Polycystic Ovary Syndrome: A Diagnostic Challenge
Section snippets
HISTORICAL PERSPECTIVE
Stein and Leventhal78 reported on seven women with polycystic ovaries and amenorrhea in 1934 in an article that has become a classic description of the syndrome that eventually bore their name. In six of the seven women, menstrual problems started around the time of menarche, with irregularity progressing to amenorrhea. Five of the women were infertile. Hyperandrogenism and obesity were common findings. After conservative therapies failed, the women underwent laparotomy, which revealed enlarged
CLINICAL PRESENTATION
The classic symptoms of amenorrhea, infertility, hirsutism, and obesity do not all need to be present to suspect a diagnosis of polycystic ovary syndrome (PCOS). Although considerable controversy remains concerning the definition of PCOS, several investigators have used a working definition from a 1990 National Institutes of Health/National Institute of Child Health and Human Development (NIH/NICHHD) conference.96 To fit this definition, a patient must have ovulatory dysfunction and evidence of
BIOCHEMICAL DESCRIPTION
Hyperandrogenism is central to the diagnosis of PCOS. Venous catheterization studies and dexamethasone suppression tests have demonstrated that the ovaries are the primary source of androgens in women with clinical PCOS.89 Although the fundamental pathophysiologic defect in PCOS is not known, identified disturbances in gonadotropins and reduced insulin sensitivity contribute to a tendency toward overproduction of androgens. Abnormal androgen clearance rates have been identified, particularly
POLYCYSTIC OVARY SYNDROME IN REAL TIME
Historically, many of the studies on PCOS women included surgical confirmation of the diagnosis (e.g., culdoscopy, laparoscopy, or wedge resection).42, 72, 93 Early ultrasonography with contact B-scanners was too crude to detect the ovarian morphology associated with PCOS. With the advent of real-time sector scanners, particularly transvaginal scanners, it became possible to obtain a picture of the polycystic ovary by noninvasive means. Indeed, the ultrasound presentation appeared remarkably
ROLE OF EXCUSION IN DIAGNOSIS
The NIH/NICHHD definition of PCOS stipulates that other diseases that can cause hyperandrogenism and ovulatory dysfunction must be excluded.96 Clinicians who espouse the use of ultrasound agree.38 Although PCOS is the most common cause of menstrual abnormalities and hyperandrogenism, a variety of diseases can be confused with the disorder, and it is especially important to be aware of the most serious of these conditions.
Androgen-producing tumors of the ovary, as well as human chronic
SUMMARY
Polycystic ovary syndrome remains a diagnostic challenge because there is no single defining test. The clinical presentation must dictate the extent of the work-up. The typical PCOS patient has a history of irregular menses and appears hirsute. Demonstration of ovulatory dysfunction and hyperandrogenism can also be made by appropriate hormonal measurements. An ultrasound showing multiple small ovarian follicles can support a diagnosis of PCOS in the patient for whom the clinical diagnosis has
References (96)
- et al.
Multifollicular ovaries: Clinical and endocrine features and response to pulsatile gonadotropin releasing hormone
Lancet
(1985) - et al.
Prevalence of hyperandrogenemia among nonhirsute oligo-ovulatory women
Fertil Steril
(1997) - et al.
Screening for 21-hydroxylase–deficient nonclassic adrenal hyperplasia among hyperandrogenic women: A prospective study
Fertil Steril
(1999) - et al.
Role of the ovary in the adrenal androgen excess of hyperandrogenic women
Fertil Steril
(1998) - et al.
Idiopathic hirsutism: An uncommon cause of hirsutism in Alabama
Fertil Steril
(1998) - et al.
Hyperandrogenism, insulin resistance, and acanthosis nigricans syndrome: A common endocrinopathy with distinct pathophysiollogic features
Am J Obstet Gynecol
(1983) - et al.
The role of color Doppler imaging in the diagnosis of polycystic ovary syndrome
Am J Obstet Gynecol
(1995) - et al.
Relation of luteinizing hormone levels to body mass index in premenopausal women
Fertil Steril
(1998) - et al.
Measurement of total serum testosterone levels using commercially available kits: High degree of between-kit variability
Fertil Steril
(1998) - et al.
Does ethnicity influence the prevalence of adrenal hyperandrogenism and insulin resistance in polycystic ovary syndrome?
Am J Obstet Gynecol
(1992)
Hereditary factors in Stein Leventhal syndrome
Am J Obstet Gynecol
Women with polycystic ovary syndrome wedge resected in 1956 to 1965: A long-term follow-up focusing on natural history and circulating hormones
Fertil Steril
Correlation of the ultrasonic appearance of the ovaries in polycystic ovarian disease and the clinical, hormonal, and laparoscopic findings
Am J Obstet Gynecol
Serum testosterone concentrations in the evaluation of androgen-producing tumors
Am J Obstet Gynecol
Clinical and biochemical features of polycystic ovarian disease
Fertil Steril
Vulvar acanthosis nigricans: A marker for insulin resistance in hirsute women
Fertil Steril
Hirsutism: Implications, etiology, and management
Am J Obstet Gynecol
Transvaginal three-dimensional ultrasound: Reproducibility of ovarian and endometrial volume measurements
Fertil Steril
Polycystic ovary syndrome: Current and future treatment paradigms
Am J Obstet Gynecol
Is the inappropriate gonadotropin secretion of patients with polycystic ovary syndrome similar to that of patients with adult-onset congenital adrenal hyperplasia?
Fertil Steril
The control of bioactive luteinizing hormone secretion in women with polycystic ovary syndrome
Am J Obstet Gynecol
Clinical and hormonal studies in hyperthecosis of the ovaries
Fertil Steril
Increased expression of messenger ribonucleic acid encoding cytochrome P450 cholesterol side-chain cleavage and P450 17-alpha-hydroxylase enzymes in ovarian hyperthecosis
Fertil Steril
Hyperinsulinemia in hyperthecosis of the ovaries
Am J Obstet Gynecol
Polycystic ovaries—a common finding in normal women
Lancet
The difference in miscarriage rates between menotropin-induced and natural cycle pregnancies is not surveillance related
Fertil Steril
Ultrasound assessment of ovarian stroma hypertrophy in hyperandrogenism and ovulation disorders: Visual analysis versus computerized quantification
Fertil Steril
Amenorrhea associated with bilateral polycystic ovaries
Am J Obstet Gynecol
Prevalence of acanthosis nigricans in an unselected population
Am J Med
Polycystic ovary syndrome
Endocrinol Metab Clin North Am
Classification of normogonadotropic infertility: Polycystic ovaries diagnosed by ultrasound versus endocrine characteristics of polycystic ovary syndrome
Fertil Steril
Warning on serum testosterone measurement [letter]
Lancet
Androgen parameters and their correlation with body weight in one hundred thirty-eight women thought to have hyperandrogenism
Am J Obstet Gynecol
Prevalence of polycystic ovaries in women with anovulation and idiopathic hirsutism
BMJ
Inappropriate gonadotropin secretion in polycystic ovary syndrome: Influence of adiposity
J Clin Endocrinol Metab
Clinical review 56. Nonclassic adrenal hyperplasia: Current concepts
J Clin Endocrinol Metab
Polycystic ovary syndrome: The spectrum of the disorder in 1741 patients
Hum Reprod
Ovarian hyperthecosis, diabetes and hirsuties in postmenopausal women
Clin Endocrinol
Ovarian stromal echogenicity in women with normal and polycystic ovaries
Hum Reprod
Endocrine abnormalities in ovulatory women with polycystic ovaries on ultrasound
Hum Reprod
Steroid secretion in polycystic ovarian disease after ovarian suppression by a long-acting gonadotropin-releasing hormone agonist
J Clin Endocrinol Metab
Heterogeneity of the polycystic ovary syndrome: Clinical, endocrine and ultrasound features in 556 patients
Clin Endocrinol
Virilizing adrenal carcinoma in a woman of reproductive age: A case presentation and literature review
Am J Obstet Gynecol
Chronic anovulation syndrome and associated neoplasia
Obstet Gynecol
Identification of virilizing adrenal tumors in hirsute women
N Engl J Med
A survey of the polycystic ovary syndrome in the Greek island of Lesbos: Hormonal and metabolic profile
J Clin Endocrinol Metab
Surgically induced ovulation in the polycystic ovary syndrome: Wedge resection revisited in the age of laparoscopy
Fertil Steril
Acanthosis nigricans, insulin action, and hyperandrogenism: Clinical, histological, and biochemical findings
J Clin Endocrinol Metab
Cited by (20)
Childhood obesity, nutrition and metabolic health
2005, Food, Diet and ObesitySurgical treatment of extreme obesity
2003, Primary Care Update for Ob/GynsEndocrine autoimmune diseases and female infertility
2014, Nature Reviews EndocrinologyMenstrual dysfunction in rural young women and the presence of polycystic ovarian syndrome
2010, Journal of Obstetrics and Gynaecology
Address reprint requests to Vivian Lewis, MD, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, University of Rochester, 601 Elmwood Avenue, Box 668, Rochester, NY 14642, e-mail: [email protected]
- *
Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, University of Rochester School of Medicine and Dentistry, Rochester, New York