Current Diagnosis and Treatments in Polycystic Ovary Syndrome

Polycystic ovary syndrome is the most common endocrinological disorder affecting women of reproductive age in approximately the world whose exact cause is unknown. Rotterdam diagnostic criteria are used as diagnostic criteria; accordingly; chronic inability to ovulate (anovulation) and consequently menstrual irregularity (amenorrhea) or prolonged menstrual cycles (oligomenorrhea), clinical or laboratory findings of hyperandrogenism (excess of male hormone), hair growth (hirsutism), male pattern hair loss, acne (acne) In laboratory, increased testosterone DHEASO4, androstenedione and ultrasonography in the ovaries and 3 of the large number of small egg vesicles (follicles) is sufficient for diagnosis.

In addition to gynecological complaints, polycystic ovary syndrome is often associated with infertility and long-term metabolic disorders due to ovulation problems. These are obesity, insulin resistance, lipid metabolism disorders, diabetes and the metabolic syndrome seen as their combination. Their long-term fear is the increase in the incidence of cardiovascular diseases (sudden heart attack, cardiovascular congestion, stroke, etc.).

 Although polycystic ovary syndrome symptoms first appear in adolescence, scientific studies have shown the effect of the environment in the uterus and the effect of genetic factors. In addition, exposure to high androgen hormones in the uterus, ethnicity and socioeconomic status and feeding habits are among other reasons.

Current studies state that insulin resistance plays a role in the pathogenesis of the syndrome. Insulin acts similar to the hormone LH and increases androgen release from the ovaries. Another accused mechanism is the androgen produced defectively in the adrenal gland. These androgens produced in large quantities prevent the ovos in the ovaries from gaining reproductive function. This is the main reason for the polycystic appearance of follicles that cannot complete their development in the ovaries. This leads to anovulation and infertility in the long term. @ of women with PCOS are infertile due to ovulation disorder.  Another important effect of this syndrome is the exposure to an unresponsive estrogen as a result of the conversion of the androgen load to continuous estrogen by aromatase enzyme activity. This poses a risk factor for breast and uterine cancer in the long term.

The diagnosis is made by the Rotterdam diagnostic criteria as mentioned above, but other endocrinological diseases must be ruled out (thyroid diseases, cushing syndrome, congenital adrenal hyperplasia, hyperprolactinemia). 

Another clinical abnormality in patients with polycystic ovary syndrome is the increased frequency of hypertension (@), the main reason being shown to be insulin resistance. Elevated blood pressure is likely to have a boosting effect on cardiovascular diseases that can be seen in PCOS patients in the long term. Therefore, patients with polycystic ovary syndrome should also be screened for hypertension from an early age.

Current scientific data suggest that patients with polycystic ovary syndrome should be grouped according to their phenotypic characteristics. Accordingly; 

• Phenotype 1 (Classic PCOS); Hyperandrogenism, polycystic ovary appearance, chronic ovulation problems (anovulation)
• Phenotype 2; Hyperandrogenism, ovulation problems (chronic anovulation) normal ovarian appearance
• Phenotype 3: Hyperandrogenism, regular menstruation, ovulation is present, polycystic image in ovaries
• Phenotype 4: Normoandrogenism (no hair growth, no increase in male hormones), ovulation problems (chronic anovulation), polycystic image in ovaries

Among these phenotypes, phenotype 1 (classic type PCOS) is most common.

TREATMENT

The major treatment lifestyle modification in patients with polycystic ovary syndrome is regular exercise and a definite weight loss. This is the most important treatment method that will slow down and restore the anovulatory process. Loss of 5-10% of the available weight can lead to the formation of ovulation and the recovery of the secondary menstrual cycle. This also reduces insulin resistance, which is the major risk factor in polycystic ovary syndrome, and reduces the likelihood of problems such as type 2 diabetes, hypertension, stroke and cardiovascular diseases that may develop in advanced age.  Treatments other than it are intended to relieve symptoms. If the patient does not want pregnancy, regulation of the menstrual cycle with oral contraceptives, as well as the use of insulin sensitizing agents are the basis of the treatment, while treatment in patients with pediatric treatment is ovulation. 

1. Stimulation of ovulation with clomiphene citrate 
2. Ovulation with gonadotropins 
3. IVF treatments.
4. Ovarian surgery in resistant cases (drilling)

Clomiphene citrate is the first agent to be used in oral treatment because it is cheap and does not require frequent monitoring. This situation varies according to the patient's age and body mass index, but the standard dose is 50 mg/day between 2-5 days of menstruation. The maximum recommended dose is 150mg / day. A maximum of 6 cycles of implementation are recommended. The cumulative pregnancy rates after 6 cycles of treatment are P-60. Hot flashes, headaches and visual complaints are side effects and these drugs are mostly well tolerated. 

The main purpose of ovulation induction in patients with polycystic ovary syndrome is to achieve fertility and achieve a single pregnancy. Gonadotropin doses used for this purpose should be administered at the lowest possible doses with a controlled increase if necessary. More than 6 trials are not recommended. In these patients strict ovo monitoring and measurement of blood estrogen levels, if necessary, is very important and necessary for the development of multiple pregnancies and ovarian hyperstimulation syndrome with ovarian overexcitation. 

Ovarian drilling is applied to the ovaries by closed surgery (laparoscopic). The main indications are polycystic ovary cases with clomiphene-resistant. Who is recommended? It can be recommended to patients with persistent LH elevation during spontaneous cycles and during clomiphene treatment. Drilling treatment is an alternative to gonadotropin treatment in clomiphene resistant cases. Today, however, it is not applied frequently because it may reduce the ovo reserve and may cause adhesions in the abdomen. Today, IVF treatment is recommended for such patients because of their less side effects, controllability and higher chance of pregnancy.

Pregnancy rates in patients with polycystic ovary syndrome are increased with new strategies in in vitro fertilization and freezing of the embryos and resting of the uterus and ovaries and successful results are obtained by preventing complications.