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This Journal Club presentation provides a summary and discussion of the following free access article published in UOG: 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 It can be accessed here: http://onlinelibrary.wiley.com/doi/10.1002/uog.11202/abstractTRANSCRIPT
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)
UOG Journal Club: August 2012
Norman RJ M et al., Lancet 2007
HyperandrogenismInfertility
Polycystic ovary syndrome (PCOS)
is the most common cause of:
*At least two of the three criteria are necessary for PCOS diagnosis
• 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
Revised 2003 consensus.Hum Reprod 2004
Rotterdam criteria for PCOS*
The inclusion of PCO ultrasound criteria into the PCOS definition is controversial because of lack of specificity.
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?
Polson DW et al., Lancet 1988Farquhar CM et al., Aust N Z J Obstet Gynaecol 1994
Duijkers IJ et al., Gynecol Endocrinol 2010Johnstone EB et al., J Clin Endocrinol Metab 2010
Polycystic ovaries (PCO)
Polycystic ovaries at ultrasound: normal variant or silent polycystic ovary syndrome?
S. Catteau-Jonard et al., UOG 2012
To determine whether PCO is a normal ovarian state or whether it reflects an abnormality in ovarian folliculogenesis similar to PCOS
Objective
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*
*Ovarian volume was not considered for PCO and PCOS definition
Exclusion criteria: • Women with at least one follicle >9 mm• Serum estradiol level > 300 pmol/L
Comparison of:• Hormonal parameters• Metabolic parameters• Ultrasound parameters
Comparative study (2004–2008)
Clinical examination:•Assessment of hirsutism •Measurement of waist circumference•Body mass index (BMI)•Blood pressure
Serum sampling:•Estradiol,17-OH-progesterone•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
Methodology
DHEAS, dehydroepiandrosterone sulfate; HDL, high-density lipoprotein; LH, luteinizing hormone: FSH, follicle-stimulating hormone; SHBG, sex-hormone-binding globulin
Follicle number = Right ovary + Left ovary
Ovarian area = Right ovary + Left ovary
ANOVA and covariance analysis with Bonferroni correction on log values
Statistical analysis
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
* p<0.05
Number of follicles 2–9 mm and AMH serum level
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.
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)
Comparison of AMH serum levels
Andro-stenedione
Testosterone0.79
(0.17–1.84)
6.09(2.1–17.36)
1.39(0.17–3.57)
< 0.05*
< 0.05*
Controls PCO PCOS P-value
4.37(0.63–7.66)
5.25(1.57–7.70)
0.90(0.14–1.80)
Androgen serum levels except for DHEAS were similar between control and PCO groups and significantly higher in PCOS group than in PCO group.
*Difference between PCO and PCOS groups; results presented as median (range)
LH was significantly higher in PCOS group than PCO group. No difference in FSH and estradiol levels between PCOS and PCO groups was observed.
Hormonal 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
Metabolic parameters
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
Polycystic ovaries at ultrasound: normal variant or silent polycystic ovary syndrome?
S. Catteau-Jonard et al., UOG 2012
• What are the criteria for polycystic ovary syndrome according to the Rotterdam consensus in 2003?
• What is the difference between polycystic ovary syndrome (PCOS) and polycystic ovaries (PCO)?
• Does number of follicles differ between patients with PCOS and PCO?• Do hormonal markers differ between patients with PCOS and PCO?• Do androgen levels differ between patients with PCOS and PCO and
women without PCO?• Are metabolic parameters affected in women with PCO?• Is PCO a normal ovarian appearance or does it reflect ovarian follicle
abnormality in a similar way to PCOS?
Discussion points