多囊卵巢综合征的现状2:治疗高雄激素,胰岛素抵抗和不孕症

K. Zoltán, Kun Ildikó, Kolcsár Melinda
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引用次数: 0

摘要

这项工作是在该杂志上发表的一篇早期文章的延续。91/1:“多囊卵巢综合征的现状1:定义、病理生理学、临床表现、诊断和并发症”)。由于多囊卵巢综合征的病理尚不完全清楚,所采用的治疗方法不构成因果治疗,只能通过致病干预来打破病理事件的恶性循环。目前还没有一个通用的治疗程序或批准的特定药物。治疗的目的可能是减少高雄激素,诱导排卵和预防并发症。患者的抱怨和怀孕的愿望也应考虑在内。在轻微的情况下,适当的生活方式(预防/治疗肥胖)就足够了,即体重减少5-10%已经可以显著改善,也有助于预防晚期并发症(糖尿病、高血压、心血管疾病、高脂血症)。口服避孕药和抗雄激素主要用于治疗雄激素过多症(多毛症、痤疮和脱发)。首选孕激素成分具有抗雄激素特性或至少雄激素中性的避孕药,如第三代避孕药。然而,联合避孕药(含孕酮、地格孕酮、屈螺酮和醋酸环丙孕酮)可能增加静脉血栓栓塞的风险,因此在高凝性的情况下是禁忌的。抗雄激素(醋酸环丙孕酮、螺内酯、非那雄胺等)也可以单独使用,但只能在有效避孕的情况下使用(因为这些药物会导致男性胎儿女性化)。胰岛素抵抗在这种疾病的发展中起着至关重要的作用。二甲双胍被用作主要治疗方法,因为近年来它还具有许多其他有益作用(例如心血管和抗癌)。详细讨论了这些多效效应及其微妙机制。我们强调避免副作用的可能性和目前对罕见禁忌症(酸中毒,缺氧条件,肾损害)的解释。降低胰岛素抵抗的药物包括噻唑烷二酮类、阿卡波糖、GLP-1激动剂、维生素D、白藜芦醇、奥曲肽,但也提到了肌醇和D-氨基肌醇的有益作用。在论文的最后一部分,讨论了不孕不育的治疗选择,重点介绍了克罗米芬、促性腺激素(“上升”、“下降”方法)、体外受精技术和用于诱导排卵的卵巢钻孔的疗效。我们详细介绍了预防卵巢过度刺激综合征和多胎妊娠的重要性和可能性。
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Current aspects of polycystic ovary syndrome II: treatment of hyperandrogenism, insulin resistance and infertility
Abstract This work is a continuation of an earlier article published in this journal (no. 91/1: “Current aspects of polycystic ovary syndrome I: definition, pathophysiology, clinical manifestations, diagnosis and complications”). As the pathology of polycystic ovary syndrome is not fully known, the treatments used do not constitute a causal therapy, only pathogenetical interventions to break the vicious circles of pathological events. It does not currently have a universal therapeutic procedure or an approved specific drug. Treatment may be aimed at reducing hyperandrogenism, inducing ovulation and preventing complications. The patient’s complaints and desire for becoming pregnant should also be taken into account. In mild cases, an appropriate lifestyle (prevention/treatment of obesity) is sufficient, i.e. a 5-10% reduction in body weight can already result in significant improvement and also serves to prevent late complications (diabetes, hypertension, cardiovascular disease, hyperlipidemia). Oral contraceptives and antiandrogens are mainly used to treat hyperandrogenism (hirsutism, acne, and alopecia). A contraceptive whose progestogen component has antiandrogenic properties, or at least is androgen-neutral, is preferred, such as third-generation contraceptives. However, combined contraceptives (containing gestodene, desogestrel, drospirenone and cyproterone acetate) may increase the risk of venous thromboembolism and are therefore contraindicated in case of hypercoagulability. Antiandrogens (cyproterone acetate, spironolactone, finasteride, etc.) can also be used independently, but only with effective contraception (as these can cause feminization of the male fetus). Insulin resistance plays a crucial role in the development of this disease. Metformin is used as primary therapy, as it also has many other beneficial effects (e.g. cardiovascular and anti-cancer) described in recent years. These pleiotropic effects and their subtle mechanisms are discussed in detail. We highlight the possibilities of avoiding side effects and the current interpretation of rare contraindications (acidosis, hypoxic conditions, renal damage). Insulin resistance lowering agents include thiazolidinediones, acarbose, GLP-1 agonists, vitamin D, resveratrol, octreotide, but the beneficial effects of myoinositol and D-chiro-inositol are also mentioned. In the last part of the paper, the treatment options for infertility are discussed, highlighting the efficacy of clomiphene citrate, gonadotropins (“step-up”, “step- down” methods), IVF techniques, and ovarian drilling used for ovulation induction. We detail the importance and possibilities of the prevention of ovarian hyperstimulation syndrome and multiple pregnancies.
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