Women's Corner
Women's Corner
1. Clinical presentations :
· Infertility in 75%
· Hirsutism in 70%
· Amenorrhea in 50%
· Obesity in 40%
· Hyperprolactinemia in 25%
· Complications :
1. Increased for endometrial carcinoma (3-folds) related to the duration chronic anovulation
2. Increased risk of postmenopusal breast cancer ( 3 folds but controversial)
3. Increased risk of diabetes mellitus (20% of patients) and CVS diseases
4. Abnormal uterine bleeding due to DUB, endometrial hyperplasia or carcinoma
5. Spontaneous abortions (30-40%) : Elevated levels of LH produces premature maturation of the oocyte and premature completion of the first meiotic division due to inhibition of the oocyte maturation inhibitor
2. Summary of the hormonal changes :
1. Elevated androgens :
· Stimulation of the theca cells by the LH raise testosterone and androstenedione
· Adrenal contribution causes elevation of the DHAS in 50%
· Decreased SHBG increases free testosterone
2. Relative unopposed hyperestrogenemia :
· Increased estrone due to peripheral conversion
· Normal or low normal estradiol : although ovarian production is decreased , this compensated for by peripheral conversion leading levels similar to that seen in the proliferative phase . Free estradiol increases.
· Reversal of E1:E2 ratio
3. Elevated LH relative to FSH (typically 3:1) : due to chronically elevated estrogen .About 30-40% do not have elevated LH:FSH ratio .
4. Elevated prolactin in 25% : due to chronically elevated estrogen leading decreased PIF
5. Increased B-endorphins
6. Hyperinsulinemia : decreased number of insulin receptors or obesity .
7. Decreased SHBG : due to hyperinsulinemia , hyperandrogenemia and obesity
3. Ultrasound :
- May detect numerous subcapsular follicles in a neck-lace like pattern
- This method is not very accurate as 25% of normal women and 14% of women on oral contraceptives will demonstrate this sonographic pattern
4. Premenstrual endometrial biopsy :
- No evidence of ovulation
- Proliferative, atrophic, hyperplastic or neoplastic
5. Laparoscopy : The ovaries are enlarged 2-5 times, with thick white smooth capsule
6. Testing for insulin resistance and hyperinsulinemia :
- Indications : obese women with android obesity identified by a Waist : Hip ratio > 0.85 (In gyoid obesity it is < 0.75) .
- Methods :
1. Glucose tolerance once or twice yearly .
2. Fasting glucose : Fasting insulin ratio less than 3 defines hyperinsulinism
3. Normally fasting insulin levels is < 20 g/ml and postprandial is < 150 g/ml
dr. Hisham Al-Inany Lecturer in Obstetrics and Gynecology Department, Cairo University, Egypt Dr. Amr Hussein Lecturer in Obstetrics and Gynecology Department, Cairo University, Egypt