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Transcript
UOG Journal Club: August 2012
Polycystic ovaries at ultrasound: normal variant
or silent polycystic ovary syndrome?
S. Catteau-Jonard, J. Bancquart, E. Poncelet, C. Lefebvre-Maunoury,
G. Robin, D. Dewailly
Volume 40 Issue 2, Date: August 2012, pages 223–229
Journal Club slides prepared by Ligita Jokubkiene
(UOG Editor for Trainees)
Polycystic ovary syndrome
(PCOS)
is the most common cause of:
Anovulation
Infertility
Hyperandrogenism
Affects 5–10 % of women of
reproductive age
Norman RJ M et al., Lancet 2007
Rotterdam criteria for PCOS*
• 12 or more follicles 2–9 mm in size in at least one ovary, or ovarian
volume >10 mL at ultrasound examination on cycle day 2–5
• Oligo- and/or anovulation
• Clinical and/or biochemical signs of hyperandrogenism
*At least two of the three criteria are necessary for PCOS diagnosis
Revised 2003 consensus.
Hum Reprod 2004
Polycystic ovaries (PCO)
Only ultrasound criteria are met: 12 or more follicles 2–9 mm in size in at
least one ovary or ovarian volume >10 mL
Observed in 21–63 % of apparently normal women
Is PCO a normal ovarian appearance or does it reflect ovarian follicle
abnormality in a similar way to PCOS?
The inclusion of PCO ultrasound criteria into the PCOS definition is
controversial because of lack of specificity.
Polson DW et al., Lancet 1988
Farquhar CM et al., Aust N Z J Obstet Gynaecol 1994
Duijkers IJ et al., Gynecol Endocrinol 2010
Johnstone EB et al., J Clin Endocrinol Metab 2010
Polycystic ovaries at ultrasound: normal variant
or silent polycystic ovary syndrome?
S. Catteau-Jonard et al., UOG 2012
Objective
To determine whether PCO is a normal ovarian state or
whether it reflects an abnormality in ovarian
folliculogenesis similar to PCOS
Comparative study (2004–2008)
Three age-matched groups of 95 women in each group:
Control group – no symptoms and normal ovaries at ultrasound
PCO group – no symptoms but PCO at ultrasound*
PCOS group – PCOS according to Rotterdam criteria*
Comparison of:
Exclusion criteria:
• Hormonal parameters
• Metabolic parameters
• Ultrasound parameters
• Women with at least one follicle >9 mm
• Serum estradiol level > 300 pmol/L
*Ovarian volume was not considered for PCO and PCOS definition
Methodology
Clinical
examination:
•Assessment of
hirsutism
•Measurement of
waist circumference
•Body mass index
(BMI)
•Blood pressure
Serum sampling:
•Estradiol,17-OHprogesterone
•Testosterone (elevated if ≥
0.6ng/mL)
•Androstenedione (elevated
if ≥ 2.2 ng/mL)
•DHEAS, LH, FSH, SHBG,
insulin
•Anti-Mullerian hormone
(AMH)
•Free-androgen index, HDL
cholesterol, triglycerides
Ultrasound
examination:
•Menstrual cycle
day 2–5
•2D transvaginal
ultrasound
•Follicles 2–9 mm
counted
DHEAS, dehydroepiandrosterone sulfate; HDL, high-density lipoprotein; LH, luteinizing
hormone: FSH, follicle-stimulating hormone; SHBG, sex-hormone-binding globulin
Statistical analysis
Follicle number = Right ovary + Left ovary
Ovarian area = Right ovary + Left ovary
ANOVA and covariance analysis with Bonferroni
correction on log values
Number of follicles 2–9 mm and AMH serum level
* p<0.05
Number of follicles and AMH level is intermediate in women with PCO: significantly
higher than in controls and significantly lower than in PCOS group. Difference in
AMH remains significant after adjustment for follicle 2–9 mm number
Comparison of AMH serum levels
Subgroups of PCOS women:
•Amenorrhea (Am) – no menstrual periods
> 3 months (n = 13)
•Oligomenorrhea (Oligo) – < 8 menstrual
periods in preceding year (n = 70)
•Eumenorrhea (Eum) – regular menstrual
cycle 25 – 35 days (n = 12)
AMH level was similar between women with PCO and eumenorrheic women with
PCOS. Both groups had significantly lower AMH levels than PCOS patients with
oligomenorrhea and amenorrhea.
Hormonal parameters
Controls
PCO
PCOS
P-value
Testosterone
0.79
(0.17–1.84)
0.90
(0.14–1.80)
1.39
(0.17–3.57)
< 0.05*
Androstenedione
4.37
(0.63–7.66)
5.25
(1.57–7.70)
6.09
(2.1–17.36)
< 0.05*
Androgen serum levels except for DHEAS were similar between control and PCO
groups and significantly higher in PCOS group than in PCO group.
LH was significantly higher in PCOS group than PCO group. No difference in FSH
and estradiol levels between PCOS and PCO groups was observed.
*Difference between PCO and PCOS groups; results presented as median (range)
Metabolic parameters
No difference in any metabolic markers (BMI, blood pressure, waist circumference,
insulin, triglycerides, SHBG, HDL cholesterol) between control and PCO groups
BMI, waist circumference and triglycerides significantly higher in women with PCOS
than control or PCO group
SHBG, HDL cholesterol levels significantly lower in PCOS than control or PCO group
Polycystic ovaries at ultrasound: normal variant or
silent polycystic ovary syndrome?
S. Catteau-Jonard et al., UOG 2012
Conclusions
• PCO is an abnormal condition that differs from controls by higher AMH
serum levels but not by hyperandrogenism. This suggests a granulosa
cell abnormality in PCO similar to that observed in PCOS
• The absence of hyperandrogenism in PCO does not seem to be linked
to the metabolic status