Gynäkologische Endokrinologie

, Volume 3, Issue 3, pp 187–198 | Cite as

Polyzystisches Ovarsyndrom

Behandlung bei unerfülltem Kinderwunsch
Zertifizierte Fortbildung

Zusammenfassung

Das polyzystische Ovarsyndrom (PCOS) hat eine Prävalenz von 3–5%. Es ist gekennzeichnet durch das Auftreten einer Oligo-/Amenorrhö in Kombination mit einer Hyperandrogenämie oder einem Hyperandrogenismus. Bei der Diagnostik müssen als Differenzialdiagnosen der adrenale Enzymdefekt sowie das Cushing-Syndrom ausgeschlossen werden. Der orale Glukosetoleranztest mit Insulinbestimmung zur Klärung einer peripheren Insulinresistenz ist nach Meinung der Autoren unbedingter Bestandteil des diagnostischen Prozedere. Bei vorwiegend kosmetischen Problemen ist unabhängig von einem Kinderwunsch der Einsatz von oralen Kontrazeptiva indiziert. Bei unerfülltem Kinderwunsch kann vor allem bei der schlanken, oligomenorrhoischen PCO-Syndrom-Patientin eine Clomifen-Stimulation initial versucht werden. Bei allen anderen Patientinnen sollte die Option einer Metformin-Therapie als individueller Heilversuch diskutiert werden. Auf Kontraindikationen beim Einsatz von Metformin ist zu achten. Gewichtsreduktion und vermehrte Bewegung sollten essenzielle Bausteine im Therapiekonzept darstellen, da sie kausalpathogenetisch die Ausgangssituation verbessern können.

Schlüsselwörter

Polyzystisches Ovarsyndrom Insulinresistenz Metformin Antidiabetika Metabolisches Syndrom 

Polycystic ovarian syndrome

Treatment of infertility patients

Abstract

Polycystic ovarian syndrome (PCOS) has a prevalence of 3–5%. Its typical features include oligo-/amenorrhea combined with hyperandrogenemia or hyperandrogenism. Regarding differential diagnosis adrenal enzyme defects as well as Cushing’s syndrome must be excluded. The oral glucose tolerance test with parallel insulin measurement is essential in daily clinical practice to evaluate insulin resistance. In cases of predominantly cosmetic problems without fertility problems, oral contraceptives can be used. In infertility patients suffering from PCOS the lean, oligomenorrheic patient can start directly with ovarian stimulation using clomiphene citrate. In all other patients, the option of metformin should be evaluated on an individual basis, and contraindications for metformin therapy must be excluded. Weight reduction and sports are essential components of the treatment concept, since they improve the conditions for becoming pregnant.

Keywords

Polycystic ovarian syndrome Insulin resistance Metformin Oral antidiabetics Metabolic syndrome 

Notes

Interessenkonflikt:

Keine Angaben

Literatur

  1. 1.
    Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (2004) Fertil Steril 81(1):19–25Google Scholar
  2. 2.
    Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS) (2004) Hum Reprod 19(1):41–47PubMedGoogle Scholar
  3. 3.
    Adams JM, Taylor AE, Crowley WF Jr, Hall JE (2004) Polycystic ovarian morphology with regular ovulatory cycles: insights into the pathophysiology of polycystic ovarian syndrome. J Clin Endocrinol Metab 89(9):4343–4350PubMedGoogle Scholar
  4. 4.
    Attia GR, Rainey WE, Carr BR (2001) Metformin directly inhibits androgen production in human thecal cells. Fertil Steril 76(3):517–524PubMedGoogle Scholar
  5. 5.
    Azziz R, Black VY, Knochenhauer ES et al. (1999) Ovulation after glucocorticoid suppression of adrenal androgens in the polycystic ovary syndrome is not predicted by the basal dehydroepiandrosterone sulfate level. J Clin Endocrinol Metab 84(3):946–950PubMedGoogle Scholar
  6. 6.
    Azziz R, Woods KS, Reyna R et al. (2004) The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab 89(6):2745–2749PubMedGoogle Scholar
  7. 7.
    Bayram N, van Wely M, Kaaijk EM et al. (2004) V. Using an electrocautery strategy or recombinant follicle stimulating hormone to induce ovulation in polycystic ovary syndrome: randomised controlled trial. BMJ 328(7433):192PubMedGoogle Scholar
  8. 8.
    Binder H, Beckmann MW, Kiesewetter F et al. (2004) Refresher Hyperandrogenämie — Teil II. Geburtsh Frauenheilk 64Google Scholar
  9. 9.
    Cheung W, Ng EH, Ho PC (2002) A randomized double-blind comparison of perifollicular vascularity and endometrial receptivity in ovulatory women taking clomiphene citrate at two different times. Hum Reprod 17(11):2881–2884PubMedGoogle Scholar
  10. 10.
    Clark AM, Ledger W, Galletly C et al. (1995) Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women. Hum Reprod 10(10):2705–2712PubMedGoogle Scholar
  11. 11.
    Clark AM, Thornley B, Tomlinson L et al. (1998) Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod 13(6):1502–1505PubMedGoogle Scholar
  12. 12.
    Coetzee EJ, Jackson WP (1979) Diabetes newly diagnosed during pregnancy: a 4-year study at Groote Schuur Hospital. S Afr Med J 56(12):467–475PubMedGoogle Scholar
  13. 13.
    Coetzee EJ, Jackson WP (1980) Pregnancy in established non-insulin-dependent diabetics. A five-and-a-half year study at Groote Schuur Hospital. S Afr Med J 58(20):795–802PubMedGoogle Scholar
  14. 14.
    Ehrmann DA, Barnes RB, Rosenfield RL et al. (1999) Prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome. Diabetes Care 22(1):141–146PubMedGoogle Scholar
  15. 15.
    Eijkemans MJ, Imani B, Mulders AG et al. (2003) High singleton live birth rate following classical ovulation induction in normogonadotrophic anovulatory infertility (WHO 2). Hum Reprod 18(11):2357–2362PubMedGoogle Scholar
  16. 16.
    Elter K, Imir G, Durmusoglu F (2002) Clinical, endocrine and metabolic effects of metformin added to ethinyl estradiol-cyproterone acetate in non-obese women with polycystic ovarian syndrome: a randomized controlled study. Hum Reprod 17(7):1729–1737PubMedGoogle Scholar
  17. 17.
    Farquhar C, Vandekerckhove P, Lilford R (2001) Laparoscopic „drilling“ by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev 4:CD001122PubMedGoogle Scholar
  18. 18.
    Farquhar CM, Williamson K, Brown PM, Garland J (2004) An economic evaluation of laparoscopic ovarian diathermy versus gonadotrophin therapy for women with clomiphene citrate resistant polycystic ovary syndrome. Hum Reprod 19(5):1110–1115PubMedGoogle Scholar
  19. 19.
    Fassnacht M, Schlenz N, Schneider SB et al. (2003) Beyond adrenal and ovarian androgen generation: Increased peripheral 5 alpha-reductase activity in women with polycystic ovary syndrome. J Clin Endocrinol Metab 88(6):2760–2766PubMedGoogle Scholar
  20. 20.
    Geisthovel F (2003) A comment on the European Society of Human Reproduction and Embryology/American Society for Reproductive Medicine consensus of the polycystic ovarian syndrome. Reprod Biomed Online 7(6):602–605PubMedGoogle Scholar
  21. 21.
    Glueck CJ, Phillips H, Cameron D et al. (2001) Continuing metformin throughout pregnancy in women with polycystic ovary syndrome appears to safely reduce first-trimester spontaneous abortion: a pilot study. Fertil Steril 75(1):46–52PubMedGoogle Scholar
  22. 22.
    Glueck CJ, Wang P, Goldenberg N, Sieve-Smith L (2002) Pregnancy outcomes among women with polycystic ovary syndrome treated with metformin. Hum Reprod 17(11):2858–2864PubMedGoogle Scholar
  23. 23.
    Glueck CJ, Wang P, Kobayashi S et al. (2002) Metformin therapy throughout pregnancy reduces the development of gestational diabetes in women with polycystic ovary syndrome. Fertil Steril 77(3):520–525PubMedGoogle Scholar
  24. 24.
    Hanefeld M, Willms B (1996) Diagnostik bei metabolischem Syndrom. Internist 37:705–711PubMedGoogle Scholar
  25. 25.
    Ibanez L, de Zegher F (2004) Ethinylestradiol-drospirenone, flutamide-metformin, or both for adolescents and women with hyperinsulinemic hyperandrogenism: opposite effects on adipocytokines and body adiposity. J Clin Endocrinol Metab 89(4):1592–1597PubMedGoogle Scholar
  26. 26.
    Imani B, Eijkemans MJ, Te Velde ER et al. (1999) Predictors of chances to conceive in ovulatory patients during clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility. J Clin Endocrinol Metab 84(5):1617–1622PubMedGoogle Scholar
  27. 27.
    Jakubowicz DJ, Iuorno MJ, Jakubowicz S et al. (2002) Effects of metformin on early pregnancy loss in the polycystic ovary syndrome. J Clin Endocrinol Metab 87(2):524–529PubMedGoogle Scholar
  28. 28.
    Kashyap S, Wells GA, Rosenwaks Z (2004) Insulin-sensitizing agents as primary therapy for patients with polycystic ovarian syndrome. Hum Reprod 19(11):2474–2483PubMedGoogle Scholar
  29. 29.
    Kerner W, Fuchs C, Redaelli M et al. (2001) Definition, Klassifikation und Diagnostik des Diabetes mellitus. In: Scherbaum WA, Lauterbach KW, Joost HG (Hrsg) Evidenzbasierte Diabetes-Leitlinien DDG, 1. Aufl. Deutsche Diabetes GesellschaftGoogle Scholar
  30. 30.
    Klein S, Fontana L, Young VL et al. (2004) Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease. N Engl J Med 350(25):2549–2557PubMedGoogle Scholar
  31. 31.
    Knowler WC, Barrett-Connor E, Fowler SE et al. (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346(6):393–403PubMedGoogle Scholar
  32. 32.
    Legro RS, Kunselman AR, Dodson WC, Dunaif A (1999) Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. J Clin Endocrinol Metab 84(1):165–169PubMedGoogle Scholar
  33. 33.
    Lord JM, Flight IH, Norman RJ (2003) Metformin in polycystic ovary syndrome: systematic review and meta-analysis. BMJ 327(7421):951–953PubMedGoogle Scholar
  34. 34.
    Ludwig M, Binder H, Beckmann MW, Schulte HM (2004) Refresher Hyperandrogenämie — Teil I. Geburtsh Frauenheilkd 64Google Scholar
  35. 35.
    Mitkov M, Pehlivanov B, Terzieva D (2005) Combined use of metformin and ethinyl estradiol-cyproterone acetate in polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol 118(2):209–213PubMedGoogle Scholar
  36. 36.
    Salpeter SR, Greyber E, Pasternak GA, Salpeter EE (2003) Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus: systematic review and meta-analysis. Arch Intern Med 163(21):2594–2602PubMedGoogle Scholar
  37. 37.
    Uusitupa M, Lindi V, Louheranta A et al. (2003) Long-term improvement in insulin sensitivity by changing lifestyles of people with impaired glucose tolerance: 4-year results from the Finnish Diabetes Prevention Study. Diabetes 52(10):2532–2538PubMedGoogle Scholar
  38. 38.
    van Santbrink EJ, Donderwinkel PF, van Dessel TJ, Fauser BC (1995) Gonadotrophin induction of ovulation using a step-down dose regimen: single-centre clinical experience in 82 patients. Hum Reprod 10(5):1048–1053PubMedGoogle Scholar
  39. 39.
    van Santbrink EJ, Fauser BC (1997) Urinary follicle-stimulating hormone for normogonadotropic clomiphene-resistant anovulatory infertility: prospective, randomized comparison between low dose step-up and step-down dose regimens. J Clin Endocrinol Metab 82(11):3597–3602PubMedGoogle Scholar
  40. 40.
    Vandermolen DT, Ratts VS, Evans WS et al. (2001) Metformin increases the ovulatory rate and pregnancy rate from clomiphene citrate in patients with polycystic ovary syndrome who are resistant to clomiphene citrate alone. Fertil Steril 75(2):310–315PubMedGoogle Scholar
  41. 41.
    Vanky E, Salvesen KA, Heimstad R et al. (2004) Metformin reduces pregnancy complications without affecting androgen levels in pregnant polycystic ovary syndrome women: results of a randomized study. Hum Reprod 19(8):1734–1740PubMedGoogle Scholar
  42. 42.
    Zawadski JK, Dunaif A (1992) Diagnostic criteria for polycystic ovarian syndrome: towards a rationale approach. In: Dunaif A, Givens JR, Haseltine F (eds) Polycystic ovary syndrome. 1st edn. Blackwell Scientific, Boston, pp 377–384Google Scholar

Copyright information

© Springer Medizin Verlag 2005

Authors and Affiliations

  1. 1.Zentrum für Hormon- und Stoffwechselerkrankungen, Reproduktionsmedizin und Gynäkologische Endokrinologie Endokrinologikum Hamburg
  2. 2.Zentrum für Hormon- und Stoffwechselerkrankungen, Reproduktionsmedizin und Gynäkologische Endokrinologie Endokrinologikum HamburgHamburg

Personalised recommendations