Comparison of clinical and hormonal characteristics among four phenotypes of polycystic ovary syndrome based on the Rotterdam criteria

PCOS phenotype focus: phenotype D under the magnifying glass

Polycystic ovary syndrome (PCOS) is defined as the combination of polycystic morphology, hyperandrogenism, and ovulatory disruption; this heterogeneity presents a conundrum for the medical community. The Rotterdam criteria have governed the diagnosis of PCOS, separating the patient cohort into four distinct phenotypes. It has been suggested that the lone normoandrogenic phenotype, so-called phenotype D, should not be classified as a PCOS subtype, with phenotypes A, B, and C displaying a hyperandrogenic biochemical and clinical profile thought to be characteristic of PCOS. To understand how to treat phenotype D patients, this review shines a spotlight on the phenotype, gathering various reports of how phenotype D is differentiated from the other PCOS phenotypes.

Cardio-metabolic risk in Rotterdam clinical phenotypes of PCOS

BACKGROUND AND AIMS

Elevated anti-Müllerian hormone (AMH) in polycystic ovary syndrome (PCOS) characterizes the clinical severity of the 4 phenotypes; but whether it also reflects the corresponding differences in cardio-metabolic risk remains to be elucidated. This study aimed to compare metabolic profile between the 4 clinical phenotypes of PCOS and to determine the influence of AMH levels on metabolic severity.

METHODS

One hundred and forty-four women with PCOS, aged between 20 and 40years, were recruited in this cross-sectional study and categorized according to the 4 phenotypes of the Rotterdam criteria. Anthropometry and blood pressure were recorded. Fasting lipid profile, fasting glucose, fasting insulin, homeostasis model assessment insulin resistance, total testosterone and AMH were estimated. Clinical, anthropometric and metabolic profiles were compared between the 4 phenotypes.

RESULTS

There were significant differences in menstrual abnormalities, weight, hip circumference, clinical hyperandrogenism, ovarian volume and AMH levels between the 4 phenotypes. Cardio-metabolic risk factors and rates of metabolic syndrome (MS) and insulin resistance (IR) were comparable.

CONCLUSION

Cardio-metabolic risk is similar in all phenotypes of PCOS despite differences in anthropometry and AMH levels. All women diagnosed with PCOS should undergo screening and lifelong surveillance for MS, IR and cardiovascular diseases, irrespective of clinical phenotype or AMH level. This needs further validation in prospective multi-center studies across the country, with larger sample sizes and adequate power.

Influence of Phenotypes on the Metabolic Syndrome of Women with Polycystic Ovary Syndrome over a Six-Year Follow-Up in Brazil

BACKGROUND

We followed polycystic ovary syndrome (PCOS) women with metabolic syndrome (MS) over a six-year treatment period and evaluated the influence of PCOS phenotypes on MS and on the risk for type 2 diabetes mellitus (T2DM).

METHODS

This was an observational study of 457 PCOS women, whose demographic, clinical, hormonal, and metabolic data underwent analysis. The PCOS women were divided into four groups per NIH recommendations.

RESULTS

After a follow-up of a mean of six years (1-20 years), 310 patients were selected to assess the development of T2DM and MS. The clinical and biochemical parameters, along with the Rotterdam phenotypes, were evaluated. Data were analyzed using Student's t- and the Pearson chi-square tests for data variation and group proportions, respectively. Additionally, multivariate analysis was applied to evaluate the effect of PCOS phenotypes on the risk for MS and T2DM. Patients of the four PCOS phenotypes did not differ in age, body mass index, total testosterone, insulin resistance, and dyslipidemia, but phenotype A patients showed the highest risk for T2DM. A decrease in androgen levels was not followed by an improved metabolic profile; instead, there was a significant increase in the number of T2DM cases.

CONCLUSION

Phenotype A women are at the highest risk for type 2 diabetes mellitus.

Possible cognition changes in women with polycystic ovary syndrome: a narrative review

Nowadays, polycystic ovary syndrome (PCOS) and cognitive dysfunction are major health problems among female. This narrative review aimed to investigate cognitive dysfunction in female with PCOS. English and Persian articles published in PubMed, Scopus, Web of Science, Google Scholar, PsycINFO, Scientific Information Database, and Cochrane Database of Systematic Reviews until May 2022 were searched. Sixteen studies involving 850 female with PCOS and 974 controls were assessed. In these studies, the association between biochemical factors and symptoms of PCOS and memory, attention, executive functioning, information processing speed, and visuospatial skills was evaluated. The literature review revealed the possible cognitive changes in female with PCOS. This study summarized the different aspects of cognitive function in female with PCOS due to medication, psychological problems (mood disorders caused by disease symptoms and complications), and biochemical markers, such as metabolic and sex hormone abnormalities. Considering the existing scientific gap regarding the possibility of cognitive complications in female with PCOS, further biological studies should be conducted to evaluate the potential mechanisms involved.

Determining the age group-based cut-off values of serum anti-Mullerian hormone concentrations to diagnose polycystic ovary syndrome

OBJECTIVE

To determine the cut-off values of the serum anti-Müllerian hormone (AMH) concentration for different age groups (21-25, 26-30, 31-35 years) to diagnose polycystic ovary syndrome (PCOS).

METHODS

In total, 187 women aged 21-35 years were included in this descriptive study. Patients diagnosed with PCOS according to the Rotterdam Criteria formed the PCOS group (n = 93), whereas those without symptoms related to PCOS formed the control group (n = 94). Follicular phase serum hormone concentrations were evaluated during the endocrinological assessment of patients with PCOS. Serum levels of estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, total testosterone, dehydroepiandrosterone sulfate, sex hormone-binding globulin, androstenedione, and AMH were measured. The free androgen index and LH/FSH ratio were calculated. Cut-off values of serum AMH concentrations for the age groups were measured using receiver operating characteristic curve analysis.

RESULTS

The prevalence rates of frank, ovulatory, normoandrogenic, and non-polycystic ovary PCOS were 69.9, 10.8, 10.8, and 8.6%, respectively. Serum AMH concentrations >5.56 ng/mL were associated with PCOS in the 21-25-year-old group. The cut-off value was 4.01 ng/mL in the 26-30-year-old group, whereas it was 3.42 ng/mL in the oldest age group. The correlation between the antral follicle count (AFC) and serum AMH level was strong for each age group.

CONCLUSIONS

The serum AMH concentration is a valuable parameter for assessing patients with symptoms indicative of PCOS. We recommend measuring serum AMH levels to support the diagnosis or to use them instead of the AFC for the Rotterdam criteria.

The prevalence and phenotypic manifestations of polycystic ovary syndrome (PCOS) among infertile Sudanese women: a cross-sectional study

BACKGROUND

Polycystic ovary syndrome (PCOS) is a global health problem associated with significant morbidity during reproductive age. Only a few published studies that address the clinical manifestations and phenotypic presentation of the disease have been conducted in Africa, including Sudan. Thus, this study aimed to evaluate the clinical and biochemical presentation of the different PCOS phenotypes among infertile Sudanese women.

METHODS

A cross-sectional, descriptive study was conducted from January to December 2019. A total of 368 infertile women with PCOS (based on the Rotterdam criteria) were recruited from a fertility center in Khartoum, Sudan. Clinical, hormonal, and ultrasonographic characteristics were described and compared between the four phenotypes of PCOS.

RESULTS

Majority (321 [87.2%]) of the women had oligo/anovulation (OA). Polycystic ovary morphology on ultrasound appeared in 236 (64.1%) women, acne in 171 (46.5%) women, acanthosis nigricans in 81 (22.0%) women, and hirsutism in 101 (27.4%) women. Phenotype D was the most prevalent among infertile Sudanese women (51.6%), followed by phenotype B (22.6%), phenotype C (18.2%), and phenotype A (7.6%). No statistical differences in the body mass index and hormonal profile between the four phenotypes were noted. Women with phenotype A were older and had high mean blood pressure, and a higher waist/hip ratio was observed among women with phenotype D.

CONCLUSION

Unlike the global distribution of PCOS phenotypes, Sudanese women uniquely expressed phenotype D as the most prevalent. More epidemiological studies are needed in the region due to geographical, ethnic, and genetic variations.

Cardio-Metabolic Disease and Polycystic Ovarian Syndrome (PCOS): A Narrative Review

Polycystic ovarian syndrome (PCOS) is considered the most common endocrine disorder affecting females in today's world. Although it has been primarily studied and discussed in terms of its reproductive symptoms such as infertility, amenorrhea or oligomenorrhea, acne, hirsutism, and mood disorders, there is yet another unexplored and under-diagnosed category in the PCOS spectrum of diseases: its cardio-metabolic consequences. PCOS patients are prone to these abnormalities from a very young age, increasing their morbidity and mortality rates compared to their regular counterparts. The usual pathogenesis of PCOS is a culmination of several genetic and environmental factors. Regarding its cardio-metabolic aspects, insulin resistance (IR) is said to be the single most important cause of a variety of metabolic risk factors, including type 2 diabetes mellitus (T2DM), metabolic syndrome (MetS), dyslipidemia, obesity, and hypertension (HTN), whereas a few other non-traditional factors such as C-reactive protein (CRP), carotid intima-media thickness (IMT), coronary artery calcification (CAC), and endothelial dysfunction are also said to be increased in PCOS patients, further increasing their risk of complications due to cardiovascular diseases (CVD). A timely diagnosis and adequate treatment of these risk factors by using lifestyle interventions, diet, and/or medications are essential to reduce the burden of PCOS in today's world. This article has highlighted an array of traditional and non-traditional cardio-metabolic consequences PCOS patients are prone to and their systematic pathogenesis. In addition, an outline of recommendations has been given in the pharmacological and non-pharmacological sections of this article, which may benefit doctors in managing this challenging condition.

Updated meta-analysis on the diagnostic accuracy of serum anti-Mullerian hormone in poly cystic ovary syndrome involving 13 509 subjects

AIM

To determine the diagnostic accuracy of anti-Mullerian hormone (AMH) in the diagnosis of polycystic ovary syndrome (PCOS).

METHODS

Two independent reviewers searched the electronic databases and search engines using PubMed, Cochrane library, and Google Scholar systematically to retrieve relevant articles published from inception to September 2021. The diagnostic efficacy of AMH was computed using the random-effects model in terms of pooled sensitivity, specificity, and diagnostic odds ratio (DOR) with 95% confidence interval (CI). A meta-regression and subgroup analysis were performed to check for any source which could explain possible heterogeneity. Risk of bias assessment was conducted using the QUADAS-2 tool recommended by Cochrane Library.

RESULTS

This meta-analysis included a total of 41 studies involving 13 509 subjects. We observed promising pooled sensitivity 0.78 (95% CI 0.74 to 0.81), specificity 0.87 (95% CI 0.84 to 0.90), and diagnostic odds ratio (DOR) 24 (95% CI 15 to 37), for AMH in detecting PCOS and discriminatory power (summary receiver operating characteristic [SROC] curves, 0.89 [95% CI 0.86-0.92]). The most prominent bias was noted in the patient selection and index test assessment.

CONCLUSIONS

With the findings of this current meta-analysis, we conclude serum AMH to be a promising biomarker for the diagnosis of PCOS, however, substantial heterogeneity among studies needs individual patient data analysis in order to identify an optimal cut-off value and homogenous findings.

REGISTRATION NUMBER AND GUIDELINES

This meta-analysis was performed according to constructed protocol registered in the PROSPERO database with registration number CRD42021246910.

Polycystic Ovarian Syndrome: A Complex Disease with a Genetics Approach

Polycystic ovarian syndrome (PCOS) is a complex endocrine disorder affecting females in their reproductive age. The early diagnosis of PCOS is complicated and complex due to overlapping symptoms of this disease. The most accepted diagnostic approach today is the Rotterdam Consensus (2003), which supports the positive diagnosis of PCOS when patients present two out of the following three symptoms: biochemical and clinical signs of hyperandrogenism, oligo, and anovulation, also polycystic ovarian morphology on sonography. Genetic variance, epigenetic changes, and disturbed lifestyle lead to the development of pathophysiological disturbances, which include hyperandrogenism, insulin resistance, and chronic inflammation in PCOS females. At the molecular level, different proteins and molecular and signaling pathways are involved in disease progression, which leads to the failure of a single genetic diagnostic approach. The genetic approach to elucidate the mechanism of pathogenesis of PCOS was recently developed, whereby four phenotypic variances of PCOS categorize PCOS patients into classic, ovulatory, and non-hyperandrogenic types. Genetic studies help to identify the root cause for the development of this PCOS. PCOS genetic inheritance is autosomal dominant but the latest investigations revealed it as a multigene origin disease. Different genetic loci and specific genes have been identified so far as being associated with this disease. Genome-wide association studies (GWAS) and related genetic studies have changed the scenario for the diagnosis and treatment of this reproductive and metabolic condition known as PCOS. This review article briefly discusses different genes associated directly or indirectly with disease development and progression.

Polycystic ovary syndrome phenotype does not have impact on oocyte morphology

PURPOSE

The primary objective of the present study of women participating in an ICSI program was to determine whether the morphologic quality of oocytes was related to the polycystic ovary syndrome (PCOS) phenotype.

METHODS

We performed a retrospective cohort study in the IVF unit at the Lille University Medical Center (Lille, France) between 2006 and 2015. Oocyte morphology (fragmented first polar body, abnormal zona pellucida, large perivitelline space, material in perivitelline space, abnormal shape of oocyte, granular cytoplasm and intracytoplasmic vacuoles) was evaluated in PCOS women and according to different subgroup (depending on the presence or absence of the cardinal features polycystic ovarian morphology (PCOM), hyperandrogenism (HA), and oligo-anovulation (OA)).

RESULTS

A total of 1496 metaphase II oocytes (n = 602 for phenotype A combining PCOM + HA + OA, n = 462 oocytes for phenotype C: PCOM + HA, and n = 432 for phenotype D: PCOM + OA) were assessed. The phenotypes A, C and D did not differ significantly with regard to the proportion of normal oocytes (adjusted percentages (95%CI): 35.2% (31.5 to 39.1%), 25.8% (21.9 to 29.9%) and 34.0% (29.7 to 38.6%), respectively: adjusted p = 0.13). Likewise, there were no significant intergroup differences in oocyte morphology. The ICSI outcome was not significantly associated with the PCOS phenotype.

CONCLUSION

The present study is the first to show that the PCOS phenotype (notably the presence vs. absence of OA and/or HA) is not significantly associated with the morphological quality of oocytes.

Antimüllerian hormone to determine polycystic ovarian morphology

OBJECTIVE

To determine a cutoff for the Elecsys AMH Plus immunoassay (Roche Diagnostics International Ltd, Rotkreuz, Switzerland) to identify polycystic ovarian morphology (PCOM), a polycystic ovary syndrome (PCOS) criterion.

DESIGN

The AMH Protein in Humans for polycystic ovaRian mOrphology DIagnostic TEsting (APHRODITE) study was a retrospective, multicenter, case-control study. The serum antimüllerian hormone (AMH) level was measured using the Elecsys AMH Plus immunoassay. The antral follicle count was determined using transvaginal ultrasound. An AMH cutoff was derived and validated in separate cohorts with cases of PCOS with full phenotype A (oligo/anovulation, hyperandrogenism, and PCOM) versus that with controls. Exploratory analyses of age and PCOS phenotype were performed.

SETTING

Not applicable.

PATIENT(S)

Polycystic ovary syndrome-positive (PCOS A-D per the Rotterdam criteria) and PCOS-negative women aged 25-45 years.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

A validated cutoff for AMH using the Elecsys AMH Plus assay for PCOM.

RESULT(S)

In the validation cohort (455 cases and 500 controls), an AMH cutoff of 3.2 ng/mL (23 pmol/L) resulted in a sensitivity of 88.6% (95% confidence interval [CI] 85.3-91.3) and specificity of 84.6% (95% CI 81.1-87.7) for PCOM diagnosis as well as an area under the receiver-operator characteristic curve of 93.6% (95% CI 92.2-95.1). In women aged 25-35 years, the sensitivity and specificity for the cutoff were 88.5% and 80.3%, respectively, versus 77.8% and 90.1%, respectively, in women aged 36-45 years. The results were consistent across PCOS phenotypes A-D.

CONCLUSION(S)

The Elecsys AMH Plus immunoassay, with a cutoff of 3.2 ng/mL (23 pmol/L), is a robust method for identifying PCOM to aid in PCOS diagnosis.

Research progress of endometrial receptivity in patients with polycystic ovary syndrome: a systematic review

Polycystic ovary syndrome (PCOS) is a neuroendocrine heterogeneous disease that frequently occurs in women of reproductive age, causing serious damage to the fertility, quality of life, and physical and mental health of patients. The current studies have proved that satisfactory endometrial receptivity is one of the conditions that must be met during the process of spermatovum position, adhesion and invasion, as well as the subsequent blastocyst division and embryo development. Women with PCOS may suffer a series of pathological processes such as changes in the expression levels of hormones and related receptors, imbalances in the proportion of miscellaneous cytokines, insulin resistance, low-grade chronic inflammation and endometrial morphological changes, which will damage endometrial receptivity from various aspects and obstruct fertilized egg nidation and embryonic development, thus causing adverse reproductive health events including infertility and abortion. This article reviews the research progress about characteristics and related influencing factors of endometrial receptivity in PCOS patients.

Improvements in PCOS characteristics and phenotype severity during a randomized controlled lifestyle intervention

RESEARCH QUESTION

What is the effect of weight loss through different interventions (three-component lifestyle intervention with short message service [SMS+] versus three-component lifestyle intervention without SMS [SMS-] versus care as usual [CAU]) on polycystic ovary syndrome (PCOS) characteristics (ovulatory dysfunction, hyperandrogenism, polycystic ovarian morphology [PCOM]) and phenotype distribution?

DESIGN

Analysis of secondary outcome measures of a randomized controlled trial. Women diagnosed with PCOS (n = 183), who wished to become pregnant, with a body mass index above 25 kg/m², were assigned to a 1-year three-component (cognitive behavioural therapy, diet, exercise) lifestyle intervention group, with or without SMS, or to CAU (advice to lose weight).

RESULTS

The prevalence of biochemical hyperandrogenism was 30.9% less in the SMS- group compared with CAU after 1 year (P = 0.027). Within-group analyses revealed significant improvements in ovulatory dysfunction (SMS+: -39.8%, P = 0.001; SMS-: -30.5%, P = 0.001; CAU: -32.1%, P < 0.001), biochemical hyperandrogenism (SMS-: -27.8%, P = 0.007) and PCOM (SMS-: -14.0%, P = 0.034). Weight loss had a significantly favourable effect on the chance of having ovulatory dysfunction (estimate 0.157 SE 0.030, P < 0.001) and hyperandrogenism (estimate 0.097 SE 0.027, P < 0.001).

CONCLUSIONS

All groups demonstrated improvements in PCOS characteristics, although these were more profound within the lifestyle intervention groups. Weight loss per se led to an amelioration of diagnostic characteristics and in the phenotype of PCOS. A three-component lifestyle intervention aimed at a 5-10% weight loss should be recommended for all women with PCOS before they become pregnant.

Body Composition and Characterization of Skinfold Thicknesses from Polycystic Ovary Syndrome Phenotypes. A Preliminar Case-Control Study

To describe whether polycystic ovary syndrome (PCOS) phenotypes vary in their body composition and skinfold (SKF) thicknesses and if they differ from women without PCOS, a preiminar case-control study was performed. A total of 117 cases were diagnosed using the Rotterdam criteria. Gynecological examinations and transvaginal ultrasound were performed in all women (266 women). Anthropometric measurements including SKF thickness were taken according to the restricted profile protocol of the international standards for the anthropometric evaluation according to the International Society of the Advancement of Kinanthropometry (ISAK). Women with PCOS had higher body mass index and percentage of fat mass with respect to controls. The endomorphy component was also significantly higher in women with PCOS than in controls. Each PCOS phenotype displayed a different representation in the somatochart respect to the others phenotypes and also compared to controls. Women with PCOS had significantly higher ∑7 SKF (p = 0.013), ∑appendicular SKF (p = 0.017) and ∑arm SKF (p = 0.019) than controls. H-O-POM phenotype had higher 7∑ SKF (p = 0.003), ∑appendicular SKF (p = 0.01), ∑arm SKF (0.005), ∑leg SKF, and ∑trunk SKF (0.008) and also a higher fast mass percentage than controls (p = 0.011). In conclusion, body composition evaluated by ISAK protocol is different in women with PCOS, especially in the complete phenotype (H-O-POM). This could have relevant implications in terms of clinical evaluation and follow-up of these women, although more researches in this field are needed.

Assessment the Correlations of Hormones, Lipid Profiles, Oxidative Stress, and Zinc Concentration in Iraqi Women with Polycystic Ovary Syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a hormonal disorder in women with unknown causes and is the leading cause of infertility in women of reproductive age, presenting a wide range of clinical manifestations worldwide. The objective of study is to compare the correlation between hormones, lipid profile, oxidative stress and Zinc concentration in PCOS patients.

METHODS

The present study examined hormone levels (progesterone, prolactin, luteinizing and follicle stimulation hormones (LH and FSH, respectively), antioxidant factors (catalase, glutathione-s- transferase), lipid profiles and zinc concentration of 50 Iraqi women patients' diagnosis with PCOS and 40 healthy women, divided in two age groups of 15-29 and 30-45 years. Body mass index was estimated for two age groups.

RESULTS

The results showed decreasing of catalase, glutathione, and Zn concentrations with an increase in age. A slightly significant increase in LH and prolactin and decrease in high-density lipoprotein (HDL-C) with an increase in age in the patient group compared to the control group was noted.

CONCLUSION

Our study demonstrated that some factors (such as family history, genetics, environmental, etc…) could play a role in altering hormone levels, lipid profiles, and antioxidant. Controlling these factors may be useful for reducing the PCOS-associated problems in women's health. Needed extensive studies to assess the correlation with insulin resistant and obesity.

Health-related quality of life in women with polycystic ovary syndrome attending to a tertiary hospital in Southeastern Spain: a case-control study

BACKGROUND

Polycystic ovary syndrome (PCOS) is a chronic condition with symptoms affecting many women at reproductive age and evaluating their health-related quality of Life (HRQoL) is an important issue. Moreover, differences in the HRQoL between women with different PCOS phenotypes have never been analyzed. Therefore, the aim of our study was to compare the HRQoL between women with PCOS -and its phenotypes- and controls attending to a tertiary hospital.

METHODS

A group of 117 women with PCOS and 153 controls were studied between 2014 and 2016. Controls were women without PCOS attending the gynecological outpatient clinic for routine examinations. Cases were women attending the same setting and diagnosed with PCOS. PCOS diagnose was performed following the Rotterdam Criteria and women were further classified by anovulatory or ovulatory phenotypic subtype. Women underwent physical and gynecological exams and completed health questionnaires including the Short Form-12v2. Eight scales and two component summary scores [Physical (PCS) and Mental (MCS), respectively] were calculated. Bivariate and multivariate analyses were performed to assess differences in HRQoL between women with PCOS and controls.

RESULTS

All women with PCOS and anovulatory PCOS presented lower score in PCS compared to controls [mean (95%CI): 53.7 (52.5-54.9) and 52.9 (51.5-54.4) vs. 55.8 (54.8-56.8); p-values< 0.01], as well as lower scores for five out of the eight scales (p-values < 0.05) after adjusting by age, body mass index, infertility, educational level and current occupation. No significant differences were observed for the MCS between women with or without PCOS or its phenotypic subtypes.

CONCLUSIONS

HRQoL was significantly decreased in adult women with PCOS and its anovulatory phenotype compared to controls attending the outpatient clinic of a tertiary hospital. These results may have implications for the clinical practice and suggest the need for specific interventions in women with PCOS.

Body Composition, Serum Concentrations of Androgens and Insulin Resistance in Different Polycystic Ovary Syndrome Phenotypes

Insulin resistance and hyperandrogenemia observed in polycystic ovary syndrome (PCOS) are associated with metabolic disturbances and could be connected with body composition pattern. To date, several studies defining the parameters of body composition using dual energy X-ray absorptiometry (DXA) method in the group of PCOS patients have been published, however, without the analysis in different phenotypes. The aim of the present study was to investigate the relationships between serum androgens concentration, insulin resistance and distribution of fat mass using DXA method in various PCOS phenotypes according to the Rotterdam criteria. We examined 146 women: 34 (38%) had PCOS phenotype A, 20 (23%) phenotype B, 20 (23%) phenotype C and 15 (16%) phenotype D (with mean age of each phenotype 25 years), and 57 control subjects (mean age of 25.5 years). Homeostasis model assessment of insulin resistance (HOMA-IR) was calculated. Serum concentrations of testosterone, androstenedione and dehydroepiandrosterone sulfate (DHEA-S) were assessed and free androgen index (FAI) was calculated. In phenotypes A, B and C, we observed higher FAI in comparison to the control group (all p < 0.01). Serum concentrations of androstenedione and DHEA-S were higher in phenotypes A and C in comparison to the control group (all p < 0.01). However, only in phenotype A we found higher visceral adipose tissue (VAT) mass and android/gynoid ratio (A/G ratio) in comparison to the control group (all p < 0.01). In phenotype A, we observed connection of VAT with FAI (r = 0.58, p < 0.01). Accordingly, A/G ratio was related with FAI in all phenotypes (all p < 0.05). Additionally, in phenotype C, A/G ratio was related to serum concentrations of DHEA-S and androstenedione (r = 0.46, p = 0.03; r = 0.53, p = 0.01, respectively). We also found connections of HOMA-IR with VAT and A/G ratio in all phenotypes (all p < 0.05). Women with phenotype A had higher amount of VAT and A/G ratio in comparison to the control group. Serum concentration of androgens and insulin resistance are connected with VAT and A/G ratio in normoandrogenic and hyperandrogenic PCOS phenotypes.

Criteria, phenotypes and prevalence of polycystic ovary syndrome

Polycystic ovarian syndrome (PCOS) is known as one of the most frequent endocrine diseases in women worldwide. However, this term does not completely capture the diversity of clinical signs associated with this syndrome e.g., menstrual irregularity and clinical features of androgen excess, which are though commonplace in women with PCOS, they are not included under the definition of PCOS, limited to polycystic ovarian morphology (PCOM). Utilizing the most globally accepted criterion used today in the diagnosis of PCOS, the authors of this article review and discuss the historical and current context of evidence as well as their limitations. This review addresses the phenotypic approach and age-dependent aspects of PCOS in adolescents, adult and peri/postmenopausal women, as presented in the NIH (1990, 2012), Rotterdam (2003), AE-PCOS Society (2006) consensuses and in the latest evidence-based international guideline (2018). Global data on the epidemiology of PCOS, including prevalence and distribution of polycystic ovarian syndrome phenotypes, is also analyzed in the article. Lastly, the authors discuss the importance and current need to perform more epidemiological studies focused on PCOS.

Genetic Basis of Polycystic Ovary Syndrome (PCOS): Current Perspectives

Polycystic ovary syndrome (PCOS) is a common infertility disorder affecting a significant proportion of the global population. It is the main cause of anovulatory infertility in women and is the most common endocrinopathy affecting reproductive-aged women, with a prevalence of 8-13% depending on the criteria used and population studied. The disease is multifactorial and complex and, therefore, often difficult to diagnose due to overlapping symptoms. Multiple etiological factors have been implicated in PCOS. Due to the complex pathophysiology involving multiple pathways and proteins, single genetic diagnostic tests cannot be determined. Progress has been achieved in the management and diagnosis of PCOS; however, not much is known about the molecular players and signaling pathways underlying it. Conclusively PCOS is a polygenic and multifactorial syndromic disorder. Many genes have been associated with PCOS, which affect fertility either directly or indirectly. However, studies conducted on PCOS patients from multiple families failed to find a fully penetrant variant(s). The present study was designed to review the current genetic understanding of the disease. In the present review, we have discussed the clinical spectrum, the genetics, and the variants identified as being associated with PCOS. The mechanisms by which variants in the genes confer risk to PCOS and the nature of the physical and genetic interaction between the genetic elements underlying PCOS remain to be determined. Elucidation of genetic players and cellular pathways underlying PCOS will certainly increase our understanding of the pathophysiology of this syndrome. The study also discusses the current status of the treatment modalities for PCOS, which is important to find new ways of treatment.

Advantages of Serum Anti-Müllerian Hormone as a Marker for Polycystic Ovarian Syndrome

OBJECTIVE

To evaluate the advantages of using anti-Müllerian hormone (AMH) in the diagnosis of polycystic ovary syndrome (PCOS).

METHODS

We compared data from 56 Han Chinese patients with PCOS and 52 female control Han Chinese individuals in terms of biochemical markers and the antral follicle count (AFC). Then, the correlation between serum AMH levels and various endocrine and metabolic factors was analyzed. We generated receiver operating characteristic (ROC) curves to assess the usefulness of AMH, AFC, the luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio, and testosterone (T), to discriminate between the PCOS and control groups.

RESULTS

The LH/FSH ratio, homeostatis model assessment of insulin resistance (HOMA-IR), testosterone (T), blood glucose (Glu), triglyceride (TG), body mass index (BMI), AFC and, in particular, serum AMH level were significantly higher in the PCOS group than in the control group (P <.05; P <.001). The serum AMH level had a significant positive effect on the likelihood of AFC changes in patients with PCOS and control-group women. The areas under the ROC curve (AUC) of AMH, AFC, LH/FSH ratio, and T were 0.952, 0.778, 0.760, and 0.665, respectively. The best cutoff point for AMH was 6.09 ng per mL, with sensitivity of 88% and specificity of 88%.

AMH in combination with SHBG for the diagnosis of polycystic ovary syndrome

Serum Anti-Müllerian hormone (AMH) level could be useful for the diagnosis of polycystic ovary syndrome (PCOS). We evaluated the hormonal status in women for the diagnosis of PCOS. A total of 77 PCOS women and 106 healthy women were enrolled in this study. Serum AMH, gonadotropins [luteinising hormone (LH) and follicle-stimulating hormone (FSH)], oestradiol, testosterone (total and free), 4-androstenedione (ANDST), dehydroepiandrosterone sulphate, sex hormone binding globulin (SHBG), prolactin, thyroid-stimulating hormone and insulin levels were measured in all enrolled women. Our data showed that insulin_, LH, testosterone, ANDST and AHM levels were significantly higher in the PCOS group and FSH and SHBG levels were lower in the PCOS group. In Receiver operating characteristic analysis, the combination of AMH with SHBG showed higher area under curves (AUC) for PCOS diagnosis with an AUC of 0.843 and a specificity of 81.1% and a sensitivity of 72.7%. Our results suggest that a combination of serum AMH and SHBG levels could be used as a diagnostic biomarker of PCOS. Impact statement What is already known on this subject? Women with PCOS have an increased risk of hypertension, altered glucose metabolism and probably an increased lifetime risk of cardiovascular diseases. There is no consensus on the diagnostic criteria for PCOS. This leads to many patients with PCOS are being undiagnosed. It is known that AMH plays a role in the follicular status of PCOS and serum AMH level is increased significantly in women with PCOS compared with normo-ovulatory women. This is why several studies have suggested the inclusion of AMH as a diagnostic criterion in PCOS. What do the results of this study add? Extensive epidemiological data is available which demonstrates an association between higher AMH levels and PCOS, but there was no information available about the combination of AMH level with other hormones and PCOS. This is the first study that has investigated the association of AMH and SHBG, together, with PCOS. Our results suggest that serum AMH and SHBG level in combination could represent a useful and practical test to screen the general population for PCOS. What are the implications of these findings for clinical practice and/or further research? Many PCOS women in the general population are undiagnosed due to lack of consensus in diagnostic criteria. Therefore, the importance of identifying women with PCOS due to the need for follow-up in short and long-term health risk.

Ovarian response to controlled ovarian stimulation in women with different polycystic ovary syndrome phenotypes

Controlled ovarian stimulation (COH) in PCOS is a challenge for fertility expert both ovarian hyperstimulation syndrome (OHSS) and oocytes immaturity are the two major complication. Ovarian response to COH vary widely among POCS patients and while some patients are more likely to show resistance to COH, other experienced an exaggerated response. The aim of our study is to investigate a possible correlation between PCOS phenotypes and the variety of ovarian response to COH and ART outcomes in patients with different PCOS phenotypes. We retrospectively analyzed a total of 71 cycles performed in 44 PCOS infertile patients attending ART at Centre of Infertility and Assisted Reproduction of Pisa University between January 2013 and January 2016. Patientsundergoing IVF with GnRH-antagonist protocol and 150-225 UI/days of recombinant FSH; triggering was carried out using 250 mg of recombinant hCG or a GnRH analogous on the basis of the risk to OHSS. We observed that Phenotype B had a tendency to have a greater doses of gonadotropins used respect to all phenotypes. Phenotype A group showed a greater serum estrogen levels compared to all phenotypes groups, a greater number of follicles of diameter between 8-12 mm found by ultrasound on the day of triggering and a greater mean number of freeze embryo. Additionally serum AMH and antral follicles count (AFC) follow the same trend in the different phenotypes ad they were significantly higher in phenotype A and in phenotype D. In conclusion this study shows that the features of PCOS phenotypes reflect the variety of ovarian response to COH as well as the risks to develop OHSS. Serum AMH and AFC are related to the degree of ovulatory dysfunction making these 'added values' in identifying the different PCOS phenotypes. Phenotype A seems to be the phenotype with the higher risk to develop OHSS and the use of GnRH as a trigger seems to improve oocyte quality. To classify PCOS phenotype at diagnosis might help clinicians to identify patients at greater risk of OHSS, customize therapy and subsequently plan the trigger agent.

Serum AMH levels and insulin resistance in women with PCOS

OBJECTIVE

To compare the serum AMH levels between women with and without insulin resistance (IR) in polycystic ovary syndrome (PCOS).

STUDY DESIGN

293 women with PCOS according to the Rotterdam criteria were enrolled into our study. Insulin resistance was diagnosed according to the Homeostatic model assessment insulin resistant (HOMA-IR) formula and the cut-off point was set to more than 2.5. Women were grouped according to the presence of insulin resistance (IR) (HOMA-IR ≥ 2.5). Serum AMH and other hormones were compared between the IR (+) and IR (-) groups. Additionally, AMH percentiles were (<25, 25-75, >75) constructed; HOMA-IR and BMI values in women with/without IR were compared in different percentiles. Further, HOMA-IR, BMI and AMH values were measured across different PCOS phenotypes.

RESULTS

The prevalence of IR was 45%. The prevalence of IR was 57% in women with BMI ≥ 25. Serum AMH levels were not significantly different among women with and without IR. Also, HOMA-IR values were not significant among different AMH percentiles. However, in each AMH percentile BMI were found to be higher in women with IR than in women without IR. The median HOMA-IR values were the highest in women with BMI ≥ 25 in both IR (+) and IR (-) groups. No significant difference was found among PCOS phenotypes in terms of HOMA-IR and BMI. Positive correlations were found between BMI, free testosterone and HOMA-IR. However, no correlation was found between AMH and HOMA-IR.

CONCLUSION

The serum AMH levels between women with IR and without IR in PCOS were not significantly different. Also, we did not reveal a correlation between serum AMH levels and IR in women with PCOS. IR was not correlated with different PCOS phenotypes either. We found a positive correlation between BMI and IR. IR should be investigated in women with PCOS having a BMI ≥ 25, independent of their phenotype or AMH levels.

Ovarian volume and PCOS: a controversial issue

Polycystic ovarian syndrome (PCOS) is a common endocrinopathy. The Rotterdam criteria indicate four distinct phenotypes. In phenotypes with the typical ovarian morphology (ovarian volume ≥10 ml) the sensibility to clomiphene citrate (CC) ovulation therapy was demonstrated inversely proportional to the ovarian volume. In this retrospective study we evaluated the influence of ovarian volume on the success rate of CC ovulation induction in women with anovulatory phenotype 2 characterized only by the presence of hyperandrogenism and anovulation (ANOV + HA). Statistical analysis was conducted by stratifying patients both on the basis of CC dose (Group 1: n = 37, 50 mg; Group 2: n = 9, 100 mg; and Group 3: n = 12, 150 mg) and on the basis of response to therapy. Eighty women were evaluated but overall only 58 women (72.5%) reached ovulation. In the phenotype studied, we didn't find any correlations between ovarian volume and the chance of ovulation with the gradient increase in CC; furthermore, ovarian volume was comparable in CC responders and non-responders. Our study has shown that in the phenotype 2 examined, ovarian volume did not have any predictive value of the dosage required to induce ovulation. The significance of this result is discussed.

Salivary and serum androgens with anti-Müllerian hormone measurement for the diagnosis of polycystic ovary syndrome

To determine the predictive value of a raised androgen level with an elevated anti-Müllerian hormone (AMH) for the diagnosis or exclusion of polycystic ovary syndrome (PCOS), a prospective cross-sectional study of 170 women (105 with PCOS type A and 65 normal) was undertaken. AMH was combined with one of, total serum testosterone (T); calculated free androgen index; salivary testosterone (salT); serum androstenedione (A); salivary androstenedione (salA). The diagnostic sensitivity and specificity of AMH (>35 pmol/l) alone for PCOS were 55% and 79% respectively. The diagnostic sensitivity and specificity of AMH (>35 pmol/l) with either an elevated T or raised FAI level for PCOS showed 100% specificity and a 100% positive predictive value. Conversely, diagnostic exclusion of PCOS was shown by an AMH <35 pmol/l with a normal T or FAI salivary testosterone giving 100% specificity and 100% positive predictive value. AMH with an elevated A or elevated salA level gave specificities of 87% and 94%, and positive predictive values 80% and 94%, respectively. Therefore, the combination of an AMH with a cut off of 35 pmol/l combined with a raised T and/or a FAI will confirm PCOS whilst a normal AMH with a normal T and/or FAI will exclude PCOS, thus addressing diagnostic uncertainty.

Anti-Müllerian hormone measurement for the diagnosis of polycystic ovary syndrome

OBJECTIVE

Anti-Müllerian hormone (AMH) is derived from the small antral follicles, and an elevated level has been suggested to add value to the Rotterdam criteria for the diagnosis of PCOS in cases of diagnostic uncertainty. Therefore, the role of AMH in the classical phenotype of PCOS was defined within a Caucasian population.

DESIGN

This was a cross-sectional study.

PATIENTS

Sixty Five women without PCOS and 110 women with PCOS fulfilling all 3 diagnostic Rotterdam criteria.

MEASUREMENTS

The main outcomes were the utility of serum AMH for the diagnosis of PCOS and its relationship to the metabolic parameters.

RESULTS

Anti-Müllerian hormone was increased in PCOS compared to controls (P < .001). Areas under the receiver operator curve showed AMH to be predictive of PCOS (0.76) using a cut-off AMH of 46 pmol/L, which is derived from the 95^th percentile of the controls that gave a 41% sensitivity and 86% specificity; an AMH cut-off of 35 pmol/L gave a 55% sensitivity and 79% specificity. Age- and BMI-adjusted multiple logistic regression showed that AMH was more predictive of PCOS independently of either serum testosterone (T) (OR = 4.04; 95% CI 1.42-11.11; P = .007) or free androgen index (FAI) (OR = 3.90; 95% CI 1.40-10.83; P = .009).

CONCLUSION

Whilst an elevated AMH has poor sensitivity, it is fourfold more likely to be associated with a diagnosis of PCOS, and supplementary to biochemical parameters will make a positive diagnosis of PCOS in 22% of patients when neither serum testosterone nor FAI is elevated.

Does insulin resistance increase thyroid volume in patients with polycystic ovary syndrome?

OBJECTIVE

To investigate the effect of gonadotropin, sex hormone levels and insulin resistance (IR) on thyroid functions and thyroid volume (TV) in polycystic ovary syndrome (PCOS).

SUBJECTS AND METHODS

69 new diagnosed PCOS patients (age 24.82 ± 6.17) and 56 healthy control female (age 26.69 ± 5.25) were involved to the study. Fasting plasma glucose, lipid profile, insulin, thyroid stimulating hormone (TSH), free thyroxine (fT4), estradiol (E2), luteinizing hormone (LH), follicle stimulating hormone levels and urine iodine were measured in all participants. Thyroid and pelvic ultrasound were performed in all participants.

RESULTS

Insulin, HOMA-IR, LH, E2 and TV were higher in PCOS group (p < 0.05). TV was significantly higher in PCOS patients with IR compared to non-IR PCOS patients (p < 0.001), while TSH, fT4, and urine iodine levels were similar between these groups (p > 0.05). There was a negative correlation between E2 and TSH (p < 0.05) and a positive correlation between TSH and TV (p < 0.05). There was a significant positive correlation between TV and LH, insulin, HOMA-IR (p < 0.05).

CONCLUSION

This study showed that TV was increased in patients with insulin resistance but differences in TSH and LH levels may affect TV changes as well.

Effect of IGF-I and TNF-α on intensification of steroid pathways in women with PCOS phenotypes are not identical. Enhancement of progesterone pathway in women with PCOS increases the concentration of TNF-α

OBJECTIVE

The aim of this study was to determine the correlations between the concentration of tumor necrosis factor (TNF-α) and insulin-like growth factor I (IGF-I) in each woman with polycystic ovary syndrome (PCOS) phenotypes based on the levels of androgen.

METHODS

Two groups of women with PCOS differing in their levels of androgens. The test group composed of 39 women with PCOS according to the Rotterdam criteria in their reproductive age. The hormonal levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroid stimulating hormone (TSH), prolactin (PRL), androstenedione, testosterone (T), estradiol (E₂) and sex hormone binding globulin (SHBG) were measured. Correlations analysis were performed calculating Spearman's rank correlation coefficient of hormones with relation to TNF-α and IGF-I.

RESULTS

There was a medium positive correlation of IGF-1 with LH levels (p < 0.05) and negative medium correlation of TNF-α with of dehydroepiandrosterone (DHEA)-SO₄ levels (p < 0.05) only in group of PCOS women with elevated androgens.

CONCLUSION

Analysis of TNF-α showed that women with high testosterone negative correlation between level of TNF-α and the concentration of DHEA-SO4. Inflammatory state involving TNF-α in women with PCOS and high concentration of androgens is caused by intensified Δ4 (progesterone) pathway and omitted or limited Δ5 (dehydroepiandrosterone) pathway of testosterone biosynthesis.

Criteria, prevalence, and phenotypes of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a highly prevalent disorder effecting reproductive-aged women worldwide. This article addresses the evolution of the criteria used to diagnosis PCOS; reviews recent advances in the phenotypic approach, specifically in the context of the extended Rotterdam criteria; discusses limitations of the current criteria used to diagnosis, particularly when studying adolescents and women in the peri- and postmenopause; and describes significant strides made in understanding the epidemiology of PCOS. This review recognizes that although there is a high prevalence of PCOS, there is increased variability when using Rotterdam 2003 criteria, owing to limitations in population sampling and approaches used to define PCOS phenotypes. Last, we discuss the distribution of PCOS phenotypes, their morbidity, and the role that referral bias plays in the epidemiology of this syndrome.

Characteristics and outcomes of in vitro fertilization in different phenotypes of polycystic ovary syndrome

Objective:

The aim of this study was to investigate whether polycystic ovary syndrome (PCOS) phenotype without polycystic ovaries (PCO) differs in terms of in vitro fertilization (IVF) outcomes compared with classic phenotypes.

Materials and Methods:

This retrospective controlled study included 262 patients who underwent IVF treatment with an indication of unexplained or tubal factor infertility (control group), ovulatory patients with PCO morphology (group 1), PCOS phenotype with oligoanovulation and hyperandrogenemia (group 2), PCOS phenotype with PCO morphology and oligoanovulation (group 3). Outcomes and baseline characteristics of IVF-embryo transfer treatments were compared among all groups.

Results:

PCOS phenotype without PCO morphology had similar IVF stimulation characteristics compared with classic phenotypes; however, a higher total gonadotropin dose was needed to achieve similar results compared with patients with PCO morphology with or without PCOS. Basal follicle-stimulating hormone level (beta coefficient=0.207, p=0.003), group (beta coefficient=-0.305, p<0.001) and age (beta coefficient=0.311, p<0.001) were significantly associated with the total gonadotropin dose. The number of good quality embryo on transfer day was significantly lower in patients with isolated PCO morphology and PCO morphology with oligoanovulation than in those with PCOS phenotype without PCO morphology.

Conclusion:

PCO morphology provides easier stimulation, whereas hyperandrogenemia provides better results as good quality embryos. However, the end point is similar in terms of biochemical, clinical, and ongoing pregnancy rates.

Consecutive lynestrenol and cross-sex hormone treatment in biological female adolescents with gender dysphoria: a retrospective analysis

Background

Prior to the start of cross-sex hormone therapy (CSH), androgenic progestins are often used to induce amenorrhea in female to male (FtM) pubertal adolescents with gender dysphoria (GD). The aim of this single-center study is to report changes in anthropometry, side effects, safety parameters, and hormone levels in a relatively large cohort of FtM adolescents with a diagnosis of GD at Tanner stage B4 or further, who were treated with lynestrenol (Orgametril®) monotherapy and in combination with testosterone esters (Sustanon®).

Methods

A retrospective analysis of clinical and biochemical data obtained during at least 6 months of hormonal treatment in FtM adolescents followed at our adolescent gender clinic since 2010 (n = 45) was conducted. McNemar’s test to analyze reported side effects over time was performed. A paired Student’s t test or a Wilcoxon signed-ranks test was performed, as appropriate, on anthropometric and biochemical data. For biochemical analyses, all statistical tests were done in comparison with baseline parameters. Patients who were using oral contraceptives (OC) at intake were excluded if a Mann-Whitney U test indicated influence of OC.

Results

Metrorrhagia and acne were most pronounced during the first months of monotherapy and combination therapy respectively and decreased thereafter. Headaches, hot flushes, and fatigue were the most reported side effects. Over the course of treatment, an increase in musculature, hemoglobin, hematocrit, creatinine, and liver enzymes was seen, progressively sliding into male reference ranges. Lipid metabolism shifted to an unfavorable high-density lipoprotein (HDL)/low-density lipoprotein (LDL) ratio; glucose metabolism was not affected. Sex hormone-binding globulin (SHBG), total testosterone, and estradiol levels decreased, and free testosterone slightly increased during monotherapy; total and free testosterone increased significantly during combination therapy. Gonadotropins were only fully suppressed during combination therapy. Anti-Müllerian hormone (AMH) remained stable throughout the treatment. Changes occurred in the first 6 months of treatment and remained mostly stable thereafter.

Conclusions

Treatment of FtM gender dysphoric adolescents with lynestrenol monotherapy and in combination with testosterone esters is effective, safe, and inexpensive; however, suppression of gonadotropins is incomplete. Regular blood controls allow screening for unphysiological changes in safety parameters or hormonal levels and for medication abuse.

Polycystic ovarian syndrome (PCOS), related symptoms/sequelae, and breast cancer risk in a population-based case-control study

PURPOSE

Despite the overlap between the clinical symptoms/sequelae of polycystic ovarian syndrome (PCOS) and many known reproductive risk factors for breast cancer, the relationship between PCOS and breast cancer remains unclear, possibly because of the complex heterogeneity and challenges in diagnosing PCOS over time. We hypothesized that PCOS, specific PCOS-related symptoms/sequelae, or clusters of PCOS-related symptoms/sequelae may be differentially associated with pre- versus postmenopausal breast cancer risk.

MATERIALS AND METHODS

Cases were 1,508 women newly diagnosed with a first primary in situ or invasive breast, and the 1,556 population-based controls were frequency-matched by age.

RESULTS

History of physician-diagnosed PCOS was reported by 2.2 % (n = 67), among whom oral contraceptive (OC) use, irregular menstruation, and infertility due to ovulatory dysfunction were common. Using unconditional logistic regression, adjusted odds ratios (95 % CI) for PCOS were increased for premenopausal [2.74 (1.13, 6.63)], but not postmenopausal breast cancer [0.87 (0.44, 1.71)]. We used cluster analysis to investigate whether risk among all women varied by PCOS-related symptoms/sequelae, such as reproductive irregularities, OC use, and components of insulin resistance. In the cluster analysis, odds ratios were elevated among premenopausal women who had a history of OC use and no ovulatory dysfunction [1.39 (1.03, 1.88)], compared to those with fewer number of PCOS-related symptoms/sequelae.

CONCLUSION

PCOS and associated PCOS-related symptoms/sequelae including OC use may play a role in the development of premenopausal breast cancer. Our findings require confirmation in studies with a larger number of premenopausal women with systematically applied diagnostic criteria for PCOS.