多囊卵巢综合征与胰岛素抵抗2013-4-1流行病学和定义•5-10%•慢性不排卵，•高雄激素水平，•不孕,•早期流产，•脂代谢异常和胰岛素抵抗•主要见于肥胖人群同时也见于正常体重者PCOS的诊断•NIHdiagnosticcriteria(1990)•TheRotterdamcriteria(2003)NIHdiagnosticcriteria(1990)•高雄激素表现(临床and/or生化)•慢性不排卵（除外卵巢特异性疾患，肾上腺疾患,甲状腺和垂体疾患。TheRotterdamcriteria(2003)•高雄激素表现•慢性不排卵;卵巢多囊样改变Patients•临床and/or生化高雄and慢性排卵减少,伴or不伴多囊卵巢•临床and/or生化高雄and多囊卵巢,但是正常月经周期•慢性不排卵and卵巢多囊样表现,但没有高雄体征病因学•遗传原因•类固醇生成原因•胰岛素分泌异常病理•卵巢产生过量雄激素•胰岛素抵抗治疗•生活方式•药物治疗COCs（口服避孕药）二甲双胍胰岛素增敏剂COCs•炔雌醇35µg/抗雄激素醋酸环丙孕酮2mg•含有三代孕酮的口服避孕药去氧孕烯屈螺酮胰岛素增敏剂•作用包括直接影响类固醇的产生和胰岛素增敏作用胰岛素增敏剂对生殖的影响Hyperandrogenism•Metformin:totaltestosterone,androstenedioneandtheadrenalandrogen,dehydroepiandrosteronesulfate•噻唑烷二酮药物不影响总睾酮水平但却显著降低雄烯二酮和脱氢表雄酮水平•显著改善多毛症不排卵和不孕•对于PCOS妇女噻唑烷二酮药物以剂量依赖方式显著促进排卵•单独应用二甲双胍,or二甲双胍加克罗米芬要显著优于促排卵药物（二甲双胍剂型和剂量会影响效果）怀孕•MetforminpregnancycategoryBdrugstoreducespontaneousabortionsreducetheriskofGDM•thiazolidinedionespregnancycategoryCdrugs代谢异常体重和脂肪组成•二甲双胍治疗能使体重中等程度降低并减少内脏脂肪，特别是与低热量饮食同时进行时这种作用最显著。但一些作用是剂量依赖的。CardiovascularRiskFactors•MetformintherapyresultedinsignificantdecreasesinsystolicbloodpressureandLDL-cholesterollevels,•bothmetforminandthiazolidinedionesimproveendothelialdysfunctioninPCOS.ThiazolidinedionesalsoimprovefibrinolysisinPCOS比较研究二甲双胍和噻唑烷二酮药物•thiazolidinedionesaremoreeffectivethanmetforminatloweringfreeorbioavailabletestosteronelevelsandAUCsforinsulinlevels.Thereis,however,minimalevidenceforadifferenceinclinicaloutcomessuchashirsutismwiththetwotherapies,andthiazolidinedionesmayresultinweightgaininwomenwithPCOS二甲双胍和口服避孕药•metforminimprovesinsulinsensitivityand,unlikeoralcontraceptives,canalsolowertriglyceridelevels.•Oralcontraceptivesmightworseninsulinsensitivity副作用•metformin：gastrointestinaldistressthiazolidinedione：•weightgain,inpartrelatedtotheirmechanismofactionasPPARγligands,andfluidretentionthatcouldresultinedemaanddilutionalanemia•anincreaseinperipheraledema,sleepdisorders,headacheandstomachpain•cardiovascularsafetyconcernsThankyou
