease can complement other, extragenital, ailments.Because PCOS often combined with Type II diabetes, hypertension, atherosclerosis.They require additional surveys have related professionals.
in the diagnosis of PCOS is often resorted to laparoscopy.Laparoscopy in PCOS allows you to visually assess the condition of the ovaries and surrounding structures.In PCOS indicate:
- bilateral ovarian enlargement (91%);
- smooth, shiny surface, "stretched" in the ovary with varying degrees of severity of vascular pattern (100%);
- in 2 times greater than the number of small follicles in the beginning stages of maturation or atresia (100%);
- thickened, very thick capsule of the ovary (97%);
- the presence of small cysts under the capsule of the ovary (100);
- pozadimatochnom in space there is no free liquid (85%).
Laparoscopy in PCOS is appointed and the patients who need a biopsy of ovarian tissue.As a rule, the procedure is required with frequent acyclic bleeding and endometrial hyperplasia.
Thus, reliable diagnostic criteria for PCOS are considered:
- the timely onset of menses;
- menstrual dysfunction (usually primary) mainly on the type of oligomenorrhea;
- first period against the background of hirsutism and obesity in every second patient;
- primary infertility;
- chronic anovulation;