Tactics of preparation for pregnancy of patients with hyperandrogenia

For unclear clinical data, if suspected of hyperandrogenism, it is necessary to conduct a test with ACTH (synakten depot). Inadequate increase in cortisol, DEA and 17OP indicates a latent, nonclassical form of adrenogenital syndrome.

Adrenal hyperandrogenism

On tests of functional diagnostics:

• NLF in alternation with anovulation;
• Infection, as the cause of miscarriage and NLF, is excluded;
• No intrauterine synechia;
• Features karyotype may or may not be;
• There is no HLA compatibility;
• No autoimmune disorders;
• According to the US, the ovaries have not changed;
• There is an android type of body structure, broad shoulders, narrow thighs, there is hirsutism;
• Hormonal parameters reveal an increase in the level of 17KS (sometimes only in the II phase of the cycle), DEA-C, 17OP increased or these indicators at the upper limit of the norm;
• In the anamnesis - undeveloped pregnancies.

In this situation, it is necessary to clarify the source of hyperandrogenism. To conduct a test with dexamethasone - lowering the levels of 17KS, 17-OP and DEA-C by 80-90% means that the source of androgens is the adrenal glands.

When establishing the diagnosis of adrenal hyperandrogenism, preparation for pregnancy consists in prescribing dexamethasone in a dose of 0.125 mg to 0.5 mg under the control of 17KS in urine or 170P and DEA-C in the blood. In most patients after the onset of dexamethasone, the menstrual cycle normalizes, normal ovulation and pregnancy are observed (often with dexamethasone test). Together with dexamethasone, metabolic therapy complexes or vitamins for pregnant women with an additional tablet of folic acid are prescribed.

In the absence of pregnancy for 2-3 cycles, one can stimulate ovulation with clostilbehyde or clomiphene at a dose of 50 mg from the 5th to the 9th day of the cycle with dexamethasone.

An alternative method of preparing for pregnancy can be giving a contraceptive with an antiandrogenic effect - Diana-35 for two or three cycles. And in the cycle, when pregnancy is planned, - dexamethasone from the 1st day of the cycle.

According to research, in 55% of patients with adrenal hyperandrogenism, the pregnancy occurred only on the background of treatment with dexamethasone. The duration of rehabilitation therapy averaged 2.4 cycles. In pregnancy, all patients with adrenal hyperandrogenia should continue taking dexamethasone in an individually selected dose, which usually does not exceed 0.5 mg (usually 1/2 or 1/4 tablet).

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Preparation for pregnancy of patients with ovarian form of hyperandrogenia

• In the anamnesis: later menarche, violation of the menstrual cycle by the type of oligomenorrhea primary, or secondary, often secondary amenorrhea. Pregnancy is rare and interrupted by the type of undeveloped pregnancy, between pregnancies, long periods of infertility;
• In tests of functional diagnostics, mainly anovulation and very rarely ovulatory cycles with NLF;
• Hirsutism, acne, striae, peculiarities of pigmentation, timbre of voice, features of morphometry, high body mass index are noted;
• When hormonal study there is an increased level of testosterone, often elevated levels of LH and FSH, the ratio of LH / FSH is more than 3; the level of 17KS is increased;
• With ultrasound, polycystic ovaries are detected;
• Infection is excluded, or cured. Given that 2/3 of patients with hyperandrogenia have an ischemic-cervical insufficiency during pregnancy, the issue of endometrial infection for them is extremely relevant;
• No autoimmune disorders;
• There is no HLA compatibility;
• Features karyotype may not be.

To clarify the genesis of hyperandrogenism, it is advisable to carry out a combined functional test with dexamethasone and HC. The test is based on direct stimulation of the chorionic gonadotropin function of the ovaries producing androgens with the simultaneous action of dexamethasone on the pituitary-adrenal system. Dexamethasone is prescribed for 0.5 mg 4 times a day for 3 days from the 6th day of the menstrual cycle. Then, in the next 3 days, concomitantly with the administration of dexamethasone at the same dose, intramuscular chorionic gonadotropin is administered at a dose of 1500-3000 IU. Determination of androgen content is carried out on the 5th day of the cycle (background), the 8th day after the application of dexamethasone and the 11th day of the cycle after the administration of the chorionic gonadotropin. In the ovarian form of hyperandrogenism, there is an increase in androgen levels after the administration of chorionic gonadotropin.

Preparation for pregnancy begins with the appointment of gestagens in the II phase of the cycle. Due to the fact that Dufaston and Utrozestan do not suppress their own ovulation, their use is preferable to other progestogens. According to studies, gestagens, suppressing LH, reduce the level of androgens. Another opinion is expressed by Hunter M. Et al. (2000) - that gestagens do not reduce the level of androgens, but contribute to the secretory transformation of the endometrium.

Duphaston in a dose of 10 mg 2 times a day, Utrozestan 100 mg 2 times a day is prescribed from the 16th day of the cycle for 10 days, 2-3 consecutive cycles under the control of the basal temperature charts. Then, dexamethasone is administered at a dose of 0.5 mg to normalize the level of COP. It should be noted that the level of testosterone in the appointment of dexamethasone does not change. Dexamethasone reduces the level of adrenal androgens, reducing their overall effect. In the next cycle (if pregnancy has not come), stimulation of ovulation with clostilbehyde in a dose of 50 mg is carried out from the 5th to the 9th day of the cycle. In the next cycle, if there is no pregnancy, the dose can be increased to 100 mg and repeat the stimulation of another 2 cycles. In this case, in the second phase of the cycle, again assign progesterone derivatives. When treating clostilbehide, folliculogenesis control is necessary:

• with ultrasound on the 13-15 day of the cycle, the dominant follicle is marked - not less than 18 mm, the thickness of the endometrium is not less than 10 mm;
• according to the rectal temperature schedule - two-phase cycle and the second phase is not less than 12-14 days;
• The level of progesterone in the middle of the second phase is more than 15 ng / ml.

Preparation for pregnancy of patients with a mixed form of hyperandrogenism

The mixed form of hyperandrogenism is extremely similar to the ovarian form of hyperandrogenism, but under hormonal research, it is determined:

• increased level of DEA;
• moderate hyperprolactinemia;
• there is no reliable increase in 17OP;
• the level of 17C was increased only in 51.3% of patients;
• increased levels of LH, lowered FSH;
• with an ultrasound of 46.1%, a typical picture of polycystic ovaries is noted, in 69.2% - small-cystic changes;
• at the raised or increased level 17KS it is marked girsutizm, excess of mass of a body (BMI - 26,5 + 07);
• at a dexamethasone test with HG a mixed source of hyperandrogenism is noted, a tendency to increase in 17C, a significant increase in testosterone and 17ОП after stimulation of CG on the background of dexamethasone suppression.

In patients with a mixed form of hyperandrogenism, stressful situations, head trauma, and encephalograms are frequently observed in the history of changes in the bioelectrical activity of the brain. These patients are characterized by hyperinsulinemia, lipid metabolism disorders, increased blood pressure.

Hyperinsulinemia often leads to the development of type II diabetes (diabetus mellitus).

Preparation for pregnancy in women with mixed genesis of hyperandrogenism begins with a decrease in body weight, normalization of lipid, carbohydrate metabolism, diet, exercise days, exercise, sedative (peritol, diphenin, rudotel). Useful sessions of acupuncture. During this stage of preparation for pregnancy, it is advisable to prescribe oral contraceptives such as Diana-35, to treat hirsutism.

At a normal level of glucose, insulin, lipids, it is advisable to administer gestagens in the second phase of the cycle against the background of taking 0.5 mg of dexamethasone, then stimulating ovulation with clostilbehyde. With an increased level of prolactin in the scheme of ovulation stimulation, we include parlodel from 10 to 14 day of the cycle at a dose of 2.5 mg 2 times a day. In the absence of the effect of therapy, in the case of non-pregnancy, similar therapy is performed no more than 3 cycles, and then can be recommended for the surgical treatment of polycystic ovaries.

When preparing for pregnancy, regardless of the form of hyperandrogenism, it is recommended that metabolic therapy complexes be prescribed. This is necessary due to the fact that glucocorticoids even in small doses have an immunosuppressive effect, and most patients with habitual miscarriage, regardless of its genesis, are virus carriers. To prevent the exacerbation of a viral infection with dexamethasone, it is advisable to use metabolic therapy complexes that, when removing tissue hypoxia, interfere with viral replication. According to our data, as a result of preparation, pregnancy occurred in 54.3% of patients. The duration of preparation averaged 6.7 cycles.