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Gürbuzer Eİ, Pelit P, Kızılkan MP, Baklacı AB, Tüzün Z, Mumuşoğlu S, Akgül S. Comparison of Diagnosis Experiences of Adolescent and Young Adult Polycystic Ovary Syndrome Patients. J Pediatr Adolesc Gynecol 2024:S1083-3188(24)00236-5. [PMID: 38906217 DOI: 10.1016/j.jpag.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 06/12/2024] [Accepted: 06/16/2024] [Indexed: 06/23/2024]
Abstract
STUDY OBJECTIVE The manner in which an individual experiences a polycystic ovary syndrome (PCOS) diagnosis may affect prognosis and vary with age. This study aimed to evaluate and compare the diagnosis experiences of adolescent and young adult PCOS patients. METHODS PCOS patients from the same institution were divided into two groups according to age and clinic (adolescents diagnosed in the adolescent medicine clinic and young adults diagnosed in the obstetrics and gynecology clinic). Patients completed a questionnaire designed to assess the information and support received during diagnosis, their satisfaction with this information, existing concerns regarding PCOS symptoms, and support requirements. RESULTS Thirty-six patients were included in each group. Among the participants, 52.8% of the adolescents and 63.9% of the young adults reported that they had consulted more than one specialist before receiving a diagnosis. We found that 83.3% of adolescents and 63.9% of young adults were satisfied with their overall PCOS diagnosis experience. The highest ratio of information given in both groups was related to medical treatment (88.9% in both groups), and the lowest ratios were associated with emotional support (13.9% vs.5.6%). Irregular menstruation was reported to be the most disturbing concern in both groups (94.4% vs.86.1%), and the biggest difference between the two groups was related to body dissatisfaction, which was observed more in adolescents (33.3% vs 5.6%). CONCLUSION While overall diagnosis experiences and satisfaction levels were similar across both groups, we identified distinct differences that may warrant attention to address age-specific needs and preferences.
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Affiliation(s)
- Eda İpek Gürbuzer
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Ankara, Turkey
| | - Pelin Pelit
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Ankara, Turkey
| | - Melis Pehlivanturk Kızılkan
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Division of Adolescent Medicine, Ankara, Turkey
| | - Ayse Bilge Baklacı
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Division of Adolescent Medicine, Ankara, Turkey
| | - Zeynep Tüzün
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Division of Adolescent Medicine, Ankara, Turkey
| | - Sezcan Mumuşoğlu
- Hacettepe University, Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Sinem Akgül
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Division of Adolescent Medicine, Ankara, Turkey.
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Zaitoun B, Al Kubaisi A, AlQattan N, Alassouli Y, Mohammad A, Alameeri H, Mohammed G. Polycystic ovarian syndrome awareness among females in the UAE: a cross-sectional study. BMC Womens Health 2023; 23:181. [PMID: 37069554 PMCID: PMC10108484 DOI: 10.1186/s12905-023-02318-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/30/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Polycystic Ovarian Syndrome (PCOS) is a common hormonal disorder affecting females of reproductive age. Clinical guidelines recommend following the diagnostic criteria of PCOS based on an appropriate assessment of the patient's clinical presentation. Sufficient awareness among the population will prompt females to seek medical attention when necessary. This study aimed to assess knowledge and awareness about PCOS among females above the age of 18 years in the United Arab Emirates (UAE) and to correlate the level of awareness with women's backgrounds, demographics, and education levels. METHODS This was a cross-sectional study conducted in early 2020. 430 females over the age of 18 years were conveniently selected and interviewed in the UAE using a 21-item questionnaire that assessed participants' awareness of PCOS as a term, its causes, symptoms, complications, treatment, and prevention. 414 entries were eligible for data analysis. IBM® SPSS® Statistics version 25 was used for data entry and analysis. RESULTS 349 participants (84.3%) were familiar with the term PCOS. However, only 21.7% of them had sufficient awareness of the syndrome (95% CI = 17.77-25.71%). Being knowledgeable of PCOS was significantly associated with having a previous diagnosis (p = 0.002) and with studying or working in a medical field (p < 0.001). In addition, females who knew someone diagnosed with PCOS were 5 times more likely to be more aware compared to those who didn't (95% CI = 2.5-10.8; p < 0.001). Age, education level, and nationality showed no correlation with the level of awareness. CONCLUSIONS Overall, the level of PCOS awareness was insufficient in the study sample. Participants whose source of information was medical practitioners demonstrated more accurate knowledge. Accordingly, awareness of PCOS needs to be raised among females in the UAE, aiding early diagnosis and improving patient-oriented outcomes.
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Affiliation(s)
- Balkis Zaitoun
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates.
| | | | - Noora AlQattan
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Yahya Alassouli
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Alshaima Mohammad
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Huriya Alameeri
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Ghada Mohammed
- Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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Ismayilova M, Yaya S. 'I'm usually being my own doctor': women's experiences of managing polycystic ovary syndrome in Canada. Int Health 2022; 15:56-66. [PMID: 35567790 PMCID: PMC9808519 DOI: 10.1093/inthealth/ihac028] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/07/2022] [Accepted: 04/16/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) is a complex, chronic condition characterized by anovulation, polycystic ovarian morphology and hyperandrogenism that requires lifelong management. To reduce the risk of comorbidity and to manage symptoms, lifestyle management and pharmaceuticals such as oral contraceptives are the most common forms of treatment and should be tailored to the individual patient. The literature to date has shown PCOS patients to experience widespread dissatisfaction with the amount and quality of information they receive from providers, along with lower levels of trust in physicians. Little is known about the lived experiences of women managing PCOS in Canada, across age groups. METHODS In-depth remote interviews explored women's lived experiences managing PCOS and the barriers and facilitators they encountered in their management journeys. Data were analyzed using thematic analysis and interpretive description methodology. RESULTS Twenty-five in-depth, telephone interviews conducted with participants (aged 18-63 y) across Canada revealed participants lacking sufficient information and guidance from physicians, especially in primary care. Areas in need of more guidance included lifestyle management and mental health. Lack of empathy and weight bias among physicians were also perceived by participants. Older participants received little guidance on treatment options postmenopause. Loss of trust and withdrawal from seeking medical care were prominent themes, along with greater self-reliance on self-management, including self-educating and self-experimenting with treatments. CONCLUSIONS Most women in this study were frustrated with the level of involvement and information provision from their doctors. Key recommendations are identified for the provision of care to younger and older patients with PCOS. Improved education for physicians may be needed to improve the quality of healthcare provision for PCOS.
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Affiliation(s)
- Miya Ismayilova
- Interdisciplinary School of Health sciences, University of Ottawa, 25 University Private, Ottawa, ON K1N 7K4, Canada
| | - Sanni Yaya
- Corresponding author: Tel: +1-613-562-5800; E-mail:
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Kazemi M, Kim JY, Wan C, Xiong JD, Parry SA, Azziz R, Lujan ME. Comprehensive evaluation of disparities in cardiometabolic and reproductive risk between Hispanic and White women with polycystic ovary syndrome in the United States: a systematic review and meta-analysis. Am J Obstet Gynecol 2022; 226:187-204.e15. [PMID: 34384776 DOI: 10.1016/j.ajog.2021.07.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/17/2021] [Accepted: 07/27/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We conducted a systematic review and meta-analysis to comprehensively compare cardiometabolic and reproductive health risk between Hispanic and White women with polycystic ovary syndrome in the United States in response to the call by the international guideline for polycystic ovary syndrome to delineate health disparities. DATA SOURCES Databases of MEDLINE, Web of Science, and Scopus were initially searched through October 25, 2020, and confirmed on February 1, 2021. STUDY ELIGIBILITY CRITERIA Observational studies comparing glucoregulatory, lipid profile, anthropometric, blood pressure, androgen, ovarian morphology, oligoanovulation, and infertility status between Hispanic and White women with polycystic ovary syndrome were included. The primary outcome was metabolic syndrome risk. Furthermore, major cardiovascular events (stroke, coronary heart disease, and heart failure) and mortality rate (cardiovascular death and total mortality) data were evaluated. Studies on adolescents (<2 years after menarche), pregnant, or menopausal-aged women (>50 years) were excluded. METHODS Data were pooled by random-effects models and expressed as mean differences and 95% confidence intervals. Risk of bias was assessed by the Newcastle-Ottawa Scale. RESULTS A total of 11 studies (n=2267; 589 Hispanic and 1678 White women) were eligible. All studies, including both White and Hispanic women, had high-quality assessment (Newcastle-Ottawa Scale score of ≥8). Hispanic women exhibited comparable metabolic syndrome prevalence (7% [95% confidence interval, -1 to 14]; P=.06; I2=0%); however, Hispanic women exhibited higher modified Ferriman-Gallwey score (0.60 [95% confidence interval, -0.01 to 1.21]; P=.05; I2=0%), fasting insulin (5.48 μIU/mL [95% confidence interval, 3.11-7.85]; P≤.01; I2=40.0%), and homeostatic model assessment of insulin resistance (1.20 [95% confidence interval, 0.50-1.89]; P≤.01; I2=43.0%) than White women. The 2 groups had comparable glucose, lipid profile, waist circumference, blood pressure, and androgen status (all P≥.08). Findings about group differences in certain reproductive outcomes (ie, ovarian dysmorphology and infertility) were contradictory and described only narratively as inclusion in the meta-analyses was not possible. No study reported on cardiovascular events or mortality. CONCLUSION Hispanic women with polycystic ovary syndrome exhibited greater impairments in glucoregulatory status than White women. Disparities in reproductive risks could not be concluded. The degree to which glucoregulatory aberrations translate into patient-pressing diseases (diabetes mellitus and infertility) remains a major roadblock given the paucity of available evidence. Our observations have supported the consideration of these disparities in the diagnostic, monitoring, and management practices for polycystic ovary syndrome and reinforced the need to elucidate mechanisms that account for the observed disparities to foster equity in polycystic ovary syndrome care.
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Affiliation(s)
- Maryam Kazemi
- Human Metabolic Research Unit, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Joy Y Kim
- Human Metabolic Research Unit, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Cynthia Wan
- Human Metabolic Research Unit, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Julia D Xiong
- Human Metabolic Research Unit, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Stephen A Parry
- Cornell Statistical Consulting Unit, Cornell University, Ithaca, NY
| | - Ricardo Azziz
- Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL; Department of Health Policy, Management and Behavior, School of Public Health, University at Albany, State University of New York, Albany, NY
| | - Marla E Lujan
- Human Metabolic Research Unit, Division of Nutritional Sciences, Cornell University, Ithaca, NY.
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Abstract
ABSTRACT Polycystic ovary syndrome (PCOS), characterized by ovulatory dysfunction and hyperandrogenism, is one of the most common endocrine disorders in women of reproductive age. Early diagnosis can help clinicians address associated long-term metabolic and reproductive health complications and mitigate the negative effects of PCOS on a patient's mental health and quality of life. Clinicians often are challenged by the diagnosis and management of PCOS because of controversies around diagnostic criteria, especially for adolescents. The International Consortium of Paediatric Endocrinology 2017 Consensus Statement provides practical guidance for clinicians to implement best practices for the identification, diagnosis, and management of PCOS in adolescents.
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Affiliation(s)
- J Leocadia Conlon
- J. Leocadia Conlon is the clinical director of Hawai'i CARES, a partnership between the Hawai'i Department of Health and the University of Hawai'i in Honolulu, Hawai'i, and an adjunct assistant professor in the George Washington University School of Medicine and Health Sciences in Washington, D.C. She is a recent graduate of the PhD program in translational health science at George Washington University, where her dissertation research focused on polycystic ovary syndrome in adolescents. Sharyn Malcolm is an attending physician in adolescent and young adult medicine, and co-medical director and director of reproductive health services at the Adolescent Health Center at Children's National Health System in Washington, D.C. She also is an assistant professor of pediatrics at George Washington University School of Medicine and Health Sciences. Maureen Monaghan is a clinical psychologist and an associate professor of psychiatry and behavioral sciences at Children's National Health System and George Washington University School of Medicine. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Torres OA, Miller E, Witchel SF. Quality Improvement in the Evaluation and Diagnosis of Polycystic Ovary Syndrome in Adolescent Girls. J Pediatr Adolesc Gynecol 2021; 34:603-609. [PMID: 33689916 DOI: 10.1016/j.jpag.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 02/23/2021] [Accepted: 03/01/2021] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE Polycystic ovary syndrome (PCOS) can be challenging to diagnose in adolescents because the diagnostic criteria for adult women overlap with normal features of pubertal development. Previous studies have highlighted inconsistencies in diagnostic criteria used by health care providers. International consensus groups have introduced recommendations to aid diagnosis of this disorder among adolescents. In this study we explored diagnostic inconsistencies and provided education for providers regarding these consensus recommendations. DESIGN Quality improvement. SETTING Teaching hospital-affiliated adolescent medicine clinic. PARTICIPANTS Adolescent medicine providers (n = 14) participated in the intervention. INTERVENTIONS Educational intervention on the basis of the 2015 international consensus recommendations was implemented to address provider inconsistencies. MAIN OUTCOME MEASURES Use of laboratory assessment and documentation for diagnosis of girls evaluated for possible PCOS. RESULTS Preintervention, providers used diverse diagnostic criteria including obesity, insulin resistance, mild acne, and minimal hirsutism with no reference to published criteria. Laboratory studies to exclude other disorders were obtained in 24/87 (28%) preintervention patients. Postintervention, the percentage of laboratory studies increased to 40/65 (62%). Oral glucose tolerance tests performed to assess for glycemic comorbidities increased from 6/87 (7%) to 16/65 (25%). After this intervention, providers included more documentation of features associated with PCOS yet did not use "at risk for PCOS" terminology. CONCLUSION After our educational intervention, providers showed greater awareness of diagnostic criteria for PCOS in adolescent girls. Medical record documentation and use of "at risk for PCOS" terminology needs improvement. Integration of specific PCOS templates in the electronic medical record might improve medical record documentation and appropriate diagnosis.
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Affiliation(s)
- Orquidia A Torres
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Selma F Witchel
- Division of Pediatric Endocrinology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Fu L, Qu F, Pan J, Wang T, Wang F. Polycystic ovary syndrome in adolescents with obesity. ACTA ACUST UNITED AC 2021; 67:468-473. [PMID: 34468616 DOI: 10.1590/1806-9282.20200890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/09/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women of reproductive age with the prevalence from 5% to 15%, and the prevalence of PCOS in adolescents with obesity seems even higher. The weight status is significantly associated with the quality of life in adolescents with PCOS. OBJECTIVE This review aims to summarize the latest findings of pathogenesis, diagnosis, comorbidity, and management in PCOS adolescents with obesity. METHODS This is a narrative review of articles published in PubMed from June 2013 to June 2020 Data were searched using the key words of "polycystic ovary syndrome" AND "adolescent" AND "obesity." RESULTS Pubertal obesity, particularly central obesity, could have a negative impact on the pathophysiology of PCOS. In adolescents with obesity, a review of medical history and a long-term follow-up for PCOS symptoms are essential to avoid misdiagnosis. There is a link between obesity and comorbidities of PCOS in adolescents. Holistic treatment and concern for related comorbidities should ideally begin as early as possible in obese adolescents once the diagnosis of PCOS is confirmed. CONCLUSION Adolescents with PCOS and obesity need more attention from physicians and researchers, and the effective interventions in the early stage are critical to improve their life quality.
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Affiliation(s)
- Leyi Fu
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fan Qu
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiexue Pan
- Obstetrics & Gynecology Hospital, Institute of Reproduction and Development, Fudan University, Shanghai, China
| | - Tian Wang
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Fangfang Wang
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Kazemi M, Kim JY, Parry SA, Azziz R, Lujan ME. Disparities in cardio metabolic risk between Black and White women with polycystic ovary syndrome: a systematic review and meta-analysis. Am J Obstet Gynecol 2021; 224:428-444.e8. [PMID: 33316275 DOI: 10.1016/j.ajog.2020.12.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/26/2020] [Accepted: 12/05/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE We conducted a systematic review and meta-analysis to summarize and quantitatively pool evidence on cardiometabolic health disparities between Black and White women with polycystic ovary syndrome in the United States in response to the call for further delineation of these disparities in the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. DATA SOURCES Databases of MEDLINE, Web of Science, and Scopus were searched initially through March 05, 2020, and confirmed on September 11, 2020. STUDY ELIGIBILITY CRITERIA Observational studies documenting cardiometabolic risk profile (glucoregulatory, lipid profile, anthropometric, and blood pressure status) in Black and White women with polycystic ovary syndrome were included. Studies on children (<17 years old) and pregnant or menopausal-aged women (>50 years) were excluded. The primary outcome was fasting glucose. Furthermore, data on major cardiovascular events (stroke, coronary heart disease, heart failure) and mortality rate (cardiovascular death, total mortality) were evaluated. METHODS Data were pooled by random-effects models and expressed as mean differences and 95% confidence intervals. Studies were weighted based on the inverse of the variance. Heterogeneity was evaluated by Cochran Q and I2 statistics. Study methodologic quality was assessed by the Newcastle-Ottawa scale. RESULTS A total of 11 studies (N=2851 [652 Black and 2199 White]) evaluated cardiometabolic risk profile and all had high quality (Newcastle-Ottawa scale score of ≥8). No studies reported on cardiovascular events and mortality rate. Black women had comparable fasting glucose (-0.61 [-1.69 to 2.92] mg/dL; I2=62.5%), yet exhibited increased fasting insulin (6.76 [4.97-8.56] μIU/mL; I2=59.0%); homeostatic model assessment of insulin resistance (1.47 [0.86-2.08]; I2=83.2%); systolic blood pressure (3.32 [0.34-6.30] mm Hg; I2=52.0%); and decreased triglyceride (-32.56 [-54.69 to -10.42] mg/dL; I2=68.0%) compared with White women (all, P≤.03). Groups exhibited comparable total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and diastolic blood pressure (all, P≥.06). CONCLUSIONS Black women with polycystic ovary syndrome have a greater tendency for an adverse cardiometabolic risk profile (increased insulin, homeostatic model assessment of insulin resistance, and systolic blood pressure) despite lower triglycerides than White women. Our observations support the consideration of these disparities for diagnostic, monitoring, and management practices in Black women and for future guideline recommendations. Given the heterogeneity among studies, future research should address the relative contributions of biologic, environmental, socioeconomic, and healthcare factors to the observed disparities. Furthermore, longitudinal research is required to address patient-pressing complications, including cardiovascular events and mortality rate in Black women with polycystic ovary syndrome as a high-risk yet understudied population.
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Affiliation(s)
- Maryam Kazemi
- Human Metabolic Research Unit, Division of Nutritional Sciences, Cornell University, Ithaca, NY.
| | - Joy Y Kim
- Human Metabolic Research Unit, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Stephen A Parry
- Cornell Statistical Consulting Unit, Cornell University, Ithaca, NY
| | - Ricardo Azziz
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL; Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Health Policy, Management, and Behavior, School of Public Health, University at Albany, Albany, NY
| | - Marla E Lujan
- Human Metabolic Research Unit, Division of Nutritional Sciences, Cornell University, Ithaca, NY.
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Çelebier M, Kaplan O, Özel Ş, Engin-Üstün Y. Polycystic ovary syndrome in adolescents: Q-TOF LC/MS analysis of human plasma metabolome. J Pharm Biomed Anal 2020; 191:113543. [PMID: 32871414 DOI: 10.1016/j.jpba.2020.113543] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/20/2020] [Accepted: 08/08/2020] [Indexed: 10/23/2022]
Abstract
Polycystic ovary syndrome (PCOS) is a hormonal disorder common among women of reproductive age. Women with PCOS may have infrequent or prolonged menstrual periods or excess male hormone levels. Metabolomics provide information on early biochemical changes in patients. Our aim was to find potential biomarkers on metabolome level to notice PCOS in adolescents and propose treatment opportunities based on our findings on metabolome level. In this study, Q-TOF LC/MS based analysis of the plasma samples of 15 healthy adolescents as control group (Group C) were compared with the plasma samples of 15 adolescents having PCOS (Group T). Raw chromatograms were processed on XCMS using Isotopologue Parameter Optimization (IPO) to optimize XCMS parameters. Finally, 2288 peaks were found but 84 of them had fold changes >1.5 based on normalized peak areas and they were statistically different (p < 0.05) between the groups. These peaks were subjected to MetaboAnalyst 4.0 - MS Peaks to Pathways utility for putative identification. The final list based on putative identification were evaluated through a clinical perspective and the statistically proved variation on the metabolite profiles of Group T and Group C presented that PCOS directly affected the lipid metabolism in the body or occurred as a result of a deformation in the lipid metabolism. Lower amount of Gamma-Tocopherol and higher amount of Coenzyme Q9, which is a product of incomplete Coenzyme Q10 biosynthesis, in the plasma samples of adolescent PCOS patients encouraged us to suggest larger randomized placebo controlled studies for Gamma-Tocopherol and Coenzyme Q10 supplements on the disease situation since our findings on metabolome level were in an accordance with the previous clinical findings.
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Affiliation(s)
- Mustafa Çelebier
- Hacettepe University, Faculty of Pharmacy, Department of Analytical Chemistry, Ankara, Turkey.
| | - Ozan Kaplan
- Hacettepe University, Faculty of Pharmacy, Department of Analytical Chemistry, Ankara, Turkey
| | - Şule Özel
- University of Health Sciences, Zekai Tahir Burak Women's Health, Training and Research Hospital, Ankara, Turkey
| | - Yaprak Engin-Üstün
- University of Health Sciences, Zekai Tahir Burak Women's Health, Training and Research Hospital, Ankara, Turkey
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Chemerinski A, Cooney L, Shah D, Butts S, Gibson-Helm M, Dokras A. Knowledge of PCOS in physicians-in-training: identifying gaps and educational opportunities. Gynecol Endocrinol 2020; 36:854-859. [PMID: 32252571 DOI: 10.1080/09513590.2020.1746761] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women. A recent study found that many obstetrics and gynecology (ObGyn) practicing physicians are unaware of the Rotterdam criteria recommended for diagnosis. Our objective was to identify gaps in trainee knowledge of PCOS diagnostic criteria and management. An online survey was sent out to US ObGyn physicians-in-training in 2018. The primary outcomes were identification of at least one component of each Rotterdam criteria (Rot-3): (1) oligomenorrhea/amenorrhea, (2) clinical or biochemical hyperandrogenism, and (3) ovarian volume or antral follicle count, and identification of all five components (Rot-5). Secondary outcomes were identification of comorbidities and management of PCOS. Multivariable logistic regression was used controlling for gender, seniority (PGY) status, program type, completion of an REI rotation, and number of PCOS patients seen. 85.4% of 347 trainees completing the survey reported using Rotterdam criteria to diagnose PCOS. However, only 55% identified Rot-3 and less than 10% identified Rot-5. Seniority (PGY4 OR 2.2; 95% CI: 1.2-4.1; p = .01) and completion of REI rotation (OR 1.8 95% CI: 1.2, 1.8; p = .006) were associated with identifying Rot-3. Similar findings were noted with identifying Rot-5. Our study identified significant gaps in knowledge regarding PCOS, suggesting an urgent need for improving strategies for trainee education to increase patient satisfaction and provide comprehensive care.
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Affiliation(s)
- Anat Chemerinski
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Laura Cooney
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Wisconsin, Madison, WI, USA
| | - Divya Shah
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Samantha Butts
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Melanie Gibson-Helm
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anuja Dokras
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Copp T, Muscat DM, Hersch J, McCaffery KJ, Doust J, Mol BW, Dokras A, Jansen J. Clinicians’ perspectives on diagnosing polycystic ovary syndrome in Australia: a qualitative study. Hum Reprod 2020; 35:660-668. [DOI: 10.1093/humrep/deaa005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/15/2019] [Indexed: 12/20/2022] Open
Abstract
Abstract
STUDY QUESTION
What are clinicians’ views about the diagnosis of polycystic ovary syndrome (PCOS), and how do they handle any complexities and uncertainties in practice?
SUMMARY ANSWER
Clinicians have to navigate many areas of complexity and uncertainty regarding the diagnosis of PCOS, related to the diagnostic criteria, limitations in current evidence and misconceptions surrounding diagnosis, and expressed concern about the risk and consequences of both under- and overdiagnosis.
WHAT IS KNOWN ALREADY
PCOS is a complex, heterogeneous condition with many areas of uncertainty, raising concerns about both underdiagnosis and overdiagnosis. Quantitative studies with clinicians have found considerable variation in diagnostic criteria used and care provided, as well as a lack of awareness around the breadth of PCOS features and poor uptake of recommended screening for metabolic complications. Clinicians’ views about the uncertainties and complexities of diagnosing PCOS have not been explored.
STUDY DESIGN, SIZE, DURATION
Semi-structured telephone interviews were conducted with clinicians from September 2017 to July 2018 to explore their perceptions about the diagnosis of PCOS, including how they handle any complexities and uncertainties in practice.
PARTICIPANTS/MATERIALS, SETTING, METHODS
A group of 36 clinicians (15 general practitioners, 10 gynaecologists and 11 endocrinologists) currently practicing in Australia, were recruited through advertising via professional organisations, contacting a random sample of endocrine and gynaecology teams across Australia and snowballing. Transcribed audio-recordings were analysed thematically using Framework analysis.
MAIN RESULTS AND THE ROLE OF CHANCE
Clinicians expressed a range of uncertainties and complexities regarding the diagnosis of PCOS, which were organised into three areas: (i) establishing diagnosis (e.g. lack of standardisation regarding diagnostic cut-offs, risk of misdiagnosis), (ii) factors influencing the diagnostic process (e.g. awareness of limitations in evidence and consideration of the benefits and harms) and (iii) strategies for handling challenges and uncertainties (e.g. using caution and communication of uncertainties). Clinicians also varied in their concerns regarding under- and overdiagnosis. Overall, most felt the diagnosis was beneficial for women provided that it was the correct diagnosis and time was taken to assess patient expectations and dispel misconceptions, particularly concerning fertility.
LIMITATIONS, REASONS FOR CAUTION
There is possible selection bias, as clinicians who are more knowledgeable about PCOS may have been more likely to participate. Clinicians’ views may also differ in other countries.
WIDER IMPLICATIONS OF THE FINDINGS
These findings underscore the vital need to first consider PCOS a diagnosis of exclusion and use caution before giving a diagnosis in order to reduce misdiagnosis, as suggested by clinicians in our study. Until there is greater standardisation of diagnostic criteria, more transparent conversations with women may help them understand the uncertainties surrounding the criteria and limitations in the evidence. Additionally, clinicians emphasised the importance of education and reassurance to minimise the potential harmful impact of the diagnosis and improve patient-centred outcomes.
STUDY FUNDING/COMPETING INTEREST(S)
The study was funded by the University of Sydney Lifespan Research Network and an NHMRC Program Grant (APP1113532). T.C. is supported by an Australian Government Research Training Program (RTP) Scholarship and a Sydney Medical School Foundation Scholarship, from the The University of Sydney, Australia. B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA and Guerbet. No further competing interests exist.
TRIAL REGISTRATION NUMBER
N/A
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Affiliation(s)
- T Copp
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
| | - D M Muscat
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
| | - J Hersch
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
| | - K J McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
| | - J Doust
- Wiser Healthcare, Centre for Research in Evidence-Based Practice, Bond University, Robina, 4226, Australia
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, 3800, Australia
| | - A Dokras
- Penn PCOS Centre, Department of Obstetrics and Gynaecology, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - J Jansen
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
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12
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Abstract
Polycystic ovary syndrome (PCOS), characterized by hormonal imbalance and ovarian dysfunction, often starts during adolescence. Inconsistent diagnostic criteria, variable provider knowledge, and lack of consensus pose specific challenges for the care of women with PCOS. These factors encourage inaccurate diagnosis with both under and overdiagnosis. This unfavorable diagnostic experience exasperates affected women and limits timely opportunities for intervention to minimize associated comorbidities, especially during the transition from pediatric to adult care. Recognition of these issues in the care of adolescents and women with PCOS inspired the development of the International Evidence-Based PCOS Guidelines, which emphasize the prevention, screening, and treatment of PCOS across the reproductive lifespan. The Guidelines and accompanying meta-analyses focus on three major categories of associated comorbidities: (1) reproductive; (2) metabolic; and (3) psychological. With the exception of infertility, this article considers common manifestations and comorbidities associated with PCOS throughout the lifecycle. Healthy lifestyle interventions with prevention of excess weight gain comprise the primary intervention for all comorbidities. Hence, early identification of girls "at risk" for PCOS and those with PCOS is a priority. Extensive guidelines for provider and patient education aim to decrease the medical, psychosocial, and economic burdens attributable to PCOS and its associated comorbidities.
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13
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Witchel SF, Oberfield SE, Peña AS. Polycystic Ovary Syndrome: Pathophysiology, Presentation, and Treatment With Emphasis on Adolescent Girls. J Endocr Soc 2019; 3:1545-1573. [PMID: 31384717 PMCID: PMC6676075 DOI: 10.1210/js.2019-00078] [Citation(s) in RCA: 214] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/30/2019] [Indexed: 02/06/2023] Open
Abstract
Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterized by hyperandrogenism and chronic anovulation. Depending on diagnostic criteria, 6% to 20% of reproductive aged women are affected. Symptoms of PCOS arise during the early pubertal years. Both normal female pubertal development and PCOS are characterized by irregular menstrual cycles, anovulation, and acne. Owing to the complicated interwoven pathophysiology, discerning the inciting causes is challenging. Most available clinical data communicate findings and outcomes in adult women. Whereas the Rotterdam criteria are accepted for adult women, different diagnostic criteria for PCOS in adolescent girls have been delineated. Diagnostic features for adolescent girls are menstrual irregularity, clinical hyperandrogenism, and/or hyperandrogenemia. Pelvic ultrasound findings are not needed for the diagnosis of PCOS in adolescent girls. Even before definitive diagnosis of PCOS, adolescents with clinical signs of androgen excess and oligomenorrhea/amenorrhea, features of PCOS, can be regarded as being "at risk for PCOS." Management of both those at risk for PCOS and those with a confirmed PCOS diagnosis includes education, healthy lifestyle interventions, and therapeutic interventions targeting their symptoms. Interventions can include metformin, combined oral contraceptive pills, spironolactone, and local treatments for hirsutism and acne. In addition to ascertaining for associated comorbidities, management should also include regular follow-up visits and planned transition to adult care providers. Comprehensive knowledge regarding the pathogenesis of PCOS will enable earlier identification of girls with high propensity to develop PCOS. Timely implementation of individualized therapeutic interventions will improve overall management of PCOS during adolescence, prevent associated comorbidities, and improve quality of life.
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Affiliation(s)
- Selma Feldman Witchel
- UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sharon E Oberfield
- Division of Pediatric Endocrinology, Columbia University Medical Center, New York–Presbyterian Morgan Stanley Children’s Hospital, New York, New York
| | - Alexia S Peña
- Robinson Research Institute, University of Adelaide, North Adelaide, South Australia, Australia
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14
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Ramezani Tehrani F, Amiri M. Polycystic Ovary Syndrome in Adolescents: Challenges in Diagnosis and Treatment. Int J Endocrinol Metab 2019; 17:e91554. [PMID: 31497042 PMCID: PMC6679603 DOI: 10.5812/ijem.91554] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 06/13/2019] [Accepted: 07/02/2019] [Indexed: 02/06/2023] Open
Abstract
CONTEXT Despite the importance of timely diagnosis and treatment of polycystic ovary syndrome (PCOS) among adolescent females, considering the paucity of data focusing on this group and controversies documented on its recognition and management, the purpose of this review was to summarize challenges and recommendations of diagnosis and treatment for adolescents with PCOS. EVIDENCE ACQUISITION This review summarizes papers documented on PCOS among adolescent females. PubMed, Scopus, Web of Science, and Google Scholar databases were searched for retrieving studies conducted on PCOS among adolescent females up to March, 2019. The final selection of papers was made based on their relevancy with the fields of diagnosis and treatment of PCOS in this age group. RESULTS Oligo-anovulation in adolescents, if persistent, is a matter for concern. Hirsutism and moderate to severe acne in adolescent females should be considered as clinical manifestations of hyperandrogenism (HA). Diagnosis of biochemical HA in adolescents with PCOS requires reliable tests using well-defined normal ranges. In adolescent females, an elevated androgen level (hyperandrogenemia) alone is not enough to detect HA, unless it is persistent and associated with anovulation. Metabolic disorders should not be used as diagnostic criteria of PCOS among adolescent females. Re-assessment of all adolescent females with probable PCOS, using reliable diagnostic criteria, is needed to avoid over diagnosis and unnecessary treatment in healthy normal females without HA. In adolescent females with PCOS, the main clinical problem is the control of menstrual irregularity and hirsutism; treatment approaches for these patients are primarily directed at the major clinical manifestations and complaints. Lifestyle modifications are baseline interventions, which can be added to special treatments, such as Oral Contraceptives (OCs), metformin, or antiandrogens for most adolescents with PCOS, particularly those with overweight or obesity. CONCLUSIONS This review emphasizes the use of standard diagnostic criteria for PCOS, developed for adolescents. Although early recognition and management of PCOS in adolescents can prevent long-term complications associated with this syndrome, clinicians should re-evaluate all such patients with features very similar to PCOS to avoid over/incorrect diagnosis using precise criteria, suggested for this age group.
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Affiliation(s)
- Fahimeh Ramezani Tehrani
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding Author: Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mina Amiri
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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15
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Sanchez N. Suitability of the National Health Care Surveys to Examine Behavioral Health Services Associated with Polycystic Ovary Syndrome. J Behav Health Serv Res 2018; 45:252-268. [PMID: 27966057 PMCID: PMC5869872 DOI: 10.1007/s11414-016-9543-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The National Institutes of Health, Office of Disease Prevention, has described polycystic ovary syndrome (PCOS) as a major public health problem for women in the USA. This study examines the suitability of the National Health Care Surveys, collected by the Centers for Disease Control and Prevention, to understand patient demographics and behavioral health services associated with PCOS-related medical visits. Data were from the 2005-2010 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. PCOS-related medical visits were identified using the International Classification of Diseases, 9th Revision, Clinical Modification code 256.4. Items on mental health and health education ordered or provided did not meet the National Center for Health Statistics criteria necessary to produce reliable national estimates (i.e., at least 30 unweighted records and a relative standard error <30%). Findings underscore the need to strengthen national surveillance to further understand behavioral health care for patients with PCOS.
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Affiliation(s)
- Ninive Sanchez
- School of Social Work, University of Missouri, 712 Clark Hall, Columbia, MO, 65211, USA.
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16
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Harris HR, Babic A, Webb PM, Nagle CM, Jordan SJ, Risch HA, Rossing MA, Doherty JA, Goodman MT, Modugno F, Ness RB, Moysich KB, Kjær SK, Høgdall E, Jensen A, Schildkraut JM, Berchuck A, Cramer DW, Bandera EV, Wentzensen N, Kotsopoulos J, Narod SA, Phelan CM, McLaughlin JR, Anton-Culver H, Ziogas A, Pearce CL, Wu AH, Terry KL. Polycystic Ovary Syndrome, Oligomenorrhea, and Risk of Ovarian Cancer Histotypes: Evidence from the Ovarian Cancer Association Consortium. Cancer Epidemiol Biomarkers Prev 2018; 27:174-182. [PMID: 29141849 PMCID: PMC5877463 DOI: 10.1158/1055-9965.epi-17-0655] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/06/2017] [Accepted: 11/06/2017] [Indexed: 12/17/2022] Open
Abstract
Background: Polycystic ovary syndrome (PCOS), and one of its distinguishing characteristics, oligomenorrhea, have both been associated with ovarian cancer risk in some but not all studies. However, these associations have been rarely examined by ovarian cancer histotypes, which may explain the lack of clear associations reported in previous studies.Methods: We analyzed data from 14 case-control studies including 16,594 women with invasive ovarian cancer (n = 13,719) or borderline ovarian disease (n = 2,875) and 17,718 controls. Adjusted study-specific ORs were calculated using logistic regression and combined using random-effects meta-analysis. Pooled histotype-specific ORs were calculated using polytomous logistic regression.Results: Women reporting menstrual cycle length >35 days had decreased risk of invasive ovarian cancer compared with women reporting cycle length ≤35 days [OR = 0.70; 95% confidence interval (CI) = 0.58-0.84]. Decreased risk of invasive ovarian cancer was also observed among women who reported irregular menstrual cycles compared with women with regular cycles (OR = 0.83; 95% CI = 0.76-0.89). No significant association was observed between self-reported PCOS and invasive ovarian cancer risk (OR = 0.87; 95% CI = 0.65-1.15). There was a decreased risk of all individual invasive histotypes for women with menstrual cycle length >35 days, but no association with serous borderline tumors (Pheterogeneity = 0.006). Similarly, we observed decreased risks of most invasive histotypes among women with irregular cycles, but an increased risk of borderline serous and mucinous tumors (Pheterogeneity < 0.0001).Conclusions: Our results suggest that menstrual cycle characteristics influence ovarian cancer risk differentially based on histotype.Impact: These results highlight the importance of examining ovarian cancer risk factors associations by histologic subtype. Cancer Epidemiol Biomarkers Prev; 27(2); 174-82. ©2017 AACR.
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Affiliation(s)
- Holly R Harris
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Ana Babic
- Dana Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Penelope M Webb
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
- Australian Ovarian Cancer Study Group, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Christina M Nagle
- Population Health Department, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | | | - Harvey A Risch
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Mary Anne Rossing
- Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Jennifer A Doherty
- Huntsman Cancer Institute, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Marc T Goodman
- Cancer Prevention and Control, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Community and Population Health Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California
| | - Francesmary Modugno
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Roberta B Ness
- The University of Texas School of Public Health, Houston, Texas
| | - Kirsten B Moysich
- Department of Cancer Prevention and Control, Roswell Park Cancer Institute, Buffalo, New York
| | - Susanne K Kjær
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Gynaecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Estrid Høgdall
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
- Molecular Unit, Department of Pathology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Allan Jensen
- Department of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Joellen M Schildkraut
- Department of Public Health Sciences, The University of Virginia, Charlottesville, Virginia
| | - Andrew Berchuck
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Daniel W Cramer
- Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Elisa V Bandera
- Cancer Prevention and Control Program, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Joanne Kotsopoulos
- Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Narod
- Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Catherine M Phelan
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, Florida
| | | | - Hoda Anton-Culver
- Department of Epidemiology, University of California Irvine, Irvine, California
| | - Argyrios Ziogas
- Department of Epidemiology, University of California Irvine, Irvine, California
| | - Celeste L Pearce
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California
| | - Anna H Wu
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, California
| | - Kathryn L Terry
- Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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17
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Copp T, Jansen J, Doust J, Mol BW, Dokras A, McCaffery K. Are expanding disease definitions unnecessarily labelling women with polycystic ovary syndrome? BMJ 2017; 358:j3694. [PMID: 28814559 DOI: 10.1136/bmj.j3694] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Tessa Copp
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, NSW 2006, Australia
- Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), University of Sydney, NSW 2006, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, NSW 2006, Australia
- Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), University of Sydney, NSW 2006, Australia
| | - Jenny Doust
- Wiser Healthcare, Bond University, QLD 4229, Australia
- Centre for Research in Evidence-Based Practice, Bond University, QLD 4229, Australia
| | - Ben Wj Mol
- Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, SA 5005, Australia
- The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Anuja Dokras
- Penn PCOS Centre, Department of Obstetrics and Gynaecology, University of Pennsylvania, Philadelphia, US
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, University of Sydney, NSW 2006, Australia
- Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), University of Sydney, NSW 2006, Australia
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18
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Dokras A, Saini S, Gibson-Helm M, Schulkin J, Cooney L, Teede H. Gaps in knowledge among physicians regarding diagnostic criteria and management of polycystic ovary syndrome. Fertil Steril 2017; 107:1380-1386.e1. [PMID: 28483503 DOI: 10.1016/j.fertnstert.2017.04.011] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 04/13/2017] [Accepted: 04/17/2017] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To identify gaps in polycystic ovary syndrome (PCOS) knowledge and practice patterns among physicians in North America in response to significant dissatisfaction identified among women with PCOS regarding their diagnosis and treatment experience. DESIGN Online survey conducted via American College of Obstetrics and Gynecology of gynecologists (ObGyn) and American Society of Reproductive Medicine of reproductive endocrinologists (REI-ObGyn) in 2015-16. SETTING Not applicable. PATIENT(S) None. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Diagnostic criteria used, key features of PCOS, management practices. RESULT(S) Of the 630 surveys completed, 70.2% were ObGyn and 64.4% were females. Overall 27.7% respondents did not know which PCOS diagnostic criteria they used. In a multivariable analysis including physician type, age, gender, and number of patients with PCOS seen annually, REI-ObGyn were less likely compared with ObGyn to report not knowing which criteria they used (adjusted odds ratio, 0.08; 95% confidence interval, 0.04, 0.16). REI-ObGyn were more likely to use the Rotterdam criteria (odds ratio, 2.26; 95% confidence interval, 1.33, 3.82). The majority of respondents recognized the clinical features associated with PCOS; however, over one-third associated "cysts on ovaries" with PCOS. The majority of responders (>85%) were aware of cardiometabolic comorbidities; however, fewer ObGyn were aware of associated depression, anxiety disorders, and reduced quality of life. More REI-ObGyn recommended lifestyle changes compared with ObGyn (56.4% vs. 41.6%). CONCLUSION(S) Our large-scale PCOS survey, conducted in response to patient concerns regarding diagnosis and treatment, highlights opportunities for physician education. Focus areas include targeting knowledge of internationally accepted Rotterdam criteria and ensuring consistent care informed by evidence-based guidelines across the reproductive, metabolic, and psychological features of PCOS.
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Affiliation(s)
- Anuja Dokras
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Shailly Saini
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melanie Gibson-Helm
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jay Schulkin
- American College of Obstetrics and Gynecology, Department of Research, Washington D.C
| | - Laura Cooney
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Helena Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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19
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Abstract
Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting reproductive-age women. PCOS causes hyperandrogenism and anovulation and increases the risk of multiple health conditions including infertility, diabetes mellitus, and cardiovascular disease. This article outlines current recommendations for diagnostic testing, treatment options, and holistic care of the woman with PCOS.
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20
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Gibson-Helm M, Teede H, Dunaif A, Dokras A. Delayed Diagnosis and a Lack of Information Associated With Dissatisfaction in Women With Polycystic Ovary Syndrome. J Clin Endocrinol Metab 2017; 102:604-612. [PMID: 27906550 PMCID: PMC6283441 DOI: 10.1210/jc.2016-2963] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/12/2016] [Indexed: 01/20/2023]
Abstract
Context Polycystic ovary syndrome (PCOS) is a complex, chronic, and under-recognized disorder. Diagnosis experience may have lasting effects on well-being and self-management. Objective To investigate PCOS diagnosis experiences, information provided, and concerns about PCOS. Design Cross-sectional study using an online questionnaire. Setting Recruitment via support group web sites in 2015 to 2016. Participants There were 1385 women with a reported diagnosis of PCOS who were living in North America (53.0%), Europe (42.2%), or other world regions (4.9%); of these, 64.8% were 18 to 35 years of age. Main Outcome Measures Satisfaction with PCOS diagnosis experience, satisfaction with PCOS information received at the time of diagnosis, and current concerns about PCOS. Results One-third or more of women reported >2 years (33.6%) and ≥3 health professionals (47.1%) before a diagnosis was established. Few were satisfied with their diagnosis experience (35.2%) or with the information they received (15.6%). Satisfaction with information received was positively associated with diagnosis satisfaction [odds ratio (OR), 7.0; 95% confidence interval (CI), 4.9 to 9.9]; seeing ≥5 health professionals (OR, 0.5; 95% CI, 0.3 to 0.8) and longer time to diagnosis (>2 years; OR, 0.4; 95% CI, 0.3 to 0.6) were negatively associated with diagnosis satisfaction (independent of time since diagnosis, age, and world region). Women's most common concerns were difficulty losing weight (53.6%), irregular menstrual cycles (50.8%), and infertility (44.5%). Conclusions In the largest study of PCOS diagnosis experiences, many women reported delayed diagnosis and inadequate information. These gaps in early diagnosis, education, and support are clear opportunities for improving patient experience.
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Affiliation(s)
- Melanie Gibson-Helm
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Helena Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria 3168, Australia
- Monash Partners Academic Health Science Centre, Clayton, Victoria 3168, Australia
| | - Andrea Dunaif
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611; and
| | - Anuja Dokras
- Division of Reproductive Endocrinology, PENN PCOS Center, University of Pennsylvania, Philadelphia, Pennsylvania 19104
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21
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Okamura Y, Saito F, Takaishi K, Motohara T, Honda R, Ohba T, Katabuchi H. Polycystic ovary syndrome: early diagnosis and intervention are necessary for fertility preservation in young women with endometrial cancer under 35 years of age. Reprod Med Biol 2016; 16:67-71. [PMID: 29259453 PMCID: PMC5715875 DOI: 10.1002/rmb2.12012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 09/28/2016] [Indexed: 12/14/2022] Open
Abstract
Aim Polycystic ovary syndrome (PCOS) is a significant risk factor for premenopausal endometrial cancer (EC) and/or atypical endometrial hyperplasia (AEH). The aim was to elucidate the clinical background and detailed menstrual history of EC and/or AEH in young women with PCOS. Methods From January 2001 to December 2013, women under 35 years of age who had been diagnosed with EC and/or AEH and who had been treated at Kumamoto University Hospital, Japan, were recruited. The patients’ clinical characteristics, clinical stages of EC and/or AEH, medication and operation methods, endocrine profiles, and menstrual history were assessed retrospectively. Results Of all the cases of EC and/or AEH, 25 (4.6%) were under 35 years of age. The mean age was 29.0 years and all the patients were nulligravida. The clinical stages of EC and/or AEH that were identified included: AEH (five cases), stage IA (18 cases), IB (one case), and IIIA (one case). Fourteen (56%) cases met the criteria for PCOS. Both the Body Mass Index and Homeostatic Model Assessment–insulin resistance were significantly higher in the patients with PCOS than in the patients without PCOS. Medroxyprogesterone acetate therapy was not effective for the patients with PCOS and they underwent a hysterectomy more often than the patients without PCOS. All the patients with PCOS exhibited irregular menstruation or amenorrhea, the mean duration of which was 13.1 years before PCOS and EC and/or AEH were diagnosed. Conclusion Although both the patients with and without PCOS had irregular menstruation, the patients with PCOS were less likely to have fertility‐sparing surgery than the patients without PCOS because they had more advanced disease or failed to respond to medroxyprogesterone acetate therapy.
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Affiliation(s)
- Yoshinori Okamura
- Department of Obstetrics and Gynecology Faculty of Life Sciences Kumamoto University Kumamoto Japan
| | - Fumitaka Saito
- Department of Obstetrics and Gynecology Faculty of Life Sciences Kumamoto University Kumamoto Japan
| | - Kiyomi Takaishi
- Department of Obstetrics and Gynecology Faculty of Life Sciences Kumamoto University Kumamoto Japan
| | - Takeshi Motohara
- Department of Obstetrics and Gynecology Faculty of Life Sciences Kumamoto University Kumamoto Japan
| | - Ritsuo Honda
- Department of Obstetrics and Gynecology Faculty of Life Sciences Kumamoto University Kumamoto Japan
| | - Takashi Ohba
- Department of Obstetrics and Gynecology Faculty of Life Sciences Kumamoto University Kumamoto Japan
| | - Hidetaka Katabuchi
- Department of Obstetrics and Gynecology Faculty of Life Sciences Kumamoto University Kumamoto Japan
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22
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Polycystic ovary syndrome and risk of endometrial, ovarian, and breast cancer: a systematic review. FERTILITY RESEARCH AND PRACTICE 2016; 2:14. [PMID: 28620541 PMCID: PMC5424400 DOI: 10.1186/s40738-016-0029-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 11/25/2016] [Indexed: 02/07/2023]
Abstract
Background Polycystic ovary syndrome (PCOS) is a complex endocrine disorder with an estimated prevalence of 4–21% in reproductive aged women. The altered metabolic and hormonal environment among women with PCOS may increase their risk of some types of cancer. Methods We performed a comprehensive review of the literature using numerous search terms for all studies examining the associations between polycystic ovary syndrome and related characteristics and cancer published in English through October 2016. This review summarizes the epidemiological findings on the associations between PCOS and endometrial, ovarian, and breast cancers and discusses the methodological issues, complexities, and underlying mechanisms of these associations. Results We identified 11 individual studies and 3 meta-analyses on the associations between PCOS and endometrial cancer, 8 studies and 1 meta-analysis for ovarian cancer, and 10 studies and 1 meta-analysis for breast cancer. Multiple studies reported that women with PCOS were at a higher risk for endometrial cancer; however, many did not take into account body mass index (BMI), a strong and well-established risk factor for endometrial cancer. The association with ovarian cancer was less clear, but a potentially increased risk of the borderline serous subtype was reported by two studies. No consistent association between PCOS risk and breast cancer was observed. Conclusion The associations between PCOS and endometrial, ovarian, and breast cancer are complex, with the need to consider many methodological issues in future analyses. Larger well-designed studies, or pooled analyses, may help clarify these complex associations.
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Abstract
Polycystic ovary syndrome (PCOS) is a familial heterogeneous disorder affecting 6% to 10% of reproductive-age women. The use of criteria developed for adult women is problematic for the adolescent girl because the clinical features associated with PCOS are normal pubertal events. The recent consensus statement on PCOS in adolescents stated that hyperandrogenism and oligomenorrhea need to persist for at least 2 years to consider the diagnosis of PCOS. Although insulin resistance, hyperinsulinism, and obesity are often associated with PCOS, these features are not considered valid diagnostic criteria. Recent genomewide association studies implicate genetic loci involved in the hypothalamic-pituitary-ovarian axis.
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Affiliation(s)
- Selma Feldman Witchel
- Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Hailey Roumimper
- Division of Pediatric Endocrinology, Diabetes & Metabolism, Columbia University Medical Center, 622 West 168th Street, PH5E-522, New York, NY 10032, USA
| | - Sharon Oberfield
- Columbia University Medical Center, Columbia University, 622 West 168th Street, PH5E-522, New York, NY 10032, USA.
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Kamangar F, Okhovat JP, Schmidt T, Beshay A, Pasch L, Cedars MI, Huddleston H, Shinkai K. Polycystic Ovary Syndrome: Special Diagnostic and Therapeutic Considerations for Children. Pediatr Dermatol 2015; 32:571-8. [PMID: 25787290 DOI: 10.1111/pde.12566] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Polycystic ovary syndrome (PCOS) is an endocrine syndrome with variable phenotypic expression and important systemic associations and sequelae, including obesity, insulin resistance, infertility, risk of endometrial cancer, and possible risk of cardiovascular events. PCOS is recognized as a condition influenced by genetic and environmental factors and distinct manifestations in all stages of life, including the prenatal period, childhood, adolescence, and adulthood. Identification of this disorder in childhood and adolescence has received growing attention, in part because of emerging evidence of the benefit of early intervention, but the diagnosis and management of PCOS in children and adolescents can be challenging. Diagnostic and therapeutic considerations of PCOS in children are reviewed to enhance identification and evaluation of patients suspected of having this disorder. When a diagnosis of PCOS is suspected in a child but cannot be confirmed, a provisional diagnosis is strongly recommended so as to prompt ongoing monitoring with an emphasis on important early interventions such as obesity reduction.
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Affiliation(s)
- Faranak Kamangar
- Department of Dermatology, University of California at Davis, Davis, California
| | - Jean-Phillip Okhovat
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Timothy Schmidt
- School of Medicine, University of California at San Francisco, San Francisco, California
| | - Abram Beshay
- Eastern Virginia Medical School, Norfolk, Virginia
| | - Lauri Pasch
- Department of Psychiatry, University of California at San Francisco, San Francisco, California.,Department of Reproductive Endocrinology, University of California at San Francisco, San Francisco, California
| | - Marcelle I Cedars
- Department of Reproductive Endocrinology, University of California at San Francisco, San Francisco, California
| | - Heather Huddleston
- Department of Reproductive Endocrinology, University of California at San Francisco, San Francisco, California
| | - Kanade Shinkai
- Department of Dermatology, University of California at San Francisco, San Francisco, California
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Abstract
One-third of North American children are overweight or obese. Pathologic obesity accounts for only a small percentage of these cases. The vast majority are the result of a complex interaction of genetic and hormonal, nutritional, physical activity, and physical and social environmental factors. Obesity increases the risk for various cardiometabolic, pulmonary, and psychosocial complications for children, which often continues into adulthood. Multidisciplinary care, focusing on family-centered behavior change, is an evidence-based, essential part of the treatment, along with pharmacologic and surgical options for more complex cases. Prevention and early intervention strategies are key to reversing the obesity epidemic.
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Affiliation(s)
- Muskaan Gurnani
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Catherine Birken
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Jill Hamilton
- Division of Endocrinology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
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Witchel SF, Oberfield S, Rosenfield RL, Codner E, Bonny A, Ibáñez L, Pena A, Horikawa R, Gomez-Lobo V, Joel D, Tfayli H, Arslanian S, Dabadghao P, Garcia Rudaz C, Lee PA. The Diagnosis of Polycystic Ovary Syndrome during Adolescence. Horm Res Paediatr 2015; 83:000375530. [PMID: 25833060 DOI: 10.1159/000375530] [Citation(s) in RCA: 164] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/26/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The diagnostic criteria for polycystic ovary syndrome (PCOS) in adolescence are controversial, primarily because the diagnostic pathological features used in adult women may be normal pubertal physiological events. Hence, international pediatric and adolescent specialty societies have defined criteria that have sufficient evidence to be used for the diagnosis of PCOS in adolescents. METHODS The literature has been reviewed and evidence graded to address a series of questions regarding the diagnosis of PCOS during adolescence including the following: clinical and biochemical evidence of hyperandrogenism, criteria for oligo-anovulation and polycystic ovary morphology, diagnostic criteria to exclude other causes of hyperandrogenism and amenorrhea, role of insulin resistance, and intervention. RESULTS AND CONCLUSION Features of PCOS overlap normal pubertal development. Hence, caution should be taken before diagnosing PCOS without longitudinal evaluation. However, treatment may be indicated even in the absence of a definitive diagnosis. While obesity, insulin resistance, and hyperinsulinemia are common findings in adolescents with hyperandrogenism, these features should not be used to diagnose PCOS among adolescent girls. © 2015 S. Karger AG, Basel.
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Affiliation(s)
- Selma F Witchel
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pa., USA
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Santos RR, Schoevers EJ, Roelen BAJ. Usefulness of bovine and porcine IVM/IVF models for reproductive toxicology. Reprod Biol Endocrinol 2014; 12:117. [PMID: 25427762 PMCID: PMC4258035 DOI: 10.1186/1477-7827-12-117] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 11/05/2014] [Indexed: 11/10/2022] Open
Abstract
Women presenting fertility problems are often helped by Assisted Reproductive Techniques (ART), such as in vitro fertilization (IVF) programs. However, in many cases the etiology of the in/subfertility remains unknown even after treatment. Although several aspects should be considered when assisting a woman with problems to conceive, a survey on the patients' exposure to contaminants would help to understand the cause of the fertility problem, as well as to follow the patient properly during IVF. Daily exposure to toxic compounds, mainly environmental and dietary ones, may result in reproductive impairment. For instance, because affects oocyte developmental competence. Many of these compounds, natural or synthetic, are endocrine disruptors or endocrine active substances that may impair reproduction. To understand the risks and the mechanism of action of such chemicals in human cells, the use of proper in vitro models is essential. The present review proposes the bovine and porcine models to evaluate toxic compounds on oocyte maturation, fertilization and embryo production in vitro. Moreover, we discuss here the species-specific differences when mice, bovine and porcine are used as models for human.
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Affiliation(s)
- Regiane R Santos
- />Institute for Risk Assessment Sciences, Faculty of Veterinary Medicine, Utrecht University,TD Utrecht,, P.O Box 80152, 3508 The Netherlands
- />Laboratory of Wild Animal Biology and Medicine, Federal University of Pará,, Rua Augusto Corrêa,Belém, CEP 66075-110 Pará Brazil
| | - Eric J Schoevers
- />Department of Farm Animal Health, Utrecht University,, Yalelaan, 104, 3584 CM Utrecht, The Netherlands
| | - Bernard AJ Roelen
- />Department of Farm Animal Health, Utrecht University,, Yalelaan, 104, 3584 CM Utrecht, The Netherlands
- />Department of Equine Sciences, Faculty of Veterinary Medicine, Utrecht University, Yalelaan, 104, 3584 CM Utrecht, The Netherlands
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