A Cross-Sectional Study on Potential Ovarian Volume and Related Factors in Women with Polycystic Ovary Syndrome from Infertile Couples

New insights into the relationship of antimüllerian hormone with polycystic ovary syndrome and its diagnostic accuracy: an updated and extended meta-analysis using a marginal beta-binomial model

OBJECTIVE

This study aimed to investigate the diagnostic role of antimüllerian hormone in polycystic ovary syndrome using an advanced marginal beta-binomial statistical model, and present the optimal cutoff by different age groups, geographical locations, body mass indexes, and other relevant factors.

DATA SOURCES

A comprehensive and systematic literature search was conducted in Web of Science, PubMed/Medline, Scopus, Cochrane Library, Embase, and ProQuest until August 2024.

STUDY ELIGIBILITY CRITERIA

Epidemiologic studies that used the Androgen Excess and Polycystic Ovary Syndrome Society, National Institutes of Health, or Rotterdam diagnostic criteria for polycystic ovary syndrome were included in this meta-analysis. Studies were eligible for inclusion if they provided information on the sensitivity and specificity of antimüllerian hormone or related data that allowed for the calculation of these parameters, and/or data on odds ratios and means.

METHODS

The diagnostic efficacy of antimüllerian hormone was assessed using the marginal beta-binomial statistical model and the summary receiver operating characteristic method in terms of pooled sensitivity, specificity, and diagnostic odds ratio with 95% confidence interval. Pooled weighted mean difference and pooled odds ratios with 95% confidence interval were estimated using a random effects model.

RESULTS

A total of 202 observational studies were included in the pooled analysis, of which 106 studies (including 19,465 cases and 29,318 controls) were used for meta-analysis of sensitivity/specificity and 186 studies (including 30,656 cases and 34,360 controls) for meta-analysis of mean difference. The pooled sensitivity, specificity, and diagnostic odds ratio for antimüllerian hormone were 0.79 (95% confidence interval, 0.52-0.97), 0.82 (95% confidence interval, 0.64-0.99), and 17.12 (95% confidence interval, 14.37-20.32), respectively. The area under the curve based on the summary receiver operating characteristic model was 0.90 (95% confidence interval, 0.87-0.93). Antimüllerian hormone levels were significantly higher in women with polycystic ovary syndrome than in control women (weighted mean difference, 4.91; 95% confidence interval, 4.57-5.27). In addition, individuals with higher antimüllerian hormone levels were more likely to be affected by polycystic ovary syndrome (odds ratio, 23.17; 95% confidence interval, 18.74-28.66; I2=94%; P<.001). A serum antimüllerian hormone concentration of >5.39 ng/mL was associated with polycystic ovary syndrome (sensitivity, 88.6%; specificity, 92.75%; likelihood ratio for a positive test result, 12.21; likelihood ratio for a negative test result, 0.12).

CONCLUSION

According to the results of this meta-analysis, serum antimüllerian hormone concentration is a valuable biomarker for the diagnosis of polycystic ovary syndrome. The cutoff points suggested by the current meta-analysis need to be evaluated and validated by future studies before their implementation into clinical practice.

The additional value of ultrasound markers in the diagnosis of polycystic ovary syndrome

OBJECTIVE

To study the value of current definitions for follicle number per ovary and ovarian volume in the diagnosis of polycystic ovary syndrome (PCOS).

DESIGN

Cross-sectional study.

SUBJECTS

Women diagnosed with PCOS after standardized screening were eligible for inclusion in the PCOS group. Women without PCOS who underwent the same screening, had regular menstrual cycles, normal hormonal values, and no other endocrine pathology were eligible for inclusion.

EXPOSURE

Not applicable.

MAIN OUTCOME MEASURE(S)

Follicle number per ovary and ovarian volume in women with PCOS, stratified by age. Linear regression models to investigate the influence of body mass index (BMI) on follicle number per ovary and ovarian volume. Differences in follicle number per ovary and ovarian volume between the PCOS phenotypes and the additional value of ovarian volume compared with follicle number per ovary.

RESULT(S)

A total of 2,492 women (16-50 years) with PCOS and 152 women without PCOS were included. Most women with PCOS up to age of 35 exhibit a follicle number per ovary ≥20 (87.8%-100%) (using an ultrasound transducer ≥8 MHz) or ≥12 (95.1%-98.6%) (using a transducer <8 MHz), followed by a decline in follicle number per ovary >35 years. Median ovarian volume was below the 10 mL cutoff in every age group, for both ultrasound transducers. Follicle number per ovary and ovarian volume were higher in women with PCOS compared with women without PCOS in every age category. In our cohort, 13/2,297 women with PCOS (0.6%) would not have received the diagnosis if ovarian volume was not considered a marker for polycystic ovarian morphology. For both ultrasound transducers, women with phenotype A (ovulatory dysfunction + hyperandrogenism + polycystic ovarian morphology) exhibited the highest follicle number per ovary and ovarian volume, followed by phenotype D (ovulatory dysfunction + polycystic ovarian morphology), then phenotype C (hyperandrogenism + polycystic ovarian morphology), and then phenotype B (ovulatory dysfunction + hyperandrogenism). No clinically significant correlation between BMI and follicle number per ovary or ovarian volume was observed.

CONCLUSION(S)

Criteria to define follicle number per ovary should be established per age category, as follicle number per ovary decreases with age. Ovarian volume shows a less clear decline with age and has a lower discriminative power, and therefore could be excluded from the diagnostic criteria. Follicle number per ovary does not need to be stratified by BMI.

Ovarian Morphology in Non-Hirsute, Normo-Androgenic, Eumenorrheic Premenopausal Women from a Multi-Ethnic Unselected Siberian Population

Polycystic ovary syndrome (PCOS) is a highly prevalent disorder in women, and its diagnosis rests on three principal features: ovulatory/menstrual dysfunction, clinical and/or biochemical hyperandrogenism, and polycystic ovarian morphology (PCOM). Currently, data on age- and ethnicity-dependent features of PCOM remain insufficient. We aimed to estimate ethnicity- and age-dependent differences in ovarian volume (OV) and follicle number per ovary (FNPO) in a healthy, medically unbiased population of Caucasian and Asian premenopausal women, who participated in the cross-sectional Eastern Siberia PCOS epidemiology and phenotype (ESPEP) study (ClinicalTrials.gov ID: NCT05194384) in 2016-2019. The study population consisted of 408 non-hirsute, normo-androgenic, eumenorrheic premenopausal women aged 18-44 years. All participants underwent a uniform evaluation including a review of their medical history and a physical examination, blood sampling, and pelvic ultrasonography. The statistical analysis included non-parametric tests and the estimation of the upper normal limits (UNLs) by 98th percentiles for OV and FNPO. In the total study population, the upper OV percentiles did not differ by ethnicity or age group. By contrast, the UNL of FNPO was higher in Caucasian women than in Asian women, and women aged <35 years demonstrated a higher UNL of FNPO compared to older women. In summary, these data suggest that the estimation of FNPO, but not OV, should take into account the ethnicity and age of the individual in estimating the presence of PCOM.

Ultrasonographic criteria in the diagnosis of polycystic ovary syndrome: a systematic review and diagnostic meta-analysis

BACKGROUND

Polycystic ovary morphology (PCOM) on ultrasonography is considered as a cardinal feature of polycystic ovarian syndrome (PCOS). Its relevance as a diagnostic criterion for PCOS was reaffirmed in the most recent International Evidence-Based Guideline for the Assessment and Management of PCOS. However, there remains a lack of clarity regarding the best practices and specific ultrasonographic markers to define PCOM.

OBJECTIVE AND RATIONALE

The aim of this systematic review and diagnostic meta-analysis was to assess the diagnostic accuracy of various ultrasonographic features of ovarian morphology in the diagnosis of PCOS.

SEARCH METHODS

Relevant studies published from 1 January 1990 to 12 June 2023 were identified by a systematic search in PubMed, Web of Science, Scopus, CINAHL, and CENTRAL. Studies that generated diagnostic accuracy measures (e.g. proposed thresholds, sensitivity, specificity) for PCOS using the following ultrasonographic markers met criteria for inclusion: follicle number per ovary (FNPO) or per single cross-section (FNPS), ovarian volume (OV), and stromal features. Studies on pregnant or post-menopausal women were excluded. Risk of bias and applicability assessment for diagnostic test accuracy studies were determined using the QUADAS-2 and QUADAS-C tool for a single index test or between multiple index tests, respectively. Diagnostic meta-analysis was conducted using a bivariate model of pooled sensitivity and specificity, and visualized using forest plots and summary receiver-operating characteristic (SROC) curves.

OUTCOMES

From a total of 2197 records initially identified, 31 studies were included. Data from five and two studies were excluded from the meta-analysis due to duplicate study populations or limited data for the index test, leaving 24 studies. Pooled results of 20 adult studies consisted of 3883 control participants and 3859 individuals with PCOS. FNPO was the most accurate diagnostic marker (sensitivity: 84%, CI: 81-87%; specificity: 91%, CI: 86-94%; AUC: 0.905) in adult women. OV and FNPS had similar pooled sensitivities (OV: 81%, CI: 76-86%; FNPS: 81%, CI: 70-89%) but inferior pooled specificities (OV: 81%, CI: 75-86%; FNPS: 83%, CI: 75-88%) and AUCs (OV: 0.856; FNPS: 0.870) compared to FNPO. Pooled results from four adolescent studies consisting of 210 control participants and 268 girls with PCOS suggested that OV may be a robust ultrasonographic marker for PCOS diagnosis albeit the current evidence remains limited. The majority of the studies had high risk of bias for the patient selection (e.g. lack of randomized/consecutive patient selection) and index test (e.g. lack of pre-proposed thresholds for comparison) domains across all ultrasonographic markers. As such, diagnostic meta-analysis was unable to determine the most accurate cutoff for ultrasonographic markers to diagnose PCOS. Subgroup analysis suggested that stratification based on previously proposed diagnostic thresholds, age, BMI, or technology did not account for the heterogeneity in diagnostic accuracy observed across the studies. Studies that diagnosed PCOS using the Rotterdam criteria had improved sensitivity for FNPO. Studies from North America had lower diagnostic accuracy when compared to Asian studies (FNPO: sensitivity) and European studies (OV: specificity, diagnostic odds ratio and positive likelihood ratio). Geographic differences in diagnostic accuracy may potentially be due to differences in age, BMI, and diagnostic criteria of the PCOS group across regions.

WIDER IMPLICATIONS

This diagnostic meta-analysis supports the use of FNPO as the gold standard in the ultrasonographic diagnosis of PCOS in adult women. OV and FNPS provide alternatives if total antral follicle counts cannot be accurately obtained. Our findings support the potential for ultrasonographic evidence of PCOM in adolescents as more data becomes available. Subgroup analysis suggests the need to investigate any relative contributions of geographical differences on PCOS phenotypes. These findings may provide the basis for the development of strategies and best practices toward a standardized definition of PCOM and a more accurate ultrasonographic evaluation of PCOS.

Ovarian volume is more closely related to the different manifestations of polycystic ovary syndrome than follicle number per ovary

OBJECTIVE

Polycystic ovary (PCO), a diagnostic component of polycystic ovary syndrome (PCOS), requires either an ovarian volume (OV) criterion or a follicle number per ovary (FNPO) criterion. This study investigated the association of OV and FNPO criteria with various manifestations of PCOS.

METHODS

This cross-sectional study was conducted at a university hospital among 100 patients newly diagnosed with PCOS (according to the revised Rotterdam criteria). Fasting blood samples were collected to measure glucose, total testosterone (TT), luteinizing hormone (LH), follicle-stimulating hormone (FSH), lipid, insulin, and hemoglobin A1c levels. An oral glucose tolerance test was performed. Transabdominal or transvaginal ultrasound of the ovaries was done, depending on patients' marital status. All investigations were conducted in the follicular phase of the menstrual cycle. OV >10 mL and/or FNPO ≥12 indicated PCO. A homeostasis model assessment of insulin resistance (IR) value ≥2.6 indicated IR, and metabolic syndrome (MS) was defined according to the international harmonization criteria.

RESULTS

Seventy-six participants fulfilled the OV criterion, 70 fulfilled the FNPO criterion, and 89 overall had PCO. Both maximum OV and mean OV had a significant correlation with TT levels (r=0.239, p=0.017 and r=0.280, p=0.005, respectively) and the LH/FSH ratio (r=0.212, p=0.034 and r=0.200, p=0.047, respectively). Mean OV also had a significant correlation with fasting insulin levels (r=0.210, p=0.036). Multivariate binary logistic regression analysis showed that IR (odds ratio [OR], 9.429; 95% confidence interval [CI], 1.701 to 52.271; p=0.010) and MS (OR, 7.952; 95% CI, 1.821 to 34.731; p=0.006) had significant predictive associations with OV alone, even after adjustment for age and body mass index.

CONCLUSION

OV may be more closely related to the androgenic and metabolic characteristics of PCOS than FNPO.

High Fat Diet Exaggerate Metabolic and Reproductive PCOS Features by Promoting Oxidative Stress: An Improved EV Model in Rats

Background and Objectives: Polycystic ovary syndrome (PCOS) is a frequent multifactorial endocrinopathy affecting women in the reproductive period, often associated with infertility and metabolic disorders. The use of animal models helps to better understand etiopathogenesis, enabling the examination of the effects of certain drugs in order to discover the best possible therapeutic approach. We tried to investigate the additional effect of estradiol-valerate (EV) and high-fat diet (HFD) in female rats to explore PCOS-related alterations with special focus on oxidative stress. Materials and Methods: Animals were divided into three groups: control group (CTRL, n = 6), estradiol-valerate group (EV, n = 6), and estradiol-valerate group on HFD (EV + HFD, n = 6). PCOS was induced by single subcutaneous injection of long-acting EV in a dose of 4 mg/per rat. We tried to improve the metabolic characteristics of the PCOS animal model by adding HFD, so the CTRL and EV group had a regular diet, while the EV + HFD group had HFD during the induction period of 60 days. Results: We observed alterations of anthropometric parameters and hormonal disturbances, along with estrus cycle impairment reassembly to obese-type PCOS phenotype. Moreover, glucose metabolism was impaired after addition of HFD to EV protocol, contrary to EV administered alone. Histological analysis confirmed more numerous cystic follicles after the combination of EV and HFD protocol. The alterations of oxidative stress markers could be related to and serve as the mechanistic base for development of PCOS-related endocrine, reproductive, and metabolic properties. Conclusions: The additive effect of EV and HFD was obvious in the majority of the parameters observed. Our study strongly demonstrated metabolic as well as reproductive properties of PCOS in rats.