Polycystic ovary syndrome gets redefined diagnosis

A quick check of your next patient chart shows a woman with irregular or absent ovulation and elevated levels of androgenic hormones. What’s your initial diagnosis?

If it is polycystic ovary syndrome (PCOS), your deduction falls in line with findings jointly issued by the Grimbergen, Belgium-based European Society for Human Reproduction and Embryology and the Birmingham, AL-based American Society for Reproductive Medicine (ASRM). The two groups recently convened a consensus workshop in Rotterdam, the Netherlands, to more exactly characterize the syndrome.1

Since the condition encompasses such a broad spectrum of signs and symptoms, diagnosis can prove difficult for clinicians. In an attempt to simplify matters, workshop participants issued the following diagnostic criteria:

For a patient to be diagnosed with PCOS, two of the following three conditions must be present: irregular or absent ovulation, elevated levels of androgenic hormones, and/or enlarged ovaries containing 12 or more follicles each.

Care must be taken in ruling out other conditions, such as androgen-secreting tumors or Cushing’s syndrome that can present the same symptoms, caution workshop participants. Also, if a woman has polycystic ovaries, but normal ovarian function, and she exhibits no signs of elevated androgen hormones, she should not be considered as having PCOS until more is known about her condition, they state.1

"PCOS remains a syndrome, and no constellation of findings or set criteria can exclusively be used for a clinical diagnosis or for inclusion in clinical research," states Robert Schenken, MD, ASRM president-elect. "Further studies are needed to assess risk levels based on different diagnostic criteria."

Understand the syndrome

Androgenic disorders are the most common endocrine-based disorders of women and affect up to 10% of American reproductive-aged females.2 About 65%-85% of hyperandrogenic women have polycystic ovary syndrome. Clinical manifestations of the disorder include hirsutism, acne, obesity, anovulation, and menstrual irregularities.2

When taking the patient’s history, note the following features: the onset and duration of signs of androgen excess; menstrual history; medication use, including exogenous androgens; lifestyle issues, including exercise, alcohol use, smoking; and family history of cardiovascular disease and diabetes.3 Look for the following symptoms during the physical examination: presence of acne, balding, or clitoromegaly; the distribution of body hair; enlargement of the ovaries based on a pelvic examination; and signs of insulin resistance, such as obesity. In women with acanthosis nigricans, a condition characterized by velvety, mossy, hyperpigmented skin, often noted on the back of the neck, beneath the breasts, or on the vulva, it is important to consider associated insulinoma or malignancy, particularly adenocarcinoma of the stomach.3

Because tests for insulin resistance are inexact, workshop participants have recommended that PCOS patients be evaluated for metabolic syndrome. Such evaluation involves measuring for abdominal obesity, triglycerides, high-density lipoproteins, high blood pressure, and fasting and two-hour glucose tolerance. In addition, there is some evidence that women with PCOS are at increased risk for cardiovascular disease and may also be at increased risk for endometrial cancer; check for both risks in your exam.4,5

More research needed

Since a 1990 conference was held by the Bethesda-based National Institutes of Health, clinicians have struggled with a universally accepted definition of PCOS.6 The reason for the confusion lies in the fact that PCOS is a syndrome, and there are likely many causes for the disorder, says Robert Rebar, MD, ASRM’s executive director. The ASRM workshop’s findings are by no means the final statement on the subject, he adds.

While the clarification of diagnostic criteria may improve the ability of clinicians and researchers to discuss PCOS, the way the criteria are framed — as two out of three required for diagnosis — may cause some confusion, he says. Further research is needed to clarify how the risks of PCOS relate to the individual patient’s manifestation of the syndrome, states Rebar.

How can you help women manage symptoms associated with PCOS? Combination oral contraceptive pills may be effective in long-term management of such symptoms as menstrual irregularities, hirsutism, and acne.2 Oral contraceptive pills also reduce the risk of endometrial cancer; the extent of this effect in women with PCOS is unknown.3

References

  1. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004; 81:19-25.
  2. Using oral contraceptives to treat polycystic ovary syndrome. Contraception Report 2001; 12:4-7, 16.
  3. Schroeder BM. ACOG releases guidelines on diagnosis and management of polycystic ovary syndrome. Am Fam Physician 2003; 67:1,619-1,620, 1,622.
  4. Dahlgren E, Janson PO, Johansson S, et al. Polycystic ovary syndrome and risk for myocardial infarction — evaluated from a risk factor model based on a prospective study of women. Acta Obstet Gynecol Scand 1992; 71:599-604.
  5. Hardiman P, Pillay OS, Atiomo W. Polycystic ovary syndrome and endometrial carcinoma. Lancet 2003; 361:1,810-1,812.
  6. Zawadski JK, Dunaif A. Diagnostic criteria for polycystic ovary syndrome: Towards a rational approach. In: Dunaif A, Givens JR, Haseltine F, eds. Polycystic Ovary Syndrome. Boston: Blackwell Scientific; 1992, pp. 377-384.