1. Neuro-endocrine syndromes in gynecology Lecture by AndriyBerbets

2. Polycystic ovarian syndrome PCOS is also known as Stein-Levental syndrome Frequency: Approximately 1% of female population suffers from PCOS 30% among patients of gynecological endocrinologist 75% of infertility with endocrine genesis

3. Polycystic ovarian syndrome Structural changes of the ovaries: Ovaries are enlarged in size 2-6 times on both sides Hyperplasia of stroma and theca cells Presence of big amount of follicles with cystic changes and atresia

4. Polycystic ovarian syndrome Structural changes of the ovaries: The average diameter of the follicle is 5-8 mm Follicles form the “necklace” of ovarian Ovarian capsule is thick

5. Polycystic ovarian syndrome Normal metabolism of androgens in females Androgens are synthesized in ovaries in follicles Peak of synthesis of androgens in ovaries comes when follicle is 5-8 mm in size Ovarian androgens (testosterone, andrestendion) are converted into estrogens (estradiol, estron)

6. Polycystic ovarian syndrome The enzyme Cytochrome P450c17 is responsible for conversion of estrogens into androgens The synthesis of this enzyme is regulated by follicle-stimulating hormone (FSH) produced by pituitary

7. Polycystic ovarian syndrome Pathogenesis Develops in puberty age Probable reasons are genetic, viral infections, obesity etc Hypothalamic gonadotropine-releasing hormone (GRH) is increased Consequently, level of luteinizing hormone (LH) increases, FSH decreases

8. Polycystic ovarian syndrome High level of LH provokes cystic atresia of follicles Low level of FSH causes deficiency of enzyme P450c17 Androgens are not converted to estrogens enough -> hyperandrogenia and lack of ovarian estrogens

9. Polycystic ovarian syndrome

10. Polycystic ovarian syndrome Patients with PCOS have more or less manifesting resistance to insulin (defect of insulin receptors) Blood level of glucose increases Obesity appears Compensatory, levels of insulin and insulin-like growth factor-1 are increased That substances cause high synthesis of androgens and estrogens by fat tissue Process does not depend from pituitary

11. Polycystic ovarian syndrome

12. Polycystic ovarian syndrome Clinical flow The average age of menarche is normal but Menstrual abnormalities (oligo- and amenorrhea) since the menarche No ovulation Primary infertility Hyperplasia of endometrius (no phases of cycle, “fat estrogens” are present)

13. Polycystic ovarian syndrome “Female type” of obesity (circumference of waist/ circumference of hips <0.85) Breasts are developed enough but 30% of patients have mastopathia Hirsutism Changes of glucose profile

14. Polycystic ovarian syndrome

15. Polycystic ovarian syndrome

16. Polycystic ovarian syndrome Diagnostics: Infertility (primary) Obesity + hirsutism Oligo- and amenorrhea High level of glucose Monophasal basal temperature, no ovulation Ovaries are enlarged on BOTH sided LH is increased, LH/FSH >2,5

17. Polycystic ovarian syndrome Ultrasound examination: Normal ovary

18. Polycystic ovarian syndrome Polycystic ovary

20. GnRH level raises -> FSH level raises

21. Since 5th to 10th days of menstrual cycle 50 mg/dayGestagens (duphaston) 15th 25th days of cycle