Anti-Müllerian Hormone Levels in Adolescence in Relation to Long-term Follow-up for Presence of Polycystic Ovary Syndrome

CONTEXT

Anti-Müllerian hormone (AMH) measured in adolescence as biomarker for prediction of adult polycystic ovary syndrome (PCOS) is doubtful but not substantiated.

OBJECTIVE

To investigate whether serum AMH levels and other PCOS-associated features in adolescence can predict the presence of PCOS in adulthood.

DESIGN AND SETTING

A long-term follow-up study based on a unique adolescent study on menstrual irregularities performed between 1990 and 1997.

PARTICIPANTS AND INTERVENTIONS

AMH was assayed in 271 adolescent girls. Data on PCOS features were combined with AMH levels. In 160 of the 271 (59%) participants, we collected information in adulthood about their menstrual cycle pattern and presence of PCOS (features) by questionnaire 2 decades after the initial study.

RESULTS

AMH was higher in adolescent girls with oligomenorrhea compared with girls with regular cycles, median (interquartile range): 4.6 (3.1-7.5) versus 2.6 (1.7-3.8) μg/L (P < 0.001). Women with PCOS in adulthood had a higher median adolescent AMH of 6.0 compared with 2.5 μg/L in the non-PCOS group (P < 0.001). AMH at adolescence showed an area under the receiver operating characteristic curve for PCOS in adulthood of 0.78. In adolescent girls with oligomenorrhea the proportion developing PCOS in adulthood was 22.5% (95% CI, 12.4-37.4) against 5.1% (95% CI, 2.1-12.0) in girls with a regular cycle (P = 0.005). Given adolescent oligomenorrhea, adding high AMH as factor to predict adult PCOS or adult oligomenorrhea was of no value.

CONCLUSIONS

Adolescent AMH either alone or adjuvant to adolescent oligomenorrhea does not contribute as prognostic marker for PCOS in adulthood. Therefore, we do not recommend routine its use in clinical practice.

Polycystic Ovary Syndrome and Incidental Diagnosis of Mosaic Turner Syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common condition in women of reproductive age. Mosaic Turner syndrome (TS) is a genetic disorder with significant phenotypic variability. The occurrence of PCOS in women with mosaic TS has been infrequently studied.

CASE

A 30-year-old nulligravid woman presented with oligomenorrhea, hyperandrogenism, infertility, and ultrasound polycystic ovary morphology. She was diagnosed with PCOS and conceived following ovulation induction. After 2 inconclusive non-invasive prenatal screening results, she was referred to medical genetics. A maternal karyotype resulted in a diagnosis of 45,X/46,XX mosaic TS. She delivered a healthy 46,XY infant at term.

CONCLUSION

PCOS can affect women with mosaic TS. Further studies are needed to better characterize the reproductive profile of women with mosaic TS, including the presentation of concurrent PCOS.

Functional and endocrine-metabolic oligomenorrhea: proposal of a new diagnostic assessment tool for differential diagnosis in adolescence

Background To develop a diagnostic assessment tool, using clinical, biochemical and sonographic markers, to help clinicians in the differential diagnosis of functional oligomenorrhea (FO) and endocrine-metabolic oligomenorrhea (EMO). Methods Sixty-two adolescents with oligomenorrhea without evident hormonal imbalances or severe energy deficit were selected. They were divided into two groups (EMO and FO) and they all underwent the following assessment: physical examination (height, weight, presence of hirsutism or acne), blood exams and transabdominal ultrasonography. The biochemical markers included: hemoglobin, thyrotropin stimulating hormone (TSH), prolactin (PRL), follicle stimulating hormone (FSH), luteinizing hormone (LH), free (FT) and total testosterone (TT), androstenedione (A), dehydroepiandrosterone sulfate (DHEAS) and sex hormone binding globulin (SHBG). Uterine and ovarian volume, ovarian morphology, endometrial thickness and pulsatility index (PI) of uterine arteries were evaluated with ultrasound. Results Body mass index (BMI), hemoglobin, LH levels and LH/FSH ratio were significantly higher in women with EMO than in those with FO. Increased androgens values were found in the EMO group, but only A and FT were significantly different (p=0.04). Ovarian volume and uterine artery PI were the only ultrasound features significantly different, with higher values in the EMO population (p<0.05). Considering these variables, with a receiving characteristic operating curve, new cut-offs were calculated, and a diagnostic assessment tool elaborated (area under curve [AUC] 0.88, specificity 99%, sensibility 59%, p<0.001]. Conclusions This diagnostic tool, specific for adolescents, could be useful in the management of oligomenorrhea. Recognizing and distinguishing EMO and FO is very important in order to establish an appropriate treatment and a correct follow-up.

[RISK FACTORS AND CLINICAL PECULIARITIES OF SECONDARY OLIGOMENORRHEA IN ADOLESCENT GIRLS]

Risk factors related to secondary oligomenorrhea (SOM) are the presence of chronic extragenital pathology, abrupt changes in body mass during a short period of time, a burdened perinatal history at the onset of SOM after a year of regular menstruations. Adolescent girls with SOM differ from their healthy peers by a frequent occurrence of hirsutism, obesity and body mass deficit, uterine hypoplasia.

New adolescent polycystic ovary syndrome perspectives

Polycystic ovary syndrome (PCOS) is a common but heterogeneous disorder that usually arises during puberty. This endocrine disorder is associated with chronic anovulation and hyperandrogenemia with clinical manifestation of oligomenorrhea, hirsutism and acne. While the underlying etiology of PCOS remains unknown, it is commonly associated with obesity and insulin resistance leading to increased risk of cardiovascular disease, dyslipidemia and type 2 diabetes mellitus in hyperandrogenemic phenotypes. Menstrual irregularities and insulin resistance in obese adolescents are usually indistinguishable from the clinical manifestations of PCOS and pose a diagnostic dilemma due to higher circulating androgens during puberty. Consequently, a universal consensus on the definition of hyperandrogenemia in adolescents has been elusive. Nevertheless, hyperandrogenemia, independent of obesity, in postmenarchal adolescents is associated with increased risk of cardiometabolic syndrome. Therefore, treatment strategies including lifestyle changes and/or use of insulin-sensitizers, hormone replacement and antiandrogens should be utilized in order to delay long-term cardiovascular and metabolic complications of this endocrinopathy.

The diagnosis of polycystic ovary syndrome in adolescents

In women, the definition of polycystic ovary syndrome (PCOS) has become broad and includes several possible phenotypes. Because several features of PCOS may be in evolution in adolescents, we suggest that only firm criteria should be used to make a diagnosis of PCOS during adolescence. Hyperandrogenism, oligomenorrhea, and ovarian morphology change during adolescence and are discussed individually. Adolescents with incomplete criteria for a firm diagnosis of PCOS should be followed up carefully and may be diagnosed at a later time.

Polycystic ovary syndrome in bulimic women--an evaluation based on the new diagnostic criteria

An association between bulimia nervosa and polycystic ovary syndrome (PCOS) has been suggested but also questioned. Since there is still a controversy about this issue, we investigated clinical and biochemical symptoms of PCOS according to the new diagnostic criteria in a large group of bulimic women compared with controls. Seventy-seven women with bulimia and 59 matched healthy women were investigated with respect to menstrual status, polycystic ovaries, hirsutism, acne and sex hormone levels. We found increased occurrence of menstrual disturbances, hirsutism and PCOS in bulimic women, whereas ovarian variables and acne did not differ from controls. Hirsutism score and indices of biologically active testosterone were positively correlated in bulimics but not in controls, while there were no major differences in serum androgens. In conclusion, this study supports an increased frequency of PCOS in bulimic women and may also indicate increased androgen sensitivity in these women. PCOS may promote bulimic behavior since androgens have appetite-stimulating effects and could impair impulse control. Menstrual disturbances and clinical signs of hyperandrogenism should be evaluated in bulimics in order to provide adequate medical care and treatment.

Predictive value of menstrual cycle pattern, body mass index, hormone levels and polycystic ovaries at age 15 years for oligo-amenorrhoea at age 18 years

BACKGROUND

On the question of how to counsel adolescents with irregular menstrual cycles or oligomenorrhoea, no clear answer has been given. Adolescents with oligomenorrhoea especially show endocrine abnormalities and may be at risk for ovulatory dysfunction and the polycystic ovary syndrome in adulthood.

METHODS

We followed a cohort of adolescents to document changes in menstrual cycle pattern between ages 15 and 18 years in the general population.

RESULTS

Two per cent (2/128) of adolescents with regular menstrual cycles developed oligomenorrhoea, and 12% (17/148) of those with irregular menstrual cycles did so. Fifty-one per cent (34/67) of the oligomenorrhoeic adolescents remained oligomenorrhoeic. Increase in body mass index (BMI), concentration of LH, androstenedione or testosterone, and polycystic ovaries (PCO) were associated with persistence of oligomenorrhoea. In multivariate analysis only a normal to high BMI (>19.6 kg/m(2)) consistently contributed significantly to predict persistent oligomenorrhoea. Glucose:insulin ratio as a marker for insulin resistance was not associated with an increased risk for oligomenorrhoea.

CONCLUSIONS

Oligomenorrhoea at age 18 years is better predicted by menstrual cycle pattern at age 15 years than by LH or androgen concentrations or PCO at this age. Not only obese, but also normal weight oligomenorrhoeic, adolescents have a high risk of remaining oligomenorrhoeic.

Common Menstrual Disorders in Adolescence: Nursing Interventions

Menstrual disorders such as amenorrhea, excessive uterine bleeding, dysmenorrhea, and premenstrual syndrome are common reasons for visits to healthcare providers by adolescent girls. Although menstrual irregularity can be normal during the first few years after menarche, other menstrual signs and symptoms may indicate a pathological condition that requires prompt attention and referral. This article discusses four common menstrual disorders seen in adolescent girls and focuses on specific nursing interventions aimed at eliciting an accurate menstrual history, providing confidentiality and communicating therapeutically, administering culturally sensitive care, and promoting independence and self-care.

Frequent misdiagnosis and mismanagement of hyperprolactinemic patients before the introduction of macroprolactin screening: application of a new strict laboratory definition of macroprolactinemia

BACKGROUND

Macroprolactin (big big prolactin) has reduced bioactivity and is measured by immunoassays for prolactin when it accumulates in the plasma of some individuals. We applied normative data for serum prolactin after treatment of sera to remove macroprolactin to elucidate the contribution of macroprolactin to misleading diagnoses, inappropriate investigations, and unnecessary treatment.

METHODS

We reviewed records of women attending a tertiary referral center who had prolactin >1000 mIU/L. Application of a reference interval to polyethylene glycol (PEG)-treated hyperprolactinemic sera identified 21 patients in whom hyperprolactinemia was accounted for entirely by the presence of macroprolactin. Presenting clinical features, diagnoses, and treatment were compared in these patients and 42 age-matched true hyperprolactinemic patients.

RESULTS

Prolactin concentrations in sera of 110 healthy individuals ranged from 78 to 564 mIU/L. The range of values for the sera after PEG treatment was 70-403 mIU/L. For macroprolactinemic samples, PEG treatment decreased mean (SD) prolactin from 1524 (202) mIU/L to 202 (27) mIU/L but decreased it only from 2096 (233) mIU/L to 1705 (190) mIU/L in true hyperprolactinemic patients (P <0.01 between groups). Oligomenorrhea or amenorrhea and galactorrhea were the most common clinical features in both groups, although they occurred more frequently in true hyperprolactinemic patients (P <0.05). Serum estradiol and luteinizing hormone concentrations were significantly higher in participants with macroprolactinemia than in those with true hyperprolactinemia (P <0.05). Among participants with retrospectively identified macroprolactinemia, pituitary imaging was performed in 93% and treatment with dopamine agonist was prescribed in 87%.

CONCLUSIONS

Macroprolactin is a significant cause of misdiagnosis, unnecessary investigation, and inappropriate treatment. The use of an appropriate reference interval for the PEG immunoprecipitation procedure may be of particular importance in those patients who have an excess of both macroprolactin and monomeric prolactin.

Is the free androgen index a useful clinical marker in male patients?

The clinical relevance of the free androgen index (FAI), a ratio of total testosterone (T) to sex-hormone binding globulin (SHBG), was investigated in a regional population of men (n = 40) and women (n = 30). The FAI correlated well with free testosterone (T) in both men (r = 0.551, p < 0.001) and women (r = 0.454, p < 0.01). However, there was considerable variability among individual patients. Moreover, the FAI showed no association with sperm parameters in male patients, although total T and free T showed weak associations. The FAI may be a cost-effective alternative to free T measurement in the diagnosis of oligomenorrhea and hirsutism in women as previously shown, but may have little relevance in men.

Endocrine profile of women with amenorrhea and oligomenorrhea

OBJECTIVES

To find out the common causes of amenorrhea and oligomenorrhea in south Indian women and to draw up a protocol for evaluation of women with these problems.

METHODS

A retrospective study of 426 women with amenorrhea and oligomenorrhea was carried out.

RESULTS

Forty-one patients had primary amenorrhea, 132 had secondary amenorrhea and 289 women presented with oligomenorrhea. Hypergonadotropic amenorrhea and congenital absence of the uterus and vagina accounted for 60% of primary amenorrhea. Chronic anovulatory disorders and premature ovarian failure were found in 72% of women with secondary amenorrhea but weight loss related amenorrhea was uncommon.

CONCLUSIONS

On the basis of the observations made, a protocol for evaluation and management of women with amenorrhea and oligomenorrhea was evolved.

The role of adrenocorticotropin testing in evaluating girls with premature adrenarche and hirsutism/oligomenorrhea

To identify biochemical predictors for future development of hirsutism and/or oligomenorrhea (H/O) in girls with premature adrenarche (PA), we performed dexamethasone-suppressed ACTH stimulation tests in girls with PA (n = 46), young women (n = 44) with H/O, and adult women (n = 31). Cortisol, androstenedione, dehydroepiandrosterone, and 17-hydroxyprogesterone were measured. Seven girls with PA (15%) and seven with H/O (16%) had evidence of nonclassical adrenal steroid biosynthetic defects [nonclassical congenital adrenal hyperplasia (NCAH)]. Twenty-five girls with PA (54%) and 28 girls with H/O (64%) had the moderately elevated 17-hydroxyprogesterone response to ACTH that has been reported in obligate heterozygotes for 21-hydroxylase deficiency. There were no clinical features that distinguished the girls with NCAH from the others. ACTH testing is an important tool in distinguishing those girls with PA and H/O who have NCAH. Although we could find no differences in other adrenal steroid hormones that might predict which of the other girls with PA might late develop H/O, black girls comprised a substantially smaller fraction of the population with H/O than of the population with PA (2% vs. 26%; chi 2 = 8.5; P less than 0.005). This observation suggests that PA, in blacks who do not have NCAH, is more likely to be a benign condition/than in other ethnic groups.

Cervical mucus and serum estradiol as predictors of response to progestin challenge

The present study was undertaken to assess the correlation between and relative predictive value of each of the following variables and progestin-induced withdrawal bleeding: cervical mucus appearance, serum E2 level, patient age, duration of amenorrhea, smoking and exercise habits, and body composition. Of 120 oligomenorrheic and amenorrheic women evaluated, only cervical mucus appearance and serum E2 level were significantly associated with response to progestin challenge. A multivariate logistical regression analysis showed cervical mucus to be the most predictive variable followed by serum E2 level. No absolute E2 level was found to discriminate between those who did and those who did not have withdrawal bleeding after progestin challenge. These data suggest that office examination of cervical mucus may be a useful indicator and guideline in planning therapy.

[Comparative analysis of the data of acupuncture electrodiagnosis and hormonal status of women with oligomenorrhea]

This study has compared acupuncture electrodiagnostic and hormonal data of oligomenorrheic women before and after an acupuncture regimen. According to the pretreatment hormonal status the patients were assigned to 3 groups: (1) ovarian hypofunction; (2) ovarian hypofunction with hyperandrogenism; (3) ovarian hypofunction with functional hyperprolactinemia. The treatment normalized the hormonal status in all 3 groups. The hormonal status of oligomenorrheic patients was found to correlate with conductivity of the skin at biologically active sites.

[Laparoscopic picture in patients with oligomenorrhea treated for chronic salpingo-oophoritis]

Sixty patients with oligomenorrhea and the painful syndrome were examined to study the course of a chronic inflammatory process of the genitals. Laparoscopy has confirmed the initial diagnosis of salpingo-oophoritis in 24 of the 60 examinees. The authors call for a more thorough examination of this patient population, for an erroneous diagnosis of a chronic inflammation leads to erroneous therapeutic strategy, consisting in irrational administration of antibacterial, balneo- and physiotherapy.

[Oligomenorrhea syndrome in infertile patients]

The paper presents the results of comprehensive studies of 100 infertile patients with oligomenorrhea. Familial predisposition to the impairments in the menstrual and reproductive functions was established as was a high rate of primary infertility and pregnancy wastage. Ninety per cent of the patients demonstrated ovarian dysfunction from the puberty, refractory anovulation was registered in the majority of the patients (70 per cent), intermittent in 22 and persistent ovulation only in 8 per cent of the examinees. Clinical and laboratory investigations confirmed hyperandrogenism in 80 per cent and hyperprolactinemia in 28 per cent of the patients. Laparoscopy demonstrated a high incidence of ovarian polycystosis (57 per cent), inflammatory genital changes (47 per cent), uterine myoma (7 per cent), and endometriosis of the external genitalia (7 per cent). There was no evidence of correlation between the content of plasma hormones, ovulatory disorders and endoscopic findings.

Use of immunocytochemistry of progesterone and estrogen receptors for endometrial dating

Endometrial progesterone and estrogen receptors were studied by immunocytochemistry using monoclonal antibodies during the menstrual cycle in normal women. We initially compared immunocytochemical staining of progesterone and estradiol receptors on endometrial fragments obtained by either aspiration or endometrial biopsy and found that immunocytochemistry could be performed easily on tissue obtained in either way. The immunocytochemical studies showed that the concentration and distribution of receptors changed markedly during the normal menstrual cycle. These changes were distributed in three characteristic phases. During phase I, corresponding to the midfollicular period (days 7-8), a small proportion (25%) of stromal and glandular cells stained positively for the progesterone receptor, whereas estrogen receptor staining was more intense and more frequent (50% of cells). Phase II, which included both the late follicular and early luteal periods (days 9-19), was characterized by a marked staining of progesterone receptors in the majority of glandular cells (75%) and somewhat less abundant and less frequent staining in stromal cells (50%). Estrogen receptor staining was present in about half of the glandular and stromal cells. Phase III, the mid- and late luteal period (days 21-27), was characterized by the disappearance of estrogen and progesterone receptor staining in glandular cells, although faint staining for both receptors was found in stromal cells. These variations in progesterone receptor staining are potentially useful for determining the effect of progesterone on endometrial maturation.

Obstetric behavior and ultrasonic uterine characteristics of oligomenorrheic women

Two groups of age-, parity-, and pregnancy-matched women, viz. 78 with oligomenorrhea (A) and 78 with normal menstrual intervals (B), plus all women with regular menstruation but in whom severe Müllerian malformations had been diagnosed during the same period (C) were followed in a prospective study to detect complications, sonographic changes, and the serum oxytocinase concentration during pregnancy and labor. Among the matched groups A and B, ultrasonic scanning revealed uterine changes in 45% and 9%, respectively (p less than 0.0005) during the 2nd trimester. Among the oligomenorrheic women who had HSG, fairly mild Müllerian malformations were found in 40%. The sonographic method in these mild and moderate anomalies had its limitations, and the findings were interpreted in several cases as fibroma or contractions. Complications occurred in 51% of the group A women who carried their pregnancies to term versus 20% in group B (p less than 0.0005). Among the primiparae the complication rates were 47% and 22%, respectively (p less than 0.025). Bleeding in early pregnancy (25%), an unstable fetal lie (28%), malpresentations (14%), and premature contractions or delivery (11%) were more common in group A (p less than 0.05-0.01). On stratification of the oligomenorrheic group without or with Müllerian anomalies (A1 and A2) the overall complication rates were 55% and 73%, respectively, and 86% in group C. Mutually, these differences are not statistically different, but all differ significantly from the control group (B) (p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

The use of clomiphene citrate

Two hundred and fifty-five women received clomiphene citrate during a 10-year period. Fifty-six were treated diagnostically and one hundred and ninty-nine therapeutically for infertility. It is concluded that clomiphene may aid in confirming the diagnosis and establishing a prognosis in patients with primary or secondary amenorrhea. The success of clomiphene therapy in patients with anovulatory infertility is related to the etiologic factor responsible for the anovulation, but results can be improved by adjustment of the therapeutic regimen used. In the present series, 48% of the patients who ovulated became pregnant, and 25.3% of the pregnancies were miscarried. Those patients who ovulated spontaneously and became pregnant after having discontinued clomiphene therapy showed only a 10% abortion rate. A review of the results indicates that both the ovulation rate and the pregnancy rate can be improved if adjustments are made in therapy to ensure normal follicular maturation and corpus luteum function.

[The clinical value of radioimmunological oestradiol assays in the diagnosis of menstrual disorders. Evidence suggesting the presence of an ovarian "inhibin" (author's transl)]

The radioimmunoassay of oestradiol 17 beta (E2) from the blood without chromatography was evaluated in regard to the diagnosis of menstrual cycle disturbances. Two significantly different classes were distinguished, viz. 1. Women with higher E2 values, consisting of three groups: normal controls, cases of oligomenorrhoea, and WHO II (normogonadotropic, clomiphen-positive amenorrhoea). 2. Women with lower E2 values, consisting of two groups: WHO I (hypogonadotropic, clomiphen-negative amenorrhoea) and WHO III (hypergonadotropic amenorrhoea). Within these classes no significant differences were found between the groups. Only values below 43.1 pg/ml can be assigned with 95% certainty to the low-value class and only values above 108.8 pg/ml can be assigned with 95% certainty to the high-value class. The fact that 40% of all E2 values in hypergonadotropic, (i.e. ovarian) amenorrhoea fell within the range of the double standard deviation of the normal group and, likewise, the fact that physiological doses of oestrogen cannot reduce postmenopausal FSH to the level found in women of reproductive age suggest that E2 is not the only FSH-reducing factor, which leads us to postulate the existence of an ovarian "inhibin".