多囊卵巢綜合症

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多囊卵巢症候群
同义词 高雄性激素無排卵(Hyperandrogenic anovulation,HA)[1]、斯-李二氏症(Stein–Leventhal syndrome)[2]
PCOS.jpg
超聲波掃描下的多囊卵巢綜合症。
醫學專科 婦科學
症状 月經失調、經血過多英语Menorrhagia多毛症痤疮、骨盆痛、不孕黑棘皮症[3]
併發症 2型糖尿病肥胖症阻塞性睡眠呼吸暂停心血管疾病情感障礙子宫内膜癌[4]
病程 長期[5]
肇因 遺傳或環境因素[6][7]
風險因子英语Risk factor 肥胖症、運動不足、家族病史[8]
診斷方法 無排卵、高雄激素卵巢囊腫[4]
相似疾病或共病 腎上腺增生症甲狀腺機能低下症高泌乳素血症英语hyperprolactinemia[9]
治療 減肥、運動[10][11]
藥物 避孕药二甲双胍抗雄激素[12]
盛行率 適產年齡 2% 至 20% 的女性[8][13]

多囊性卵巢綜合症Polycystic ovary syndrome,簡稱PCOS),又稱斯-李二氏症Stein-Leventhal syndrome),是一連串女性因為雄性激素上升所導致的症狀[4]。多囊性卵巢的症狀包含月經不規律或是無月經月經量過多英语Menorrhagia多毛症粉刺、盆腔疼痛、難以受孕黑棘皮症[14]。相關的病症包含第二型糖尿病肥胖症阻塞性睡眠呼吸暫停心血管疾病情感障礙子宮內膜癌[4]

多囊性卵巢會受基因遺傳與環境因素影響[7]。其危險因子包含肥胖症、運動量不足或是有家族病史。如果有以下三種症狀中的兩種便可診斷患者有多囊性卵巢:無排卵、雄性激素過高與卵巢囊腫[4]。囊腫可以由超音波影像檢測。其他造成類似症狀的疾病包含先天性腎上腺增生症甲狀腺機能低下症高泌乳素血症英语hyperprolactinemia[9]

多囊卵巢綜合症目前並無特效藥[15]。治療則包括減重和運動等轉變生活型態的方式,避孕藥物也許對於調整經期、抑制多餘的毛髮生長和青春痘有所幫助。二甲双胍抗雄性激素英语anti-androgen可能有所幫助。另外針對青春痘和多毛等症狀的症狀治療也有一定效果[12]。減重或是使用可洛米分英语clomiphene、降血糖藥物每福敏英语metformin對於改善不孕的狀況有所幫助。當其他治療都沒有效果時,則考慮進行體外人工授精英语In vitro fertilization[16]

多囊卵巢綜合症是18歲到44歲女性間,最常見的內分泌疾病英语endocrine disorder[17]。一般認為,多囊卵巢綜合症的發生率,從青春期開始,會在女性生育年齡期間攀升至少百分之二十(根據鹿特丹診斷指引,英國為百分之26、澳洲為百分之17.8、土耳其為百分之19.9、伊朗為百分之15.2[18]。)多囊卵巢綜合症是現今導致不孕的主要原因之一[4]。目前已知最早的多囊卵巢綜合症,是在1721年間在義大利的記錄[19]

體徵及症狀[编辑]

常見的體徵和症狀如下:

原因[编辑]

多囊卵巢綜合症是不確定因素造成的不勻相失調。[20][24][25]有一些證據指出它是一種基因疾病。 這些證據包括病例的家族群集、同卵雙胞胎相比更高的一致性和多囊卵巢綜合症的內分泌和代謝特徵的遺傳性[7][24][25]

致病性的基因發生在體染色體顯性遺傳,在女性身上具有高度的基因外顯性但是多變的表現度;這代表小孩有50%的機率從雙親的基因遺傳到誘發致病的異變基因片段,並且,如果女兒接受到異變基因,會出現一定程度上的病徵[25][26][27][28]。 異變基因可能從父母雙方遺傳而來,並且也同時可以遺傳給兒女(可能成為帶原者或是早期脫髮或毛髮過多症狀者) [26][28]表現型: 有一部分患者個疾病表現為卵泡膜分泌過多的雄性素 [27]。確切的基因影響方式尚未被確認[7][25][29]。在少數的案例,單個基因的突變有可能造成綜合性的突變症狀[30]。目前對該綜合症的發病病理機致的研究指出,多囊卵巢綜合症為複雜的多基因疾病[31]

多囊卵巢綜合症症狀的嚴重程度似乎主要取決於肥胖症[7][17][32]

多囊卵巢綜合症也可視為一種代謝疾病,因為其的部分症狀為"可逆的"。 即便多囊卵巢綜合症由28個症狀組成,其仍被視為一種婦科疾病。

即使多囊卵巢綜合症的病名表明卵巢為該疾病的病理核心,但是囊腫為一種症況而非病因。就算兩個卵巢被摘除,部分多囊卵巢綜合症的症狀仍會持續下去,其症狀在不存在囊種的狀況下仍有可能出現。自從1935年Stein和Leventhal首次描述以來,診斷、症狀和致病因素的標準仍為爭議的主題之一。因為卵巢為首要受影響的器官,婦科學者們通常視其為一種婦科疾病。然而,近年來許多觀察顯示多囊性卵巢唯一種多重系統性失調疾病,主要問題源自於下視丘賀爾蒙調節失調 ,許多器官也與此調節有關。多囊性卵巢這個名稱源自於超聲波診斷之影像。多囊性卵巢綜合症的症狀非常多變,且只有約百分之15的患者可由超音波影像看出其卵巢中有囊腫。[33]

多囊卵巢綜合症或許與產前經期、表觀遺傳學因子、環境影響(尤其是工業中產生的內分泌干擾素[34]雙酚A與特定藥物)和肥胖比例增加有關,上述原因一有可能是使病症惡化的緣由。[34][35][36][37][38][39][40]

發病機制[编辑]

多囊性卵巢的發展會刺激卵巢持續製造分泌過量的雄性激素,尤其是睪固酮,通常會伴隨著以下的其中一個症狀或是兩者皆有(幾乎肯定其具有遺傳易受性[27]):

多囊性卵巢綜合症因其在超音波診斷中普遍可見的大量卵巢囊腫聞名。這些「囊腫」其實是未成熟的濾泡而非囊腫。這些濾泡由初級濾泡發育而成, 但在空腔濾泡期早期因為卵巢功能停止發育,這些濾泡會出現在卵巢周邊,在超音波檢驗的影像中看起來像成串的珍珠[來源請求]

患有多囊性卵巢症候群的婦女因為下視丘釋放促性腺激素釋放激素的頻率增加,導致黃體成長激素與濾泡刺激素的比值升高[41]

大多數具有PCOS的婦女具有胰島素抵抗或肥胖的症狀。 他們的胰島素濃度異常的提高導致"下丘腦 - 垂體 - 卵巢軸"區域中的異常並引起PCOS的症狀。高胰島素血症提高GnRH的釋放頻率、黃體成長激素量多過濾泡刺激素,因而佔了主導地位、增加卵巢雄激素的產生、減少濾泡的成熟並減少SHBG的作用[20]。 此外, 胰島素過多, acting through its cognate receptor in the presence of component cAMP signalling, upregulates 17α-hydroxylase英语17α-hydroxylase activity via PI3K英语PI3K, 17α-hydroxylase activity being responsible for synthesising androgen precursors.[42]The combined effects of hyperinsulinemia contribute to an increased risk of PCOS.[43]Insulin resistance is a common finding among women with a normal weight as well as overweight women.[10][17][23]

Adipose tissue possesses aromatase英语aromatase, an enzyme that converts androstenedione to estrone and testosterone to estradiol. The excess of adipose tissue in obese women creates the paradox of having both excess androgens (which are responsible for hirsutism and virilization英语virilization) and estrogens (which inhibits FSH via negative feedback).[44]

PCOS may be associated with chronic inflammation,[20][45]with several investigators correlating inflammatory mediators with anovulation and other PCOS symptoms.[46][47]Similarly, there seems to be a relation between PCOS and increased level of oxidative stress.[48]

It has previously been suggested that the excessive androgen production in PCOS could be caused by a decreased serum level of IGFBP-1英语IGFBP-1, in turn increasing the level of free IGF-I, which stimulates ovarian androgen production, but recent data concludes this mechanism to be unlikely.[49]

PCOS has also been associated with a specific FMR1英语FMR1 sub-genotype. The research suggests that women with heterozygous-normal/low FMR1 have polycystic-like symptoms of excessive follicle-activity and hyperactive ovarian function.[50]

Transgender men may experience a higher than expected rate of PCOS due to increased testosterone, if they choose to take hormone therapy as part of their gender presentation.[51][52]

診斷[编辑]

並不是每一個多囊卵巢綜合症的病人都有出現多囊卵巢的症狀, 也並非所有卵巢曩腫的病患都有多囊卵巢綜合症的症狀;雖然骨盆超聲波英语pelvic ultrasound 是主要的診斷工具, 但也並不是唯一個診斷工具[53]。 雖然該綜合徵與廣泛的症狀相關,最直接的診斷方法是使用鹿特丹診斷標準。

定義[编辑]

以下是兩種常見的定義:

美國國立衛生研究院診斷標準[编辑]

在1990年,由國立衛生研究院 (美國)/ 美國國家兒童健康與人類發展中心英语NICHD贊助的協商研討會提出,如果一個人具有以下所有症狀,表示該員罹患多囊卵巢綜合症[54]:
  1. 出現排卵不規則英语oligoovulation的症狀
  2. 出現雄性素過剩英语androgen excess的症狀 (臨床上或生化上)
  3. 排除可能導致月經不規則和雄激素過多的其他疾病導致上述症狀的產生

鹿特丹診斷標準(Rotterdam diagnostic criteria)[编辑]

2003年,鹿特丹 ESHRE / ASRM贊助的共識研討會提出,在沒有可能導致這些發現的其他實體的情況下,如果滿足3項標準中的任何一項,多囊卵巢就會出現[17][55][56]
  1. 出現排卵不規則英语oligoovulation無排卵英语anovulation或是兩者同時出現
  2. 具有雄性激素過剩英语androgen excess症狀
  3. 具有多囊卵巢症狀 (藉由 婦科超聲波英语gynecologic ultrasound檢查)

鹿特丹診斷標準涵蓋更廣泛的有症狀婦女,最顯著的部分是在於並未有雄性素過剩的婦女也被列入在其中。 評論家認為,從研究雄激素過多的婦女獲得的結果不一定可以推廣到給沒有雄激素過剩的婦女身上[57][58]

Androgen Excess PCOS Society
2006年,Androgen Excess PCOS Society提出了一套嚴謹診斷標準[17]
  1. 具有雄性激素過剩症狀
  2. 出現排卵不規則、無排卵或多囊卵巢症狀,亦或同時出現上述症狀
  3. 排除會引起過量雄激素活性的其他因素*

標準評估[编辑]

  • 若需依據病史診斷上,月經週期、痤瘡、多毛症、肥胖症均為具體的判斷依據。 一份臨床預測規則英语clinical prediction rule發現這四項指標在診斷PCOS方面具有77.1%的靈敏度(95%的信賴區間下62.7%–88.0%)和93.8%的特異性(95%的信賴區間下82.8%–98.7%)[59]
  • Gynecologic ultrasonography, specifically looking for small ovarian follicles. These are believed to be the result of disturbed ovarian function with failed ovulation, reflected by the infrequent or absent menstruation that is typical of the condition. In a normal menstrual cycle, one egg is released from a dominant follicle – in essence, a cyst that bursts to release the egg. After ovulation, the follicle remnant is transformed into a progesterone-producing corpus luteum, which shrinks and disappears after approximately 12–14 days. In PCOS, there is a so-called "follicular arrest"; i.e., several follicles develop to a size of 5–7 mm, but not further. No single follicle reaches the preovulatory size (16 mm or more). According to the Rotterdam criteria, which are widely used for diagnosis,[10]12 or more small follicles should be seen in an ovary on ultrasound examination.[54]More recent research suggests that there should be at least 25 follicles in an ovary to designate it as having polycystic ovarian morphology (PCOM) in women aged 18–35 years.[60]The follicles may be oriented in the periphery, giving the appearance of a 'string of pearls'.[61]If a high resolution transvaginal ultrasonography machine is not available, an ovarian volume of at least 10 ml is regarded as an acceptable definition of having polycystic ovarian morphology instead of follicle count.[60]
  • Laparoscopic examination may reveal a thickened, smooth, pearl-white outer surface of the ovary. (This would usually be an incidental finding if laparoscopy were performed for some other reason, as it would not be routine to examine the ovaries in this way to confirm a diagnosis of PCOS.)[來源請求]
  • Serum (blood) levels of androgens (hormones associated with male development), including androstenedione and testosterone may be elevated.[17]Dehydroepiandrosterone sulfate levels above 700–800 µg/dL are highly suggestive of adrenal dysfunction because DHEA-S is made exclusively by the adrenal glands.[62][63]The free testosterone level is thought to be the best measure,[63][64]with ~60% of PCOS patients demonstrating supranormal levels.[22]The Free androgen index (FAI) of the ratio of testosterone to sex hormone-binding globulin (SHBG) is high[17][63]and is meant to be a predictor of free testosterone, but is a poor parameter for this and is no better than testosterone alone as a marker for PCOS,[65]possibly because FAI is correlated with the degree of obesity.[66]

Some other blood tests are suggestive but not diagnostic. The ratio of LH (Luteinizing hormone) to FSH (Follicle-stimulating hormone), when measured in international units, is elevated in women with PCOS. Common cut-offs to designate abnormally high LH/FSH ratios are 2:1[67]or 3:1[63]as tested on Day 3 of the menstrual cycle. The pattern is not very sensitive; a ratio of 2:1 or higher was present in less than 50% of women with PCOS in one study.[67]There are often low levels of sex hormone-binding globulin,[63]in particular among obese or overweight women.[來源請求]

Anti-Müllerian hormone (AMH) is increased in PCOS, and may become part of its diagnostic criteria.[68][69][70]

相關條件[编辑]

  • Fasting biochemical screen and lipid profile[63]
  • 2-Hour oral glucose tolerance test (GTT) in women with risk factors (obesity, family history, history of gestational diabetes)[17]may indicate impaired glucose tolerance (insulin resistance) in 15–33% of women with PCOS.[63]Frank diabetes can be seen in 65–68% of women with this condition.[來源請求] Insulin resistance can be observed in both normal weight and overweight people, although it is more common in the latter (and in those matching the stricter NIH criteria for diagnosis); 50–80% of people with PCOS may have insulin resistance at some level.[17]
  • Fasting insulin level or GTT with insulin levels (also called IGTT). Elevated insulin levels have been helpful to predict response to medication and may indicate women needing higher dosages of metformin or the use of a second medication to significantly lower insulin levels. Elevated blood sugar and insulin values do not predict who responds to an insulin-lowering medication, low-glycemic diet, and exercise. Many women with normal levels may benefit from combination therapy. A hypoglycemic response in which the two-hour insulin level is higher and the blood sugar lower than fasting is consistent with insulin resistance. A mathematical derivation known as the HOMAI, calculated from the fasting values in glucose and insulin concentrations, allows a direct and moderately accurate measure of insulin sensitivity (glucose-level x insulin-level/22.5).[來源請求]
  • Glucose tolerance testing (GTT) instead of fasting glucose can increase diagnosis of impaired glucose tolerance and frank diabetes among people with PCOS according to a prospective controlled trial.[71]While fasting glucose levels may remain within normal limits, oral glucose tests revealed that up to 38% of asymptomatic women with PCOS (versus 8.5% in the general population) actually had impaired glucose tolerance, 7.5% of those with frank diabetes according to ADA guidelines.[71]

鑑別診斷[编辑]

Other causes of irregular or absent menstruation and hirsutism, such as hypothyroidism, congenital adrenal hyperplasia (21-hydroxylase deficiency), Cushing's syndrome, hyperprolactinemia, androgen secreting neoplasms, and other pituitary or adrenal disorders, should be investigated.[17][56][63]

管理[编辑]

多囊卵巢綜合症的主要治疗方法包括:生活方式的改變及藥物治療[72]

主要治療目標大致可分為下列四點:

在各個領域間,何為最佳治療方式仍是相當大的爭議,其中一個主要原因即是缺乏比較不同療程的大規模臨床試驗。樣本往往是不太可靠英语Sampling error因此可能產生矛盾的結果。

而有助於減輕體重或降低胰島素排斥的一般干預措施對於所有這些目標都是有益的,因為它們被認為是潛在的病因。

由於多囊卵巢綜合症似乎會引起嚴重的情緒障礙,因此適當的精神支持對於病情可能是有益的。[73]

飲食[编辑]

多囊卵巢綜合症與超重或肥胖有關,減肥是恢復規律月經的最有效方法,但是很多女性很難達到並維持顯著的體重減輕。 2013年的科學評估發現,與飲食組成無關,重量和體重組成、懷孕率英语Pregnancy rate、月經規律、排卵、雄激素過高、胰島素抗性、脂質以及生活質量均有相似的降低。[74]然而,低GI飲食英语low GI diet其中大部分的碳水化合物從水果、蔬菜和全穀物獲得,而不是營養素均衡的健康飲食,會導致更嚴重的月經失衡[74]

維生素D缺乏症可能在代謝症候群的發展中發揮一定的作用,故遵照醫囑補充缺乏的營養素是極為重要的[75][76]。然而,2015年的系統評估並沒有發現維生素D具有減輕多囊卵巢綜合症中代謝和激素失調情況的證據。[77]截至2012年,使用營養補充品預防多囊卵巢綜合症患者代謝缺陷的干預措施已經在小型、不受控制的和非隨機的臨床試驗中進行了測試;而所得數據不足以推薦使用。[78]

藥物[编辑]

用於治療多囊卵巢綜合症的藥物有避孕藥二甲雙胍。口服避孕藥能增加體內性激素结合球蛋白生產,促進游離睾酮的結合。這減少了由高睾丸激素引起的多毛症狀,並調節恢復正常月經週期。二甲雙胍是在2型糖尿病中常用的一種降低胰島素排斥的藥物,並在英國,美國,澳大利亞和歐盟標示外使用英语Off-label use用來治療多囊卵巢綜合症中的胰島素排斥。在許多情況下,二甲雙胍也能協助卵巢功能並恢復正常排卵[20][75][79]螺內酯可用於其抗雄激素作用,而二氟甲基鳥氨酸則可用於減少面部毛髮。較新的胰島素抵抗藥物噻唑烷二酮(格列酮)英语thiazolidinedione顯示出與二甲雙胍相當的功效,但二甲雙胍具有更輕微的副作用[80][81]英國國家健康與照顧卓越研究院英语National Institute for Health and Clinical Excellence在2004年提出建議,當其他治療未能產生效果時,將給予給予BMI高於25的病患服用二甲雙胍[82][83]。二甲雙胍在每種類型的多囊卵巢綜合症中可能並非有效的,因此對於是否應該用作一般一線治療存在一些分歧[84]羟甲基戊二酸单酰辅酶A还原酶抑制剂在治療潛在代謝綜合徵方面的應用尚不清楚[85]

多囊卵巢綜合症可能導致難以受孕,因為它會導致不規律排卵。試圖懷孕時,會使用誘導生育的藥物包括排卵誘導劑克羅米酚或 脈衝亮丙瑞林 。 二甲雙胍與克羅米酚組合使用時,可提高生殖治療的療效。[86]二甲雙胍被認為在懷孕期間使用是安全的,於美國的懷孕分級為B[87]。2014年的評論得出結論,在三個月內使用二甲雙胍治療的女性並不會增加產下先天性障礙嬰兒的風險[88]

不孕症[编辑]

多毛症及痤瘡[编辑]

月經不規律[编辑]

如果恢復生育能力不是主要目標,那麼月經紊亂通常可以用避孕藥來調節[20][75]。 The purpose of regulating menstruation, in essence, is for the woman's convenience, and perhaps her sense of well-being; there is no medical requirement for regular periods, as long as they occur sufficiently often.

如果不期望定期的月經週期,則不一定需要不規則循環的治療。大多數專家說,如果至少每三個月發生一次月經,那麼子宮內膜就會經常流下來,以防止增加子宮內膜異常或癌症的風險。[89] 如果月經頻率極低或根本沒來,推薦使用某些形式的助孕素。[90] 其中一種替代方案即是定期服用一次口服助孕素(例如,每三個月)以誘發可預測的月經出血。[20]

替代藥物[编辑]

2017年的一項審查得出結論,肌醇D-手性肌醇英语D-chiro-Inositol可以調節月經週期和改善排卵,但缺乏影響懷孕機率的證據[91]。 2012年審查發現,肌醇的補充似乎有效改善多囊性卵巢綜合症的幾種激素紊亂 [92] 。2011年的審查,沒有足夠的證據來證實D-手性肌醇英语D-chiro-Inositol有任何有益的作用 [93]。沒有足夠的證據支持使用針灸 [94]

預測[编辑]

多囊性卵巢綜合症的高風險伴隨症狀:

早期診斷和治療可能會降低其中一些風險,如II型糖尿病和心臟病。[106]

卵巢癌和乳腺癌的風險總體上沒有顯著增加。[95]

流行病學[编辑]

多囊性卵巢綜合症的盛行率受到診斷標準的影響。 世界衛生組織在2010年時估計全世界約有一億一千六百萬名女性(約3.4%的女性)受多囊性卵巢綜合症影響。[107]一份以鹿特丹診斷診斷指引為準的多囊性卵巢綜合症流行率社區研究發現大約有百分之18的女性患有多囊性卵巢,而這些患者約有百分之70先前並未被確診出患有多囊性卵巢綜合症。[17]

約有百分之8到25的一般女性到超音波診斷中會看到有多囊性卵巢。[108][109][110][111]百分之14服用口服避孕藥的女性發現有多囊性卵巢14%[109]。卵巢囊腫也是使用子宮環後常見的副作用。[112]

歷史[编辑]

這種症狀最早在1935年由美國婦科醫生Irving F. Stein, Sr.與Michael L. Leventhal首次描述,其原始名稱為斯-李二氏症[53][54]

目前已知最早的多囊卵巢綜合症,是在1721年間在義大利的記錄[19]。而有關於卵巢囊腫的相關變化描述最早紀錄於1844年[19]

名稱[编辑]

這種綜合徵的其他名稱包括多囊卵巢疾病、功能性卵巢雄激素過多症、卵巢濾泡膜細胞增殖英语Hyperthecosis、硬皮囊性卵巢綜合徵和斯-李二氏症。 斯-李二氏症為其原始名稱,現在使用這個名稱都僅限於具有不孕症多毛症和擴大的多囊性卵巢的閉經女性患者[53]

這種疾病最常見的名稱來自逾期在醫學影像中可見多囊性卵巢而得此稱[20]。多囊性卵巢在靠近卵巢表面處有極大量正在發育的卵,其在超音波影響中可用肉眼鑑別[53],看起來像許多小囊腫[113]或一串珍珠。

參見[编辑]

參考文獻[编辑]

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Category:Endocrine gonad disorders英语Category:Endocrine gonad disorders