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van der Ham K, Laven JSE, Tay CT, Mousa A, Teede H, Louwers YV. Anti-müllerian hormone as a diagnostic biomarker for polycystic ovary syndrome and polycystic ovarian morphology: a systematic review and meta-analysis. Fertil Steril 2024; 122:727-739. [PMID: 38944177 DOI: 10.1016/j.fertnstert.2024.05.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 07/01/2024]
Abstract
IMPORTANCE As part of the 2023 international evidence-based polycystic ovary syndrome (PCOS) guideline, this meta-analysis investigated the inclusion of Anti-Müllerian hormone (AMH) levels in the diagnostic criteria for PCOS. OBJECTIVE To answer the following three questions: 1) Are AMH levels effective in diagnosing PCOS in adult women? 2) Are AMH levels effective in diagnosing PCOS in adolescents? Are AMH levels effective in diagnosing polycystic ovarian morphology (PCOM)? DATA SOURCES Searches were conducted in six databases until July 31, 2023. STUDY SELECTION AND SYNTHESIS Eligible studies were those conducted in humans, published in English, and reporting sensitivity, specificity, and/or area under the curve values. Extracted data included study population, age, body mass index, AMH assay, cut-off value of AMH levels, sensitivity, specificity, and area under the curve values. The risk of bias was assessed using the quality assessment of diagnostic accuracy studies tool. A random effects model was used to test diagnostic accuracy. MAIN OUTCOMES Pooled sensitivity and specificity to use AMH levels for PCOS diagnosis in adults as well as adolescents and for detecting PCOM in adults. RESULTS Eighty-two studies were included. The adult AMH-PCOS meta-analyses (n = 68) showed a pooled sensitivity and specificity of 0.79 (95% confidence interval [CI], 0.76-0.82; I2 = 86%) and 0.87 (95% CI, 0.84-0.89; I2 = 91%). The adolescent AMH-PCOS meta-analysis (n = 11) showed a pooled sensitivity and specificity of 0.66 (95% CI, 0.58-0.73; I2 = 74%) and 0.78 (95% CI, 0.71-0.83; I2 = 45%). The adult AMH-PCOM meta-analysis (n = 7) showed a pooled sensitivity and specificity of 0.79 (95% CI, 0.72-0.85; I2 = 94%) and 0.87 (95% CI, 0.78-0.93; I2 = 94%). CONCLUSION AND RELEVANCE: This study investigated the most profound change in the 2023 international evidence-based PCOS guideline, which now recommends AMH levels for defining PCOM in adults in accordance with the diagnostic algorithm. Antimüllerian hormone levels alone are insufficient for PCOS diagnosis and are nonspecific for PCOM in adolescents. Multiple factors influence AMH levels and cause heterogeneity as well as limitations in this study. Consequently, no international cut-off value could be recommended, emphasizing the need for research on more individualized cut-off values.
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Affiliation(s)
- Kim van der Ham
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, the Netherlands.
| | - Joop S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Chau Thien Tay
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Melbourne, Victoria, Australia
| | - Aya Mousa
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Melbourne, Victoria, Australia
| | - Helena Teede
- Monash Centre for Health Research and Implementation (MCHRI), Monash University, Melbourne, Victoria, Australia
| | - Yvonne V Louwers
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Yong EL, Teoh WS, Huang ZW. Polycystic ovary syndrome v.2023: Simplified diagnostic criteria for an East Asian phenotype. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:669-678. [PMID: 38920160 DOI: 10.47102/annals-acadmedsg.202369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Two decades after the Rotterdam 2003 consensus workshop, there have been considerable advances in elucidating the pathophysiology and epidemiology of polycystic ovary syndrome (PCOS). This has prompted the re-examination of the features that characterise this common condition. Current definitions have led to great heterogeneity in the prevalence of PCOS and have contributed to inconsistent treatment protocols and assessment of therapeutic outcomes. Diagnosis is further complicated by the lack of universal agreement on threshold cut-offs for ovarian dysfunction and ethnic differences in hirsutism; both of which are key features in the definitions that are commonly used currently. These challenges often result in dissatisfaction with medical care among PCOS patients and their physicians. Method Our factor analysis mathematically identified anti-Mullerian hormone (AMH), associated polycystic ovarian morphology (PCOM) and serum testosterone as the only significant cluster associated with menstrual cycle length variability. Results and Conclusion As such, we propose a simplified criteria wherein the presence of at least 2 of the 3 features below would be sufficient to define PCOS: (1) chronic oligo-ovulation or anovulation as indicated by oligomenorrhea (cycle lengths >35 days) or amenorrhea; (2) PCOM: raised AMH ≥37.0 pmol/L instead of transvaginal ultrasound assessment of ovaries; and (3) Androgen excess, or raised serum androgens above the laboratory reference for women. Further studies are required to examine whether the proposed criteria would reduce diagnostic confusion and improve care and outcomes, especially among patients of East Asian ethnicities.
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Affiliation(s)
- Eu-Leong Yong
- Department of Obstetrics and Gynaecology, National University Hospital, National University of Singapore, Singapore
| | - Wei Shan Teoh
- Department of Obstetrics and Gynaecology, National University Hospital, National University of Singapore, Singapore
| | - Zhong Wei Huang
- Department of Obstetrics and Gynaecology, National University Hospital, National University of Singapore, Singapore
- NUS Bia-Echo Asia Centre for Reproductive Longevity and Equality, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Riepsamen AH, Donoghoe MW, Indran IR, Hechtman L, Robertson DM, Gilchrist RB, Ledger WL, Yong E. Serum GDF9 and BMP15 as potential markers of ovarian function in women with and without polycystic ovary syndrome. Clin Endocrinol (Oxf) 2023; 98:567-577. [PMID: 36372988 PMCID: PMC10952143 DOI: 10.1111/cen.14851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/31/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Growth differentiation factor-9 (GDF9) and bone morphogenetic protein-15 (BMP15) are critical paracrine regulators of female fertility and are predominantly expressed by oocytes. However, it is unknown if serum concentrations reflect changes in ovarian function and/or reproductive endocrine disorders. This study aimed to determine if serum GDF9/BMP15 are associated with ovarian, pituitary, oestrogenic, androgenic and metabolic characteristics and the ovarian pathologies, polycystic ovarian morphology (PCOM) and polycystic ovary syndrome (PCOS). DESIGN Women aged 21-45 years (n = 381) were included from a cross-sectional study at the National University Hospital, Singapore. PATIENTS Participants were volunteers and patients with possible PCOS. MEASUREMENTS Anthropometric measurements, transvaginal ultrasound scans and serum sampling were performed and a questionnairecompleted. Serum GDF9 and BMP15 concentrations were matched with menstrual cycle length, ovarian protein and steroid hormone production, pituitary hormone production and metabolic assessments in women with PCOM or PCOS and those with neither (control). RESULTS Serum GDF9 and BMP15 were detectable in 40% and 41% of women, respectively and were positively correlated with each other (r = 0.08, p = 0.003). GDF9, but not BMP15, was positively correlated with ovarian volume (p = 0.02) and antral follicle count (AFC) (p = 0.004), but not with anti-Müllerian hormone (p = 0.05). However, serum GDF9 and BMP15 concentrations were not significantly different between control, PCOM and PCOS women, nor associated with androgenic or metabolic PCOS features. However, the relationship between GDF9 and AFC differed between control, PCOM and PCOS women (p = 0.02). CONCLUSIONS Serum GDF9 and BMP15 concentrations somewhat reflect ovarian but not androgenic or metabolic characteristics of PCOS, with increased GDF9 reflecting high AFC as seen in PCOM/PCOS.
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Affiliation(s)
- Angelique H. Riepsamen
- Fertility & Research Centre, School of Clinical MedicineUniversity of New South Wales SydneyNew South WalesSydneyAustralia
| | - Mark W. Donoghoe
- Stats Central, Mark Wainwright Analytical CentreUniversity of New South Wales SydneySydneyNew South WalesAustralia
| | - Inthrani R. Indran
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
- Department of Pharmacology, Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
| | - Leah Hechtman
- Fertility & Research Centre, School of Clinical MedicineUniversity of New South Wales SydneyNew South WalesSydneyAustralia
| | - David M. Robertson
- Fertility & Research Centre, School of Clinical MedicineUniversity of New South Wales SydneyNew South WalesSydneyAustralia
| | - Robert B. Gilchrist
- Fertility & Research Centre, School of Clinical MedicineUniversity of New South Wales SydneyNew South WalesSydneyAustralia
| | - William L. Ledger
- Fertility & Research Centre, School of Clinical MedicineUniversity of New South Wales SydneyNew South WalesSydneyAustralia
| | - Eu‐Leong Yong
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
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Lam C, Huang Z, Shen L. Infographics and the Elaboration Likelihood Model (ELM): Differences between Visual and Textual Health Messages. JOURNAL OF HEALTH COMMUNICATION 2022; 27:737-745. [PMID: 36519844 DOI: 10.1080/10810730.2022.2157909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Effective health communication is vital to improving health outcomes. One increasingly popular form of health communication is the use of infographics. Despite its popularity, there is a lack of empirical investigation regarding its information processing mechanism. We applied the Elaboration Likelihood Model (ELM) to study the conditions that lead to elaboration. Participants were randomly assigned to two groups: a text-only health message and a health infographic. Results showed that the infographic had better image appeal rating than the text-only message, and the group that viewed the infographic reported greater elaboration. In addition, for both groups, prior knowledge, ease of understanding, and image appeal had effects on elaboration. Presentation format (text-only vs infographic) interacted with prior knowledge to impact elaboration. Our findings demonstrate that visual design cannot be sidelined as a peripheral interest, but should be positioned as one of the focal points in health communication research.
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Affiliation(s)
- Chervin Lam
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Bia-Echo Asia Centre for Reproductive Longevity & Equality (ACRLE)
| | - Zhongwei Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Bia-Echo Asia Centre for Reproductive Longevity & Equality (ACRLE)
| | - Liang Shen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Teoh WS, Ramu D, Indran IR, Chua MWJ, Thu WPP, Yong EL. Diagnosis and management of polycystic ovary syndrome: Perspectives of clinicians in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:204-212. [PMID: 35506403 DOI: 10.47102/annals-acadmedsg.2021474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION To harmonise the diagnostic processes of polycystic ovary syndrome (PCOS) and enable clinicians to provide better patient care, it is critical to understand the knowledge gaps in PCOS diagnosis. We evaluated how clinicians in endocrinology, family medicine, general practice and gynaecology diagnose PCOS. METHODS This cross-sectional survey involved 208 clinicians from specific subspecialties across various healthcare settings in Singapore. RESULTS A total of 160 responses were included in the final analysis. Among all the diagnostic criteria, the Rotterdam 2003 criteria was most frequently used (66.3%). More than half of the gynaecologists reported having a standardised workplace protocol while the majority from other specialties reported otherwise. A large percentage of respondents (60.5%) were unable to identify the correct PCOS clinical features, which is concerning. Only 8.8% of respondents used clinical and biochemical hyperandrogenism, menstrual disturbances and pelvic ultrasound to diagnose PCOS without performing unnecessary and incorrect investigations. Most clinicians recognised insulin resistance/type 2 diabetes mellitus and fertility problems as complications while only a few recognised psychological complications. Many clinicians (37.3%) sought standardisation of PCOS diagnosis and management guidelines for improvement in PCOS care and 81.9% of respondents would appreciate standardised educational materials. CONCLUSION This is the first study to the best of our knowledge that gives an insight into the diagnostic and management processes of PCOS among various healthcare institutions in Singapore. This study calls for greater harmonisation of diagnostic processes and holistic evidence-based management of patients with PCOS through standardised workplace protocols and patient education resources.
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Affiliation(s)
- Wei Shan Teoh
- Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Neubronner SA, Indran IR, Chan YH, Thu AWP, Yong EL. Effect of body mass index (BMI) on phenotypic features of polycystic ovary syndrome (PCOS) in Singapore women: a prospective cross-sectional study. BMC WOMENS HEALTH 2021; 21:135. [PMID: 33794861 PMCID: PMC8017849 DOI: 10.1186/s12905-021-01277-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 03/22/2021] [Indexed: 11/23/2022]
Abstract
Background A diagnosis of Polycystic Ovary Syndrome (PCOS) and its related phenotypic features including increased hair growth can affect a woman’s social and emotional well-being. We aim to determine firstly, if excess body weight affects menstrual cycle length, excessive hair growth and other phenotypic features in healthy women without PCOS and secondly, whether having PCOS exacerbates the effects of high body mass index (BMI). Methods A prospective cross-sectional study involving healthy women (21–45 years) recruited at an annual health screen for hospital staff and volunteers from the university community, and PCOS cases referred to tertiary gynecological clinics in Singapore. To dissect the independent and/or combinatorial effects of PCOS and BMI on the phenotypic features, subjects were divided into four categories: non-PCOS (normal BMI), non-PCOS (high BMI), PCOS (normal BMI), and PCOS (high BMI). General linear modelling was performed to compare clinical, ovarian, hormonal and metabolic parameters across these four categories. Results Of 389 participants, 134 (34.4%) were classified as PCOS and the remaining 255 (65.6%), as the non-PCOS population. Overall 45.2% of women had high BMI (≥ 23). Compared to non-PCOS subjects, women with PCOS had a higher BMI (mean (SD): 25.14 ± 6.46 vs 23.08 ± 4.36, p < 0.001). Women with PCOS and high BMI had increased hair growth with modified Ferriman-Gallwey (mFG) scores that were 2.96-fold higher versus healthy-normal BMI women (mean difference; 1.85, 95% CI 0.80–2.90). Compared to healthy-high BMI women, PCOS women with high BMI had significantly higher mean differences in mFG scores (1.79, 95% CI 0.64–2.93). In PCOS women, having high BMI also significantly increased mFG scores by 1.85-fold (mean difference; 1.82. 95% CI 0.52–3.12). This effect was mirrored by the additive effect of BMI and PCOS on free androgen index. No independent effect of high BMI on rates of oligomenorrhoea, antral follicle count, ovarian volume or serum androgens were observed. Conclusions We observed an additive effect of body weight to increase hair growth in women with PCOS. Maximum mFG scores were present in PCOS women with high BMI. Such increases in mFG score may affect the self-esteem of women with PCOS.
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Affiliation(s)
- Samantha A Neubronner
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 12, Singapore, Republic of Singapore, 119228
| | - Inthrani R Indran
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 12, Singapore, Republic of Singapore, 119228.,Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore
| | - Angelica Win Pa Thu
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 12, Singapore, Republic of Singapore, 119228
| | - Eu-Leong Yong
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, 1E Kent Ridge Road, Level 12, Singapore, Republic of Singapore, 119228.
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Actkins KV, Singh K, Hucks D, Velez Edwards DR, Aldrich M, Cha J, Wellons M, Davis LK. Characterizing the Clinical and Genetic Spectrum of Polycystic Ovary Syndrome in Electronic Health Records. J Clin Endocrinol Metab 2021; 106:153-167. [PMID: 32961557 PMCID: PMC7765638 DOI: 10.1210/clinem/dgaa675] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 09/19/2020] [Indexed: 02/08/2023]
Abstract
CONTEXT Polycystic ovary syndrome (PCOS) is one of the leading causes of infertility, yet current diagnostic criteria are ineffective at identifying patients whose symptoms reside outside strict diagnostic criteria. As a result, PCOS is underdiagnosed and its etiology is poorly understood. OBJECTIVE We aim to characterize the phenotypic spectrum of PCOS clinical features within and across racial and ethnic groups. METHODS We developed a strictly defined PCOS algorithm (PCOSkeyword-strict) using the International Classification of Diseases, ninth and tenth revisions and keywords mined from clinical notes in electronic health records (EHRs) data. We then systematically relaxed the inclusion criteria to evaluate the change in epidemiological and genetic associations resulting in 3 subsequent algorithms (PCOScoded-broad, PCOScoded-strict, and PCOSkeyword-broad). We evaluated the performance of each phenotyping approach and characterized prominent clinical features observed in racially and ethnically diverse PCOS patients. RESULTS The best performance came from the PCOScoded-strict algorithm, with a positive predictive value of 98%. Individuals classified as cases by this algorithm had significantly higher body mass index (BMI), insulin levels, free testosterone values, and genetic risk scores for PCOS, compared to controls. Median BMI was higher in African American females with PCOS compared to White and Hispanic females with PCOS. CONCLUSIONS PCOS symptoms are observed across a severity spectrum that parallels the continuous genetic liability to PCOS in the general population. Racial and ethnic group differences exist in PCOS symptomology and metabolic health across different phenotyping strategies.
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Affiliation(s)
- Ky’Era V Actkins
- Department of Microbiology, Immunology, and Physiology, Meharry Medical College, Nashville, Tennessee
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kritika Singh
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Donald Hucks
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Digna R Velez Edwards
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Epidemiology Center, Institute of Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Quantitative Sciences, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melinda Aldrich
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeeyeon Cha
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa Wellons
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lea K Davis
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
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Valdimarsdottir R, Wikström AK, Kallak TK, Elenis E, Axelsson O, Preissl H, Ubhayasekera SJKA, Bergquist J, Poromaa IS. Pregnancy outcome in women with polycystic ovary syndrome in relation to second-trimester testosterone levels. Reprod Biomed Online 2021; 42:217-225. [PMID: 33077357 DOI: 10.1016/j.rbmo.2020.09.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/25/2020] [Accepted: 09/21/2020] [Indexed: 11/30/2022]
Abstract
RESEARCH QUESTION Do women with polycystic ovary syndrome (PCOS) have higher testosterone levels during pregnancy and what role does high testosterone play in the development of obstetric complications? DESIGN Retrospective cohort study from Uppsala University Hospital, Sweden. The study population consisted of women with PCOS (n = 159) and a comparison group of women without PCOS matched for body mass index (n = 320). Plasma testosterone levels were measured in the early second trimester by liquid chromatography with tandem mass spectrometry, and women with PCOS were grouped into tertiles according to their testosterone levels. Possible associations with obstetric complications, maternal metabolic factors and offspring birth weight were explored by multivariable logistic and linear regression models. RESULTS Compared with women who do not have PCOS, women with PCOS had higher total testosterone (median 1.94, interquartile range [IQR] 1.21-2.64 versus 1.41, IQR 0.89-1.97; P < 0.001), and free androgen index (median 0.25, IQR 0.15-0.36 versus 0.18, IQR 0.11-0.28; P < 0.001). Women with PCOS who had the highest levels of testosterone had increased risk for preeclampsia, even when adjusted for age, parity, country of birth and smoking (adjusted OR 6.16, 95% CI 1.82 to 20.91). No association was found between high testosterone in women with PCOS and other obstetric complications. CONCLUSIONS Women with PCOS have higher levels of total testosterone and free androgen index during pregnancy than women without PCOS matched for body mass index. Preliminary evidence shows that women with PCOS and the highest maternal testosterone levels in early second trimester had the highest risk of developing preeclampsia. This finding, however, is driven by a limited number of cases and should be interpreted with caution.
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Affiliation(s)
| | - Anna-Karin Wikström
- Department of Women's and Children's Health, Uppsala University, Uppsala 751 85, Sweden
| | | | - Evangelia Elenis
- Department of Women's and Children's Health, Uppsala University, Uppsala 751 85, Sweden
| | - Ove Axelsson
- Department of Women's and Children's Health, Uppsala University, Uppsala 751 85, Sweden; Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
| | - Hubert Preissl
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, German Center for Diabetes Research (DZD e.V.), Tübingen, Germany; Department of Internal Medicine IV, Division of Endocrinology, Diabetology, and Nephrology, University Hospital Tübingen, Tübingen, Germany
| | - S J Kumari A Ubhayasekera
- Department of Chemistry - BMC, Analytical Chemistry and Neurochemistry, Uppsala University Uppsala, Sweden
| | - Jonas Bergquist
- Department of Chemistry - BMC, Analytical Chemistry and Neurochemistry, Uppsala University Uppsala, Sweden
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Bansal P, Sardana K, Arora P, Khurana A, Garga UC, Sharma L. A prospective study of anti-mullerian hormone and other ovarian and adrenal hormones in adult female acne. Dermatol Ther 2020; 33:e13974. [PMID: 33185003 DOI: 10.1111/dth.13974] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/18/2020] [Accepted: 07/02/2020] [Indexed: 11/30/2022]
Abstract
Polycystic ovarian syndrome (PCOS) diagnosis in adult female acne (AFA) is tough owing to unreliable ultrasonography in virgins or obese females and inconsistent hyperandrogenemia. We analyzed hormones in AFA and established a diagnostic cut-off value of anti-mullerian hormone (AMH) for PCOS. Female acne patients aged ≥25 years were assessed with total testosterone (TT), sex hormone binding globulin (SHBG), free androgen index (FAI), AMH, 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone sulfate (DHEAS), follicle stimulating hormone (FSH), and luteinizing hormone (LH). Rotterdam's criteria defined PCOS. AMH was measured (Access AMH assay) to calculate the diagnostic cut off value using receiver operating characteristic (ROC) curve. Of 120 cases, 25.83% had PCOS. This group had significant clinical hyperandrogenism, truncal and adolescent acne, polycystic ovarian morphology (PCOM), and raised hormones (AMH, TT, FAI, LH, and LH/FSH). AMH levels were significantly higher in the PCOS group (6.91 ± 3.85 ng/mL) and positively correlated with TT, FAI, 17OHP, LH, and LH/FSH ratio. AMH at >5.1 ng/mL (sensitivity-70.97% and specificity-82.02%) predicted PCOS and correlated with PCOM. AMH (>5.1 ng/mL) is useful for diagnosing PCOS and surrogate for hyperandrogenemia and PCOM. Its correlation with hormones in non PCOS AFA highlights its sensitivity to diagnose endocrinological derangements.
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Affiliation(s)
- Prekshi Bansal
- Department of Dermatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Kabir Sardana
- Department of Dermatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Pooja Arora
- Department of Dermatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Ananta Khurana
- Department of Dermatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Umesh Chandra Garga
- Department of Radiodiagnosis, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Lokesh Sharma
- Department of Biochemistry, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
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Qu X, Donnelly R. Sex Hormone-Binding Globulin (SHBG) as an Early Biomarker and Therapeutic Target in Polycystic Ovary Syndrome. Int J Mol Sci 2020; 21:E8191. [PMID: 33139661 PMCID: PMC7663738 DOI: 10.3390/ijms21218191] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023] Open
Abstract
Human sex hormone-binding globulin (SHBG) is a glycoprotein produced by the liver that binds sex steroids with high affinity and specificity. Clinical observations and reports in the literature have suggested a negative correlation between circulating SHBG levels and markers of non-alcoholic fatty liver disease (NAFLD) and insulin resistance. Decreased SHBG levels increase the bioavailability of androgens, which in turn leads to progression of ovarian pathology, anovulation and the phenotypic characteristics of polycystic ovarian syndrome (PCOS). This review will use a case report to illustrate the inter-relationships between SHBG, NAFLD and PCOS. In particular, we will review the evidence that low hepatic SHBG production may be a key step in the pathogenesis of PCOS. Furthermore, there is emerging evidence that serum SHBG levels may be useful as a diagnostic biomarker and therapeutic target for managing women with PCOS.
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Affiliation(s)
- Xianqin Qu
- School of Life Sciences, University of Technology Sydney, Ultimo, NSW 2007, Australia
| | - Richard Donnelly
- School of Medicine, University of Nottingham, Derby DE22 3DT, UK;
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Xu H, Shi L, Feng G, Xiao Z, Chen L, Li R, Qiao J. An Ovarian Reserve Assessment Model Based on Anti-Müllerian Hormone Levels, Follicle-Stimulating Hormone Levels, and Age: Retrospective Cohort Study. J Med Internet Res 2020; 22:e19096. [PMID: 32667898 PMCID: PMC7546624 DOI: 10.2196/19096] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Previously, we reported a model for assessing ovarian reserves using 4 predictors: anti-Müllerian hormone (AMH) level, antral follicle count (AFC), follicle-stimulating hormone (FSH) level, and female age. This model is referred as the AAFA (anti-Müllerian hormone level-antral follicle count-follicle-stimulating hormone level-age) model. OBJECTIVE This study aims to explore the possibility of establishing a model for predicting ovarian reserves using only 3 factors: AMH level, FSH level, and age. The proposed model is referred to as the AFA (anti-Müllerian hormone level-follicle-stimulating hormone level-age) model. METHODS Oocytes from ovarian cycles stimulated by gonadotropin-releasing hormone antagonist were collected retrospectively at our reproductive center. Poor ovarian response (<5 oocytes retrieved) was defined as an outcome variable. The AFA model was built using a multivariable logistic regression analysis on data from 2017; data from 2018 were used to validate the performance of AFA model. Measurements of the area under the curve (AUC), sensitivity, specificity, positive predictive value, and negative predicative value were used to evaluate the performance of the model. To rank the ovarian reserves of the whole population, we ranked the subgroups according to the predicted probability of poor ovarian response and further divided the 60 subgroups into 4 clusters, A-D, according to cut-off values consistent with the AAFA model. RESULTS The AUCs of the AFA and AAFA models were similar for the same validation set, with values of 0.853 (95% CI 0.841-0.865) and 0.850 (95% CI 0.838-0.862), respectively. We further ranked the ovarian reserves according to their predicted probability of poor ovarian response, which was calculated using our AFA model. The actual incidences of poor ovarian response in groups from A-D in the AFA model were 0.037 (95% CI 0.029-0.046), 0.128 (95% CI 0.099-0.165), 0.294 (95% CI 0.250-0.341), and 0.624 (95% CI 0.577-0.669), respectively. The order of ovarian reserve from adequate to poor followed the order from A to D. The clinical pregnancy rate, live-birth rate, and specific differences in groups A-D were similar when predicted using the AFA and AAFA models. CONCLUSIONS This AFA model for assessing the true ovarian reserve was more convenient, cost-effective, and objective than our original AAFA model.
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Affiliation(s)
- Huiyu Xu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.,Key Laboratory of Assisted Reproduction, Ministry of Education, Beijing, China.,National Clinical Research Center for Obstetrics and Gynecology, Beijing, China.,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
| | - Li Shi
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.,Key Laboratory of Assisted Reproduction, Ministry of Education, Beijing, China.,National Clinical Research Center for Obstetrics and Gynecology, Beijing, China.,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
| | - Guoshuang Feng
- Big Data and Engineering Research Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhen Xiao
- Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Lixue Chen
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.,Key Laboratory of Assisted Reproduction, Ministry of Education, Beijing, China.,National Clinical Research Center for Obstetrics and Gynecology, Beijing, China.,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
| | - Rong Li
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.,Key Laboratory of Assisted Reproduction, Ministry of Education, Beijing, China.,National Clinical Research Center for Obstetrics and Gynecology, Beijing, China.,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
| | - Jie Qiao
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.,Key Laboratory of Assisted Reproduction, Ministry of Education, Beijing, China.,National Clinical Research Center for Obstetrics and Gynecology, Beijing, China.,Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
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Lee RWK, Khin LW, Hendricks MS, Tan HH, Nadarajah S, Tee NWS, Loh SF, Tai BC, Chan JK. Ovarian biomarkers predict controlled ovarian stimulation for in vitro fertilisation treatment in Singapore. Singapore Med J 2020; 61:463-468. [PMID: 33043373 DOI: 10.11622/smedj.2020130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Ovarian biomarkers have been shown to predict responses to controlled ovarian hyperstimulation (COH) during in vitro fertilisation (IVF) in predominantly Caucasian populations, with limited studies performed in Southeast Asian women in Singapore. METHODS We evaluated the performance of serum anti-Müllerian hormone (AMH), follicle-stimulating hormone and oestradiol levels, antral follicle count (AFC), body mass index, ovarian volume, and age to establish thresholds for the prediction of poor (< 4 oocytes retrieved) and excessive responses (> 19 oocytes retrieved) in 263 women undergoing COH. Univariate and multivariate logistic regression analysis and receiver operating characteristic curves were used to calculate probabilities for poor and excessive responders to COH. RESULTS 36 (13.7%) and 50 (19.0%) women had poor and excessive response to COH, respectively. An AMH value of 0.69 ng/mL predicted poor ovarian response with positive likelihood ratio (LR) of 2.94, compared to an AFC of ≤ 5 when the positive LR is 2.36. Conversely, an AMH value of ≥ 3.06 ng/mL predicted excessive ovarian response with positive LR of 2.24, compared to an AFC cut-off of ≥ 12 with positive LR of 1.93. CONCLUSION AMH levels and AFC are equivalent in the prediction of both poor and excessive ovarian response in women undergoing IVF. Our study highlights the importance of establishing population-specific cut-off biomarker values so that protocols can be tailored to optimise IVF treatment.
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Affiliation(s)
- Ryan Wai Kheong Lee
- Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
| | - Lay Wai Khin
- Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
| | | | - Heng Hao Tan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
| | - Sadhana Nadarajah
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
| | - Nancy Wen Sim Tee
- Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, Singapore
| | | | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore.,NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jerry Ky Chan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore.,Programme in Cancer and Stem Cell Biology, Duke-NUS Medical School, Singapore
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Sardana K, Bansal P, Sharma LK, Garga UC, Vats G. A study comparing the clinical and hormonal profile of late onset and persistent acne in adult females. Int J Dermatol 2020; 59:428-433. [DOI: 10.1111/ijd.14748] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/07/2019] [Accepted: 11/22/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Kabir Sardana
- Department of Dermatology Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research New Delhi India
| | - Prekshi Bansal
- Department of Dermatology Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research New Delhi India
| | - Lokesh K. Sharma
- Department of Biochemistry Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research New Delhi India
| | - Umesh C. Garga
- Department of Radiodiagnosis Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research New Delhi India
| | - Gauri Vats
- Department of Dermatology Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research New Delhi India
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Bansal P, Sardana K, Sharma L, Garga UC, Vats G. A prospective study examining isolated acne and acne with hyperandrogenic signs in adult females. J DERMATOL TREAT 2019; 32:752-755. [PMID: 31868042 DOI: 10.1080/09546634.2019.1708245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Adult female acne (AFA) occurs beyond 25 years of age and can present either as isolated acne or with hyperandrogenic signs. METHODS 120 females aged ≥ 25 years were evaluated for acne, hirsutism and androgenetic alopecia. Hormonal assessment included total testosterone (TT), sex hormone binding globulin (SHBG), free androgen index (FAI), Anti Mullerian Hormone (AMH), 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone sulfate (DHEAS), follicle stimulating hormone (FSH), luteinizing hormone (LH), thyroid stimulating hormone (TSH) and prolactin. Polycystic ovary syndrome (PCOS) was diagnosed using Rotterdam's criteria. RESULTS The mean GAGS score was 15.57 ± 4.04.71.66% females had acne with hyperandrogenic signs (hirsutism, 55.81%; hyperseborrhoea, 65.12%; irregular menses, 36.05%) and 18.33% had increased androgen levels. The group with hyperandrogenic signs had longer duration of disease, truncal acne, significant adolescent acne history, stress, inappropriate diet and PCOS compared to the isolated acne group. The mean androgen levels were higher in the former but the difference was statistically insignificant. CONCLUSIONS Adult female acne can be associated with hyperandrogenic features though routine hormonal tests may not reveal an underlying abnormality except PCOS. End-organ hypersensitivity is the most plausible explanation and thus justifies the use of antiandrogens in its management.
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Affiliation(s)
- Prekshi Bansal
- Department of Dermatology, Dr. Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research New Delhi, New Delhi, India
| | - Kabir Sardana
- Department of Dermatology, Dr. Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research New Delhi, New Delhi, India
| | - Lokesh Sharma
- Department of Biochemistry, Dr. Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research New Delhi, New Delhi, India
| | - Umesh Chandra Garga
- Department of Radiodiagnosis, Dr. Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research New Delhi, New Delhi, India
| | - Gauri Vats
- Department of Dermatology, Dr. Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research New Delhi, New Delhi, India
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Lim AJR, Indran IR, Kramer MS, Yong E. Phenotypic spectrum of polycystic ovary syndrome and their relationship to the circadian biomarkers, melatonin and cortisol. Endocrinol Diabetes Metab 2019; 2:e00047. [PMID: 31294078 PMCID: PMC6613235 DOI: 10.1002/edm2.47] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/07/2018] [Accepted: 09/24/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE Firstly, to investigate whether polycystic ovary syndrome (PCOS) shows a continuum of severity with increasing number of phenotypic features comprising the Rotterdam criteria for PCOS and secondly, to explore relationships of these phenotypes to the circadian biomarkers, cortisol and melatonin. BACKGROUND Studies characterizing the spectrum of PCOS subphenotypes give little emphasis to the distinction among women who manifest zero, one or two of the three phenotypic features comprising the Rotterdam criteria. The relationship of circadian biomarkers to PCOS phenotypes is unclear. DESIGN Cross-sectional study of 321 participants from 2011 to 2016 conducted at the National University Hospital (NUH), Singapore. PARTICIPANTS Participants included women who attended a health screen for NUH staff, volunteers from the university community, and women referred for possible PCOS from gynaecological clinics at NUH and KK Women's and Children's Hospital (Singapore). METHODS All participants underwent a physical examination, ovarian ultrasound scan and follicular-phase blood testing, and completed a health and lifestyle questionnaire. RESULTS A significant positive linear trend in all clinical and biochemical characteristics of PCOS with increasing number of phenotypic features comprising the Rotterdam criteria. We observed a similar trend in serum cortisol and melatonin, two biomarkers of the circadian rhythm. CONCLUSION PCOS may not be an "all-or-none" condition, but rather a continuous spectrum. The positive relationship between number of PCOS criteria with melatonin and cortisol merits further investigation on the role of circadian biorhythms in the pathogenesis of PCOS.
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Affiliation(s)
- Audrey J. R. Lim
- Department of Obstetrics & GynaecologyYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
| | - Inthrani R. Indran
- Department of Obstetrics & GynaecologyYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
- Department of Pharmacology, Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
| | - Michael S. Kramer
- Department of Obstetrics & GynaecologyYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
- Faculty of Medicine, Departments of Epidemiology, Biostatistics & Occupational Health and of PediatricsMcGill UniversityMontrealQuebecCanada
| | - Eu‐Leong Yong
- Department of Obstetrics & GynaecologyYong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
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Valdimarsdottir R, Valgeirsdottir H, Wikström AK, Kallak TK, Elenis E, Axelsson O, Ubhayasekhera K, Bergquist J, Piltonen TT, Pigny P, Giacobini P, Poromaa IS. Pregnancy and neonatal complications in women with polycystic ovary syndrome in relation to second-trimester anti-Müllerian hormone levels. Reprod Biomed Online 2019; 39:141-148. [DOI: 10.1016/j.rbmo.2019.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/26/2019] [Accepted: 02/08/2019] [Indexed: 12/16/2022]
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Abstract
Polycystic ovary syndrome (PCOS) presents with a spectrum of conditions resulting from androgen excess, anovulation and metabolic syndrome. Patients with PCOS may see their primary care physicians for various presentations, including hirsutism, acne, menstrual irregularities, infertility, obesity, and psychiatric disorders such as anxiety and depression. Management of these patients should include screening for Type 2 diabetes mellitus, dyslipidaemia and hypertension. Treatment should be targeted to each patient's phenotype and personal expectations such as desire for pregnancy. Psychological well-being due to the effects on physical appearance is also an important consideration. Diet and exercise are major components in the management of patients with PCOS and obesity. The first-line therapy for fertility and metabolic syndrome in PCOS is lifestyle modification with diet and exercise, followed by pharmacological therapy.
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Affiliation(s)
| | - Choon How How
- Care and Health Integration, Changi General Hospital, Singapore.,Family Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Thomas F J King
- Department of Endocrinology, Changi General Hospital, Singapore.,Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
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