Which hormone tests for the diagnosis of polycystic ovary syndrome?

Thyroid autoimmunity in different phenotypes of polycystic ovary syndrome: a single-center experience

PURPOSE

Polycystic ovary syndrome (PCOS) has been associated with Hashimoto's thyroiditis (HT) and 4 phenotypes have been described in this syndrome. The aim of this work was to investigate the frequency of anti-thyroid antibodies (TAb) and thyroid function in the 4 phenotypes of PCOS.

PATIENTS

This study included 448 patients with PCOS: 260 (58.0%) with phenotype A, 119 (26.6%) with phenotype B, 38 (8.5%) with phenotype C and 31 (6.9%) with phenotype D.

RESULTS

TAb positivity was detected in 90/448 patients (20.1%) and was statistically significant higher (p = 0.03) in the grouped phenotypes A-B (83/379, 21.9%) than in phenotypes C-D (7/69, 10.1%). Positive anti-thyroglobulin antibodies (TgAb) were detected in 74/448 (16.5%) patients and positive anti-thyroperoxidase antibodies (TPOAb) in 66/448 (14.7%) patients. Both TgAb and TPOAb positivity was higher but not statistically significant in phenotype A-B than phenotype C-D. High titer TgAb (> 100 UI/ml) frequency was significantly higher (p = 0.005) in grouped phenotypes A-B (39/379, 10.3%) than in phenotypes C-D (0/69, 0.0%), while no significant difference was observed for low titer TgAb (≤ 100 UI/ml). According to a binary logistic regression analysis hypothyroidism was significantly associated with TAb positivity (OR 4.19; CI 2.25-7.79; p < 0.01) but not with PCOS phenotype. Androgen profile was not associated with TAb positivity.

CONCLUSION

A higher frequency of positive TAb and of high titer TgAb and TPOAb have been detected in PCOS women with phenotypes A and B, probably in relation to the greater imbalances between estrogen and progesterone levels present in these phenotypes.

D, R. C. M, T. G. K, A. P. Novel Technique for Confirmation of the Day of Ovulation and Prediction of Ovulation in Subsequent Cycles Using a Skin-Worn Sensor in a Population With Ovulatory Dysfunction: A Side-by-Side Comparison With Existing Basal Body Temperature Algorithm and Vaginal Core Body Temperature Algorithm

Objective: Determine the accuracy of a novel technique for confirmation of the day of ovulation and prediction of ovulation in subsequent cycles for the purpose of conception using a skin-worn sensor in a population with ovulatory dysfunction.

Methods: A total of 80 participants recorded consecutive overnight temperatures using a skin-worn sensor at the same time as a commercially available vaginal sensor for a total of 205 reproductive cycles. The vaginal sensor and its associated algorithm were used to determine the day of ovulation, and the ovulation results obtained using the skin-worn sensor and its associated algorithm were assessed for comparative accuracy alongside a number of other statistical techniques, with a further assessment of the same skin-derived data by means of the “three over six” rule. A number of parameters were used to divide the data into separate comparative groups, and further secondary statistical analyses were performed.

Results: The skin-worn sensor and its associated algorithm (together labeled “SWS”) were 66% accurate for determining the day of ovulation (±1 day) or the absence of ovulation and 90% accurate for determining the fertile window (ovulation day ±3 days) in the total study population in comparison to the results obtained from the vaginal sensor and its associated algorithm (together labeled “VS”).

Conclusion: SWS is a useful tool for confirming the fertile window and absence of ovulation (anovulation) in a population with ovulatory dysfunction, both known and determined by means of the timing of ovulation. The body site where the skin-worn sensor was worn (arm or wrist) did not appear to affect the accuracy. Prior diagnosis of known causes of ovulatory dysfunction appeared to affect the accuracy to a lesser extent than those cycles grouped into late ovulation and “early and normal ovulation” groups. SWS is a potentially useful tool for predicting ovulation in subsequent cycles, with greater accuracy obtained for the “normal ovulation” group.

Effect of aging on clinical features and metabolic complications of women with polycystic ovary syndrome

PURPOSE

To assess the distribution of clinical features and metabolic abnormalities of polycystic ovary syndrome (PCOS) women according to their age.

METHODS

Retrospective study on 602 women (mean age 23.9 ± 6.2 years), diagnosed according to International PCOS Network Guidelines criteria as having PCOS in a University-based Hospital. Anthropometric features, hormonal and metabolic parameters were measured and compared between the different age groups (group A ≤ 20 years; group B 21-30 years; group C > 30 years).

RESULTS

Patients in group A were more often hyperandrogenic, while in group C hypertension, dyslipidemia, obesity, impaired fasting glucose, and insulin resistance (IR) were more prevalent. After adjusting for BMI, age correlated positively with sex hormone-binding globulin (SHBG), IR, total- and LDL-cholesterol, and negatively with DHEAS, insulin, and free androgen index (FAI). SHBG was significantly associated with IR and atherogenic dyslipidemia, while FAI levels were linked to hypertension, independently of other factors considered. Furthermore, the regression analysis showed a stronger relationship between BMI and metabolic outcomes, regardless of age.

CONCLUSION

Polycystic ovarian syndrome (PCOS) phenotype changes with age. Clinical and biochemical hyperandrogenism are a major concern in young PCOS women, while metabolic burden tends to increase with aging. Some of the cardiovascular risk factors are dependent on FAI and SHBG levels, whereas BMI confirms its key role in the genesis of most of the metabolic sequelae in PCOS, independently of age.

The effects of thylakoid-rich spinach extract and aqueous extract of caraway (Carum carvi L.) in letrozole-induced polycystic ovarian syndrome rats

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrine disorder. The aim of the present study was to evaluate the effects of the oral administration of thylakoid-rich spinach extract and the caraway aqueous extract in letrozole-induced polycystic ovary syndrome rats.

METHODS

Sixty female Sprague-Dawley rats were randomly divided into five groups of 12 animals each. Letrozole (1 mg/kg) was administered orally for a period of 28 days to induce PCOS. Sham and PCOS control rats received 1 mL/day of distilled water, and the three groups of PCOS rats were given 150 mg/kg of metformin, 3 g/kg of caraway, and thylakoid at a dose of 6 mg chlorophyll/gr food intake/day by oral gavage for 8 weeks. Finally, blood samples were collected and the right ovary of rats was removed, weighed, and fixed in 4% buffered formalin to determine the biochemical and stereological parameters.

RESULTS

Compared to the PCOS control group, consuming metformin, thylakoid, and caraway extracts significantly improved the fasting blood sugar (FBS), tumor necrosis factor-alpha (TNF-α), malondialdehyde (MDA), luteinizing hormone (LH), insulin resistance, and body weight, increased the volume of the corpus luteum, and reduced the number of atretic follicles after 8 weeks (푃< 0.05). Although caraway treatment caused a significant increase in the HDL-C (High-density lipoprotein cholesterol) level (P < 0.001), no significant change was observed in terms of HDL-C in the thylakoid and metformin groups compared to the PCOS control group.

CONCLUSION

Our data showed that the consumption of thylakoid and caraway extracts for 8 weeks may have beneficial effects on the biochemical and stereological factors in PCOS-induced rats.

Mitochondrial dysfunction: An emerging link in the pathophysiology of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder characterized by irregular menstrual cycles, hyperandrogenism and subfertility. Due to its complex manifestation, the pathogenic mechanism of PCOS is not well defined. Cumulative effect of altered genetic and epigenetic factors along with environmental factors may play a role in the manifestation of PCOS leading to systemic malfunction. With failure of genome-wide association study (GWAS) and other studies performed on nuclear genome to provide any clue for precise mechanism of PCOS pathogenesis, attention has been diverted to mitochondria. Mitochondrion plays an important role in cellular metabolic functions and is linked to Insulin Resistance (IR). Recently, increasing reports suggest that mitochondrial dysfunction may be a contributing factor in the pathogenesis of PCOS. Hence, in this review, we have discussed mitochondrial biology in brief and emphasizes on genetic and epigenetic aspects of mitochondrial dysfunction studied in PCOS women and PCOS-like animal models. We also highlight underlying mechanism behind mitochondrial dysfunction contributing to PCOS and its related complications such as obesity, diabetes, cardiovascular diseases, metabolic syndrome, non-alcoholic fatty liver disease (NAFLD) and cancer. Furthermore, contrasting remarks against involvement of mitochondrial dysfunction in PCOS pathophysiology have also been presented. This review enhances our understanding in relation to mitochondrial dysfunction in the etiology of PCOS and stimulates further research to explore a clear link between mitochondrial dysfunction and PCOS pathogenesis and progression. Understanding pathogenic mechanisms underlying PCOS will open new windows to develop promising therapeutic strategies against PCOS.

Ovarian Volume in Korean Women with Polycystic Ovary Syndrome and Its Related Factors

Objectives

The aim of this study was to determine the relationship of ovarian volume (OV) to age, height, and weight in Korean young women with the polycystic ovary syndrome (PCOS) undergoing ultrasonography (US) and to investigate the relationship between ovarian follicle count and volume on US and serum hormone levels including the levels of the anti-Müllerian hormone (AMH) and gonadotropin.

Methods

A total of 272 Korean nulliparous women aged 15 to 39 years who were newly diagnosed with PCOS at a university hospital were included in this study. Evaluation of the ovaries and measurement of OVs in all cases were randomly performed by ultrasound. The OV and follicle number (FN) were obtained in all cases.

Results

In Korean women with PCOS, mean OV was 7.9 ± 3.6 cm³ (right) and 6.7 ± 3.1 cm³ (left). Mean FN in the PCOS group was 14.2 ± 4.6 (right) and 13.8 ± 4.3 (left). OV and ovarian FN were unrelated to patient weight, height and body mass index. The left ovarian FN was related to patient age. AMH levels ranged from 5.31 to 43.1 ng/mL and the mean level was 13.9 ± 7.2 ng/mL. Serum AMH was related to OV and FN, and serum total testosterone was related to FN in Korean women with PCOS.

Conclusions

In Korean nulliparous women with PCOS, OV was smaller than that in other ethnic groups and the right OV was larger than the left OV. Ovarian FN, AMH, testosterone are good markers for the diagnosis of PCOS in Korean women.

Hyperinsulinemia and Insulin Resistance: Scope of the Problem

No abstract available.

Phenotypic Characterization of Polycystic Ovary Syndrome in Adolescents Based on Menstrual Irregularity

OBJECTIVE

Polycystic ovary syndrome (PCOS) in adolescents is associated with adverse metabolic outcomes. The association of menstrual irregularity with metabolic risk among adolescents with PCOS was assessed.

METHOD

A retrospective medical record review of 366 adolescents with PCOS aged 13-18 years was conducted, from which 265 girls newly diagnosed with PCOS were included and divided into those presenting with primary amenorrhea (PA), secondary amenorrhea (SA) and oligomenorrhea (OM). Androgen concentrations and markers of metabolic risk were compared among the groups.

RESULTS

Most subjects presented with OM (PA = 17, SA = 30 and OM = 218). Subjects with PA were younger than those with OM but not different from those with SA. Mean BMI was not different between groups. Total testosterone and insulin levels were higher in PA than SA and OM (p < 0.01 and 0.02, respectively). Fasting glucose was higher in PA than OM (p = 0.048) but not different from SA. Triglyceride levels were higher in PA than SA and OM (p < 0.001 each). More subjects with PA and SA had metabolic syndrome (52%) than those with OM (29.1%) (p = 0.027). The differences in triglycerides and glucose persisted despite BMI adjustment in multivariate regression models.

CONCLUSION

Adolescents with PCOS presenting with PA are at risk of metabolic disease beyond expected based on BMI.

Clinical characteristics in Taiwanese women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is one of the most common hormonal endocrine disorders in women of reproductive age. It consists of a heterogeneous collection of signs and symptoms that together form a disorder spectrum. The diagnosis of PCOS is principally based on clinical and physical findings. The extent of metabolic abnormalities in women with PCOS varies with phenotype, body weight, age, and ethnicity. For general population, the prevalence of hyperandrogenism and oligomenorrhea decreases with age, while complications such as insulin resistance and other metabolic disturbances increase with age. Obese women with PCOS have a higher risk of developing oligomenorrhea, amenorrhea, hyperandrogenemia, insulin resistance, and lower luteinizing hormone (LH) to follicle stimulation hormone (FSH) ratios than non-obese women with PCOS. The LH to FSH ratio is a valuable diagnostic tool in evaluating Taiwanese women with PCOS, especially in the diagnosis of oligomenorrhea. Overweight/obesity is the major determinant of cardiovascular and metabolic disturbances in women of reproductive age.

MicroRNAs Related to Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is the most common, though heterogeneous, endocrine aberration in women of reproductive age, with high prevalence and socioeconomic costs. The syndrome is characterized by polycystic ovaries, chronic anovulation and hyperandrogenism, as well as being associated with infertility, insulin resistance, chronic low-grade inflammation and an increased life time risk of type 2 diabetes. MicroRNAs (miRNAs) are small, non-coding RNAs that are able to regulate gene expression at the post-transcriptional level. Altered miRNA levels have been associated with diabetes, insulin resistance, inflammation and various cancers. Studies have shown that circulating miRNAs are present in whole blood, serum, plasma and the follicular fluid of PCOS patients and that they might serve as potential biomarkers and a new approach for the diagnosis of PCOS. In this review, recent work on miRNAs with respect to PCOS will be summarized. Our understanding of miRNAs, particularly in relation to PCOS, is currently at a very early stage, and additional studies will yield important insight into the molecular mechanisms behind this complex and heterogenic syndrome.

Total testosterone quantitative measurement in serum by LC-MS/MS

Reliable measurement of total testosterone is essential for the diagnosis, treatment and prevention of a number of hormone-related diseases affecting adults and children. A mass spectrometric method for testosterone determination in human serum was carefully developed and thoroughly validated. Total testosterone from 100 μL serum is released from proteins with acidic buffer and isolated by two serial liquid-liquid extraction steps. The first extraction step isolates the lipid fractions from an acidic buffer solution using ethyl acetate and hexane. The organic phase is dried down and reconstituted in a basic buffer solution. The second extraction step removes the phospholipids and other components by hexane extraction. Liquid chromatography-isotopic dilution tandem mass spectrometry is used to quantify the total testosterone. The sample preparation is automatically conducted in a liquid-handling system with 96-deepwell plates. The method limit of detection is 9.71 pmol/L (0.280 ng/dL) and the method average percent bias is not significantly different from reference methods. The performance of this method has proven to be consistent with the method precision over a 2-year period ranging from 3.7 to 4.8% for quality control pools at the concentrations 0.527, 7.90 and 30.7 nmol/L (15.2, 228, and 886 ng/dL), respectively. This method provides consistently high accuracy and excellent precision for testosterone determination in human serum across all clinical relevant concentrations.

Anti-Müllerian hormone, testosterone and free androgen index following the dose-adjusted unilateral diathermy in women with polycystic ovary syndrome

OBJECTIVE

The aim of this study was to investigate changes of anti-Müllerian hormone, testosterone and free androgen index after two diathermy methods. We have also aimed at evaluating prognostic value of these parameters for an ovulatory response.

STUDY DESIGN

This prospective, comparative study included ninety-six women with polycystic ovary syndrome unresponsive to clomiphene citrate. Patients were assigned to two groups; the first group underwent unilateral laparoscopic ovarian drilling with thermal doses adjusted to ovarian volume: median of 720J (IQR), while the second group underwent bilateral drilling with fixed doses of 1200J. Anti-Müllerian hormone (AMH), testosterone (T), free androgen index (FAI)and luteinizing hormone (LH) were measured at baseline, at 1st and 6th month of follow up.

RESULTS

AMH, T and LH levels significantly decreased (P<0.001, P≤0.024, P<0.001) after diathermy in both responders and nonresponders from either treatment group. On contrary, FAI levels (P<0.001) significantly changed only in responders, irrespective of the treatment. In 1st and 6th month of follow up median levels of AMH, T and FAI among responders from different treatment groups were equivalent, whereas the responders in bilateral group had higher LH levels in the 1st month of follow up (P=0.003). Nonresponders differed between treatment groups only in AMH level which was decreased in unilateral group throughout the follow up (P≤0.021). The baseline value of T (semi-standardized coefficient, β=-0.28) and value of T in the 1st month (β=-0.72) after the diathermy were significant and consistent indicator of the response to therapy within 6months and the ovulation response in the 1st month.

CONCLUSIONS

The value of T is the strongest and consistent indicator of ovulatory response after diathermy.

CLINICAL TRIAL REGISTRATION

www.ClinicalTrials.gov , NCT01833949.

Elevated serum levels of anti-Müllerian hormone can be introduced as a new diagnostic marker for polycystic ovary syndrome

OBJECTIVE

To determine the possible role of anti-Müllerian hormone (AMH) in the diagnosis of polycystic ovary syndrome (PCOS) with a larger population of women and to evaluate its role as a new diagnostic marker.

DESIGN

Cross-sectional study.

SETTING

University hospital.

POPULATION

A total of 570 women, with PCOS (n = 419) and without PCOS (n = 151).

METHODS

Serum basal hormone; AMH, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and thyroid-stimulating hormone (TSH) levels were measured. Mean hormone levels were compared and the predictive value of serum AMH level was evaluated with the use of the receiver operating characteristic (ROC) curve analysis.

RESULTS

No statistically significant differences were found between PCOS women and control groups in terms of age, body mass index and TSH levels. Differences between mean serum, FSH, LH and estradiol levels and LH/FSH ratio were found to be statistically significant (p < 0.001). Mean serum AMH level was higher in PCOS women than in controls (7.34 vs. 2.24 ng/mL, p < 0.001). The area under the ROC curve assay yielded a satisfactory result of 0.916 (95% confidence interval 0.897-0.935, p < 0.0001). The best compromise between 89.8% specificity and 80% sensitivity was obtained with a cut-off value of 3.94 ng/mL for PCOS diagnosis.

CONCLUSIONS

Serum AMH measurement is very valuable in the diagnosis of PCOS women. The serum AMH level in women with hyperandrogenism or oligo-anovulation could indicate the diagnosis of PCOS when reliable ultrasonography data are not available or when typical clinical and laboratory findings are not available. The serum AMH level is a new and useful diagnostic tool in PCOS diagnosis.

Endocrinology of hirsutism

Hirsutism represents a primary clinical indicator of androgen excess. The most common endocrine condition causing hirsutism is polycystic ovary syndrome (PCOS). Diagnosing PCOS is not easy as the signs and symptoms are heterogenous. The newest diagnostic guideline made by the Androgen Excess and PCOS Society in 2006, claims the presence of hyperandrogenism, and ovarian dysfunction (oligo / anovulation and / or polycystic ovaries). Obesity associated reproductive and metabolic dysfunctions may aggravate the symptoms of PCOS. PCOS might be underdiagnosed in non obese women because lean PCOS phenotypes might be underestimated for the syndrome. Effective medical treatment of PCOS and associated hirsutism depends on the endocrinological expertise and experience of the therapist in each individual case. An algorithm for the treatment has not been established yet.

Comparison of hormonal and metabolic markers after a high-fat, Western meal versus a low-fat, high-fiber meal in women with polycystic ovary syndrome

OBJECTIVE

To determine the effect of meal composition on postprandial T levels in women with polycystic ovary syndrome (PCOS).

DESIGN

Randomized, crossover design.

SETTING

Academic research center.

PATIENT(S)

Fifteen women with PCOS.

INTERVENTION(S)

We evaluated changes in T, sex hormone binding globulin (SHBG), DHEAS, cortisol, glucose, and insulin for 6 hours after a high-fat, Western meal (HIFAT) (62% fat, 24% carbohydrate, 1 g fiber) and an isocaloric low-fat, high-fiber meal (HIFIB) (6% fat, 81% carbohydrate, 27 g fiber).

MAIN OUTCOME MEASURE(S)

Change in T levels.

RESULT(S)

Testosterone decreased 27% within 2 hours after both meals. However, T remained below premeal values for 4 hours after the HIFIB meal and 6 hours after the HIFAT meal. Insulin was twofold higher for 2 hours after the HIFIB meal compared with the HIFAT meal. Glucose was higher for 1 hour after the HIFIB meal compared with the HIFAT meal. DHEAS decreased 8%-10% within 2-3 hours after both meals, then increased during the remainder of the study period. Cortisol decreased during the 6-hour period after both meals.

CONCLUSIONS

Diet plays a role in the regulation of T levels in women with PCOS. Further studies are needed to determine the role of diet composition in the treatment of PCOS.

Best practice in primary care pathology: review 4

This fourth best practice review examines four series of common primary care questions in laboratory medicine are examined in this review: (1) safety monitoring for three common drugs; (2) use of prostate-specific antigen; (3) investigation of vaginal discharge; and (4) investigation of subfertility. The review is presented in question-answer format, referenced for each question series. The recommendations represent a precis of the guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents and evidence-based medicine reviews, supplemented by Medline Embase searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most of them are consensus based rather than evidence based. They will be updated periodically to take account of new information.

Endometriosis as a model for inflammation–hormone interactions in ovarian and breast cancers

Chronic inflammation has been implicated in a variety of cancers. In this review, we consider associations between endometriosis and cancers both local (ovarian) and distant (breast). We review the epidemiological data linking endometriosis to ovarian and breast cancers. We then consider evidence for a role for sex steroid hormones and for inflammation in the aetiology of each of these cancers. Finally, we consider that endometriosis may promote alterations in sex steroid hormones and inflammatory mediators. A possible explanation for the association between endometriosis and these reproductive cancers may then be local and systemic enhancement of aberrant inflammatory and hormonal mediators. If this hypothesis is true, endometriosis may need to be considered as a risk factor for ovarian and breast cancers, triggering increasingly intensive surveillance. Moreover, treatments for endometriosis may require consideration of the impact on long-term cancer risk.

Ultrasound diagnosis of polycystic ovaries in women who have no symptoms of polycystic ovary syndrome is not associated with subfecundity or subfertility

OBJECTIVE

To evaluate the effect on fertility of the appearance of polycystic ovaries in women who have no symptoms of polycystic ovary syndrome.

DESIGN

Case-control study.

SETTING

Teaching hospitals in Hull, United Kingdom.

PATIENT(S)

Women with the appearance of polycystic ovaries on ultrasound and women with normal ovaries.

INTERVENTION(S)

A questionnaire about previous subfertility, pregnancies, menstrual pattern, features of polycystic ovary syndrome, gynecological history, and individual lifestyle factors.

MAIN OUTCOME MEASURE(S)

Time to pregnancy (TTP) and relative risk (RR) of subfertility in symptomatic and asymptomatic subgroups of both groups.

RESULT(S)

Women with PCOs took longer TTP and were significantly less fertile if they were obese (RR = 2.6), had menstrual disturbances (RR = 4.6), hirsutism (RR = 2.5), and/or acne (RR = 2.7). Further reductions in fecundity occurred with an increasing number of symptoms (threefold, sevenfold, and 10-fold longer TTP with two, three, and four symptoms, respectively). The TTP of women with no symptoms was not significantly longer and they were not more likely to be subfertile than women with normal ovaries. These symptoms were not associated with significantly reduced fecundity in women with normal ovaries.

CONCLUSION(S)

The appearance of polycystic ovaries has been shown to have no significant impact on fertility in women with no symptoms. Appearances alone do not reflect the pathological features of polycystic ovary syndrome, and additional diagnostic criteria should be considered. Obesity, menstrual disturbances, and/or hyperandrogenism are factors associated with subfertility in women with polycystic ovaries.

ACP best practice no 170. Investigation of infertility with the emphasis on laboratory testing and with reference to radiological imaging

This review will discuss the investigation of infertility, with emphasis on laboratory testing and reference to the value of other investigations, including clinical and radiological. The role of laboratory investigations is viewed within an appropriate clinically directed pathway that includes medical, surgical, and social history together with environmental factors. Because embryology and assisted reproduction techniques are developing rapidly and produce continuous changes in everyday practice, this article gives a critical review of the plethora of tests that are currently used.

New approach to polycystic ovary syndrome and other forms of anovulatory infertility

Anovulation can be classified in the clinic on the basis of serum hormone assays. Low gonadotropins along with low estrogen concentrations are suggestive of a central origin of the disease, whereas low estrogen levels along with elevated gonadotropins indicate a primary defect at the ovarian level. Most anovulatory patients (approximately 80%) present with serum FSH and estradiol levels within the normal range (World Health Organization class II). Polycystic ovary syndrome (PCOS) is a common but poorly defined heterogeneous clinical entity. Historically, characteristic ovarian abnormalities represented a hallmark of the syndrome. Because several etiological factors may lead to a similar end point (i.e., polycystic ovaries), the development of a clinically applicable classification of the syndrome has proven difficult. Clinical, morphological, biochemical, endocrine, and, more recently, molecular studies have identified an array of underlying abnormalities and added to the confusion concerning the pathophysiology of the disease. Despite the vast literature regarding the etiology and classification of PCOS, no consensus has been reached regarding the validity of criteria used to diagnose the syndrome. For instance, the significance of elevated serum luteinizing hormone (LH) concentrations, insulin resistance or polycystic-appearing ovaries assessed by ultrasound for PCOS diagnosis remains uncertain. In contrast, hyperandrogenism and chronic anovulation generally are believed to be mandatory diagnostic features. Patients with PCOS might visit a dermatologist for hirsutism, a generalist, or internist for complaints related to obesity or a gynecologist for irregular or absent bleeding. However, most patients seek the care of a gynecologist because of cycle abnormalities (oligomenorrhea) and infertility. In PCOS, serum FSH and estradiol (E2) levels are usually found to be within the (broad) normal ranges, whereas LH may either be normal or elevated. Because PCOS with normal or high LH does not seem to represent different clinical entities, it seems justifiable to consider this syndrome as a subgroup of WHO-II patients, although estrogen levels may be tonically elevated in these patients. This review will focus on characteristics of the heterogeneous group of WHO-II patients in an attempt to identify factors involved in the etiology and possible ovulation induction outcome of PCOS.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to outline the current classification of anovulatory infertility and to explain the characteristics and features used for classification.

Insulin sensitivity and fertility

This review sets in context significant recent advances in the understanding of the pathophysiology of polycystic ovary syndrome (PCOS). The occurrence of variable insulin sensitivity in individuals is discussed. Information is presented to demonstrate that prolonged anovulation decreases insulin sensitivity and, conversely, that improvement in insulin sensitivity normalizes ovarian function in PCOS. In addition, a meta-analysis of studies on metformin and troglitazone treatment in PCOS is presented.

Polycystic ovary syndrome. A diagnostic challenge

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 been made. Other causes of hyperandrogenism and ovulatory dysfunction should be excluded.

Effects of the insulin sensitizing drug metformin on ovarian function, follicular growth and ovulation rate in obese women with oligomenorrhoea

Hyperinsulinaemic insulin resistance is commonly associated with hyperandrogenaemia, and menstrual dysfunction. The aim of this study was to examine the effects of the insulin sensitizing drug, metformin, on ovarian function, follicular growth, and ovulation rate in obese women with oligomenorrhoea. Twenty obese subjects with oligomenorrhoea [polycystic ovarian syndrome; (PCOS)] were observed longitudinally for 3 weeks prior to and for 8 weeks during treatment with metformin (850 mg twice per day). Fifteen patients completed the study. The frequency of ovulation was significantly higher during treatment than before treatment (P = 0.003). A significant decline in both testosterone and luteinizing hormone concentrations was recorded within 1 week of commencing treatment. Patients with elevated pretreatment testosterone concentrations showed the most marked increase in ovulation rate (P < 0.005), and significant reductions in circulating testosterone from 1.02 to 0.54 ng/ml (P < 0.005) after only 1 week of treatment. However, the sub-group with raised fasting insulin showed less marked changes, and the sub-group with normal testosterone concentrations showed no effect of treatment. Metformin had a rapid effect upon the abnormal ovarian function in hyperandrogenic women with PCOS, correcting the disordered ovarian steroid metabolism and ovulation rate; however, there appeared to be no effect in cases where the circulating androgen concentration was normal.

Increased peripheral androgen activity in infertile Korean women with polycystic ovaries

The present investigation was designed to determine whether infertile women with polycystic ovaries (PCO) have sonographic or endocrinological differences compared with women with PCO proven to be fertile. Sonographic morphology of the ovary was not significantly different between the groups. However, serum concentrations of 3alpha-androstanediol glucuronide (3alpha-diolG) were significantly higher in infertile women with PCO than in those proven to be fertile. Furthermore, a significant positive correlation was noted between 3alpha-diolG and luteinizing hormone (LH) in infertile women, but not in those who were fertile. The higher correlation between serum 3alpha-diolG concentrations and serum LH concentrations seen in infertile women with PCO, with the lack of a significant difference in LH concentrations between infertile and fertile women, suggests that serum 3alpha-diolG may be a leading cause of subfertility in women with PCO. Accordingly, our evidence for increased 3alpha-diolG in the infertile group needs to be confirmed by further studies, including direct 5alpha-reductase assay, adrenal function tests and evaluation of hepatic conjugation activity.

Variation of luteinizing hormone and androgens in oligomenorrhoea and its implications for the study of polycystic ovary syndrome

We measured luteinizing hormone (LH) and androgen concentrations in patients at different phases of the oligomenorrhoeic cycle and compared the results with those of patients with normogonadotrophic amenorrhoea. Several blood samples separated by >/=7 days were obtained from each of 72 patients with oligomenorrhoea and 18 with normogonadotrophic amenorrhoea. The oligomenorrhoeic cycle was divided into five phases: the postmenstrual phase week 1 (day 1-7) and week 2 (day 8-14), the specific oligomenorrhoeic phase (SOP, day 15 after a menstruation to day 21 before the next menstruation), the possibly peri-ovulatory phase (days 21-11 before menstruation) and the premenstrual phase (days 10-1 before menstruation). Samples obtained in the possibly peri-ovulatory phase were excluded. Within individuals LH concentrations were significantly higher during the SOP than during all other phases of the oligomenorrhoeic cycle (paired t-test, P = 0.0001-0.03). In contrast to the other phases of the oligomenorrhoeic cycle, no significant differences in gonadotrophins, androgen or oestradiol concentrations were found between the SOP and normogonadotrophic amenorrhoea. In oligomenorrhoea timing of blood sampling influences the measurement of LH and androgen concentrations, and the accurate interpretation of these measurements requires that the dates of menstruation both before and after the sample is taken should be known. In patients with oligomenorrhoea blood samples should be obtained during the SOP, when the endocrinology is comparable with that of normogonadotrophic amenorrhoea.

Neuroendocrine aspects of polycystic ovary syndrome

A series of investigations have emphasized the heterogeneous nature of the clinical condition known as PCOS and have delineated several factors that may contribute to the hyperandrogenemia and anovulation in this condition. Currently, it remains unclear whether intrinsic abnormalities of ovarian steroidogenesis, the effects of hyperinsulinemia in augmenting LH stimulation of ovarian androgen production, and the persistent rapid frequency of LH/GnRH secretion are primary factors in all patients. Indeed, these factors may have variable roles in different patients, all of whom present with the clinical syndrome of PCOS. A consensus has emerged that abnormalities in the neuroendocrine control of GnRH secretion exist in a significant subset of patients and lead to persistent hypersecretion of LH, which seems to be an important component of the syndrome, particularly in nonobese patients. The relative frequency of primary abnormalities in the regulation of GnRH secretion versus secondary changes reflecting altered circulating concentrations of ovarian steroid remains uncertain. No clear evidence exists for an underlying neuroendocrine abnormality of GnRH regulation in all patients. The recent data showing insensitivity of the hypothalamic GnRH pulse generator to E2 progesterone feedback have suggested potential mechanisms that may explain the abnormalities of GnRH secretion seen in adolescent girls in whom the clinical syndrome of PCOS is destined to develop. Further studies are required in adolescents to establish whether GnRH regulation is impaired during puberty or whether data in adults simply reflect the long-term effects of elevated androgens, estrogens, or other hormones on the hypothalamus. Studies in carefully delineated subgroups of patients with PCOS are needed to establish these points, with a long-term goal of providing patients with improved methods of inducing ovulation and reducing hyperandrogenemia.

Obesity regulates bioavailable testosterone levels in women with or without polycystic ovary syndrome

OBJECTIVE

To evaluate [1] the effects of levels of sex hormone-binding globulin (SHBG), albumin, and total testosterone on the distribution of testosterone between SHBG-bound and non-SHBG-bound fractions; [2] the independent effects of polycystic ovary syndrome (PCOS) and body mass index on serum levels of total testosterone, non-SHBG-bound testosterone, SHBG, and albumin; and [3] the usefulness of levels of total testosterone and non-SHBG-bound testosterone and of the free androgen index in the diagnosis of PCOS.

DESIGN

Retrospective clinical study.

SETTING

An academic research environment.

PATIENT(S)

Forty-three women with oligomenorrhea and PCOS. Twenty-five women with regular menstrual cycles and without hirsutism served as controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Levels of non-SHBG-bound testosterone, total testosterone, SHBG, and albumin in serum.

RESULT(S)

Levels of total testosterone and non-SHBG-bound testosterone, and the free androgen index were higher in patients with PCOS than in healthy controls. PCOS did not have an effect on the levels of SHBG or albumin, or on the percentage of non-SHBG-bound testosterone. Levels of SHBG and albumin were inversely related to body mass index. The percentage and concentration of non-SHBG-bound testosterone and the free androgen index were directly related to body mass index. Hirsutism did not have an effect on any outcome measure.

CONCLUSION(S)

The distribution of total testosterone into SHBG-bound and non-SHBG-bound fractions is associated with body mass index, not with PCOS. The high levels of non-SHBG-bound testosterone and the high free androgen index in patients with PCOS reflect mainly high levels of total testosterone. Thus, the measurement of levels of non-SHBG-bound testosterone and the calculation of the free androgen index provide no further information in the diagnosis of PCOS beyond that provided by the measurement of levels of total testosterone.

Hormonal etiology of epithelial ovarian cancer, with a hypothesis concerning the role of androgens and progesterone

In the United States, ovarian cancer is the fourth most frequent cause of cancer death among women, following lung, breast, and colorectal cancers. Each year, approximately 26,000 women are diagnosed with ovarian cancer and 14,000 die of it. Germline mutations in BRCA1, BRCA2, or other genes have been implicated in a small fraction of cases. However, it has been suggested that, for the great majority of patients, the risk of epithelial ovarian cancer could be related to "incessant ovulation" (i.e., to the chronically repeated formation of stromal epithelial clefts and inclusion cysts following ovulation) or to some type of hormonal stimulation of ovarian epithelial cells, either on the surface of the ovary or within ovarian inclusion cysts, possibly mediated through excessive gonadotropin secretion. From the evidence to date, the relative importance of these two hypotheses--incessant ovulation and gonadotropin stimulation--cannot be distinguished. While either or both may play a role in the development of ovarian cancer, it appears that an additional major factor must also be involved. The purpose of this review is to evaluate evidence for and against the incessant ovulation and gonadotropin hypotheses, as well as to consider the possibility that risk of ovarian cancer may be increased by factors associated with excess androgenic stimulation of ovarian epithelial cells and may be decreased by factors related to greater progesterone stimulation. Many features of the evidence bearing on the pathophysiology of ovarian cancer appear to support a connection with androgens and progesterone.

Endocrine methods of ovulation induction

The rationale of ovulation induction is to achieve the development of a single follicle and ultimately a singleton healthy baby. Problems faced by women with anovulatory polycystic ovary syndrome are the sensitivity of the ovary to stimulation and health issues such as obesity. This chapter will discuss medical management including strategies to lose weight, address hyperinsulinaemia with insulin-sensitizing agents, such as metformin, and outline methods of ovulation induction from the usual first-line therapy of clomiphene citrate and the subsequent use of gonadotrophin therapy in clomiphene-resistant patients. Appropriately directed surgical ovulation induction with laparoscopic ovarian diathermy appears to be as efficacious as gonadotrophin therapy but will not be discussed in the context of this chapter.

Polycystic ovary syndrome: current and future treatment paradigms

Polycystic ovary syndrome is characterized by excess levels of circulating androgens and by chronic anovulation. Although the fundamental pathophysiologic defect has not been determined, women with polycystic ovary syndrome are known to be uniquely insulin resistant. Obesity in polycystic ovary syndrome aggravates the underlying predisposition towards insulin resistance. Diagnostic criteria that focus on menstrual irregularity are more likely to discriminate insulin-resistant women than are such criteria as abnormal gonadotropin secretion or ovarian morphologic characteristics. About 40% of patients with polycystic ovary syndrome demonstrate glucose intolerance (either impaired glucose tolerance or type 2 diabetes) in response to an oral glucose challenge. The lack of a clear causal mechanism in the syndrome has led to a multitude of symptom-oriented treatments, with few therapies improving all aspects of the endocrine abnormalities associated with polycystic ovary syndrome. Many of these therapies-such as ovulation induction with medical agents-hold increased risks for women with polycystic ovary syndrome, including ovarian hyperstimulation syndrome and multiple gestation. Empirical studies of interventions that improve insulin sensitivity in polycystic ovary syndrome (either weight loss and diet programs or pharmaceutical agents) have been shown to improve the endocrine abnormalities in the syndrome. Initial results with antidiabetic agents (specifically insulin-sensitizing agents) are promising but need to be confirmed with larger, randomized studies.

Polycystic ovaries and associated metabolic abnormalities in Indian subcontinent Asian women

OBJECTIVES

To determine the prevalence of polycystic ovaries (PCO) in Asian women living in England who are of Indian subcontinent origin or ancestry and to investigate the relationship between the presence of PCO and/or non-insulin dependent diabetes mellitus (NIDDM) and insulin sensitivity and other metabolic parameters.

DESIGN

A random sample of Indian subcontinent Asian women was obtained from the lists of local General Practitioners and a translating service. These women were invited to attend for a medical history questionnaire, examination, venous blood sample for hormonal assessment and transvaginal ovarian ultrasonography. Groups of women without PCO or NIDDM, with NIDDM but not PCO, with PCO but not NIDDM and with both NIDDM and PCO were drawn at random from this population and from Indian subcontinent Asian women attending the Diabetes Unit. They underwent further studies, including measurement of insulin sensitivity using a short intravenous insulin tolerance test.

SUBJECTS

212 Indian subcontinent Asian women aged 18-40 took part in the initial study. Insulin sensitivity was measured in 13 women without PCO or NIDDM, 13 women with NIDDM but not PCO, 15 women with PCO but not NIDDM and 12 women with both NIDDM and PCO.

MEASUREMENTS

The main outcome measures were prevalence of polycystic ovaries, clinical features of hyperandrogenism, fertility, blood pressure, serum gonadotrophins, testosterone and sex hormone binding globulin, fasting blood lipids, glucose and insulin, and insulin sensitivity.

RESULTS

The prevalence of PCO in Indian subcontinent Asian women was 52% (110/212). There were significant associations between PCO and menstrual irregularity; infertility; the Ferriman and Gallwey score for body hair distribution; the presence of acanthosis nigricans and the fasting blood glucose concentration. There were no differences between women with PCO and those with normal ovarian morphology with respect to systolic and diastolic blood pressure, fasting total, HDL and LDL cholesterol and triglyceride concentrations. The subgroup of women without PCO or NIDDM had the highest insulin sensitivity (189.1 +/- 46.4 mumol glucose/l/min, mean +/- SD) and the women with both PCO and NIDDM had the lowest insulin sensitivity (80.5 +/- 30.9 mumol glucose/l/min). There was no significant difference in insulin sensitivity between those with PCO but not NIDDM (125.0 +/- 59.5 mumol glucose/l/min) and those with NIDDM but not PCO (120.8 + 38.0 mumol glucose/l/min). The effects of NIDDM and PCO on insulin sensitivity were independent; the effect of PCO on insulin sensitivity was -60 mumol glucose/l/min (95% confidence interval -100 to -21, P = 0.004) and the effect of NIDDM was -68 mumol glucose/l/min (95% confidence interval -105 to -31, P < 0.001). There were no significant relationships between insulin sensitivity and fasting plasma insulin, systolic or diastolic blood pressure, fasting serum cholesterol or triglyceride.

CONCLUSIONS

The prevalence of polycystic ovaries in Indian subcontinent Asian women is very high and it has significant clinical associations. Polycystic ovaries and non-insulin dependent diabetes mellitus are associated with similar degrees of reduced insulin sensitivity in this population. Their effects are independent suggesting that these changes in insulin sensitivity involve different mechanisms. Polycystic ovaries unlike non-insulin dependent diabetes mellitus, are not associated with a defect in the secretion of insulin.

Epidemiologic and etiologic aspects of primary infertility in the Kashmir region of India

OBJECTIVE

To assess the magnitude of primary infertility and to study its etiologic aspects in India.

DESIGN

After proper randomization, 10,063 married couples were interviewed to ascertain the prevalence of primary infertility. A definitive protocol was followed to determine the etiology of primary infertility in 250 consecutive couples.

SETTING

Tertiary care medical center in the Kashmir valley of India.

PATIENT(S)

Couples married for > or = 1 year; 250 consecutive couples attending an endocrine clinic for primary infertility.

INTERVENTION(S)

A logical investigative protocol was followed to identify the etiology of infertility.

MAIN OUTCOME MEASURE(S)

Magnitude of primary infertility in the community as well as the male, female, or combined etiology of infertility.

RESULT(S)

Fifteen percent of the couples interviewed had primary infertility, among whom 4.66% had unresolved infertility at the time of the survey. The etiology of infertility in 250 consecutive couples revealed a female factor in 57.6%, a male factor in 22.4%, combined factors in 5.2%, and an undetermined cause in 14.8%.

CONCLUSION(S)

Primary infertility is as common and distressing a problem in India as in other parts of the world. Semen abnormalities (22.4%), anovulation (17.2%), ovarian failure (8.8%), hyperprolactinemia (8.4%) and tubal disease (7.2%) are common causes of infertility. The pattern of infertility in India is the same as in other parts of the world, except that infertile couples report late for evaluation.

Determinants of abnormal gonadotropin secretion in clinically defined women with polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder of reproductive age women characterized in its broadest definition by the presence of oligoamenorrhea and hyperandrogenism and the absence of other disorders. Defects of gonadotropin secretion, including an elevated LH level, elevated LH to FSH ratio, and an increased frequency and amplitude of LH pulsations have been described, but the prevalence of these defects in a large, unbiased population of PCOS patients has not been determined. Sixty-one women with PCOS defined by oligomenorrhea and hyperandrogenism and 24 normal women in the early follicular phase had LH samples obtained every 10 min for 8-12 h. Pool LH levels from the frequent sampling studies were within the normal range in the 9 PCOS patients (14.8%) who were studied within 21 days after a documented spontaneous ovulation. Excluding these post-ovulatory patients, 75.0% of the PCOS patients had an elevated pool LH level (above the 95th percentile of the normal controls), and 94% had an elevated LH to FSH ratio. In the anovulatory PCOS patients, pool LH correlated positively with 17-OH progesterone (R = 0.30, P = 0.03), but not with estradiol, estrone, testosterone, androstenedione, or DHEA-S. Pool LH and LH to FSH ratio correlated positively with LH pulse frequency (R = 0.40, P = 0.004 for pool LH, and R = 0.39; P = 0.005 for LH/FSH). There was also a strong negative correlation between pool LH and body mass index (BMI) (R = -0.59, P < 10(-5)). The relationship between BMI and LH secretion in the PCOS patients appeared to be strongest with body fatness, as pool LH was correlated inversely with percent body fat, whether measured by skinfolds (R = -0.61, P < 10(-5)), bioimpedance (R = -0.55, P < 10(-4)), or dual energy x-ray absorptiometry (DEXA) (R = -0.70, P = 0.001; n = 18 for DEXA only). By DEXA, the only body region that was highly correlated with pool LH was the trunk (R = -0.71, P = 0.001). The relationship between body fatness and LH secretion occurred via a decrease in LH pulse amplitude (R = -0.63, P < 10(-5) for BMI; R = -0.58, P < 10(-4) for bioimpedance; and R = -0.64, P = 0.004 for whole body DEXA), with no significant change in pulse frequency with increasing obesity (R = -0.17, P = 0.23 for BMI).

IN CONCLUSION

1) the prevalence of gonadotropin abnormalities is very high in women with PCOS selected on purely clinical grounds, but is modified by recent spontaneous ovulation; 2) the positive relationship between LH pulse frequency and both pool LH and LH to FSH ratio supports the hypothesis that a rapid frequency of GnRH secretion may play a key etiologic role in the gonadotropin defect in PCOS patients; 3) pool LH and LH pulse amplitude are inversely related to body mass index and percent body fat in a continuous fashion; and 4) the occurrence of a continuous spectrum of gonadotropin abnormalities varying with body fat suggests that nonobese and obese patients with PCOS do not represent distinct pathophysiologic subsets of this disorder.

Visualization of clinical data with neural networks, case study: polycystic ovary syndrome

In medicine, the use of neural networks has concentrated mainly on classification problems. Clinicians are often interested in knowing what a patient's status is compared with other similar cases. Compared with biostatistics neural networks have one major drawback: the reliability of the classification is difficult to express. Therefore, clear visualization of the measurements can be more helpful than the calculated probability of a disease. The self-organizing map is the most widely used neural network for data visualization. Although, visualization can be attached to almost any feed-forward network as well. In this paper, we describe a topology-preserving feed-forward network and compare it with the self-organizing map. The two neural network models are used in a case study on the diagnosis of polycystic ovary syndrome, which is a common female endocrine disorder characterized by menstrual abnormalities, hirsutism and infertility.

Classification of normogonadotropic infertility: polycystic ovaries diagnosed by ultrasound versus endocrine characteristics of polycystic ovary syndrome

OBJECTIVE

To investigate the predictive value of polycystic ovaries for endocrine signs of polycystic ovary syndrome (PCOS).

DESIGN

Controlled descriptive study.

SETTING

Academic tertiary care fertility clinic.

PATIENT(S)

Normogonadotropic (FSH levels between 1 and 10 mIU/mL conversion factor to SI unit, 1.0) oligomenorrheic or amenorrheic women visiting our fertility clinic and a control group of regularly cycling, healthy, normal weight volunteers recruited by advertisement.

INTERVENTION(S)

Single blood samples and transvaginal sonography were performed.

MAIN OUTCOME MEASURE(S)

Serum levels of FSH, LH, androstenedione (A), and T and ovarian volume, ovarian stroma density, and follicle number.

RESULT(S)

In control women, the 95th percentile was calculated for ovarian volume, follicle number, and stroma count as well as endocrine parameters. The use of these upper limits of normal in the study group resulted in 217 (66%) patients with polycystic ovaries on ultrasound (defined as increased mean ovarian volume and/or mean follicle number per ovary), whereas only 120 (36%) patients exhibited elevated serum androgens (increased A and/or T concentrations) and 155 (47%) showed elevated LH levels. Sensitivity and specificity of single or combined sonographic parameters for prediction of elevated serum LH or androgen concentrations were limited.

CONCLUSION(S)

In the study group of normogonadotropic oligomenorrhea or amenorrheic infertile women, we set strict cutoff levels for various criteria used in the literature for defining PCOS. Groups defined by sonographic or endocrine PCOS criteria did overlap, but sonographic parameters had limited predictive value for abnormal hormone serum levels.

Value of buserelin testing in the evaluation of hirsute women

It has been recently reported that many hirsute women are affected with functional ovarian hyperandrogenism (FOH)-a term that encompasses the heterogeneous polycystic ovary syndrome- and show an abnormal ovarian steroidogenic response to gonadotropin-releasing hormone (Gn-RH) agonists. The aims of the present study were to determine the prevalence of FOH by the assessment of 17-hydroxyprogesterone (17-OHP) response to the Gn-RH agonist buserelin, to correlate these abnormal responses to other parameters suggestive of PCOS, and to assess the possible adrenal origin of hyperandrogenism. Therefore, in 33 consecutive women with hirsutism serum LH, FSH, 17-OHP, dehydroepiandrosterone sulfate (DHEA-S), androstenedione (A), cortisol levels were evaluated in basal conditions and after the administration of buserelin (0.5 mg sc) and ACTH (tetracosactide 0.25 mg iv). Two patients were affected with a non classic congenital adrenal hyperplasia (CAH)-21OH deficiency. In 5 other women ACTH test caused a rate increase 17-OHP (30-0)/30 min > 19 nmol/L/min (0.25 +/- 0.03; mean +/- SE), suggesting the possible existence of heterozygote non classic CAH-21OH. One patient showed a DHEA-S response to ACTH (from 10.3 to 17.2 mumol/L), which was compatible with late-onset 3 beta-Hydroxy-delta 5 steroid dehydrogenase deficiency. Out of the 25 patients with normal responsiveness to ACTH, 11 women (group A) showed higher 17-OHP and A levels, in comparison to normal women, both in basal conditions (17-OHP = 4.18 +/- 0.72 vs 1.74 +/- 0.34 nmol/L, p < 0.005; A = 11.8 +/- 1.2 vs 6.0 +/- 0.7 nmol/L, p < 0.05) and after buserelin (17-OHP = 15.61 +/- 1.31 vs 6.96 +/- 0.9 nmol/L; A = 19.0 +/- 1.9 vs 7.5 +/- 0.8 nmol/L; p < 0.001). In 6 of these 11 patients basal and buserelin-stimulated LH levels were higher than in normals. The remaining 14 patients (group B) showed normal baseline and buserelin-stimulated 17-OHP and A concentrations. In this group only 2 patients had high basal and stimulated LH levels. An augmented LH/FSH ratio was present in 5 and 1 cases of groups A and B, and polycystic ovaries at ultrasonography were observed in 7 and 8 cases of groups A and B, respectively. It is to note that an abnormal 17-OHP response to buserelin was present also in 3 of the 5 patients with abnormal 17-OHP rise after ACTH test, suggesting an adrenal and ovarian cause of hyperandrogenism. In conclusion, an abnormal response to one or both stimulation test was present in 57% of cases: an adrenal origin of hirsutism was detected in 15%, a combined adrenal and ovarian origin was found in 9% and an ovarian cause was present in 33%. Buserelin testing is an useful means to reveal the presence of FOH.

Optimal use of hormone determinations in the biochemical diagnosis of the polycystic ovary syndrome

OBJECTIVE

To investigate, using logistic regression analysis and receiver operator characteristic analysis, the biochemical diagnosis of polycystic ovary syndrome (PCOS) and if it could be improved by using an array of hormone measurements chosen to yield optimal and cost-effective discrimination between women with PCOS and healthy women.

DESIGN

Retrospective clinical study.

SETTING

Outpatient clinic of reproductive endocrinology at Turku University Central Hospital, Turku, Finland.

PATIENTS

Fifty-four oligomenorrheic women with PCOS diagnosed by ovarian ultrasonography, and 29 healthy regularly menstruating women with normal ovarian morphology.

MAIN OUTCOME MEASURES

Concentrations of LH, FSH, androstenedione (A), T, and sex hormone-binding globulin in serum.

RESULTS

Luteinizing hormone, FSH and A, when used in combination, were the hormonal analytes of highest clinical utility. Diagnostic sensitivity, specificity, and overall concordance of 98%, 93%, and 96%, respectively, were attained. Each of the analytes used alone yielded lower degree of discrimination.

CONCLUSIONS

Simultaneous use of the levels of LH, FSH, and A in serum can be used effectively for classification between women with PCOS and healthy women.

Serum free testosterone in polycystic ovary syndrome measured with a new reference method

OBJECTIVE

To quantify the actual serum free T with a specific new reference method in women with polycystic ovary syndrome (PCOS) and to analyze the effects of serum free T, total T, and the T:sex hormone-binding globulin (SHBG) ratio on the diagnosis of PCOS.

SETTING

Outpatient clinic of reproductive endocrinology at Turku University Central Hospital, Turku, Finland.

PATIENTS

Forty-four oligomenorrheic women with PCOS and 26 weight-matched control women with regular menstrual cycles.

MAIN OUTCOME MEASURES

The concentrations of free T, total T, androstenedione (A), LH, FSH, SHBG, and insulin in serum.

RESULTS

The mean concentrations of free T, total T, A, and LH as well as the LH:FSH and T:SHBG ratios were higher, whereas the mean concentrations of FSH was lower in the women with PCOS than in healthy women. No differences were found in the free T, total T, or T:SHBG levels or in the body mass indexes (BMIs) between the hirsute (n=26) and nonhirsute (n = 18) women with PCOS. Both elevated free T concentrations and high T:SHBG ratios were associated with obesity, but serum total T was independent of BMI. The serum free T measurement discriminated PCOS women from controls to a similar extent as total T and T:SHBG ratio as judged by a receiver operating characteristics analysis.

CONCLUSIONS

The present data indicate that determination of free T provides little additional information in the diagnosis of hirsutism or PCOS and does not have to be included to the basic evaluation of these patients. Only half of women with PCOS exhibited elevated serum free T concentrations.

Ovarian morphology and insulin sensitivity in women with bulimia nervosa

OBJECTIVE

Hyperinsulinaemia has a role in the development of hyperandrogenism and polycystic ovary syndrome in women of normal weight. Polycystic ovaries are common in women with bulimia nervosa and this study aimed to determine whether women with bulimia nervosa are insulin resistant and to examine the relation between insulin sensitivity and ovarian morphology.

DESIGN

A short intravenous insulin tolerance test was used as a direct measure of insulin sensitivity in a group of women with bulimia nervosa and a control group.

PATIENTS

A series of 12 women with bulimia nervosa and normal weight was compared with a control group of 9 healthy women who had no clinical signs of eating disorder or hyperandrogenism and did not have polycystic ovaries.

MEASUREMENTS

Bulimic behaviour was assessed using the BITE (Bulimia Investigation Test, Edinburgh) questionnaire and clinical interviews. Ovarian morphology was assessed using transabdominal ultrasonography. Insulin sensitivity and serum insulin, fasting glucose, LH, FSH, prolactin, testosterone, androstenedione and sex hormone binding globulin (SHBG) were measured and compared between the two groups.

RESULTS

Ten of the 12 women with bulimia nervosa underwent ovarian ultrasound examination and they all had polycystic ovaries. There was no difference in serum LH, FSH, testosterone, androstenedione of SHBG concentrations between the women with bulimia nervosa and the non-bulimic control group. Fasting blood glucose concentrations were normal in all the women studied and did not differ between the women with bulimia nervosa and the control women. There was also no difference in fasting serum insulin or insulin sensitivity between the women with bulimia nervosa and the nonbulimic women.

CONCLUSIONS

Bulimia nervosa is not associated with insulin resistance and chronic hyperinsulinaemia.

The independent effects of polycystic ovary syndrome and obesity on serum concentrations of gonadotrophins and sex steroids in premenopausal women

OBJECTIVE

To investigate the basal levels of gonadotrophins and sex steroids, with special reference to the effects of obesity and body fat distribution, in premenopausal women, both those with polycystic ovary syndrome (PCOS) and those with normal ovaries and regular menstrual cycles.

DESIGN

Cross-sectional study. The separate effects of obesity (and body fat distribution and fasting insulin levels) and PCOS on endocrine variables were evaluated by means of analysis of covariance.

PATIENTS

Sixty-seven women with anovulatory menstrual cycles and polycystic ovaries according to ultrasonography and 59 women with normal ovaries and regular cycles, both groups covering a wide range of body mass index (BMI, PCOS, 17.6-37.4, mean 25.7 kg/m2; controls, 18.8-40.9, mean 25.1 kg/m2).

MEASUREMENTS

Serum levels of gonadotrophins, sex steroid hormones, prolactin and GH obtained in the early follicular phase in the controls, fasting insulin levels, anthropometric measures (BMI, skinfolds, waist hip ratio).

RESULTS

Mean serum concentrations of LH, androstenedione, testosterone, the free androgen index (FAI; all P < 0.0001) and DHEAS (P < 0.01) were higher, and serum FSH (P < 0.01) and serum SHBG levels lower (P < 0.0001), in the PCOS group than in the controls. Women with PCOS had a more pronounced upper body fat distribution and higher fasting insulin levels than the controls. Independent of PCOS, BMI was positively associated with serum levels of FSH (P < 0.001) and negatively with levels of LH (P < 0.05), LH/FSH ratio (P < 0.0001), SHBG (P < 0.0001) and androstenedione (P < 0.01), whereas for levels of testosterone, FAI and DHEAS the impact of obesity differed significantly between the groups. Thus, in the PCOS group, testosterone levels (P < 0.05) and the FAI (P < 0.001) were positively associated with BMI, whereas they were constant throughout the entire range of BMI in the controls. DHEAS levels were positively associated with BMI in the PCOS group (P < 0.05) and negatively in the controls (P < 0.01). Measures of upper body fat were related to testosterone and FAI levels, independent of BMI.

CONCLUSIONS

Lower FSH levels were found in women with PCOS than during the early follicular phase of normally ovulating women, suggesting a role in anovulation in PCOS. Obesity itself exerted effects on endocrine variables, with the net result of a reduced LH/FSH ratio and lower serum levels of androstenedione and SHBG in both groups; obesity was associated with increased levels of DHEAS, testosterone and FAI exclusively in the women with PCOS. The results underline the endocrine impact of obesity and body fat distribution and the necessity of applying reference values of BMI matched subjects when establishing the endocrine profile of women with PCOS.

Cycle abnormalities in infertile women with regular menstrual cycles: effects of clomiphene citrate treatment

OBJECTIVE

To investigate the incidence and nature of cycle abnormalities and the effect of clomiphene citrate (CC) treatment in women with apparently ovulatory cycles and unexplained infertility.

DESIGN

Nonrandomized, open study of patients before and during treatment.

SETTING

The Reproductive Medicine Clinic of a District General Hospital.

PATIENTS

Thirty-five women with regular, apparently ovulatory menstrual cycles and unexplained infertility.

INTERVENTIONS

Detailed ultrasound and hormonal cycle tracking was performed before and during treatment with CC.

MAIN OUTCOME MEASURES

Serial ultrasound scans and measurements of serum LH, FSH, E2, and P.

RESULTS

Before treatment, 54% of cycles were uniovulatory, 40% were characterized by cyst formation, and 6% were characterized by poor follicular growth. Fifty-one percent of pretreatment cycles had normal hormone profiles, 31% had defective luteal phases, 14% had increased early follicular phase serum FSH levels, and 9% had increased early follicular phase serum LH levels. Treatment with CC reduced the incidence of cyst formation to 9% and the incidence of luteal phase defects to 3%. However, 28% of CC-treated cycles showed ultrasound features of overstimulation and 51% had high follicular phase E2 peaks so that only 34% of CC-treated cycles had normal hormone profiles.

CONCLUSIONS

Cycle abnormalities are common in unexplained infertility. The incidence of cyst formation and luteal phase defects, the most common abnormalities in this group, is reduced by CC treatment.