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#爱 Ask Curiosity# Don’t confuse ovarian cysts, polycystic ovary syndrome and ovarian hyperstimulation syndrome
Ovarian cysts, polycystic ovary syndrome and ovarian hyperstimulation syndrome Syndrome is not the same thing. Don't get confused. Many patients who seek medical treatment cannot distinguish these things, and there are many who confuse them.
Ovarian cysts or polycystic ovaries during infertility treatment are mostly caused by improper use of ovulation induction drugs. Generally, after stopping the drug, it will naturally return to normal in three to six months. Don’t be too impatient. It is best to wait patiently for natural recovery.
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Pregnancy media professor said that pregnancy is a systematic project, related to many factors between the man, the woman and both parties. It is recommended that you go to the professional department of a regular hospital for systematic testing and treatment. This way you can avoid detours and get pregnant as soon as possible!
Attachment: Medical common sense between ovarian cysts, polycystic ovary syndrome and ovarian hyperstimulation syndrome
Ovarian cysts are a type of ovarian tumor in a broad sense and are common in all ages. The disease can occur, but it is most common in those aged 20 to 50 years. Ovarian tumors are common tumors of the female genitalia, with various properties and shapes, namely: unilateral or bilateral, cystic or solid, benign or malignant, among which cystic tumors are more common, with a certain proportion of malignant tumors.
Diagnosis of ovarian cysts often differs in difficulty depending on the size and characteristics of the tumor. When asking detailed medical history, attention should not only be paid to the reproductive organs, but also to the general condition and the history of other important organs; combined with In clinical manifestations and physical examination, in addition to paying attention to the characteristics of the tumor itself, it is also important to understand the general condition. Therefore, not only gynecological examination, but also systemic examination, especially abdominal examination, is also extremely important. When necessary, the correct diagnosis can be obtained by using other auxiliary diagnostic methods and a comprehensive analysis of the medical history.
Patients with ovarian cysts may have a history of abdominal mass without severe symptoms or other manifestations of impact on the body; through abdominal inspection, palpation and bimanual examination, the uterus and Boundaries and mobility of the mass.
Ovarian hyperstimulation syndrome (OHSS) is a complication caused by various assisted reproductive technologies, especially the application of multiple ovulation induction drugs. The human body's excessive response to ovulation induction drugs is a series of clinical symptoms characterized by the development of multiple follicles in both ovaries, ovarian enlargement, abnormal capillary permeability, and extravasation of abnormal body fluids and proteins into the third space of the human body. complications. In recent decades, with the development of infertility treatment, the number of patients with OHSS has also increased dramatically. Its pathological characteristics are capillary proliferation and increased permeability throughout the body. This phenomenon is more common in ovarian tissue. Typical clinical manifestations include bilateral ovarian enlargement, hyperestrogenemia, ascites, electrolyte acid-base balance disorder, blood hypercoagulability, hemoconcentration, and oliguria. In severe cases, renal failure, vascular embolism, disseminated intravascular coagulation and death may occur.
OHSS is one of the unavoidable complications during artificial assisted reproduction.
Once it occurs, the condition must be closely observed. Due to the stimulation of chorionic gonadotropin, hypergonadotropinemia causes the development of most follicles, which leads to hyperestrogenemia, increases capillary permeability, and causes polycystic ovarian enlargement, pleural effusion, and ascites. wait. Therefore, the condition should be closely observed, including vital signs, consciousness, breathing, skin elasticity, abdominal pain and other signs of ovarian rupture or torsion. Monitor body weight and abdominal circumference every day, and record 24-hour intake and output. Measurements should be done regularly, usually before breakfast, and the input and output should be recorded in detail and accurately.
Due to the large retention of body fluids, water and salt should be strictly controlled while maintaining effective blood volume to prevent renal failure and thrombosis caused by blood concentration. Carefully observe the clinical efficacy to provide the basis for formulating the best treatment measures.
Corresponding auxiliary inspections should be followed. A variety of monitoring methods are used, including B-ultrasound, hematocrit, liver function, kidney function, electrolytes, routine hematuria and serum estradiol. Adjust the HCG dose in a timely manner according to blood estrogen levels. Comprehensive all test reports, understand the condition in a timely manner, and make optimal adjustments to the treatment plan. Patients with mild OHSS are self-limiting and only need to rest and monitor the development of the disease; patients with moderate and severe OHSS should pay attention to posture, dietary care and observation of the condition, especially the principles of drug treatment. Through these active and effective Treatment and nursing measures can reduce the symptoms of OHSS, promote the outcome of the disease, and avoid the occurrence of OHSS crisis.
OHSS is a self-limiting disease that usually occurs 3 to 7 days after HCG injection. If you are not pregnant, the course of the disease is about 14 days; if you are pregnant, it will continue for a period of time and the condition may worsen. Because OHSS is an iatrogenic disease caused by super-excretion. First, strengthen the monitoring of estrogen (E2) levels and B-ultrasound during superovulation, and adjust the dosage of gonadotropin in a timely manner. For those who are likely to develop severe OHSS, HCG injection should be stopped or delayed, and HCG should be replaced with progesterone for luteal support. If OHSS is severe during the IVF-ET cycle, the embryos can be cryopreserved and transplanted later in the natural cycle. It has been reported in many literatures that when B-ultrasound monitoring shows that the ovarian diameter is greater than 5cm, medication should be terminated in time to avoid the occurrence of OHSS.
Polycystic ovary syndrome (PCOS; Stein-Leventhal Syndrome; sclerocystic ovary disease) is characterized by chronic anovulation, amenorrhea or oligomenorrhea, infertility, obesity, hirsutism and polycystic ovaries Sexual enlargement is a syndrome with clinical characteristics. Polycystic ovary syndrome is a terminal ovarian pathological change caused by dysfunction of the polyendocrine axis. Its initial neuroendocrine changes are an increase in GnRH-GnH release frequency and pulse amplitude, and an increase in the LH/FSH ratio, usually greater than or equal to 3.
The clinical phenotypes of PCOS are diverse, and the cause is currently unclear.
Diagnosis In 1935, Stein and Leventha first reported this disease and it was named Stein-Leventhal syndrome (S-L syndrome). In 1960, it was renamed polycystic ovary syndrome (PCOS) because the patient was characterized by cystic enlargement of both ovaries. Due to the high clinical heterogeneity of PCOS, the cause and pathogenesis of PCOS are still unclear. In 2003, experts from the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine (ESHRE/ASRM) convened an expert meeting of the PCOS International Collaboration Group to formulate an international standard for PCOS. Diagnostic criteria, the specific diagnostic criteria are as follows:
1. Oligoovulation or anovulation;
2. Clinical manifestations of hyperandrogenism and/or hyperandrogenemia;
3. Ultrasound shows polycystic ovaries (one or both ovaries have more than 12 follicles with a diameter of 2 to 9 mm, and/or the ovarian volume is greater than 10 ml);
Among the above 3 items Meet 2 criteria, and exclude other diseases such as congenital adrenal hyperplasia, Cushing's syndrome, androgen-secreting tumors.
In order to formulate the diagnosis and treatment standards for PCOS in China, the Endocrinology Group of the Obstetrics and Gynecology Branch of the Chinese Medical Association discussed and initially formulated the current expert knowledge on the diagnosis and treatment of PCOS in China in 2006 in Chongqing. In 2007, the current expert knowledge on diagnosis and treatment of PCOS in China was released. Experts recommend that the 2003 Rotterdam International Diagnostic Standards for PCOS be adopted at this stage. That is, rare ovulation or no ovulation; clinical manifestations of hyperandrogenism and/or hyperandrogenemia; polycystic ovarian changes: ≥12 follicles with a diameter of 2 to 9 mm on one or both sides of the ovary, and/or ovarian volume ≥10 ml ; Meet 2 of the above 3 items, and exclude other causes of hyperandrogenism: congenital adrenal hyperplasia, Cushing's syndrome, androgen-secreting tumors, etc.
The main purpose of treatment for polycystic ovary syndrome is to establish a normal menstrual cycle with ovulation, restore fertility, and eliminate hirsutism.
Once a normal menstrual cycle is established, pregnancy can occur, the ovaries no longer produce excess androgens, and hirsutism disappears. Treatment options to restore a normal menstrual cycle are as follows.
1. Drug treatment
At present, drug treatment of PCOS has replaced surgical treatment as the first-line treatment method, and the purpose of treatment is mainly related to the patient's fertility requirements.
(1) Drug treatment to reduce hyperandrogenism
1) Oral contraceptive pill (OCP) has been used as a traditional long-term treatment method for women with PCOS, mainly Used to protect the endometrium, regulate the menstrual cycle, and improve hirsutism and/or acne by reducing androgens produced by the ovaries. OCP is a simple and economical treatment for PCOS patients who do not want to have children, but recent studies have shown that it may reduce insulin sensitivity and glucose tolerance in PCOS women. Common side effects include headache, weight gain, mood changes, and decreased sexual desire. , gastrointestinal reactions and breast pain, attention should be paid.
2) Glucocorticoids are used to treat hyperandrogenemia caused by excessive synthesis of androgens by the adrenal glands. Dexamethasone and prednisone are more effective because they have greater affinity with receptors. It can inhibit the secretion of ACTH from the pituitary gland and reduce the secretion of adrenal androgens that are dependent on ACTH. Be aware of the potential for hypothalamic-pituitary-adrenal axis suppression with long-term use.
3) Spironolactone is an aldosterone analogue. Its enzyme inhibitory effect is similar to that of cyproterone acetate, so the two therapeutic effects are also similar. At the same time, it has an anti-androgen effect. Its mechanism of action in treating hyperandrogenemia is to competitively bind to the androgen receptor, competitively bind to the receptor with dihydrotestosterone (DHT) in peripheral tissues, inhibit 17α hydroxylase, and cause T and A decrease.
4) Flutamide is a steroid complex that is a potent and highly specific non-steroidal anti-androgen. It has no intrinsic hormone or anti-gonadotropin effects and cannot reduce steroid synthesis. , but inhibits androgenic effects through receptor binding. Compared with cyproterone acetate, serum androgen (including total and free testosterone) levels increased after treatment, but because the androgen target organ effects were antagonized, clinical manifestations did not worsen despite the increase in serum androgen levels. Long-term use of large amounts may cause liver damage. In addition, it has not yet been determined whether it will cause fetal malformations. Therefore, contraception should be used while taking the medicine.
(2) Ovulation induction drug treatment
PCOS patients with fertility requirements often need ovulation induction treatment to become pregnant. Drug ovulation induction treatment for PCOS has made great progress in the past 50 years. Great progress has been made, but some patients have poor results using conventional methods, so choosing an appropriate plan is the key to ovulation induction treatment.
1) Clomiphene (CC): also known as clomiphene, also known as clomiphene and chlorpheniramine. There is now consensus that clomiphene is the treatment of choice for polycystic ovary syndrome. Clomiphene can induce the hypothalamus to release gonadotropin-releasing hormone, which in turn promotes the pituitary gland to release follicle-stimulating hormone and promotes normal follicle development. Increased follicle-stimulating hormone concentration is the key to inducing ovulation in patients with polycystic ovary syndrome. Clomiphene treatment can induce ovulation in more than 80% of patients, and the pregnancy rate when used alone is 30% to 60%. The two most significant side effects of clomiphene are mild ovarian enlargement (13.6%) and multiple pregnancy. Other side effects include hot flashes (10.4%), abdominal distension (5.5%) and rarely visual disturbances (1.5%). . Although the FDA recommends a maximum daily dose of 250 mg, the highest dose commonly used clinically is 150 mg. Treatment should be done at the lowest dose possible. The specific usage starts from the 5th day of the menstrual cycle, 50 mg once a day, for 5 consecutive days. Ovulation usually occurs 7 to 10 days after taking the drug. If 1 or 2 cycles of treatment is ineffective, increase to 100 mg per day for 5 days. Measure basal body temperature during medication and observe whether there is a biphasic curve of ovulation. Some patients are ineffective in CC treatment and are called clomiphene resistance. However, the current definition of clomiphene resistance is different. The maximum dose ranges from 150 to 250 mg. After three consecutive cycles, there is no ovulation reaction.
2) Gonadotropin (Gn) For patients with CC resistance, gonadotropin (Gn) is a commonly used ovulation induction drug, including FSH and HMG. Currently, there are various preparations of Gn, such as hMG, urinary FSH and recombinant FSH, but they all have problems such as high price, risk of multiple pregnancy and ovarian hyperstimulation syndrome (OHSS).
The conventional method is to start menstruation on 3 to 5 days, and take 1 HMG/d or pure FSH 75IU/d every day. The ovulation rate and pregnancy rate are higher, but the incidence of ovarian overstimulation syndrome (OHSS) and the multiple pregnancy rate are high. At present, low-dose slow-increase programs are mostly used. This method has an ovulation rate of 70 to 90%, a single follicle development rate of 50% to 70%, a cycle pregnancy rate of 10 to 20%, and an OHSS incidence rate of 0% to 5%. However, treatment The cycle is long and the cost to the patient is relatively high.
3) Letrozole ovulation induction treatment is a new indication for aromatase inhibitors (AIs). This type of drug was mainly used for the treatment of breast cancer in the past. They can be used alone or in combination with FSH. Major side effects include gastrointestinal effects, fatigue, hot flashes, head and back pain. The currently commonly used aromatase inhibitor drug in clinical practice is letrozole, which is mainly used for patients with clomiphene resistance. The ovulation rate reaches 80%, which is more than the third to third menstrual period after the start of the menstrual cycle or after progesterone withdrawal bleeding. Apply for 7 days (***5 days), and the subsequent monitoring process is the same as clomiphene.
(3) Insulin sensitizer (ISD) treatment
A major feature of PCOS is insulin resistance, leading to compensatory hyperinsulinemia in order to maintain normal glucose tolerance (glucose normal response of insulin after ingestion). In young women with PCOS, hyperinsulinemia is a major risk factor for impaired glucose tolerance and later cardiac disease. In addition, hyperinsulinemia can also cause increased ovarian androgen synthesis, leading to anovulation, amenorrhea, and infertility. Many PCOS women are obese, and insulin resistance becomes more obvious due to weight gain; non-obese PCOS women (accounting for 20% to 50% of PCOS) mostly have an increased waist/hip ratio and have more obvious insulin resistance than the normal group. tendency. The main insulin-sensitizing drugs are metformin, troglitazone, rosiglitazone, ioglitazone and D-Chiro-Inosito. Their main indications are insulin resistance and impaired glucose tolerance. Or PCOS women with type 2 diabetes.
(4) Traditional Chinese medicine method of activating blood circulation and nourishing kidneys also has good and satisfactory results in inducing ovulation.
2. Surgical treatment
The treatment of PCOS patients has always been a difficult issue in clinical treatment. The earliest effective treatment method was bilateral wedge ovarian resection (BOWR) reported by Stein and Leventhal in 1935. This method ushered in the era of surgical treatment of infertility. Surgical treatment can reduce part of the granulosa cells in the ovary, and the production of androgens in the ovarian stroma is reduced, thereby reducing the level of circulating androgens, thereby reducing GnRH, causing a further decrease in serum androgen concentration. This also shows that the ovarian stroma is also affected by the pituitary gland- Ovarian axis regulation. Due to the reduction in androgen levels, most patients can resume spontaneous ovulation and menstruation after surgery, and some may become pregnant naturally, but most pregnancies occur around 6 months after surgery. Surgical treatment is divided into the following types according to different methods:
(1) Bilateral ovarian wedge resection (BOWR) is the earliest and effective method to treat anovulatory PCOS. Surgery requires removal of 1/3 of the ovary. Ovarian tissue, Stein et al. reported that 95% of patients can return to normal menstruation after surgery, and the pregnancy rate can reach 85%. Subsequent reports have confirmed the effectiveness of this method, but the success rate varies greatly. However, this method has many disadvantages. Reactions include post-operative adhesion formation leading to tubal infertility, and postoperative premature ovarian failure has also been reported. Because this method causes more damage, it is rarely used now.
(2) Laparoscopic ovarian electrocautery or laser drilling treatment (LOD) The current preferred surgical treatment method is laparoscopic ovarian drilling using thermal penetration or laser to induce ovulation after surgery. The treatment response improved, the rate of multiple gestations was reduced due to medical intervention, and the incidence of postoperative adhesions was significantly reduced compared with wedge resection of the ovaries. It is mainly suitable for the second-line treatment of clomiphene-resistant patients. It has a high single-follicle rate and avoids multiple births and OHSS problems. It is especially effective for those with a BMI less than 29 and a free androgen index less than 4, with an ovulation rate of 80%~ 90%, pregnancy rate 60% to 70%.
(3) Transvaginal hydrolaparoscopy (THL) is mainly used to examine the structures of fallopian tubes and ovaries in patients with infertility without obvious pelvic causes.
Clomiphene-resistant PCOS patients were treated with ovarian drilling through THL, and the cumulative pregnancy rate reached 71% 6 months after surgery.
3. Assisted reproductive technology
For PCOS patients who ovulate but are still not pregnant after applying standard ovulation induction cycle treatment for more than 6 months, or multiple drugs for ovulation induction treatment and Patients who require auxiliary treatment for anovulation and are eager to become pregnant can choose assisted reproductive technology through embryo transfer. However, due to the hyperandrogenism and insulin resistance of PCOS, various functional disorders of the reproductive and endocrine systems are caused, which makes PCOS patients prone to Gn hyperreaction during IVF treatment, resulting in excessive follicles and excessive blood E2, and thus Increased incidence of OHSS, excessive LH levels reduce egg cell quality and reduce fertilization rate, making PCOS patients a relatively difficult problem in assisted reproductive treatment.