Das polyzystische Ovarsyndrom: Aktuelle Evidenz und praktische Empfehlungen

Abstract

Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in women of childbearing age. Due to hyperandrogenism and chronic anovulation affected women may suffer from hirsutism, androgenetic alopecia, acne, menstrual disturbance and sub-/infertility. Furthermore underlying insulin resistance promotes hyperandrogenemia, overweight and risk for diabetes. Therefore, routine evaluation of glycemic status is recommended. Treatment strategies are based on therapeutic lifestyle changes and focus on patient-important complaints. First line pharmacologic treatment for infertility in women with PCOS is letrozole. Clomiphene and metformin can be used alternatively with lower success rates. Women seeking medical advice for hyperandrogenism can be offered oral contraceptive pills with the lowest effective estrogen dose without any preference of a certain gestagen. Risk for deep vein thrombosis should be taken into account when choosing estrogen dose and type of gestagen. Antiandrogen substances such as spironolactone should only be prescribed in combination with safe contraception due to their risk of fetal undervirilisation. Additionally, substance specific risks should be considered. Baseline treatment of overweight or metabolic issues includes behaviour modification, weight reduction and physical activity. Additional benefit can be reached by combination of lifestyle changes with metformin. Studies indicate a positive effect of inositol and antidiabetic substances like liraglutide and empagliflozin but should be regarded as experimental therapies.

Das polyzystische Ovarsyndrom (PCOS) umfasst ein weites Symptomspektrum – von Hirsutismus, Alopezie, Akne, Adipositas, Sub-/Infertilität und Insulinresistenz bis zum Diabetes mellitus mit wesentlich eingeschränkter Lebensqualität der Patientinnen [1]. Dieser Beitrag bietet eine kurze Übersicht zum Management des PCOS mit den Neuerungen zu Diagnostik und Therapie der aktuellen Leitlinie des International PCOS Network [2].

Schlüsselwörter

polyzystisches Ovarsyndrom - Anovulation - Hyperandrogenismus - Hirsutismus - Insulinresistenz

Key words

polycystic ovary syndrome - anovulation - hyperandrogenism - hirsutism - insulin resistance

• Literatur

• 1 Hahn S, Janssen OE, Tan S. et al. Clinical and psychological correlates of quality-of-life in polycystic ovary syndrome. Eur J Endocrinol 2005; 153: 853-860 . doi:10.1530/eje.1.02024
• 2 Teede HJ, Misso ML, Costello MF. et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Clin Endocrinol 2018; 89: 251-268 . doi:10.1111/cen.13795
• 3 Moghetti P, Tosi F, Bonin C. et al. Divergences in insulin resistance between the different phenotypes of the polycystic ovary syndrome. J Clin Endocrinol Metab 2013; 98: E628-E637 . doi:10.1210/jc.2012-3908
• 4 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 . doi:10.1093/humrep/des463
• 5 Wojciechowski P, Lipowska A, Rys P. et al. Impact of FTO genotypes on BMI and weight in polycystic ovary syndrome: a systematic review and meta-analysis. Diabetologia 2012; 55: 2636-2645 . doi:10.1007/s00125-012-2638-6
• 6 Rubin KH, Glintborg D, Nybo M. 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 . doi:10.1210/jc.2017-01354
• 7 Barry JA, Azizia MM, Hardiman PJ. Risk of endometrial, ovarian and breast cancer in women with polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update 2014; 20: 748-758 . doi:10.1093/humupd/dmu012
• 8 Moghetti P, Castello R, Negri C. et al. Metformin effects on clinical features, endocrine and metabolic profiles, and insulin sensitivity in polycystic ovary syndrome: a randomized, double-blind, placebo-controlled 6-month trial, followed by open, long-term clinical evaluation. J Clin Endocrinol Metab 2000; 85: 139-146 . doi:10.1210/jcem.85.1.6293
• 9 Tan S, Hahn S, Benson S. et al. Metformin improves polycystic ovary syndrome symptoms irrespective of pre-treatment insulin resistance. Eur J Endocrinol 2007; 157: 669-676 . doi:10.1530/EJE-07-0294
• 10 Costello MF, Misso ML, Balen A. et al. Evidence summaries and recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome: assessment and treatment of infertility. Hum Reprod Open 2019; 2019: hoy021 . doi:10.1093/hropen/hoy021
• 11 Martin KA, Anderson RR, Chang RJ. et al. Evaluation and treatment of hirsutism in premenopausal women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103: 1233-1257 . doi:10.1210/jc.2018-00241
• 12 Unfer V, Nestler JE, Kamenov ZA. et al. Effects of inositol(s) in women with PCOS: A systematic review of randomized controlled trials. Int J Endocrinol 2016; 2016: 1849162 . doi:10.1155/2016/1849162
• 13 Tang T, Lord JM, Norman RJ. et al. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev 2012; 5: CD003053 . doi:10.1002/14651858.CD003053.pub5
• 14 Pundir J, Psaroudakis D, Savnur P. et al. Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials. BJOG 2018; 125: 299-308 . doi:10.1111/1471-0528.14754
• 15 Crawford TJ, Crowther CA, Alsweiler J. et al. Antenatal dietary supplementation with myo-inositol in women during pregnancy for preventing gestational diabetes. Cochrane Database Syst Rev 2015; 12: CD011507 . doi:10.1002/14651858.CD011507.pub2
• 16 Jensterle M, Kravos NA, Goricar K. et al. Short-term effectiveness of low dose liraglutide in combination with metformin versus high dose liraglutide alone in treatment of obese PCOS: randomized trial. BMC Endocr Disord 2017; 17: 5 . doi:10.1186/s12902-017-0155-9
• 17 Frossing S, Nylander M, Chabanova E. et al. Effect of liraglutide on ectopic fat in polycystic ovary syndrome: A randomized clinical trial. Diabetes Obes Metab 2018; 20: 215-218 . doi:10.1111/dom.13053
• 18 Nylander M, Frossing S, Clausen HV. et al. Effects of liraglutide on ovarian dysfunction in polycystic ovary syndrome: a randomized clinical trial. Reprod Biomed Online 2017; 35: 121-127 . doi:10.1016/j.rbmo.2017.03.023
• 19 Salamun V, Jensterle M, Janez A. et al. Liraglutide increases IVF pregnancy rates in obese PCOS women with poor response to first-line reproductive treatments: a pilot randomized study. Eur J Endocrinol 2018; 179: 1-11 . doi:10.1530/EJE-18-0175
• 20 Javed Z, Papageorgiou M, Deshmukh H. et al. Effects of empagliflozin on metabolic parameters in polycystic ovary syndrome: A randomized controlled study. Clin Endocrinol 2019; 90: 805-813 . doi:10.1111/cen.13968
• 21 Ferriman D, Gallwey JD. Clinical assessment of body hair growth in women. J Clin Endocrinol Metab 1961; 21: 1440-1447
• 22 Miller X. Alopecia androgenetica der Frau. In: Moll I. Hrsg. Duale Reihe Dermatologie. 8.. vollständig überarbeitete Auflage. Stuttgart: Thieme; 2016.