Controversies in the diagnosis of polycystic ovarysyndrome

摘要

Polycystic ovary syndrome is a common endocrinological condition which is foundto be prevalent in 5–10% of women of reproductive age. Historically, acombination of anovulation and androgen excess was considered a hallmark in thediagnosis of polycystic ovary syndrome. Addition of ultrasound features ofpolycystic ovary syndrome has improved the detection of variation in thepolycystic ovary syndrome phenotype. Despite the widespread use of consensusdiagnostic criteria, there remain several unresolved controversies in thediagnosis of polycystic ovary syndrome. Difficulty arises in methods ofassessment and types of androgens to be measured to detect biochemicalhyperandrogenism, setting a cut-off value for the diagnosis of clinicalhyperandrogenism, setting an ultrasound threshold of antral follicle count todiagnose polycystic ovaries and also diagnosing this condition in adolescencewhere there is no clear definition for ‘irregular cycles’. This article looks atvarious controversies in the diagnosis of polycystic ovary syndrome. Keywords: PCOS, diagnosis, polycystic ovary syndromeIntroductionPolycystic ovary syndrome (PCOS) is a common endocrinological condition which isfound to be prevalent in 5–10% of women in the reproductive age group~(1) and can vary between subpopulations. It was in 1935 that Stein and Leventhalfirst described this unique gynaecological condition. They described this syndromebased on seven women who had a combination of obesity, hirsutism, amenorrhoea andbilateral enlarged polycystic ovaries.~(2,3) Since its firstcharacterisation, there has been a vast evolvement in our understanding of itsetiology, diagnosis and treatment. In the early 1990s, the National Institutes ofHealth (NIH) first proposed a diagnostic criterion for PCOS. It defined PCOS as acombination of oligo-anovulation and androgen excess after ruling out all otherreasons for anovulatory infertility.~(4) Ultrasound criteria for polycystic ovaries were considered ‘suggestive’ butnot diagnostic of PCOS. These criteria were based on consensus expert opinion ratherthan the evidence from clinical trials. In 2003, the European Society for HumanReproduction and Embryology (ESHRE) and the American Society for ReproductiveMedicine (ASRM) amended the NIH criteria and included ultrasound features ofpolycystic ovaries as the third diagnostic criteria.~(5) The diagnosis of PCOS was established if a woman met two criteria out of thethree. This was based on the observation that polycystic ovaries were consistent inwomen with biochemical and clinical evidence of the syndrome. Women with PCOSdiagnosed by the Rotterdam Criteria can be further divided into four phenotypes, Ato D, based on the criteria qualifying for diagnosis. In 2006, the Androgen ExcessSociety (AES) reviewed existing data and concluded that the original criteria set byNIH in 1990s can be accepted along with some modifications based on the expertopinion at the 2003 Rotterdam conference. In addition to the above classifications,Aziz and colleagues,~(6) in an AES guideline, suggested nine phenotypes incorporating the criteria ofanovulation/oligo-ovulation, clinical hirsutism, biochemical hyperandrogenism andultrasound feature of polycystic ovaries. The Rotterdam criteria were endorsed bythe global PCOS guideline published in 2018. The various diagnostic criteria aresummarised in Table1. Table 1. Diagnostic criteria for PCOS.1990 NIH guidelines:Patient satisfies both criteria:(1) Clinical orbiochemical hyperandrogenism(2) Oligomenorrhoea oroligo-ovulationOther causes of hyperandrogenism andanovulatory subfertility should be excluded.2003 ESHRE/ASRM or Rotterdam guidelines:Patient satisfies two of three criteria:(1)Oligomenorrhoea or oligo-ovulation(2) Clinical orbiochemical hyperandrogenism(3) Polycystic ovaries onultrasoundOther causes of hyperandrogenism andanovulatory subfertility should be excluded.2006 AES guidelines:Patient satisfies both criteria:(1)Hyperandrogenism: hirsutism or biochemicalhyperandrogenism(2) Ovarian dysfunction:oligo-anovulation or polycystic ovariesOther causes ofhyperandrogenism and anovulatory subfertility should beexcluded.Open in a separate windowAES, Androgen Excess Society; ASRM, American Society for ReproductiveMedicine; ESHRE, European Society for Human Reproduction and Embryology;NIH, National Institute of Health; PCOS, polycystic ovary syndrome.