diagnosis of pcos - jane norman

8/11/2019 Diagnosis of PCOS - Jane Norman

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Diagnosis of polycystic ovarian

syndrome.

August 2006

Prof Jane Norman

Division of Developmental Medicine

University of Glasgow


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Stein & Leventhal (1935)

Seven women with amenorrhoea, hirsutism,obesity and enlarged ovaries who

underwent ovarian wedge resection

all seven resumed regular menstruation

two conceived


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Ehrmann DA et al 2005 N Engl J Med 352: 1223


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Rotterdam Consensus workshop

PCOS is syndrome of ovarian dysfunction alongwith the cardinal features hyperandrogenism andpolycystic ovary morphology

No single diagnostic criterion is sufficient The diagnosis of PCOS can be made on the basisof two out of the three of the following

Oligo- or anovulation

Clinical or biochemical signs of hyperandrogenism

Polycystic ovaries on ultrasound or direct inspection

Other causes of hyperandrogenism should be

excluded Human Reproduction (2004) 19: 1Fertility Sterility (2004) 81:19


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The polycystic ovary


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PCO : ultrasound


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Ultrasound criteria for diagnosis of PCO

twelve or more subcapsular follicular cysts2 9 mm in diameter

and / or

Increase in ovarian volume up to 10ml3

(determined by transvaginal ultrasound)


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Prevalence of PCO / PCOS

Setting n PCO %

Polson et al

1988

Volunteers 257 23

Clayton et al

1992

GP practice 190 22

Farquhar et al1994

Electoral roll 183 21

Michelmore et al

1999

GP practice 224 34


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Clinical symptoms of women with PCOConway et al

1989

Balen et al

1995

Eden et al

1999

(n = 556) (n = 1741) (n=1019)

Amenorrhoeic

/ oligo

71% 66% 75%

Hirsutism 61% 66% 34%

Obesity 35% 38% 31%

Infertility 29% 75%* 14%

Acanthosis 2% 2.5% 0.5%

CAH 1.9%


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Prevalence of PCO in symptomaticwomen

Condition Proportion with PCO

Oligomenorrhoea 87 %

Amenorrhoea 26 %

Hirsutism 92 %

Adams et al, 1986


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Spectrum of PCOS

Ultrasound

features

Clinical / biochemical

features of hyperandrogenism

Oligomenorrhoea /amenorrhoea


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Biochemical features of PCOS

testosterone / FAI elevated

(> 3nmol/ml or > 7)

insulin resistance

LH elevated


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Clinical features of PCOS

Oligo / anovulation Clinical signs of androgen excess

Hirsutism / (acne) / rarely clitoromegaly

Obesity

Acanthosis nigricans

Enlarged ovaries on inspection


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Hirsutism - definition

Presence of terminal(coarse) hairs in females

in a male-like pattern

Prevalence 5 15% of

women


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Modified Ferriman Gallwey score

Hatch et al, 1981 Am J Obstet Gynecol 140: 815-30


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Acanthosis nigricans


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No single diagnostic criterion is sufficient

The diagnosis of PCOS can be made on the basisof two out of the three of the following







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How to diagnose PCOS

1. Consider other possible diagnoses

Congenital adrenal hyperplasia

Defect of 21-hydroxylase enzyme

17-OHP accumulates


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Steroid biosynthetic pathway

www.angelfire.com


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21 hydroxylase deficiency

www.angelfire.com


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17-OHP accumulates

Cushings syndrome


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Cushings syndrome


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17-OHP accumulates

Cushings syndrome

Androgen secreting tumour


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2. Do laboratory evaluation Minimum

Serum testosterone

DHEA sulphate

17 OHP


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Dynamic testing for 17 OHP

Indicated only if random test is abnormal


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Laboratory evaluation Minimum

Serum testosterone

DHEA sulphate

17 OHP

Optional 24 hr urinary free cortisol

Prolactin

Sex hormone binding globulin / free androgen index LH / FSH

Lipids and insulin resistance?


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3. If uncertain after doing the preceeding,

ultrasound of ovaries is helpful

Diagnostic criteria: twelve or more subcapsular follicular cysts 2

9 mm in diameter

and / or

Increase in ovarian volume up to 10ml


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Ehrmann DA 2005 New Engl J Med 352: 1223

Suggested diagnostic algorithm


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No single diagnostic criterion is sufficient

The diagnosis of PCOS can be made on the basisof two out of the three of the following







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NICHD 1990 diagnostic criteria

PCOS is clinical or biochemical evidence ofhyperandrogenism and chronic anovulation

after exclusion of other disorders

USS criteria not relevant


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Controversies in Rotterdam criteria

Broader criteria than NICHD New criteria also include:

Women with hirsutism and

hyperandrogenemia, PCOS on scan but regular

cycles

Women with PCOS and oligomenorrhoea but

without androgen excess


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US Viewpoint

Widespread adoption of the diagnostic criteriasuggested in Rotterdam should be consideredpremature

Women with hirsutism and hyperandrogenemia,PCOS on scan but regular cycles

Insulin disturbance and ovarian dysfunction only mild(Carmina 2001)


without androgen excess Women with non androgenic disorders including prolactinoma, and transiently

in physiological conditions such as puberty have PCOS

Azziz R 2005 Fertil Steril 83: 1343


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UK viewpoint

Expanded diagnostic criteria helpful

Women with hirsutism and hyperandrogenemia,PCOS on scan but regular cycles

Share many of the biochemical features of classic PCOS Carmina 2001, although insulin resistance tends to be less


without androgen excess Other disorders should be excluded no risk of

misdiagnosing POF

Uncommon (3%)

Most have disorders of androgen production on dynamictesting

Testosterone levels dont affect response to O.I

Franks S (2006) J Clin Endocrinol Metab 91:786


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Screening for metabolic disorders in PCOS 2003

conference consensus

1. No tests of insulin resistance are necessary to

make the diagnosis of PCOS, nor are they needed

to select treatments.

2. Obese women with PCOS should be screened for

the metabolic syndrome, including glucose

intolerance with an oral glucose tolerance test.

3. Further studies are necessary in non-obese

women with PCOS to determine the utility of these

tests, athough they may be considered if additional

risk factors for insulin resistance, such as a family

history of diabetes, are present.

Fertility Sterility (2004) 81:19


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Criteria for the metabolic syndrome in PCOS.

110 126 mg /dL and/or 2-h glucose 140

199 mg/dL.

5. Fasting and 2-h glucose fromoral GTT

130 / 854. Blood pressure

< 50mg / dL3. HDL-C

150mg / dL2. Triglycerides

> 88 mm (> 35 inch)1. Abdominal obesity (waist

circumference)

Cut offRisk factor

Fertility Sterility (2004) 81:19


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diagnosis of pcos - jane norman

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