1-PCOS and OVULATION LAZY-INFERTILITY TREATMENT
2-PCOS and HAIR GROWTH (HYPERANDROGENISM) CAUSES AND TREATMENT
I would like to talk about PCOS (POLY CYSTIC OVARIAN SYNDROME), which we encounter very frequently and which needs to be followed at every stage of a woman's life, causing discomfort in addition to the infertility problem. Although it is seen in 20% to 25% of infertile couples; In addition to infertility, menstrual irregularity, increased androgenic hair growth (excessive hair growth on the face, chin, chest and abdomen), hair loss, acne is a disorder that women who do not want to have children often consult gynecologists with these complaints. Another aspect of the matter is; PCOS (poly cystic ovary syndrome) patients have an increased risk of developing type 2 diabetes, hypertension, cardiovascular diseases, endometrium and breast cancer in the following years. Therefore, PCOS is an important general health problem.
WHAT IS PCOS?
During follicle growth, cessation of follicle development and atresia (regression and disappearance) due to increased androgenism in the environment. It is a disease characterized by chronic anovulation (absence of ovulation) and dozens of cysts arranged like a pearl necklace (string of prayer beads) with a diameter of 5-12 mm in the ovaries. There are menstrual delays due to the absence of ovulation. Excess androgen due to active theca cells in the ovaries prevents ovulation and causes hirsutism (excessive hair growth). The cause of PCOS is that, in most of these women, reduced insulin sensitivity during the rapid growth period, called pubertal adrenaline, between the ages of 13-14, continues into older ages. Hyperinsulinism due to insulin resistance leads to hyperandrogenism. In these women's later years, disorders called metabolic diseases or syndrome x are common. Increased hyperinsulinemia due to insulin resistance reduces SHBGs. Circulating testosterone increases twofold. IGF-1 increases, which increases the production of androgens in the theca cells.
HOW SHOULD PCOS BE TREATMENT?
Since PCOS has insulin resistance; Insulin sensitizing drugs such as metformin are useful in the treatment, especially in obese patients. to have no desire for children n in women; To prevent excessive hair growth; Anti-androgenic birth control pills may be given. The progesterone in them reduces androgen production by lowering the constantly released LH. It also reduces the amount of testosterone in free circulation by increasing the synthesis of SHBGs.
PCOS (poly cystic ovary syndrome) is a WHO Group 2 ovulation disorder. The first option for patients who want to have children is a drug called clomiphene citrate, which is structurally similar to estrogen. It can stimulate ovulation by stimulating FSH in the pituitary. It should not be used for more than 6 months. If no response is obtained, it is necessary to use drugs such as FSH under the supervision of an external specialist doctor. In patients with a body mass index of more than 30, even a 5% weight loss can restore ovulation.
WHAT IS POLY CYSTIC OVARY (PCO)?
Coincidentally, during ultrasound checks; Cysts in the ovaries with a diameter of around 10-12 mm, such as a string of prayer beads or a necklace of pearls; The disorder that causes menstrual delays and ovulation laziness, as well as masculine hairiness (hyper andronegenism), that is, the absence of hair on the face, chin, moustache, nipples and abdomen, is called Poly Cystic Ovary. If there is no pubescence or egg laying laziness, no treatment is required. Only; Annual checks are required to determine whether the cysts are growing or not. If you have masculine hair growth (face, chin, moustache, nipples, abdominal area) and ovulation laziness and desire to have children (in which case the diagnosis is called PCOS, not PCO), the treatment described in the above paragraph is required.
2-PCOS and HAIR GROWTH (HYPERANDROGENISM) CAUSES AND TREATMENT
WHAT IS HAIR GROWTH (Hirsutism)?
Due to androgen hormone excess, The disease that occurs when the thin colorless hairs (vellus type hairs) on the face, abdomen and chest become thicker and longer (terminal hair) is called hirsutism.
Hair growth is not a hair disease. As a result of the increased androgen hormones in the body turning into Di-hydro testosterone, which is the more active form of the testosterone hormone, with the increase of 5-Alpha reductase enzyme activity in the skin, there is an increase in hair growth, sebaceous glands and acne (pimples).
Hair. How is its development?
Hair does not develop continuously. Active and It has inactive periods.
1-Anagen Phase: growth period
2-Catagen Phase: regression phase
3-Telogen Phase: rest period
Excessive testosterone in women Its activity accelerates the anagen phase (growth phase) in hair development. In girls, hair growth (hirsutism) occurs as a result of the transformation of vellus type thin and colorless hairs in puberty (13-14 years old) into thick (terminal) hairs under the influence of testosterone and its active form in the skin, DHT (di-hydro testosterone).
REASONS FOR HAIR GROWTH AND INCREASE OF ANDROGEN HORMONES
1-95% of the reasons for hair growth in women is the increase in androgens. The main reason for this is due to the increase in the production of hormones called androstendione in the ovarian theca cells due to laziness in ovulation.
2-Androstendione hormone then turns into testosterone hormone. While the ovaries normally produce 25% of testosterone in women, when there is an increase in androstendione due to laziness in ovulation, testosterone increases 2-fold.
3-Testosterone hormone is also produced by DHT (di hydro testosterone), which is more active in the skin and increases hair growth, acne and oiliness. ) hormone.
How much testosterone is in the blood?
80% of testosterone goes to SHBG (sex hormone binding globulin), 19% to albumin. It depends. 1% is active in free circulation. In women with hair growth, the amount of free testosterone increases from 1% to 2%. For this; In hair growth studies, both total and free testosterone hormone levels should be checked. It is the amount of free testosterone that causes hair growth.
What are the diseases that cause hair growth in women?
1-Poly Cystic Ovarian Syndrome (PCOS): 95% of the hair growth in women is caused by this disease. It occurs due to disease. The reason for the hair growth caused by the increase in androgens due to the absence of ovulation was explained in the above paragraphs.
2-Hyperinsulinemia: What is insulin resistance?, why does hyperinsulinemia occur?, the decrease in glucose response to a given insulin is called insulin resistance. In other words, although glucose should enter the cell under the influence of insulin, it does not and glucose increases in the blood.
Insulin Resistance = Syndurum X = What is Metabolic Syndurum?
a ) Triglycerides over 150mg/dl �
b) HDL Cholesterol being below 50 mg/dl
c) Waist circumference in women being over 85cm
d) FBG (fasting blood sugar) being 110 mg/dl and above
e) Blood pressure being over 130/80
Excessive hair growth also occurs in this type of women.
How does the increase in insulin in the blood cause hair growth?
Insulin increases IGF-1 activity and increases andrsotendione hormone production in theca cells in the ovaries. Androstendione then turns into testosterone, which then turns into the DHT hormone, increasing hair growth. The second reason why insulin increases lead to increased hair growth is that insulin reduces the production of SHBG (sex hormone binding globilin) in the liver. Thus, since testosterone binding will decrease, the amount of free testosterone will increase.
WHAT OTHER DISEASES EXCEPT PCOS CAUSE HAIR?
Note: 95% of the reason for hair growth is due to increased androgen production in the ovaries, such as poly cystic ovary syndrome. The diseases described below are rare diseases that account for only 1 to 5% of hair growth in women. These diseases are as follows;
1-Increased activity in the adrenal gland, the best example of which is Cushing's syndrome.
2-Tumors: androgen-secreting tumors in the ovaries or adrenal gland. It is very rare.
3-Enzyme deficiencies, 21 Hydroxylase and 11 Beta hydroxylose enzyme defects.
4-Pregnancy: Hair growth may increase due to the increase in hormones during pregnancy.
4 -Menopause: It occurs as a result of the transformation of E1, an inactive estrogen, into testosterone in the skin during menopause.
WHAT ARE THE LABORATORY TESTS TO BE REQUESTED FOR HAIR GROWTH?
1- Testosterone (both total and free)
2- 17-OH progesterone
3- DHEAS
4- Prolactin
5- Thyroid tests (if there is hair loss)
6- If hyperinsulinemia is considered (if the patient is obese ) insulin triggers and 2-hour 75 gram glucose load test
7- Ultrasonography
8- If a tumor is suspected; further examinations
HOW IS THE TREATMENT OF HAIR?
The treatment to be mentioned here is the treatment of hair growth originating from the ovary, which is the cause of 95% of hair growth.
1-Birth control pills (oral contraceptives): k� They have the following effects in the treatment of acne.
a) They reduce the increased LH.
b) They increase the production of SHBG (sex hormone binding globins). Thus, circulating free testosterone decreases.
c) In the skin; It reduces the production of DHT, which is the more active testosterone, by reducing the 5 alpha reductase enzyme activity.
2-Spironolactone: It is the antagonist of androgens. It reduces androgen production via P450C. It is also a diuretic, accelerating urine flow. It reduces 5 alpha reductase activity.
3-Cyproterone Acetate: The progesterone in it suppresses LH. It also reduces androgen activity by binding to androgen receptors.
4-Metformin (insulin sensitizers): If there are hyperinsulinemia-obesity-syndrome symptoms, these drugs are added to the treatment.
5-Dexamethasone: hair growth, kidney If it originates from the adrenal gland and DHES is high in the blood, these drugs are used for treatment.
6-Finaseride: It reduces greasiness and hair growth on the skin by reducing 5 alpha reductase enzyme activity.
7- If there is hair growth due to a tumoral cause, special treatments are applied.
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