Polycystic Ovary Syndrome: A Diagnostic Challenge

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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

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    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

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