PCOS: a diagnostic challenge

Women's perceptions of polycystic ovary syndrome following participation in a clinical research study: implications for knowledge, feelings, and daily health practices

OBJECTIVE

Polycystic ovary syndrome (PCOS) is a complex endocrine disorder that affects 6% to 10% of reproductive aged women. It is a poorly understood and often undiagnosed condition that has implications for the health of affected women. We assessed changes in knowledge, feelings, and daily health practices related to PCOS in clinical research study participants.

METHODS

Sixty-eight women who had received counselling and education about PCOS while participating in a clinical research study were invited to complete an online survey that assessed levels of concern, knowledge, healthy dieting, active living, and health care satisfaction before and after the study. Differences and associations between scores were analyzed by paired t tests and Pearson correlation.

RESULTS

Forty-three women (63%) completed the survey. After taking part in a clinical research study, participants believed they had increased knowledge of (P < 0.001) and concern about (P = 0.029) the etiology and health consequences of PCOS, better lifestyle practices (P < 0.001), and improved health care satisfaction (P = 0.045). Enhanced knowledge of PCOS was positively associated with changes in concern (P = 0.045), healthy dietary habits (P = 0.04), activity levels (P = 0.003), and health care satisfaction (P < 0.001). After the study, women felt empowered to participate in the management of their condition and communicate with their primary care providers.

CONCLUSION

Women with PCOS felt that they had more knowledge and motivation to implement preventive health strategies after participating in a clinical research study. Education about how PCOS affects their immediate and long-term health enabled women with PCOS to feel physical and psychological benefits and to engage more with their health care providers.

Depressive symptoms related to infertility and infertility treatments

This article reviews depressive symptoms in women as they relate to infertility and infertility treatments. Common causes of infertility in women are discussed and the literature on depressive symptoms before and during various infertility treatments is presented. Recommendations are made from a psychiatric perspective regarding how to manage depressive symptoms in women in the context of infertility.

Successful birth following transfer of frozen-thawed embryos produced from in-vitro matured oocytes

It is well established that ovarian hyperstimulation syndrome (OHSS) is more frequent in patients with polycystic ovarian syndrome. In-vitro maturation (IVM) of immature oocytes presents a potential alternative for the fertility treatment and prevention of OHSS for these patients. This report describes the case of a 26-year old woman with a successful pregnancy and delivery following the transfer of frozen-thawed embryos derived from in-vitro matured oocytes. She had three failed cycles of ovarian stimulation (using low-dose step-up gonadotrophin protocol) with or without intrauterine insemination cycles, an ovulation-induction cycle with luteal long protocol, two fresh IVM cycle and one frozen-thawed IVM cycle. During the IVF cycle, she developed moderate OHSS and required hospitalization for 3 weeks. Following four unsuccessful IVF or IVM cycles, 15 months after the last cryopreservation, six fertilized oocytes were thawed for a scheduled embryo transfer. Following thawing, four fertilized oocytes survived and cleaved. Four frozen-thawed embryos were transferred. Six weeks after embryo transfer an ongoing intrauterine single pregnancy with fetal heartbeat was confirmed by transvaginal ultrasound. An uneventful pregnancy and delivery via Caesarean section at 39 weeks resulted in the birth of a normal healthy infant.

Treatment of hirsutism with myo-inositol: a prospective clinical study

The aim of this study was to evaluate the effects of myo-inositol treatment in hirsute women; changes in lipid pattern and insulin sensitivity were also considered. Forty-six hirsute women were enrolled at the first Institute of Obstetrics and Gynecology and evaluated at baseline and after receiving myo-inositol therapy for 6 months. Body mass index (BMI), hirsutism, serum concentrations of total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, apolipoprotein B, lipoprotein(a), serum adrenal and ovarian androgens, fasting glucose and insulin concentrations were evaluated. No changes in BMI were observed. The hirsutism decreased after therapy (P < 0.001). Total androgens, FSH and LH concentrations decreased while oestradiol concentrations increased. There was a slight non-significant decrease in total cholesterol concentrations, an increase in HDL cholesterol concentrations and a decrease in LDL cholesterol concentrations. No significant changes were observed in serum triglyceride, apolipoprotein B and lipoprotein(a) concentrations. Insulin resistance (P < 0.01), analysed by homeostasis model assessment, was reduced significantly after therapy. Administration of oral myo-inositol significantly reduced hirsutism and hyperandrogenism and ameliorated the abnormal metabolic profile of women with hirsutism.

Polycystic ovary syndrome and prolactinoma association

Hyperprolactinemia is the most common pituitary hormone hypersecretion syndrome in both men and women. Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies affecting 5%-10% of reproductive age women. Here, we present a patient with irregular menses, obesity, hirsutism and infertility, and hyperprolactinemia who was diagnosed as PCOS and prolactinoma and admitted to our clinic. Prolactinoma and PCOS association is a rare condition. This 33-year-old woman was admitted to the internal medicine outpatient clinic for irregular menses, obesity, hirsutism and infertility, and hyperprolactinemia. Her laboratory results were as follows: prolactin was 74 ng/mL (normal range:1.8-20.3 ng/mL). Pelvic ultrasonography was correlated with polycystic ovary syndrome. Pituitary MRI showed 6x8 mm microadenoma at left half. Bromocriptine was started with 1.25 mg/day and increased to 5 mg/day. After six months of bromocriptine treatment her prolactin level was normal and no adenoma was detected in pituitary MRI. PCOS and prolactinoma association should be taken into account in PCOS cases with mild hyperprolactinoma.

Characteristics of different phenotypes of polycystic ovary syndrome in a Bulgarian population

AIM

Our aim was to investigate the percentage occurrence of different phenotypes of polycystic ovary syndrome (PCOS) in a Bulgarian population, and their clinical, biochemical and hormonal characteristics.

METHODS

The study included 70 women with PCOS, diagnosed according to the European Society of Human Reproduction & Embryology/American Society for Reproductive Medicine criteria. The women were divided into four phenotypes: hyperandrogenism (HA) + oligo-/anovulation (OA) + polycystic ovaries at ultrasound (PCO) (full-blown syndrome, phenotype A); HA + OA (former National Institutes of Health definition, phenotype B); OA + PCO (phenotype C); and HA + PCO (phenotype D). Serum levels of testosterone, immune-reactive insulin, sex hormone-binding globulin, dehydroepiandrosterone sulfate and lipid metabolism parameters were measured. Free androgen index and homeostasis model assessment of insulin resistance were calculated. Body mass index and waist-to-hip ratio were assessed.

RESULTS

The percentages of phenotypes A, B, C and D in a Bulgarian population are 58.6%, 11.4%, 10.0% and 20.0%, respectively. The women with the classical form of PCOS (phenotypes A and B) were more obese, had more strongly expressed hyperandrogenemia, and were more insulin-resistant compared with the women of phenotypes C and D.

CONCLUSION

There is a significant difference in anthropometric, hormonal and metabolic indices between the classical form and the clinical variants of PCOS in the studied Bulgarian population.

Searching for polycystic ovary syndrome in postmenopausal women: evidence of a dose-effect association with prevalent cardiovascular disease

OBJECTIVE

To test the hypothesis that polycystic ovary syndrome (PCOS) is associated with an increased risk of atherosclerotic cardiovascular disease (CVD) in older postmenopausal women.

DESIGN

Cross-sectional study of community-dwelling non-estrogen-using postmenopausal-white women (N=713; mean+/-SD age, 73.8+/-7.9 years; mean body mass index, 24.0+/-3.5 kg/m) participating in the Rancho Bernardo Study. A putative PCOS phenotype was defined as the presence of three or more of the following features: (1) recalled history of irregular menses, (2) symptomatic premenopausal hyperandrogenism or biochemical evidence of current biochemical hyperandrogenism, (3) history of infertility or miscarriage, (4) central obesity, or (5) insulin resistance. Atherosclerotic CVD was determined from clinical history, electrocardiography, and structured interviews using validated techniques. The analysis was stratified by diabetes status, ascertained from medical history or 75-g oral glucose tolerance tests.

RESULTS

The PCOS phenotype was present in 9.3% of the entire cohort and 5.8% of nondiabetic women. The prevalence of CVD was similar between women with the phenotype and unaffected women (27.3% vs 24.4%). Among women with intact ovaries and no diabetes, there was a stepwise graded association between an increasing number of features of the PCOS phenotype (ie, none to three or more) and prevalent CVD (P=0.02). A similar association was also observed for coronary heart disease alone (P=0.03).

CONCLUSIONS

Among nondiabetic postmenopausal women with intact ovaries, prevalent atherosclerotic CVD is associated with features of a putative PCOS phenotype. This finding supports the thesis that PCOS increases the risk of atherosclerotic CVD after menopause.

Impact of folate and homocysteine metabolism on human reproductive health

Folates belong to the vitamin B group and are involved in a large number of biochemical processes, particularly in the metabolism of homocysteine. Dietary or genetically determined folate deficiency leads to mild hyperhomocysteinemia, which has been associated with various pathologies. Molecular mechanisms of homocysteine-induced cellular dysfunction include increased inflammatory cytokine expression, altered nitric oxide bioavailability, induction of oxidative stress, activation of apoptosis and defective methylation. Whereas the involvement of folate metabolism and homocysteine in ageing-related diseases, in several developmental abnormalities and in pregnancy complications has given rise to a large amount of scientific work, the role of these biochemical factors in the earlier stages of mammalian reproduction and the possible preventive effects of folate supplementation on fertility have, until recently, been much less investigated. In the present article, the possible roles of folates and homocysteine in male and female subfertility and related diseases are systematically reviewed, with regard to the epidemiological, pathological, pharmacological and experimental data of the literature from the last 25 years.

The ESHRE/ASRM consensus on polycystic ovary syndrome (PCOS) – an extended critical analysis

The 'ESHRE/ASRM consensus on diagnosis, nomenclature and long-term health risks of polycystic ovarian syndrome (PCOS)' (conference in Rotterdam, Netherlands, March, 2003), which was criticized shortly after its oral presentation in 2003, is still being debated following its publication in 2004. Therefore, an extended, intensive analysis of all parameters and their combinations has been performed, differentiating between inclusion and exclusion criteria. By doing this, the profound significance of the endocrinological part of the syndrome is highlighted. The nomenclature, semantic meaning of terms, definitions, structural balancing, specificity, practicability, flexibility, limitations and reproducibility for both individualization, as well as grouping from the clinical and scientific perspective, have been examined in detail. This analysis supports previous critical comments, and reaches the conclusion that the recommendations of the consensus lack accuracy and specificity, a weakness that results in the risk of overdiagnosis and in a lack of reproducibility. Altogether, they fail to fulfil the criteria of universal guidelines on several levels. Instead, a profound paradigm shift is demanded, from an inconsistent perception to a more systematic, balanced and comprehensive view. A short indication on an alternative sweeping concept of a strictly defined, therapy-targeted classification and diagnostic procedure of female functional androgenization is presented.

Effects of transdermal testosterone administration on insulin sensitivity, fat mass and distribution, and markers of inflammation and thrombolysis in human immunodeficiency virus–infected women with mild to moderate weight loss

OBJECTIVE

To determine the effects of raising serum T levels into the high normal female range by transdermal T administration on insulin sensitivity, fat volume, and markers of inflammation and thrombolysis in HIV-infected women with recent weight loss.

DESIGN

Placebo-controlled, randomized clinical trial.

SETTING

Academic clinical research center.

PATIENT(S)

Fifty-two HIV-infected, menstruating women with >5% weight loss over the prior 6 months and current T<33 ng/dL.

INTERVENTION(S)

Placebo or T patches twice weekly for 24 weeks to achieve nominal delivery of 300 microg T daily.

MAIN OUTCOME MEASURE(S)

Testosterone by liquid chromatography-tandem mass spectrometry, insulin sensitivity by the frequently sampled intravenous glucose tolerance test (FSIVGT), abdominal and thigh fat volumes by magnetic resonance imaging (MRI), and C-reactive protein (CRP) as a measure of inflammation and plasminogen-activated inhibitor-1 (PAI-1) levels as a marker of thrombolysis.

RESULT(S)

Serum and free T levels significantly increased into the high normal female range in T-treated but not placebo-treated women. Insulin sensitivity by FSIVGT, whole body, thigh SC, and intra-abdominal fat volumes, and CRP and PAI-1 levels did not change significantly in either group and were not significantly different between the two groups. Fasting insulin increased in the placebo group and fell slightly in the T group, resulting in significant differences in change between groups.

CONCLUSION(S)

Twenty-four weeks of elevation of serum T levels into the high normal female range in HIV-infected women with mild to moderate weight loss by transdermal T patches did not adversely affect insulin sensitivity, whole-body fat mass or regional fat distribution, or markers of inflammation and thrombolysis. More prolonged and larger studies are needed to determine the effects of higher doses of T on body composition and insulin sensitivity in women.

Comparison of clinical and laboratory characteristics of cases with polycystic ovarian syndrome based on Rotterdam’s criteria and women whose only clinical signs are oligo/anovulation or hirsutism

This study was an attempt to determine whether the hormonal and clinical profiles of polycystic ovarian syndrome (PCOS) or non-PCOS cases whose only admission signs were oligo/anovulation or hirsutism. This retrospective study comprised a total number of 118, age-matched, young Turkish women with initial admission signs and symptoms of menstrual disorders (MD) like oligo/anovulation or hirsutism. Of these, 66 cases were diagnosed as PCOS, based on 2003 Rotterdam criteria [presence of two of first three criteria such as oligo- and/or anovulation, signs of clinical hyperandrogenism (HA-c) and/or biochemical signs of hyperandrogenism (HA-b) and polycystic ovaries on ultrasonography after exclusion of specific identifiable disorders]. Fifty-two women were diagnosed as cases of oligo/anovulation or hirsutism before the era of PCOS Rotterdam's consensus criteria. These two PCOS and non-PCOS cases were evaluated in terms of body mass index (BMI), waist-to-hip ratio, serum FSH, LH, estradiol (E2), dehydroepiandrosterone sulphate (DHEAS), androstendione (A) 17 hydroxyprogesterone (17-HP), fasting insulin, C-peptide levels, sex hormone-binding globulin (SHBG) and finally, ultrasonographic ovarian morphology. PCOS cases with unilateral and bilateral polycystic ovarian morphology on ultrasound scan were analyzed based on Rotterdam criteria. No statistically significant difference was detected among two groups, in terms of BMI, waist-to-hip ratio, serum FSH, LH, E2, fasting insulin, C-peptide levels (P > 0.05). However, blood levels of DHEAS, A and 17-HP were higher, whilst SHBG levels were remarkably lower (P = 0.008) in PCOS cases. Among PCOS group, hormonal and clinical characteristics did not differ, irrespective or uni- or bilaterality of ovarian morphology on ultrasonographic scan. Percentages of cases with androgenic alopecia, oily skin/acnea and increased ovarian volume were higher in PCOS group; whereas Ferriman-Gallwey score >/= 8 were similar between two groups. Total but not free testosterone remained high in PCOS group (P < 0.01). In both PCOS and non-PCOS cases, a linear correlation was apparent between BMI and insulin levels (r (s )= 0.69 and 0.32, P < 0.05, respectively). Among PCOS group, MD + HA-b + HA-c (n = 40) was present in 60.6% of subjects, MD + HA-b (n = 12) in 18.2%, and MD + HA-c (n = 14) in 21.2%. The three phenotypes did not differ in mean BMI, waist-to-hip ratio and biochemical characteristics. To conclude, non-PCOS women with only sign or symptom of oligo/anovulation or hirsutism had a more favorable endocrine milieu. These cases should be followed in vigilance in an aim to confront the development of short- and long-term adverse effects of impending PCOS in the future. Furthermore, different phenotypes of PCOS cases were clinically or biochemically similar in characteristics.

The Lived Experience of Women Diagnosed With Polycystic Ovary Syndrome

OBJECTIVE

To uncover the meaning of living with polycystic ovary syndrome.

DESIGN

Phenomenology.

SETTING

A women's health care practice in northeast United States.

PARTICIPANTS

A purposive sample consisting of 12 women, ages 21 to 48 years, who had been previously diagnosed with polycystic ovary syndrome.

DATA COLLECTION

Semistructured interviews.

RESULTS

Analysis of the participants' responses revealed the following themes: (a) identifying differences, (b) wanting to be normal, (c) searching for answers, (d) gaining control, (e) attempting to achieve femininity, (f) letting go of guilt, and (g) dealing with it.

CONCLUSIONS

Polycystic ovary syndrome is a syndrome that impacts women both physically and psychosocially. Nurses can play a key role in assisting women afflicted with this hormonal disturbance through education and support.

Determinants of emotional distress in women with polycystic ovary syndrome

BACKGROUND

The goals were to analyse the incidence of mental distress in women with untreated polycystic ovary syndrome (PCOS) using self-report measures, to characterize PCOS patients at risk for psychiatric disease with regard to sociodemographic and clinical characteristics, and to assess the impact of emotional distress on quality of life.

METHODS AND RESULTS

Complete metabolic, hormonal, clinical and self-report psychological data [emotional distress, Symptom Check List 90 (SCL-90-R); quality of life, Short-Form Health Survey 36 (SF-36); sexual satisfaction, visual analogue scales; sociodemographic data] were obtained from n = 143 untreated women with PCOS. Prior psychiatric diagnoses were exclusionary. Twenty-two patients (15.4%) had a possible psychological disorder, based on SCL-90-R global severity index (GSI) scores > or =63 (SCL cases). SCL cases had significantly elevated body mass index (BMI), but did not differ from SCL non-cases in other clinical, endocrine, metabolic or sociodemographic variables. Stepwise multiple regression analyses identified GSI as a significant predictor of SF-36 Psychological Sum score, along with age and current wish to conceive (R2 = 0.47); the SF-36 Physical Sum score was predicted by BMI and education (R2 = 0.27), but not GSI.

CONCLUSIONS

Psychiatric illness may go undetected in a proportion of PCOS patients. Although the majority of patients exhibit subclinical levels of psychological disturbances, emotional distress together with obesity lead to large decrements in quality of life in PCOS.

The hirsutism scoring system should be population specific

The aim of our study was to evaluate severity of hirsutism, assessed via the Ferriman-Gallwey scoring system in 12 different androgen-sensitive skin areas among 65 consecutive hirsute patients with functional androgen excess (polycystic ovary syndrome and idiopathic hirsutism) from the Central Anatolian region of Turkey. Results of this descriptive study showed that the buttocks/perineum, sideburn, and neck areas greatly contributed to the total hirsutism score, rather than the upper arm, upper back, and upper abdomen.

BMI as a modifying factor in the relations between age at menarche, menstrual cycle characteristics, and risk of preeclampsia

To examine the relations between age at menarche and menstrual cycle characteristics and preeclampsia risk, we analyzed data from a case-control study conducted from 1998 to 2002. Usual menstrual cycle characteristics among 286 preeclampsia cases and 471 normotensive controls were assessed using a structured interview during postpartum hospitalization. We used multivariable logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI), adjusting for confounders. We also examined the influence of pre-pregnancy body mass index (BMI) on selected hypothesized relations. Among lean women (pre-pregnancy BMI < 25 kg/m(2)), preeclampsia risk was lower in those reporting cycles > or = 36 days in length (adjusted OR 0.78, CI 0.35-1.83) and menarche at > or = 14 years (adjusted OR 0.48, 95% CI 0.28-0.82). In contrast, among overweight or obese women, preeclampsia risk was higher in those with long cycles (OR 3.11, 95% CI 0.62-1.56, p(interaction) = 0.16) and late menarche (OR 1.53, 95% CI 0.59-3.97, p(interaction) = 0.03). These data suggest that adiposity influences the relations between usual menstrual cycle length, age at menarche, and preeclampsia. Overweight women with long cycles are at particularly high preeclampsia risk.

Different routes of progesterone administration and polycystic ovary syndrome: a review of the literature

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in woman of reproductive age. Although extensive studies have been performed in past decades to investigate the pathobiological mechanisms underlying the unset of this disease, its etiology remains unknown. Progesterone is a hormone of paramount importance in ovulation, implantation and luteal phase support. Low levels of progesterone have been found in the early luteal phase in PCOS patients. Granulosa cells from polycystic ovaries show an altered progesterone production. Moreover, the lack of cyclical exposure to progesterone may have a role in the development of the gonadotropin and androgen abnormalities found in PCOS patients. Ovulation failure and progesterone deficiency may facilitate the hypothalamic-pituitary abnormalities causing the associated disordered luteinizing hormone secretion in PCOS. Progesterone may be administered to PCOS patients in the following cases: to induce withdrawal bleeding, to suppress secretion of luteinizing hormone, in ovulation induction in clomiphene citrate-resistant patients and in luteal phase support in assisted reproduction. We discuss the pharmacologic characteristics of the different routes of progesterone administration with reference to these diverse indications, the therapeutic objectives and patient compliance.

The peroxisome proliferator activated receptor gamma Pro12Ala polymorphism is associated with a lower hirsutism score and increased insulin sensitivity in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is characterized by hyperandrogenism and chronic anovulation. The genetic background of the insulin resistance frequently associated with PCOS is unclear.

OBJECTIVES

To examine the influe nce of the Pro12Ala polymorphism of the peroxisome proliferator activated receptor gamma (PPARgamma), which is thought to play a role in the regulation of insulin sensitivity, on endocrine and metabolic parameters in PCOS patients.

METHODS

PPARgamma alleles were analysed in 102 PCOS patients (age 27 +/- 5.3 years) and 104 age matched control women. PCOS was defined by the NIH-criteria as the presence of chronic oligo- or anovulation and hyperandrogenism. Family history and clinical parameters were evaluated by personal interview and physical examination, parameters of insulin resistance [homeostasis model assessment (HOMA) and Matsuda-index] were evaluated with a glucose tolerance test.

RESULTS

Seventy-nine (77.5%) PCOS patients were carriers of the wild-type PPARgamma allele (Pro/Pro), while 23 (22.5%) had at least one Ala allele (X/Ala), with an equal distribution in controls. X/Ala PCOS women were more insulin-sensitive, evidenced by lower fasting insulin, HOMA index and insulin secretion. Differences in insulin resistance did not depend on body mass index. The genotype had no influence on lipid status, leptin, adiponectin, ghrelin, or family history of type 2 diabetes. A significantly lower proportion of Pro/Ala patients had hirsutism and they had on average lower hirsutism scores than Pro/Pro patients. No relationship was found between the Pro/Ala polymorphism and other signs of hyperandrogenism.

CONCLUSION

The Pro12Ala polymorphism of the PPARgamma gene is associated with increased insulin sensitivity and lower hirsutism scores in PCOS women.

Ovulation induction with urinary FSH or recombinant FSH in polycystic ovary syndrome patients: a prospective randomized analysis of cost-effectiveness

The aim of this prospective, randomized trial was to compare the clinical results and the cost-effectiveness of urinary FSH (uFSH) and recombinant FSH (rFSH) in ovarian stimulation for intrauterine insemination (IUI) cycles in polycystic ovary syndrome (PCOS) patients. One-hundred and seventy PCOS infertile patients undergoing IUI were enrolled, and protocols of ovarian stimulation with uFSH or rFSH were randomly assigned. The total number of cycles performed was 379 (182 and 197, respectively). The main outcome measures were the number of mature follicles, the days of stimulation, the number of ampoules and IU used per cycle, the biochemical/clinical pregnancy rates, the number of multiple pregnancies and the cost-effectiveness. No statistically significant differences were found in the follicular development, length of stimulation, pregnancy rates, delivery rates and multiple pregnancies between the two groups. In the uFSH group, the cost per cycle remained significantly lower (218.51 +/- 88.69 versus 312.22 +/- 118.12; P < 0.0001), even though a significantly higher number of IU of gonadotrophins were used (809.3 +/- 271.9 versus 589.1 +/- 244.7; P < 0.0001). The cost-effectiveness (i. e. within a group, the total cost of all cycles divided by no. of clinical pregnancies) was 1729.08 in the uFSH group and 3075.37 in the rFSH group. In conclusion, uFSH and rFSH demonstrated the same effectiveness in ovarian stimulation in IUI cycles in PCOS patients. The urinary preparation is more cost-effective due to the difference of its cost per IU.