Das polyzystische Ovarsyndrom

Ohne Zusammenfassung     

Endokrine Krankheitsbilder im Jugendalter

Zusammenfassung Die endokrinen Krankheitsbilder im Jugendalter sind am häufigsten durch eine primäre oder sekundäre Amenorrhö gekennzeichnet. Die Diagnostik umfasst neben dem Ausschluss einer genitalen Fehlbildung bei der primären Amenorrhö die Bestimmung von LH, FSH, E2, Testosteron, DHEA-S, Prolaktin und TSH. Eine Analyse des Chromosomensatzes ist bei allen Formen der hypergonadotropen Amenorrhö und bei nicht eindeutig zu klassifizierenden Krankheitsbildern erforderlich. Mehr als 90% der Störungen lassen sich so erkennen. Finden sich genetische Defekte oder eine komplette Gonadendysgenesie, werden sich neben einer Substitutionstherapie mit Hormonersatzpräparaten Fragen zu einer möglichen Eizellspende im Ausland stellen. Das Syndrom der polyzystischen Ovarien (PCOS) ist bereits im Jugendalter die häufigste Form der sekundären Amenorrhö. Das Risiko eines metabolischen Syndroms mit Insulinresistenz, Diabetes mellitus, Hypertonus, Adipositas, kardiovaskulären und onkologischen Erkrankungen ist erhöht. Präventiv wichtig sind Gewichtsnormalisierung, der Einsatz von Insulinsensitizern und antiandrogenen Ovulationshemmern. Der sekundäre hypogonadotrope Hypogonadismus findet sich typischerweise bei Mädchen mit Essstörungen, in chronischen Stresssituationen und bei Leistungssportlerinnen. Die Prognose hinsichtlich späterer Fertilität ist bei Überwindung der auslösenden Faktoren gut.     

Ovarialtumoren im Kindes- und Jugendalter

Zusammenfassung Ovarialmalignome im Kindes- und Jugendalter müssen anders eingesch?tzt werden als Ovarialkarzinome bei der erwachsenen Frau. Die hohe Sensibilit?t der mal. Keimzelltumoren gegenüber den genannten Chemotherapeutika er?ffnet die M?glichkeit der Prim?roperation unter m?glichst konservativen Gesichtspunkten. Eine Strahlentherapie kommt lediglich beim Dysgerminom in Frage. In jedem Fall mu? der Therapieerfolg durch Second-look-Operation gesichert werden.     

Syndrom polyzystischer Ovarien und Adipositas im Jugendalter

Nearly 20% of the adolescent females in Germany are overweight. A typical comorbidity of overweight is polycystic ovary syndrome (PCOS). The diagnosis of PCOS in adolescents needs to be based on the criteria hyperandrogenemia and/or hirsutism as well as oligomenorrhea or amenorrhea. All other diseases with hyperandrogenism need to be excluded. PCOS is caused, among other things, by insulin resistance, which is increased particularly in central obesity. Therefore, other diseases associated with insulin resistance such as metabolic syndrome, type 2 diabetes mellitus, or fatty liver are frequent in girls with PCOS. The treatment of choice for obesity and PCOS is weight reduction, which is difficult to achieve in clinical practice. Drug treatment for hirsutism or menstrual irregularities depends on the accompanying risk factors.     

Bakterielle und virale Vulvaerkrankungen im Kindes- und Jugendalter

Bacterial and viral infections of the vulva and the perianal region are the most frequent genital disorders in pediatric gynecology. The typical symptoms of vulvitis are redness, itching and burning as a result of poor genital hygiene, but the inflammatory reaction of the vulva can also be concomitant with respiratory infections. Recurrent inflammation leads to synechia of the labia minora, a condition, which induces urethro-vaginal reflux. This, in turn, increases the irritation of the vulva. Itching and burning are also typical symptoms for lichenificaton of the vulva. Juvenile lichen sclerosus is characterized by a high rate of spontaneous remission in puberty, but in childhood the lesions remain symptomatic, presenting cutaneous atrophy with white discoloration, fissures and edema as well as scratches with microbial superinfection. Condylomata acuminata and vulva papillomatosis in childhood are primarily induced by HPV 6 and 11. Recent studies have improved our understanding of the possible transmission routes of the human papilloma virus during insemination, pregnancy, the post-natal period and childhood.     

Sexualdelikt und sexueller Missbrauch im Kindes- und Jugendalter

As experience shows, the gynecological examination makes only a poor contribution to serve as evidence of childhood sexual abuse. The integrity of the genital structures does not lock out sexual offense, as sexual activities often do not leave a mark sign: at least 30% of provable abused children had insuspect anatomic findings. According to these facts, the child has to be examined carefully, its body, the external genitals, i. e. vulva, vestibulum, hymen and the perianal region. The medical investigation has to be exactly documented with the use of photographs in case of suspicious findings, with consideration of the child's age, the number of episodes, the interval between sexual abuse and gynecological examination. A qualified expert opinion can only be delivered, when the investigator has knowledge about physiological variability and the abnormal alterations of infant's genital anatomy. Sexual abuse can only be proved with the detection of sperm or a bite injury in the genital region. The detection of sperm is time-limited and the event of the sexual assault often does not correspond with the time of gynecological examination. In puberty the physiological stretching of the hymen has to be considered. The coitus could have taken place without any alteration, when the hymen is low-structured and under high oestrogenic influence. Competent cooperation between pediatric psychologists, pediatricians and pediatric gynecologists is indispensable in the detection of sexual abuse in children.     

Polyzystisches Ovarsyndrom

Polycystic ovarian syndrome, with a prevalence of 5–10% the most common endocrinopathy in women of reproductive age, is more than a cosmetic or fertility problem. Due to its long-term consequences it poses a severe health problem. As insulin resistance is the core pathophysiology of PCOS, it is associated with the metabolic syndrome (diabetes mellitus type II, dyslipidemia, hypertension, and atherosclerosis). The risk of myocardial infarction, stroke, or peripheral arterial occlusion is increased. In pregnant PCOS women the rate of spontaneous abortions as well as the risk of developing gestational diabetes is higher. In the treatment of PCOS the collaboration of gynecology and internal medicine is necessary. A change of lifestyle with healthy food and more physical exercise as well as the use of oral antidiabetic drugs are discussed.     

Polyzystisches Ovarsyndrom

Polycystic ovarian syndrome (PCOS) has a prevalence of 3–5%. Its typical features include oligo-/amenorrhea combined with hyperandrogenemia or hyperandrogenism. Regarding differential diagnosis adrenal enzyme defects as well as Cushing’s syndrome must be excluded. The oral glucose tolerance test with parallel insulin measurement is essential in daily clinical practice to evaluate insulin resistance. In cases of predominantly cosmetic problems without fertility problems, oral contraceptives can be used. In infertility patients suffering from PCOS the lean, oligomenorrheic patient can start directly with ovarian stimulation using clomiphene citrate. In all other patients, the option of metformin should be evaluated on an individual basis, and contraindications for metformin therapy must be excluded. Weight reduction and sports are essential components of the treatment concept, since they improve the conditions for becoming pregnant.     

Ernährungsempfehlungen beim polyzystischen Ovarsyndrom

Improving insulin sensitivity and reducing hyperinsulinemia are essential parts of treatment for polycystic ovary syndrome (PCOS). Many PCOS patients feature the metabolic syndrome which predicts gestational diabetes and type 2 diabetes, cardiovascular disease (CVD), and certain cancers. First-line therapy for PCOS in overweight patients is weight loss. This is accompanied by an increase in insulin sensitivity and an improvement of hormonal and metabolic abnormalities. As weight loss strategies show poor compliance and little long-term effects, dietary modifications that enable these improvements without weight loss need to be considered. Low-fat, high-carbohydrate diets not only induce high glycemic and insulinemic responses but also worsen dyslipidemia. In contrast a “low glycemic and insulinemic diet” (LOGI) which focuses on the quality of carbohydrates and a reduction of carbohydrate intake improves hormonal and metabolic abnormalities even in the absence of weight loss.     

Das Mikrobiom im Kontext von Endokrinologie und Reproduktion

Gynäkologische Endokrinologie -     

Polyzystisches Ovarsyndrom (PCOS) bei Jugendlichen

Zusammenfassung Das polyzystische Ovarsyndrom (PCOS) wird bei Jugendlichen oft übersehen. Die typischen Befunde wie Androgenisierungserscheinungen, Hyperinsulinämie oder Zyklusstörungen werden oft auch im Rahmen der normalen pubertären Entwicklung gesehen. Risikofaktoren für eine spätere PCOS-Entwicklung sind ein niedriges Geburtsgewicht, eine prämature Pubarche und in der Pubertät persistierende Zyklusstörungen und Übergewicht. Vor allem wegen der möglichen Langzeitfolgen einer Insulinresistenz ist eine umfassende Diagnostik bei Jugendlichen notwendig. Die Therapie basiert in erster Linie auf der Einstellung auf antiandrogene Ovulationshemmer, bei Insulinstoffwechselstörungen ist eine Behandlung mit Metformin zu erwägen, auch wenn noch keine umfassenden Studien dazu vorliegen.     

Therapieoptionen bei polyzystischem Ovarsyndrom mit oder ohne Kinderwunsch

Polycystic ovary syndrome (PCOS) in one of the most common gynecological diseases in women and can influence several stages in a woman??s life. As PCOS patients suffer from a higher risk of developing diabetes mellitus, hypertension or endometrial carcinoma, a basic therapy is mostly indicated. This always includes a healthy and active lifestyle. Young patients without a desire for children should be offered an oral contraceptive, whereas for patients with an active wish for children, a fertility-promoting treatment is the therapy of choice. To increase fertility, pharmacological options range from the insulin sensitizer metformin or the selective estrogen receptor modulator clomifen to the follicular growth initiating gonadotropin follicle stimulating hormone (FSH). At the same time laparoscopic ovarian drilling (LOD) and in vitro maturation (IVM) offer non-pharmacological approaches. These therapeutic options can be combined after consultation with the patient.     

Das Recht auf Selbstbestimmung im Sterben hat seine Grenzen

A patient’s right to self-determination for practicing medical measures is extensive. Limitations exist, however, in borderline areas, e.g. in demanding active euthanasia by a doctor. This article discusses the penal limits of death on demand (§216 Penal Code), whereby criminally relevant behavior of a doctor is placed in contrast to a (still) permitted euthanasia. A special chapter deals with the limits of the right to self-determination for severely impaired newborns. Finally, reform attempts will be presented as long as these will lead to a strengthening of the right to self-determination of the patient for a dignified death.