多囊卵巢综合征的分型探讨

Exploration of the classification of polycystic ovarian syndrome

目的 探讨不同分型方法用于多囊卵巢综合征（PCOS）分型时,其临床、内分泌、糖和脂代谢紊乱的特征,以指导临床治疗.方法 将192例PCOS 患者按鹿特丹修订的分型标准分为A组110例[长期无排卵;具有雄激素水平升高的临床和（或）生化依据;卵巢增大,单侧卵巢体积大于10 ml或超声下至少有直径2～9 mm的小卵泡≥12个;并排除其他疾病所致的雄激素增多症];B组46例[长期无排卵;具有雄激素水平升高的临床和（或）生化依据,并排除其他疾病所致的雄激素增多症]; C组36例（长期无排卵;卵巢增大,单侧卵巢体积＞10 ml或超声下至少有直径2～9 mm的小卵泡≥12个;并排除其他疾病所致的雄激素增多症）.又按肥胖与否将192例患者分为肥胖型PCOS 70例（OB-PCOS组）和非肥胖型PCOS 122 例（NOB-PCOS组）.以同期就诊、年龄及体重匹配、基础体温（BBT）双相的输卵管因素不孕症患者104例为对照组.采用多毛评分及痤疮评分法对192例患者进行评分并测定其血清生殖激素、胰岛素、血脂及血糖的水平.采用空腹胰岛素（FINS）及胰岛素曲线下面积（IAUC）评估高胰岛素血症;采用稳态模型的胰岛素抵抗指数（HOMA-IR）评估胰岛素抵抗;糖耐量试验（OGTT）及葡萄糖曲线下面积（GAUC）评估糖代谢状态.采用游离雄激素指数（FAI）评估雄激素增多症及雄激素生物学活性.结果 （1）评分：多毛评分A组为（7.1±1.8）分,B组为（6.9±1.9）分,均明显高于C组的（3.9±1.5）分,差异有统计学意义（P＜0.01）;痤疮评分A组为（0.9±1.1）分,B组为（0.7±1.1）分,均高于C组的（0.2±0.4）分,差异也有统计学意义（P＜0.01）;OB-PCOS组与NOB-PCOS组多毛评分及痤疮评分比较,差异均无统计学意义（P＞0.05）.（2）黑棘皮症：A组的发生率为21.8%（20/110）,B组的发生率为19.6%（9/46）,C组的发生率为0（0/36）,A、B组黑棘皮症的发生率均明显高于C组,差异有统计学意义（P＜0.01）;OB-PCOS组黑棘皮症的发生率为35.0%（25/70）,NOB-PCOS组为6.0%（8/122）,两组比较,差异有统计学意义（P＜0.01）. （3）生殖激素：①FAI：A组为2.6±1.8,B组为2.2±1.4,均明显高于C 组的1.2±0.6,差异有统计学意义（P＜0.01）;OB-PCOS组FAI为3.4±1.8,NOB-PCOS组为1.8±1.2,两组比较,差异也有统计学意义（P＜0.01）.②黄体生成素（LH）与卵泡刺激素（FSH）的比值：NOB-PCOS 组LH/FSH为2.4±1.1,明显高于OB-PCOS 组的1.5±0.8,差异有统计学意义（P＜0.01）,A、B、C 3组比较,差异无统计学意义（P＞0.05）.（4）生化指标：OB-PCOS组FINS、HOMA-IR、IAUC、GAUC、甘油三酯（TG）分别为（17±11）mIU/L、1.0±0.6、（249±128）mIU·h·L^-1、（19.6±7.8）mmol·h·L^-1和（1.9±1.0）mmol/L,均明显高于NOB-PCOS组的（8±10）mIU/L、0.1±0.8、（132±81）mIU·h·L^-1、（16.7±3.4）mmol·h·L^-1和（1.1±0.7）mmol/L,分别比较,差异均有统计学意义（P均＜0.01）;A、B、C 3组间上述生化指标比较,差异均无统计学意义（P＞0.05）.结论 鹿特丹修订的PCOS分型方法可反映疾病的基本特征;而肥胖分型不仅能反映病情的基本特征和严重程度,而且对代谢并发症的风险评估具有重要意义.

Objective To investigate the clinical presentation, hormonal profile and metabolic abnormalities in subgroups of women with PCOS and explore a reasonable classification for PCOS. Methods A cross-sectional study of 192 women with PCOS （14 -38 years of age） was performed. The patients were divided into 3 groups of A, B and C according to the revised 2003 consensus on diagnostic criteria and also divided into 2 groups according to body mass index（BMI） ： group A（ n = 110）, long term anovulation, clinical and biochemical evidence of high androgen level, ovary enlargement with its size larger than 10 ml or number of small follicles of 2 -9 mm ≥ 12 under ultrasound with exclusion of other diseases caused by high androgen;group B（ n = 46）, long term anovulation, clinical and biochemical evidence of high androgen level;group C（ n = 36） , long term anovulation, ovary enlargement with its size larger than 10 ml or number of small follicles of 2 -9 mm ≥ 12 under ultrasound with exclusion of other disease caused by high androgen; obesity PCOS group （ OB-PCOS, n = 70 ） , BMI ≥ 25 （ kg/m^2 ） ; no obesity PCOS group （ NOB-PCOS, n = 122）, BMI 〈 25（kg/m^2）. One hundred and four women with bilateral tubal block factor caused infertility served as control group. Anthropometric measurements, Ferriman Gallwey hirsutism scoring, presence of acne and acanthosis nigricans were noted. Hormonal profile was assessed by measuring follicle-stimulating hormone （FSH）, luteinizing hormone （LH）, free testosterone （FT）, prolactin （PRL）, sex hormone binding globulin （SHBG）. The metabolic profile was investigated by measurements of oral glucose tolerance test （ OGTT ） , serum lipid levels, including total cholesterol （ Chol ） , triglyeerides （ TG ） , high-density lipoprotein （HDL）, and low-density lipoprotein （LDL）. Hyperinsulinemia was estimated by measurement of fasting insulin （FINS） and insulin area under the curve （IAUC）. The extent of insulin resistance （IR） and hyperandrogenism was estimated by homeostasis model assessment（HOMA） and free androgen index（FAI） respectively. Results （ 1 ） Clinical phenotypes ： the presence of obesity was 36.4% （ 70/192 ）, among which 80.0% （56/70） were central obesity. Higher rates of acanthosis nigricans were observed in OB-PCOS group （35.7% ,25/70） compared with NOB-PCOS group （7.4% ,9/122;P 〈 0. 01 ）. Waist to hip ratio（WHR） was lower in group C than those in groups A and B（P 〈0.05）. （2） Endocrinology：FAI level was higher in OB-PCOS group than in NOB-PCOS group （ P 〈 0. 01 ） ,whereas LH/FSH ratio was lower in OB-PCOS group compared with NOB-PCOS group （ P 〈 0.01 ）. FAI level was higher in groups A and B than in group C （P〈0. 01）. SHBG, LH/FSH ratio did not differ between groups A, B, and C. （3） Metabolism： the prevalence of IR was 43.2% （83/192）. A higher prevalence was observed in group OB-PCOS （82. 8% ,58/ 70 ） compared with group NOB-PCOS（ 20. 5% ,25/122;P 〈 0.01 ）. FINS, HOMA-IR,glucose area under the curve （ GAUC ） , IAUC and TG were higher in group OB-PCOS than in group NOB-PCOS （ P 〈 0. 01 ） , whereas HOMA-IR,lipid profile did not differ between groups A, B, and C. Conclusion The classification according to the revised 2003 consensus on diagnosis reflects the basic characteristics of PCOS;while the classification based on obesity shows the severity of hyperandrogenism and degree of IR, and thus has substantial significance for evaluation of metabolic complications.