An Update on Polycystic Ovary Syndrome

An Update on Polycystic Ovary Syndrome

Bradley Trivax, Ricardo Azziz
US Endocrine Disease 2007 - Issue 1
Published: October 2008
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Over the past decade, there have been different diagnostic criteria used to evaluate patients with polycystic ovary syndrome (PCOS). Regardless of the diagnostic criteria used, the principal features of PCOS include androgen excess, ovulatory dysfunction, and/or polycystic ovaries.1–4 PCOS is a heterogeneous disorder that is recognized as one of the most common endocrinopathies affecting women. It is critical to note that PCOS is a diagnosis determined by exclusion, such that other disorders of androgen excess or ovulatory dysfunction with clearly defined origins are excluded. These include 21-hydroxylase-deficient non-classic adrenal hyperplasia (NCAH), Cushing’s syndrome, adrenal tumors, and Cushing’s disease. Ovarian and other adrenal androgen-secreting neoplasms must be ruled out as well. Also, disorders that affect ovulatory dysfunction such as thyroid dysfunction or hyperprolactinemia are often ruled out. However, the prevalence of these abnormalities in patients with apparent hyperandrogenism is low: approximately 2–3%.5,6

Obtaining a Diagnosis of the Patient with Possible Polycystic Ovary Syndrome
Whenever attempting to diagnose PCOS, it is important to define the population at high risk for having the syndrome. Women with unwanted hair growth7,8 or menstrual disturbances9,10 are highly likely to have PCOS.11,12

Women with a family history of PCOS should be considered as well. Most importantly, the performance of a thorough history and physical examination in the evaluation of the patient with possible PCOS is critical in arriving at the diagnosis. The four features of the syndrome that should be evaluated include hirsutism, hyperandrogenemia, ovulatory dysfunction, and polycystic ovarian morphology. These findings comprise the cornerstones of the diagnosis, again regardless of the criteria used.

Hirsutism and Polycystic Ovary Syndrome
Hirsutism is the most visible and troubling clinical feature of PCOS. Whereas facial and body hair can be worrisome to patients, only excess terminal hair in a male-type pattern signals androgen excess. Hirsutism most often affects the face, chin, and an area below the umbilicus, which is an extension of pubic hair growth. The modified Ferriman-Gallwey (mFG) score13 is the most common method of determining the presence of hirsutism. A visual score is assessed based on the method originally reported by Ferriman and Gallwey.14 Nine body areas are assigned a score of 0–4 based on the density of terminal hairs. A score of 0 represented the absence of terminal hairs and a score of 4 represented extensive terminalhair growth. Using this approach, cut-off values for defining hirsutism have been reported to be scores of 6–8 or greater.5,15,16 Additionally, the prevalence of hirsutism in PCOS can vary according to race and ethnicity. Overall, hirsutism is an important feature of PCOS, affecting approximately 65–75% of non-Asian patients with PCOS.

Hyperandrogenemia and Polycystic Ovary Syndrome
Hyperandrogenemia is a critical component of the PCOS diagnosis. It is defined as supranormal levels of circulating endogenous androgens. The most frequent androgen measured is testosterone (T): total, unbound, or free. Serum T circulates bound to sex-hormone-binding globulin (SHGB), and only the unbound or free T acts on target tissues. Clinicians must be mindful of the limitations and pitfalls inherent in the measurement of T, specifically the highly variable and inaccurate direct assays for total and free T.17–19 Measurement of total and free T should be performed by a highquality assay. In addition to an accurate methodology, it is critical that each individual laboratory establish its own set of normal ranges established in well characterized, healthy control women. Overall, in patients diagnosed by the 1990 National Institutes of Health (NIH) criteria, approximately 70% of PCOS patients demonstrate elevated free-T levels. The value of additional measurements of androstenedione and dihydrotestosterone sulfate (DHEAS) is less clear, but measuring these androgens may identify an additional 10–20% of patients as hyperandrogenemic.19 Finally, it is important to note that measurements of circulating androgens, including free T, should be used only as part of the diagnosis of PCOS and not as the sole criterion. Androgen measures are most useful in diagnosing hyperandrogenism in patients without overt or obvious signs of hyperandrogenism, such as adolescents, patients of Asian extraction, or other women without gross evidence of hirsutism.

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