Polycystic Ovary Syndrome (PCOS): Can We Unify Two Points of View

Polycystic Ovary Syndrome (PCOS): Can We Unify Two Points of View

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Polycystic Ovary Syndrome (PCOS): Can We Unify Two Points of View?

R.A. Lobo

Department of Obstetrics & Gynecology, Columbia University College of Physicians & Surgeons, New York, NY, U.S.A.

Although PCOS is an extremely prevalent disorder in women and is likely to be the most common endocrinopathy, figures of the prevalence of PCOS in women varies considerably depending on how it is diagnosed (1). The reason for all the confusion is the heteterogeneity and wide spectrum of symptoms and signs in PCOS. In the United States, the predominant view is that the diagnosis is based on the finding of irregular cycles and anovulation together with androgen excess. This diagnosis is independent of ovarian morphological findings, but other disorders such as tumors, congenital adrenal hyperplasia and Cushing’s syndrome need to be ruled out. This was the view of a meeting of “experts” at NIH in 1990 (2) which has been referred to as a consensus meeting, but was never designed to be this. Using this definition, the prevalence of PCOS is thought to be in the range of 3-8% (3).

In Europe, the focus has been on the ultrasound finding of polycystic ovaries (4). The presence of polycystic ovaries and some other finding is sufficient for the diagnosis of PCOS. This includes any of a variety of findings: obesity, androgen excess, biochemical changes and irregular menses and anovulation. Since up to 20% of all women may have polycystic ovaries, the prevalence of the disorder is much higher using this definition. Clearly many of these women are ovulatory, which was considered not to occur in women with PCOS.

In the last 10 years, these opposite views have been coming closer together. Clearly we among others have confirmed the presence of ovulatory function in patients who otherwise have very characteristic features of PCOS (5,6). This has been acknowledged to be a legitimate form of PCOS in the most recent NIH-Sponsored meeting on PCOS (7). What percentage of the overall population with PCOS has ovulatory function is unclear but it is this investigator’s view that this sub typing of PCOS is appropriate. It is also acknowledged that obesity and certain biochemical features of PCOS need not be present for the diagnosis. Because insulin resistance may be difficult to diagnose, this too is not a requirement for the diagnosis.

In terms of ovarian findings on ultrasound, the difficulty here is the lack of consistency regarding criteria for this diagnosis (8). Here too a spectrum exists for the valid diagnosis of polycystic ovaries. Nevertheless if we are liberal about this ultrasound diagnosis in women who have the classical features of PCOS (anovulation and androgen excess) polycystic ovaries will be found in essentially all of these women diagnosed to have PCOS.

Perhaps the only remaining area of controversy is that of the importance of androgen excess. For this investigator, it remains very important in distinguishing between the syndrome (PCOS) and the more innocent findings of polycystic ovaries on ultrasound. However, it is acknowledged that the diagnosis can be very subtle and may not be obvious with routine screening blood tests. For example it is clear that androgen excess can be diagnosed with the presence of skin abnormalities such as hirsutism, without elevations of serum androgens. Other cases can be diagnosed in women with polycystic ovaries when an ovarian androgen response is evoked by gonadotropin or GnRH- agonist stimulation (6,9).

In ovulatory women who only have the ultrasound findings, subtle metabolic abnormalities (low HDL-C and insulin resistance) have been diagnosed (9). Thus it is suggested that a wide spectrum exists which varies from women who only have ultrasound findings (who may or may not express the syndrome at some point in the future) to other women with the full characteristic features of the syndrome. Because of the potential serious metabolic and CV abnormalities which can be expressed in the disorder, a close monitoring of all women within the spectrum should be undertaken (10). This is even more important in women who are obese and have more severe menstrual abnormalities, two conditions where insulin resistance is more severe.

In conclusion there is now much more consistency in unifying the “two points of view,” in the diagnosis of PCOS. It is clear that this is a very heterogeneous disorder that represents a spectrum of abnormalities. It is not a disease per se and thus the term PCOD should not be used (11). Polycystic ovaries on ultrasound in PCOS is a near universal finding. Whereas ovulatory function can be seen in a subset of women with the disorder, this investigator feels it is important to have some evidence of hyperandrogenism. Close monitoring of all women with the disorder is important in order to reduce the morbidity associated with the disorder.

References

  1. CARMINA, E, LOBO RA. Polycystic ovary syndrome (PCOS) arguably the most common endocrinopathy is associated with significant morbidity in women. J Endocrinol Metab 84:1897-9, 1999.
  2. ZAWDAKI JK, DUNAIF A. Diagnostic criteria for polycystic ovary syndrome: towards a rationale approach. In: Dunaif A, Given JR, Haseltine FP, Merriam GR, eds. Current Issues in Endocrinology and Polycystic Ovary Syndrome, Blackwell, Boston, pp377-84,1992.
  3. NESTLER JE. Polycystic ovary syndrome: a disorder for the generalist. Fertil Steril 70:811-12, 1998.
  4. BALEN AH. The pathogenesis of polycystic ovary syndrome: the enigma unravels. Lancet 354:966-7, 1999.
  5. CARMINA E, WONG L, CHANG L, PAULSON RJ et al. Endocrine abnormalities in ovulatory women with polycystic ovaries on ultrasound. Hum Reprod 12:905-09, 1997.
  6. CARMINA E, LOBO RA. Do hyperandrogenic women with normal menses have PCOS? Fertil Steril 71:319-22, 1999.
  7. CHANG RJ, Polycystic ovary syndrome: Diagnosis criteria. In: Polycystic Ovary Syndrome. CHAANG RJ, Heindel JJ, Dunaif A. Marcel Dekker, eds. New York/Basel, pp 361-65, 2002.
  8. DEWAILLY, D, YANN R, LIONS, C, ARDAENS, Y. Ultrasound examination of polycystic and multifollicular ovaries. In: Polycystic Ovary Syndrome. Chang RJ, Heindel JJ, Dunaif A, eds. Marcel Dekker, New York/Basel, pp 63-75, 2002.
  9. CHANG P, LINDHEIM SR, LOWRE C, FERIN M, et al. Normal ovulatory women with polycystic ovaries have hyperandrogenic pituitary-ovarian responses to gonadotropin-releasing hormone-agonist testing. J Clin Endocrinol Metab 85:995-1000, 2000.
  10. LOBO RA, CARMINA E. The importance of diagnosing the polycystic ovary syndrome. Ann Int Med 132:989-93, 2000.
  11. LOBO RA. A disorder without identity: “HCA,” “PCO,” “PCOD,” “PCOS,” “SLS.” What are we to call it? Fertil Steril 63:1158-60, 1995.

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