不同体质指数及临床表型的多囊卵巢综合征患者代谢特征研究

Metabolic characteristics of polycystic ovary syndrome patients with different body mass index andclinical phenotypes

目的分析不同体质指数（BMI）分层和各型多囊卵巢综合征（PCOS）患者的内分泌和代谢特征，为PCOS的诊断和治疗提供个体化临床综合管理新思路。 方法选取2012年12月至2016年12月于南京大学医学院附属鼓楼医院内分泌科就诊的388例PCOS患者为研究组，另选取同期年龄、BMI匹配的无高雄激素表现、月经规律的女性66名作为对照组。再根据BMI将研究组分为肥胖亚组（BMI≥25 kg/m2）252例和非肥胖亚组（BMI〈25 kg/m2）136例。根据鹿特丹诊断标准中规定的4个表型临床表现将研究组分为OH亚组[稀发排卵和/或无排卵（O）＋高雄激素表现（H）]48例、OP亚组[O＋卵巢多囊样改变（P）]102例、HP亚组49例及OHP亚组189例。另根据有无H将研究组分为HA亚组286例和无H亚组（Non-HA）102例。采用t检验、单因素方差分析等比较各组临床内分泌及代谢相关参数。 结果（1）肥胖亚组内分泌及代谢指标与非肥胖亚组比较，差异均有统计学意义（均P〈0.05）；OH、HP、OHP亚组空腹血清胰岛素（FINS）均高于对照组[（20±13）、（21±13）、（22±15）比（15±10）mU/L，P〈0.05]，OHP亚组高于OP亚组[（22±15）比（17±12）mU/L，P〈0.05]；OHP亚组稳态模型胰岛素抵抗指数（HOMA-IR）高于对照组（5.2±3.9比3.4±2.4，P〈0.05）。（2）OH、HP及OHP三亚组高密度脂蛋白胆固醇（HDL-C）低于对照组，HP亚组低密度脂蛋白胆固醇（LDL-C）高于对照组和OP亚组（均P〈0.05）。（3）HA亚组BMI[（28±6）kg/m2]、FINS[（22±14）mU/L]、餐后2 h血清胰岛素[（153±111）mU/L]、HOMA-IR（5±4）高于Non-HA亚组[（26±6）kg/m2、（17±12）mU/L、（121±88）mU/L、4±3]，而HDL-C[（1.1±0.3）mmol/L]及性激素结合球蛋白（SHBG）[（22±13）nmol/L]低于Non-HA亚组[（1.2±0.3）mmol/L、（41±23）nmol/L]，差异均有统计学意义（t=-2.805~3.891，均P〈0.05）。（4）Spearman相关分析显示，SHBG与空腹血糖、FINS、HOMA-IR、血尿酸、甘油三酯（TG）、LDL-C呈负相关（r=-0.233^-0.147，均P〈0.05），与HDL-C呈正相关（r=0.384，P〈0.001）；游离雄激素指数（FAI）与FINS、HOMA-IR、血尿酸、TG呈正相关（r=0.143~0.231，P〈0.05），与HDL-C呈负相关（r=-0.160，P=0.012）。 结论高雄激素血症及肥胖可加重PCOS患者内分泌和代谢紊乱风险，不同临床表型的PCOS患者存在不同的内分泌代谢特征。

ObjectiveTo analyze the endocrine and metabolic characteristics of patients with polycystic ovary syndrome （PCOS） with different body mass indexes （BMI） and clinical phenotypes, so as to provide some new clues for the individualized and comprehensive clinical management of PCOS. MethodsA total of 388 PCOS patients from December 2012 to December 2016 and 66 women with regular menstruation and normal androgen level matched with age and BMI were enrolled in this study. The PCOS patients were further divided into obese group and non-obese group according to their BMI, or were divided into four subgroups according to their clinical manifestations based on the 2003 Rotterdam criteria： oligo-and/or anovulation （O）＋hyperandrogenism （H）, O＋polycystic ovary morphology （P）, H＋P and O＋H＋P. According to the status of hyperandrogenism, the PCOS patients were also divided into two subgroups： hyperandrogenism group （HA） and non-hyperandrogenism group （non-HA）. The hormones and metabolic parameters were compared between different groups. Spearman correlation analysis was used for analyzed the association among sex hormones and glucose, lipid and uric acid metabolism and other related indicators. Results（1） There were significant differences in hormones and metabolic parameters between obese group and non-obese group （all P〈0.05）. The fasting insulin （FINS） in OH, HP and OHP group was significantly higher than that in control group [（20±13）, （21±13）, （22±15） vs （15±10） mU/L, all P〈0.05]. The serum FINS level in OHP group was significantly higher than that in OP group [（22±15） vs （17±12） mU/L, P〈0.05]. Homeostasis model assessment-insulin resistance （HOMA-IR） in OHP group was significantly higher than that in control group （5.2±3.9 vs 3.4±2.4, P〈0.05）. （2） The serum level of high density lipoprotein-cholesterol （HDL-C） in OH group, HP group and OHP group was significantly lower than that in control group. The serum level of low density lipoprotein-cholesterol （LDL-C） in HP group was significantly higher than that in control group and OP group （all P〈0.05）. （3） The differences in BMI, FINS, postprandial insulin, HOMA-IR, HDL-C and sex hormone binding globulin （SHBG） between HA group and non-HA group[（28±6） vs （26±6） kg/m2, （22±14） vs （17±12） mU/L, （153±111） vs （121±88） mU/L, 5±4 vs 4±3, （1.1±0.3） vs （1.2±0.3） mmol/L, （22±13） vs （41±23） nmol/L, t=-2.805-3.891] were significant （all P〈0.05）. （4） SHBG was negatively correlated with fasting plasma glucose, FINS, HOMA-IR, serum uric acid （SUA）, triglyceride （TG） , LDL-C （r=-0.233--0.147, all P〈0.05）, and was positively correlated with HDL-C （r=0.384, P〈0.001）. Free androgen index was positively correlated with FINS, HOMA-IR, SUA, TG （r=0.143-0.231, all P〈0.05）, and was negatively correlated with HDL-C （r=-0.160, P=0.012）. ConclusionHyperandrogenism and obesity may increase the risk of endocrine and metabolic disorders in PCOS patients. PCOS patients with different clinical phenotypes have different endocrine and metabolic characteristics.