Unilateral polycystic ovary. Case report

Unilateral ovarian enlargement in adolescents with polycystic ovary syndrome: a variant of bilateral disease

AIMS

To evaluate clinical, biochemical and radiological features in adolescent females with unilateral polycystic ovary (UniPCO) versus bilateral polycystic ovary (BiPCO) in patients with polycystic ovarian syndrome (PCOS), and to compare the association of insulin resistance (IR) and metabolic syndrome (MS) between the two groups.

SETTING

Pediatric endocrine clinic.

METHODS

A retrospective chart review of girls with the diagnosis of PCOS was performed. They were divided into two groups: PCOS with UniPCO and BiPCO.

RESULTS

No difference was seen between the two groups in regard to clinical parameters. LH/FSH ratio was significantly higher in patients with BiPCO. No difference was seen in free testosterone, lipids, MS or IR between groups. Ultrasound showed a mean ovarian volume of 13.2 +/- 1.5 ml on the affected side in UniPCO and 16.1 +/- 1.2 ml in BiPCO. Ovarian follicle location was mostly peripheral in both UniPCO and BiPCO. Multiple follicles were found in the majority of cases. IR and MS were present in 40% of girls with UniPCO and 38% and 23%, respectively, in girls with BiPCO.

CONCLUSION

UniPCO may be a forerunner of BiPCO and may represent an early point along the continuum. Later, the unaffected ovary continues to increase in volume, resulting in BiPCO. Metabolic abnormalities of patients with UniPCO highlights that as well as being a precursor of BiPCO, it also imparts considerable health risks.

The Pregnancy in Polycystic Ovary Syndrome study: baseline characteristics of the randomized cohort including racial effects

OBJECTIVE

To report the baseline characteristics and racial differences in the polycystic ovary syndrome (PCOS) phenotype from a large multicenter clinical trial (PPCOS).

DESIGN

Double-blind, randomized trial of three treatment regimens (with extended release metformin or clomiphene citrate).

SETTING

Academic medical centers.

PATIENT(S)

Six hundred twenty-six infertile women with PCOS, aged 18-39 years, with elevated T levels and oligomenorrhea (exclusion of secondary causes), seeking pregnancy, with > or = 1 patent fallopian tube, normal uterine cavity, and a partner with sperm concentration > or = 20 x 10(6)/mL in > or = 1 ejaculate.

INTERVENTION(S)

Baseline characterization.

MAIN OUTCOME MEASURE(S)

Historical, biometric, and biochemical measures of PCOS.

RESULT(S)

There were no significant differences in baseline variables between treatment groups. The overall mean (+/-SD) age of the subjects was 28.1 +/- 4.0 years, and the mean body mass index was 35.2 kg/m2 (+/-8.7). Polycystic ovaries (PCOs) were present in 90.3% of the subjects, and the mean volume of each ovary was 10 cm3 or more. Of the subjects, 7% had ovaries that were discordant for PCO morphology. At baseline, 18.3% of the subjects had an abnormal fasting glucose level (> 100 mg/dL). Asians tended to have a milder phenotype, and whites and African Americans were similar in these measures.

CONCLUSION(S)

The treatment groups were well matched for baseline parameters, and we have added further information to the PCOS phenotype.

Characterization of unilateral polycystic ovary compared with polycystic ovary syndrome

Twelve patients with unilateral polycystic ovarian morphology demonstrated milder degrees of ovarian and other endocrine dysfunction than polycystic ovary syndrome patients and had fewer incidences of hyperprolactinemia and hyperandrogenism.

Ultrasound evaluation of PCO, PCOS and OHSS

Polycystic ovary syndrome (PCOS) and the concomitant androgen excess may be particularly distressing and disruptive for women. Thus, PCOS requires a prompt diagnosis and adequate treatment. However, the criteria used for diagnosis and definition of PCOS are as heterogeneous as the pathology itself. The advent of ultrasonographic examination of the ovaries has provided the biggest single contribution to the diagnosis of PCOS, having a high concordance rate with laparoscopy and histological examination. In fact, the assessment of ovarian morphology by transvaginal ultrasound and Doppler flow analysis of both intra-ovarian and uterine arteries seems to provide an insight into the pathological state and the degree of progression of the disease, and may be useful in the prevention and management of ovarian hyperstimulation syndrome during ovarian stimulation.

Polycystic ovary syndrome: a new ultrasonographic and color Doppler pattern

The aim of this study was to evaluate whether patients with partial bilateral polycystic ovaries show different ovarian and uterine blood flow to those with complete bilateral polycystic ovaries, and to investigate whether there is a correlation between ultrasonographic and hormonal parameters. Fifteen patients with partial polycystic ovaries and eighteen patients with complete bilateral polycystic ovaries underwent clinical, biochemical, gray-scale and color Doppler ultrasonographic evaluation. Hormonal (luteinizing hormone (LH), follicle-stimulating hormone (FSH), LH/FSH concentration ratio, estradiol, prolactin, androstenedione, testosterone), clinical (body mass index, Ferriman-Gallwey score), ultrasonographic (ovarian volume, number and distribution of subcapsular follicles, stromal score) and Doppler (uterine artery and intraparenchymal vessels pulsatility index, ovarian stromal vascularization) parameters were evaluated, in the early follicular phase (cycle day 3-5) in oligomenorrheic patients, or at random in amenorrheic patients. Significantly higher androstenedione plasma levels and LH/FSH concentration ratios were observed in complete bilateral polycystic ovaries. In partial polycystic ovaries, gray-scale and color Doppler ultrasonography showed different features in affected and unaffected areas of the ovary, similar to polycystic and normal ovary appearance respectively. In conclusion, PCOS does not predetermine a single ultrasonographic or Doppler pattern.

How common are polycystic ovaries and the polycystic ovarian syndrome in women with Cushing's syndrome?

OBJECTIVE

Women with Cushing's syndrome (CS) may present with menstrual irregularity and symptoms/signs of hyperandrogenism, a phenotype similar to that of the polycystic ovarian syndrome (PCOS); however, currently there are no data on the prevalence of either polycystic ovaries (PCO) and/or PCOS in patients with CS. The aim of this study was to investigate their presence among women of reproductive age presenting with CS by analysing clinical, endocrinological and ultrasonographic features.

DESIGN

Prospective study of all women within the reproductive age (range 18-40 years) who presented with CS between August 1994 and January 2000.

SUBJECTS AND METHODS

Thirteen women (median age 32 years, range 18-39 years) with CS were evaluated. The diagnosis of CS was based on the presence of appropriate clinical features and an elevated serum midnight cortisol with failure to suppress 0900 hours serum cortisol to less than 50 nmol/l following a formal low-dose dexamethasone suppression test (LDDST). All women had their clinical features relevant to possible hyperandrogenism, menstrual disorder and infertility recorded, and circulating gonadotrophins, oestradiol, androgens and SHBG levels measured; ovarian ultrasonography was performed during their initial assessment. Relevant MR/CT imaging of the pituitary and/or adrenal glands was performed.

RESULTS

Eleven women had ACTH-dependent CS [nine Cushing's disease (CD), one ectopic ACTH syndrome due to a bronchial carcinoid, one periodic CS of unknown origin); two patients had ACTH-independent CS (adrenal adenomas). All women with CS had at least one symptom/sign of hyperandrogenism (13 hirsutism, seven acne, five male-pattern alopecia). Nine women (70%) had menstrual disturbances (four oligomenorrhoea, four amenorrhoea, one polymenorrhoea) while four women (30%) had a normal menstrual pattern. Serum oestradiol levels for the group as a whole were similar to those observed in the early follicular phase of normally menstruating women; however, seven women had low oestradiol, LH and FSH levels suggestive of hypogonadotrophic hypogonadism. Serum androgen levels (testosterone, androstendione and DHEAS), even in the presence of symptoms/signs of hyperandrogenism, were within the normal reference range but SHBG levels were uniformly decreased even in women with normal menstrual cycles. There was a negative correlation between urinary free cortisol, but not mean serum cortisol, and serum oestradiol, testosterone and SHBG levels (r = - 0.8, r = - 0.86 and r = - 0.66, P<0.02, P<0.01 and P<0.05, respectively), but not LH or FSH levels. Despite the fact that seven of these 13 patients lacked normal gonadotrophin stimulation, ovarian volumes of both ovaries were relatively preserved: right 7.3 ml, range 2.8-12.8 ml, and left 5.3 ml, range 2.3-13 ml. Women who were defined as oestrogen sufficient (E2 > 140 pmol/l) had higher serum androstenedione, and lower urinary free cortisol levels, than women who were oestrogen deficient (E2 < 140 pmol/l). Six of the 13 women (46%) had ovarian morphology suggestive of PCO, four of six oestrogen sufficient women and two of seven oestrogen deficient women. The results did not differ according to the underlying cause of CS.

CONCLUSIONS

PCO and PCOS are common in women with Cushing's syndrome; women with Cushing's syndrome and only moderately elevated cortisol secretion maintain gonadotrophin stimulation to the ovary with normal oestradiol levels, in contrast to women with Cushing's syndrome and higher cortisol secretion who develop hypogonadotrophic hypogonadism. However, even in the latter group, high ovarian volumes were maintained and some had ovarian morphology suggestive of PCO.

Ultrasound diagnosis of polycystic ovaries

Ultrasound characterization of ovarian morphology has become an important aspect of gynecological endocrinology. The classic ultrasound features of polycystic ovaries are an increased number of small follicles together with abundant stroma. The exact criteria vary according to the ultrasound technique used. The method, however, has been validated both laparoscopically and histologically. Using laparoscopic inspection as a reference test, ultrasonography was calculated to have a sensitivity of 91% and a specificity of 100%. As a group, anovulatory women with PCO have the classic endocrine features of polycystic ovarian syndrome, but in a proportion of cases the finding of PCO at scan appears to be irrelevant to the presenting disorder. Ultrasound diagnosis of PCO is also limited by its inability to display either ovary in about 16% of women.

Polycystic ovaries in patients with hypogonadotropic hypogonadism: similarity of ovarian response to gonadotropin stimulation in patients with polycystic ovarian syndrome

OBJECTIVE

To characterize the ovarian response in patients with isolated hypogonadotropic hypogonadism with ultrasound (US) findings of polycystic ovaries (PCO).

DESIGN

Twenty-seven treatment cycles in patients with hypogonadotropic hypogonadism and US findings of normal ovaries were compared with 31 cycles in patients with hypogonadotropic hypogonadism and US-diagnosed PCO. Forty-one cycles in the hypogonadotropic hypogonadism and US-diagnosed PCO were compared with 59 cycles of patients with polycystic ovarian syndrome (PCOS) to examine pattern of response after ovulation induction.

SETTING

Specialist Reproductive Endocrine Unit.

PATIENTS, PARTICIPANTS

Twenty hypogonadotropic patients in whom 10 had US findings of PCO and 13 patients with PCOS.

MAIN OUTCOME MEASURE

Serum estradiol (E2) concentration, number of leading follicles on US, cancellation, and pregnancy rate.

RESULTS

Hypogonadotropic patients with US-diagnosed PCO had higher baseline ovarian volume (P less than 0.02) compared with patients with hypogonadotropic hypogonadism with normal ovaries. After ovarian stimulation, a higher mean serum E2 concentration (P less than 0.001), endometrial thickness (P less than 0.001), and increased number of leading follicles (P less than 0.0001) were found in hypogonadotropic patients with US-diagnosed PCO, compared with hypogonadotropic patients with US findings of normal ovaries. Patients with PCOS had a higher serum E2 concentration (P less than 0.008), although they were treated for fewer days (P less than 0.0001) and with fewer ampules of gonadotropin (P less than 0.001) compared with patients with hypogonadotropic hypogonadism with US-diagnosed PCO.

CONCLUSIONS

We have characterized a group of hypogonadotropic patients with US findings of PCO, in which the ovarian response to ovulation induction was similar to patients with PCOS. The results have practical and theoretical implications for the etiology and treatment of patients with PCO.

Oestrogen and androgen states in oligo-amenorrhoeic women with polycystic ovaries

Oestrogen and androgen states have been studied in relation to ovarian morphology defined by ultrasonography in 65 women with oligo-amenorrhoea. Of the 48 women with polycystic ovaries (PCO), 44 (92%) had a withdrawal bleed following progestogen challenge (indicating oestrogenization) compared with just three (18%) of the 17 with non-PCO (P less than 0.001). Median serum concentrations of oestradiol and oestrone were statistically significantly higher in the PCO group but the ranges overlapped widely. Of the four women with PCO but oestrogen deficiency, two were hirsute and had evidence of a severe form of the disorder. The other two were not hirsute and appeared to have hypothalamic dysfunction associated with weight loss overriding the disorder due to pre-existing PCO. Compared with the non-PCO group, the PCO subgroup without hirsutism (n = 31) had statistically significantly higher median values of LH, testosterone, androstenedione, and dehydroepiandrosterone sulphate concentrations, and free androgen index. Concentrations of androgen, but not LH, were significantly higher still in the PCO subgroup with hirsutism (n = 17).

Clinical presentation, hormonal profiles and ultrasonic ovarian morphology in women with suspected polycystic ovarian disease

The aim of this study is to determine the clinical presentation, hormonal profiles and ultrasonic ovarian morphology in a group of Thai women with polycystic ovarian disease. The patients consisted of 54 women who had abnormal menstruation, androgenic symptoms, LH to FSH ratio of at least 3 and normal serum prolactin. The clinical and hormonal profiles of the patients were similar to the previous reports from developed countries. The typical ultrasonic cystic appearance of the ovaries was observed in about two-thirds of the patients. The patients with cystic ovaries had lower mean body weight but higher mean serum LH and FSH than the control group.