2018 Uluslarası kanıta dayalı Polikistik Over Sendromu değerlendirme ve yönetim rehberi doğrultusunda uzun dönem risklerin yönetimi

Abstract

Polikistik Over Sendromu (PKOS); üreme çağındaki kadınlarda izlenen sık endokrin ve metabolik bozukluktur. Yüksek prevalansına rağmen farklı fenotipleri, yaş bağımlı heterojen kliniği ve etnik farklılıkları hem klinisyen hem de hasta açısından tanıda zorluklara yol açmaktadır. PKOS oluşumunun temel mekanizmaları halen tam olarak bilinmemektedir. Güncel bilgiler ışığında PKOS’un bir çok faktörün bir araya gelmesi ile oluşan multifaktoriyel bir sendrom olduğu kabul edilmektedir. Her ne şekilde olursa olsun gerek insülin rezistansı gerekse de hiperandrojenemi veya bu ikisinin beraber varlığı hastaları ilerleyen dönemlerde obezite, dislipidemi, kompensatuvar hiperinsülineminin eşlik ettiği insülin rezistansı, tip 2 diabetes mellitus, metabolik sendrom ve kardiyovasküler hastalıklar açısından yüksek risk grubuna almaktadır. PKOS yaşamın farklı dönemlerinde reprodüktif, metabolik, sistemik veya psikolojik etkileri ayrı ayrı kliniklerde ön plana çıkabilir. PKOS’ a eşlik eden hastalıklar çoğunlukla bilinmekle birlikte bu hasta grubunda eşlik eden hastalıklar açısından optimal tarama, total risk değerlendirmesi ve klinik yönetimle ilgili algoritmalar hala oldukça tartışmalıdır. Olguların yönetiminde baskın şikayete yönelik tanı ve tedavi planlaması yapılırken, hastalığın heterojen özelliği gözardı edilmekte, hastalığın komorbiditeleri ve uzun dönem riskleri üzerinde çoğunlukla yeterli danışmanlık yapılmamaktadır.  Oysa yaşam süresi boyunca hastalığın seyrinde belirgin klinik varyasyon izlenmekle beraber kronik süreçte PKOS’a eşlik eden medikal problemler yükledikleri ek komorbiditelerle hastaların karşısına yeniden çıkabilmektedir. Bu yayının amacı PKOS tanı ve yönetiminde ‘2018 Uluslarası kanıta dayalı PKOS değerlendirme ve yönetim rehberi (2018 PKOS Rehberi) doğrultusunda  eşlik eden hastalıklar ve bu hastalıklara bağlı uzun dönem riskler açısından önerilerin detaylı olarak irdelenmesidir.

Keywords

• polikistik over sendromu,menapoz,obezite,insülin direnci,kardiyovasküler hastalık

The management of long-term risks of Polycystic Ovary Syndrome in accordance to 2018 international guideline for the assessment and management of polycystic ovary syndrome.

Abstract

Polycystic Ovary Syndrome (PCOS); is the most common endocrine and metabolic disturbance during reproductive period in women. Although its high prevalence, different phenotypes, heterogeneous clinic presentations related to age and ethnical differences; result in diagnostic dilemmas for both the clinicians and the patients. The exact pathophsiology of PCOS is yet to be defined. PCOS is thought to be a multi-systemic disease currently. In any case, both insulin resistance and hyperandrogenemia, and the presence of both conclude with an increased long-term risk of patients for obesity, dyslypidemi, insulin resistance with compensatuar hyperinsulinemia, metabolic syndrome and cardiovascular diseases. Reproductive, metabolic, systemic, or psychological effects of PCOS may come into prominence separately in different periods of life. Although the comorbidities of PCOS are mostly known, the algorithms related to optimal screening, total risk assessment, and clinical management are still controversial for comorbidities in this patient group.

While the diagnosis and treatment planning for the complaints, the heterogeneous nature of the disease is generally ignored, and there is often insufficient consultation on the comorbidities and long-term risks of the disease. However there is a marked clinical variation in the course of the disease throughout life, medical problems associated with PCOS may reappear with additional comorbidities in the chronic process. The aim of this review is to examine the recommendations with respect to the 2018 International Evidence Based PCOS Assessment and Management Guideline (2018 PCOS Guideline) in terms of concomitant co morbid diseases and long-term risks related to PCOS.

Keywords

• polycystic ovary syndrome,menapouse,obesity,insulin resistance,cardiovascular disease

References

1. Referanslar1) Bozdag, G., et al., The prevalence and phenotypic features of polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod, 2016;31:2841-2855.
2. 2) March WA, Moore VM, Willson KJ, et al. The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Hum Reprod, 2010;25: 544–551.
3. 3) International evidence-based guideline for the assessment and management of polycstic ovary syndrome 2018. monash.edu/medicine/sphpm/mchri/pcos.
4. 4)Kahsar-Miller MD, Nixon C, Boots LR, Go RC, Azziz R. Prevalence of polycystic ovary syndrome (PCOS) in first-degree relatives of patients with PCOS. Fertil Steril, 2001;75:53-58.
5. 5) Goodman NF, Cobin RH, Futterweit W, Glueck JS, Legro RS, Carmina E; American Association of Clinical Endocrinologists (AACE); American College of Endocrinology (ACE); Androgen Excess and PCOS Society (AES). American Association of Clinical Endocrinologists, American College of Endocrinology, and Androgen Excess and PCOS Society Disease State Clinical Review: Guide to the practices in the evaluation and treatment of polycystic ovary syndrome- Part 1. Endocr Pract, 2015;21:1291-1300.
6. 6) Asagami T, Holmes TH, Reaven G. Differential effects of insulin sensitivity on androgens in obese women with polycystic ovary syndrome or normal ovulation. Metabolism, 2008;57:1355-60. doi: 10.1016/j.metabol.2008.05.002.
7. 7) Macut D, Bjekic-Macut J, Savic-Radojevic A. Dyslipidemia and oxidative stress in PCOS. Front Horm Res, 2013;40:51–63.
8. 8) National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) ird Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) nal report. Circulation, 2002;106:3143–3421.

9. 9) Xavier LB, Soter MO, Sales MF, Oliveira DKD, Reis HJ, Candido AL, Reis FM, Silva IO, Gomes KB, Ferreira CN. Evaluation of PCSK9 levels and its genetic polymorphisms in women with polycystic ovary syndrome. Gene, 2018;644:129–136.
10. 10) Palomba S, Falbo SSA, La Sala GB. Complications and challenges associated with polycystic ovary syndrome: current perspectives. Int J Womens Health, 2015;7:745–763.
11. 11) Carmina, E., A.M. Campagna, and R.A. Lobo, A 20-year follow-up of young women with polycystic ovary syndrome. Obstet Gynecol, 2012;119:263-269.
12. 12) Elting MW, Korsen TJM, Rekers-Mombarg LTM:Woman with polycystic ovary syndrome gain regular menstrual cycles when aging. Human Reprod, 2000;15:24.
13. 13)American Diabetes Association, Standards of Medical Care in Diabetes-2017. Diabetes Care, 2017:40(Suppl 1).
14. 14) Nordic Multicenter Collaboration Study. J Clin Endocrinol Metab, 2015;100:3400-3407.
15. 15) Brown, Z.A., et al., The phenotype of polycystic ovary syndrome ameliorates with aging. Fertil Steril, 2011;96:1259-1265.
16. 16) Stepto NK, Cassar S, Joham AE, et al. Women with polycystic ovary syndrome have intrinsic insulin resistance on euglycaemic–hyperinsulaemic clamp. Hum Reprod, 2013;28: 777–784.
17. 17) Diamanti-Kandarakis E & Dunaif A. Insulin resis- tance and the polycystic syndrome revisited: an update on mechanisms and implications. Endocr Rev, 2012;33:981–1030.
18. 18) Moran LJ, Misso ML, Wild RA, Norman RJ. Impaired glucose tolerance, type 2 diabetes and metabolic syndrome in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update, 2010;16:347-363.
19. 19)Rubin, K.H., et al., Development and Risk Factors of Type 2 Diabetes in a Nationwide Population of Women With Polycystic Ovary Syndrome. J Clin Endocrinol Metab, 2017;102:3848-3857.
20. 20) Diamanti-Kandarakis E, Kouli C, Alexandraki K, Spina G. Failure of mathematical indices to accurately assess insulin resistance in lean, overweight, or obese women with polycystic ovary syndrome. J Clin Endocrinol Metab, 2004;89:1273-1276.
21. 21) Dunaif A. Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocr Rev, 1997;18:774-800.
22. 22) Arslanian SA, Lewy VD, Danadian K. Glucose intolerance in obese adolescents with polycystic ovary syndrome: roles of insulin resistance and beta-cell dysfunction and risk of cardiovascular disease. J Clin Endocrinol Metab, 2001;86:66-71.
23. 23) Kakoly, N.S., et al., Ethnicity, obesity and the prevalence of impaired glucose tolerance and type 2 diabetes in PCOS: a systematic review and meta-regression. Human Reproduction Update, 2018.
24. 24) de Groot, P.C., et al., PCOS, coronary heart disease, stroke and the in uence of obesity: a systematic review and meta-analysis. Human Reproduction Update, 2011;17:495-500.
25. 25)ACOG Practice Bulletin No. 194: Polycystic Ovary Syndrome. Obstet Gynecol, 2018;131:157-171.
26. 26) Ehrmann DA, Liljenquist DR, Kasza K, Azziz R, Legro RS, Ghazzi MN; PCOS/Troglitazone Study Group. Prevalence and predictors of the metabolic syndrome in women with polycystic ovary syndrome. J Clin Endocrinol Metab, 2006;91:48-53.
27. 27) Calderon-Margalit, R., et al., Prospective association of polycystic ovary syndrome with coronary artery calci cation and carotid-intima-media thickness: the Coronary Artery Risk Development in Young Adults Women’s study. Arteriosclerosis, Thrombosis & Vascular Biology, 2014;34:2688-2694.
28. 28) Iftikhar S, Collazo-Clavell ML, Roger VL, St Sauver J, Brown RD Jr, Cha S, Rhodes DJ. Risk of cardiovascular events in patients with polycystic ovary syndrome. Neth J Med, 2012;70:74-80.
29. 29) Solomon CG, Hu FB, Dunaif A, Rich-Edwards JE, Stampfer MJ, Willett WC, Speizer FE, Manson JE. Menstrual cycle irregularity and risk for future cardiovascular disease. J Clin Endocrinol Metab, 2002;87:2013-2017.
30. 30) Mokhlesi, B., et al., Risk of obstructive sleep apnea in obese and nonobese women with polycystic ovary syndrome and healthy reproductively normal women. Fertil Steril, 2012;97:786-791.
31. 31) Andersen, M.L. and S. Tu k, The effects of testosterone on sleep and sleep-disordered breathing in men: its bidirectional interaction with erectile function. Sleep Med Rev, 2008; 12:365-379.
32. 32) Helvaci N, Karabulut E, Demir AU, Yildiz BO. Polycystic ovary syndrome and the risk of obstructive sleep apnea: a meta-analysis and review of the literature.Endocr Connect, 2017;6:437-445.
33. 33) Dumesic, D.A. and R.A. Lobo, Cancer risk and PCOS. Steroids, 2013;78(8):782-785.
34. 34) Harris, H.R. and K.L. Terry, Polycystic ovary syndrome and risk of endometrial, ovarian, and breast cancer: a systematic review. Fertil Res Pract, 2016;2:14.
35. 35) Brinton, L.A., et al., Fertility drugs and endometrial cancer risk: results from an extended follow-up of a large infertility cohort. Hum Reprod, 2013;28(10):2813-2821.
36. 36) Sidra S, Tariq MH, Farrukh MJ, Mohsin M. Evaluation of clinical manifestations, health risks, and quality of life among women with polycystic ovary syndrome. PLoS One, 2019:11;14:e0223329.
37. 37) Dokras, A., et al., Androgen Excess-Polycystic Ovary Syndrome Society Position Statement on Depression, Anxiety, Quality of Life and Eating Disorders in Polycystic Ovary Syndrome. Fertility and Sterility, 2018. In Press.
38. 38)Veras, A.B., et al., Sexual dysfunction in patients with polycys tic ovary syndrome: clinical and hormonal correlations. Compr Psychiatry, 2011;52(5): 486-489.
39. 39) Deeks, A., M. Gibson-Helm, and H. Teede. Negative body image and lower self-ef cacy in women with polycystic ovary syndrome. in Australian Society for Health and Behavioural Medicine, 2010. Brisbain.
40. 40) Karacan, E., et al., Body Satisfaction and Eating Attitudes among Girls and Young Women with and without Polycystic Ovary Syndrome. Journal of Pediatric and Adolescent Gynecology, 2014;27(2):72-77.