Polycystic Ovary Syndrome

    Polycystic ovary syndrome (PCOS) affects approximately 4% of women of reproductive age and is characterized by chronic anovulation and hyperandrogenism. It is the most common cause of infertility in women.
    It is characterized clinically by acne, alopecia, hirsutism, menstrual irregularity and infertility.
    The most common laboratory findings include increased luteinizing hormone (LH), increased LH / FSH ratio (follicle stimulating hormone), increased androgen (both ovarian and adrenal) and circulating estrogen. Other routine laboratory findings are oral test abnormal glucose and lipid profile alterations in tolerance.
    All this together with echocardiographic images characteristics define the syndrome.
    Therapeutic allows two broad approaches that can overlap: the correction of the manifestations of hyperandrogenism and treatment of disorders of the reproductive axis (anovulation, infertility).
    Antiandrogens are mainly indicated to treat symptoms virilising.
    Alternatives to induce ovulation are numerous: clomiphene citrate and the old wedge resection human gonadotropins, pulses of GnRH (gonadotropin releasing hormone), measures or drugs to modify insulin levels, and finally technical endoscopic surgical added to reduce ovarian mass.
Keywords: Polycystic Ovary Syndrome. polycystic ovarian disease
INTRODUCTION
 

Polycystic ovary syndrome is probably the most prevalent endocrinopathy in women and the most common cause of anovulatory infertility origin. Committed belongs to the age group population of childbearing age. The pathogenesis is unknown and their clinical and biochemical characteristics are heterogeneous. (1)
    It is known to be associated with metabolic abnormalities characteristic and has long-term implications on health. (1)
    The aim of this work is to updated data published in recent years on this syndrome, emphasizing in particular as regards the therapeutic conduct review.
DEFINITION
    The polycystic ovary syndrome is the association of hyperandrogenism with chronic anovulation in women without adrenal glands or underlying pituitary disease, with ovaries exhibiting typical ultrasonographic features such as the presence of more than 8 follicles less than 10 mm in diameter, arranged in and peripheral hyperechoic stoma. (1, 2)
ETIOLOGY
    It is unknown, it is believed that it would be multifactorial, such as increased ovarian androgens, or be secondary to hypothalamic-pituitary dysfunction, adrenal hyperandrogenism, and even hyperinsulinism, among others. (1, 3)
PREVALENCE
    Around the world at least 20% of women of reproductive age have polycystic ovaries, a condition in which the ovaries become enlarged and develop multiple small cysts. About three quarters of these women have PCOS (polycystic ovarian syndrome), which is characterized by one or more symptoms including menstrual abnormalities, hirsutism, obesity and infertility. (4) The clinical syndrome of hyperandrogenism with oligomenorrhea or amenorrhea is in the 1% to 4% of these women. (5, 7).
    Corresponds to approximately 75% of cases of anovulatory infertility (2).
CLINIC
    Women with PCOS may exhibit a wide range of clinical symptoms. The typical presentation described by Stein and Leventhal is a clinical triad of amenorrhea, hirsutism and obesity, coupled with the presence of bilateral polycystic ovaries. (5)
    Hyperandrogenism manifested as hirsutism, acne or male pattern alopecia. Hirsutism is observed in about 80% of cases and may be associated with acne. The most affected areas are the chin, upper lip, the periareolar area and the anterior midline body. (1, 3, 6) it has also been seen in some cases, increased increasingly severe muscle mass and voice. (1)
    Amenorrhea is interrupted at times by metrorragias. As a result of chronic anovulation, infertility patients present that can be remedied with specific treatment. (6)
    Obesity is observed in 50% of cases, there is a close relationship between this, the insulin resistance and hyperinsulinemia. (3)
    Acanthosis nigricans, characterized by hyperpigmentation and hyperkeratosis of the skin, usually affects the vulva, the root of the thighs, neck and armpits. (1, 2, 3)
    It is known that these symptoms, not exclusive PCOS is also associated with other endocrine dysfunctions of diverse etiology Cushing's syndrome, congenital adrenal hyperplasia, virilizing ovarian and adrenal tumors, hyperprolactinemia, hyperthyroidism and hypothyroidism. (5) Discarded these pathologies, we think this syndrome to a woman with menstrual irregularities hirsutism likely to develop mild to severe with an increase in testosterone levels and weight gain (there are women who do not have). (5, 8)
    Chronologically frequently symptoms begin around puberty, before the final timing of the hypothalamic-pituitary-ovarian cyclic interactions (8)
    Moreover, PCOS is associated with an increased risk of myocardial infarction or stroke due to factors such as hypertension, obesity, hyperandrogenism and hypertriglyceridemia. (9)
LABORATORY
   
The only constant anomaly detected in the laboratory of patients with PCOS is hyperandrogenism and, accordingly, it is more appropriate to make a diagnosis of hyperandrogenism for this disorder and do not use a designation of Stein-Leventhal syndrome. (5)
    elevated levels of free progesterone, androstenedione, LH (luteinizing hormone), increasing the ratio LH / FSH (follicle stimulating hormone) (70% of cases), free estradiol, estrone, and fasting insulin is observed; and a reduction of SHBG levels (steroid hormone binding globulin). FSH levels are normal or decreased. (10)
    The adrenal androgen secretion and cortisol is increased in women with PCOS. This increase can be explained by dysregulation of hydroxysteroid dehydrogenase 11A, which causes an increased cortisol to cortisone oxidation of which it can not be explained only by obesity. (eleven)
    Also in the ovary there is increased production of androgens, particularly testosterone, because the activity of the hydroxylase 17A and (to a lesser extent) 17, 20 are increased lyase; the net effect is an increase in testosterone production. (6, 12)
    Because of the high prevalence of impaired glucose tolerance and type II diabetes in these patients, it is advisable to perform routine tests of oral glucose tolerance. It is also necessary to obtain a lipid profile and evaluate blood pressure due to the long-term risk of cardiovascular disease. (12, 13, 14,15)
TREATMENT
    The absence of a clear causal mechanism in the syndrome has led to the development of multiple treatments aimed at correcting symptoms taking into account the needs of the patient and clinical situation. (16)
    PCOS patients seeking treatment for three main reasons: hyperandrogenism, infertility and menstrual irregularities. (13,17, 18)
    In obese women the loss of 5% or more of total body weight is capable of severely reverse the symptoms. (19) This would probably result of decreased insulin levels and resistance to it, with the consequent reduction in ovarian androgen production and circulation of free testosterone (18,19).
hyperandrogenism:
- Hirsutismo:
    If mild or moderate and localized, it can be treated simply with cosmetic measures. (2) In more severe cases, drug therapy can offer:
    The most widely used antiandrogen cyproterone acetate is (synthetic progesterone effect antigonadotropo much as antiandrogen). (20) The combination of this with ethinyl estradiol suppression of hyperandrogenism achieved with improvement of clinical symptoms and normalization of hormonal changes that characterize PCOS. (2, 3, 20)
    Another drug used is Spironolactone (mineralocorticoid antagonist and androgen receptor antagonist) (3). Use of this can be associated with occasional vaginal bleeding therefore generally administered with is oral contraceptive. (2. 3)
    More recently it has been reported the successful use of pure antiandrogens such as flutamide, as well as GnRH agonists (gonadotropin releasing hormone). (2)
    Any of the schemes employed requires prolonged for the improvement in hirsutism, on average exceeding 6 months time is achieved. (3)
- Alopecia:
    Antiandrogens (flutamide, finasteride) are the treatment of choice for androgen-dependent alopecia. (2)
- Acne:
    It can be treated in the first instance with a range of antibiotics, but these do not provide satisfactory results other options include derivatives of retinoic acid and antiandrogens. (2)
infertility:
    When women with polycystic ovary syndrome want to conceive, the primary objective is the induction of ovulation.
Medical treatment:
    The treatment of choice for induction of ovulation in PCOS is a case of clomiphene citrate. (2, 8) This drug provides positive results in approximately 75% of patients. The drug resistance in the remaining 25% could be due to hyperinsulinemia accompanying this syndrome (particularly obese women). (20, 21, 22, 23) has recently been shown that the response in this patient group would be increased by reducing insulin secretion metformin together with a weight reduction program and exercises. (13, 16, 19, 24) Use of Metformin has been used successfully by various clomiphene alone or associated groups. (9.23)
    Gonadotrophin stimulation is the next step in treating women who are resistant to clomiphene. However, the results of gonadotrophin stimulation in PCOS are unsuccessful (low pregnancy rate, high rate of multiple pregnancies (25), and ovarian hyperstimulation syndrome). Consequently, some researchers have achieved better results with initial use of low doses of gonadotropins, followed by small increments, pointing to manage only the threshold dose of FSH to facilitate the maturation of a single follicle. (2, 5)
    Another alternative to achieve monofollicular ovulation is pulsatile administration of GnRH, with unsatisfactory results. In the absence of evidence to suggest a benefit of GnRH this should not be recommended as standard treatment in this patient group. (25)
Surgical treatment:
    Traditionally it consists in wedge resection of the ovaries (conducted since 1906). Restores menstrual periods, achieving acceptable pregnancy rates. Its mechanism of action is unclear and carries the risk of creating adhesions that compromise future fertility by adding a mechanical factor infertility. (2, 3, 5, 8)
    Laparoscopic ovarian diathermy or laser drilling was introduced by Gjonnaess (26) based on the principle of being able to achieve the same effects wedge resection avoiding mechanical injury. (27, 28, 29, 30)
    However, recent studies have compared medical treatment with surgical management, showing no significant differences in the results of both groups. (1, 2)
menstrual irregularities:
    Monophasic cycles can be treated with natural gestagens as micronized progesterone, from day 15 to 25 a predetermined artificial cycle or medroxyprogesterone, in the same way as above. The goal with both schemes is to reduce the undesirable effects of sustained estrogen stimulation of the endometrium. (25, 31, 32)
    Oral contraceptives may be another form of treatment, and allow lower levels of LH and ovarian androgen production and increase SHBG. It is advisable to use contraceptives low doses of estrogen and progestins without androgenic effect. Within these it is useful and gestodene ethinyloestradiol, or ethinyl estradiol and cyproterone. (3)
CONCLUSION
The pharmacological armamentarium with which it has so far been successful in controlling symptoms, and improves pregnancy rates in women who desire offspring.
Weight reduction in the obese patient often achieved correcting anomalies gonadotropins and sex steroids, which leads sometimes to spontaneous resumption of ovulation, and other times to a reduction in the doses of inducing agents ovulation.
It has also been seen that improves insulin resistance and lipid profile, with the consequent reduction of the risks that these situations entail.
Cuneiform resection of ovaries established for decades the basic treatment of the syndrome and with excellent results in the hands of those who described. Given the success of nonsurgical treatment has been virtually abandoned in the reservándosela today for special circumstances.
Endoscopic surgery with the use of lasers or cautery open up interesting possibilities for reducing ovarian mass with minimal adhesions and good results.