Association between ovarian volume and serum insulin levels in ovulatory patients with idiopathic hirsutism

Polycystic ovary syndrome: reviewing diagnosis and management of metabolic disturbances

Polycystic ovary syndrome (PCOS) is a common condition in women at reproductive age associated with reproductive and metabolic dysfunction. Proposed diagnosed criteria for PCOS include two out of three features: androgen excess, menstrual irregularity, and polycystic ovary appearance on ultrasound (PCO), after other causes of hyperandrogenism and dysovulation are excluded. Based on these diagnostic criteria, the most common phenotypes are the "classic PCOS"--hyperandrogenism and oligomenorrhea, with or without PCO; the "ovulatory phenotype"--hyperandrogenism and PCO in ovulatory women; and the "non-hyperandrogenic phenotype", in which there is oligomenorrhea and PCO, without overt hyperandrogenism. The presence of obesity may exacerbate the metabolic and reproductive disorders associated with the syndrome. In addition, PCOS women present higher risk for type 2 diabetes and higher prevalence of cardiovascular risk factors that seems to be associated with the classic phenotype. The main interventions to minimize cardiovascular and metabolic risks in PCOS are lifestyle changes, pharmacological therapy, and bariatric surgery. Treatment with metformin has been shown to improve insulin sensitivity, lowering blood glucose and androgen levels. These effects are more potent when combined with lifestyle interventions. In conclusion, besides reproductive abnormalities, PCOS has been associated to metabolic comorbidities, most of them linked to obesity. Confounders, such as the lack of standard diagnostic criteria, heterogeneity of the clinical presentation, and presence of obesity, make management of PCOS difficult. Therefore, the approach to metabolic abnormalities should be tailored to the risks and treatment goals of each individual woman.

Follicle number, not assessments of the ovarian stroma, represents the best ultrasonographic marker of polycystic ovary syndrome

OBJECTIVE

To compare the diagnostic potential of ultrasonographic markers of ovarian morphology, used alone or in combination, to predict polycystic ovary syndrome (PCOS).

DESIGN

A diagnostic test study using cross-sectional data collected from 2006-2011.

SETTING

Academic hospital and clinical research unit.

PATIENT(S)

Eighty-two women with PCOS and 60 healthy female volunteers.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Follicle number per ovary (FNPO), ovarian volume (OV), follicle number per single cross-section (FNPS), follicle distribution pattern, stromal area, ovarian area, stromal-to-ovarian area ratio (S:A), and stromal index (SI).

RESULT(S)

Follicle number per ovary best predicted PCOS (R(2) = 67%) with 85% sensitivity and 98% specificity, followed by OV (R(2) = 44%), and FNPS (R(2) = 36%). Neither S:A nor SI had predictive power for PCOS. In combination, FNPO+S:A and FNPO+SI most significantly predicted PCOS (R(2) = 74% vs. 73%, respectively). The diagnostic potentials of OV and FNPS were substantially improved when used in combination (OV+FNPO, R(2) = 55%).

CONCLUSION(S)

As a single metric, FNPO best predicted PCOS. Although the addition of S:A or SI improved the predictive power of FNPO, gains were marginal, suggesting limited use in clinical practice. When image quality precludes a reliable estimation of FNPO, measurements of OV+FNPS provide the next closest level of diagnostic potential.

Androgenicity and venous endothelial function in post-menopausal women

BACKGROUND

Endothelial dysfunction is one of the early signs of cardiovascular damage. High androgen levels have been related to inflammatory endothelial markers in pre- and post-menopausal women.

AIM

This cross-sectional study aimed at investigating whether free androgen index (FAI) [estimated by dividing total testosterone (nmol/l) by SHBG (nmol/l) x 100] is related to endothelial function during post-menopause.

SUBJECTS AND METHODS

Twenty-six post-menopausal women were assessed with the dorsal hand vein compliance technique. Acetylcholine (Ach) and sodium nitroprusside (SNP) dose-response curves were constructed to test endothelium-dependent and independent relaxation, respectively.

RESULTS

Mean age was 54 yr (+/-4) and median time since menopause was 6 yr (interquartile range: 3-9). Patients were stratified according to FAI levels into two groups: FAI greater than or less than the group median of 2.5. Waist-to-hip ratio (WHR) was significantly higher in the group with FAI>2.5, as well as median dose of Ach for maximal vasodilation [720 (360-3600) ng/min with FAI>2.5 vs 36 (0.36-360) ng/min with FAI<or=2.5; p=0.005]. Maximal vasodilation with SNP was similar in both groups. Positive correlations were observed between Ach doses and maximal vasodilation and FAI (r=0.473, p=0.015), waist (r=0.510, p= 0.011), and WHR (r=0.479, p=0.021). SHBG was negatively correlated with Ach doses (rs=-0.400, p=0.043).

CONCLUSIONS

This study suggests that FAI, even within normal limits, is related to early changes in endothelial function in healthy post-menopausal women. Longitudinal studies are required to determine the clinical relevance of these findings.

Hirsutism: investigation and management

In all hirsute women, a careful diagnostic evaluation should be performed, and the findings will largely influence the therapeutic decisions and the follow-up of the patients. An assay of serum 17-OH progesterone is needed, while the measurement of total testosterone and sex hormone-binding globulin, with the calculation of free androgen index, are useful to assess androgen secretion. Other tests should be suggested only according to responses of specific clinical questions. Owing to their high cardiovascular and metabolic risk, patients with polycystic ovary syndrome should have an oral glucose-tolerance test and a complete lipid profile. No ideal treatment for hirsutism exists but, with careful combination of pharmacological treatments and direct hair removal, it is generally possible to obtain a prolonged improvement of hirsutism.

Mild androgen phenotypes

Mild androgen phenotypes are found in 30-40% of patients referred to an endocrine clinic because of suspected hyperandrogenic syndrome. These disorders are characterized by clinical or biological signs of hyperandrogenism in women with normal ovulatory menstrual cycles. Three main mild androgen disorders may be distinguished: ovulatory polycystic ovarian syndrome (PCOS), idiopathic hyperandrogenism, and idiopathic hirsutism. Ovulatory PCOS includes ovulatory hyperandrogenic patients presenting with polycystic ovaries. Using ESHRE/ASRM criteria for diagnosis of PCOS, this disorder is now part of PCOS spectrum. While in vivo and in vitro studies have confirmed the similarities between the two forms of PCOS, ovulatory PCOS presents clinicians with some unique problems. In fact, fertility is not a problem, but insulin resistance is present, and although milder than in classic PCOS it may be associated with an increased cardiovascular and metabolic risk. Because of this, an ovarian sonography should be performed in all ovulatory hyperandrogenic patients, and when polycystic ovaries are found cardiovascular and metabolic risk should be carefully evaluated. Ovulatory PCOS patients with altered glucose tolerance and/or with dyslipidaemia may need treatment with insulin-sensitizing agents. Idiopathic hyperandrogenism regroups ovulatory patients with increased androgen levels and normal ovaries, while idiopathic hirsutism includes ovulatory patients presenting with hirsutism but normal circulating androgens and normal ovaries. The differentiation between these two disorders may be difficult because commercial assays of androgen levels are generally unreliable. While idiopathic hyperandrogenism may be associated with insulin resistance, neither disorder is associated with an increased cardiovascular risk. The main clinical problem is hirsutism, and this may be approached by aesthetic or pharmacological therapies.

Determinants of ovarian volume in pre-, menopausal transition, and post-menopausal women: a population-based study

OBJECTIVE

To verify the association of smoking, parity, body mass index, use of oral contraceptives, and hormone therapy with ovarian volume in pre-, menopausal transition, and post-menopausal women from southern Brazil.

METHODS

Cross-sectional study with 273 women aged 36-62 years, representative of the urban population of Passo Fundo, southern Brazil. Participants completed an in-home interview and had their anthropometric measurements and ultrasound exams performed at a clinical center, using a standardized method. The right and left ovaries were measured by ultrasound. Mean ovarian volume was calculated according to age, menopausal status, smoking habit, parity, body mass index (BMI), use of oral contraceptives (OC), and hormone therapy (HT).

RESULTS

Ovarian volume decreased after the age of 44 years when adjusted for menopausal status and OC use (p = 0.010). The mean ovarian volume decreased with menopausal status adjusted for age (p = 0.001) and with current OC use, adjusted for age (p = 0.001). There was a positive association between ovarian volume and BMI>or=30 in every woman adjusted for menopausal status and age (p = 0.005). On the other hand, there was no association with smoking, past OC use, and HT. In a linear regression model, post-menopause, menopausal transition, age, and BMI were significantly and independently associated with ovarian volume.

CONCLUSION

Ovarian volume decreases with menopausal transition and even more in post-menopause. The reduction of ovarian volume also occurred with aging and OC use. Ovarian volume, however, is positively associated with obesity. Smoking, parity, and hormone treatment do not affect ovarian volume in pre-, menopausal transition, and post-menopausal women.