Clinical features associated with PCOS include obesity, hirsutism or acne, cycle abnormalities and infertility. Therefore, depending on the primary complaint these patients visit different medical specialists such as general practitioner, pediatrician, dermatologist, medical endocrinologist and gynecologist. The variability in primary complaint asks for different approaches in the work-up of these patients. Hence, doctors usually see just a proportion of the overall spectrum of PCOS and they apply different inclusion criteria for the diagnosis. Still, we all refer to these patients with the same PCOS, causing much confusion.
The 1990 NIH consensus workshop proposed chronic anovulation along with clinical or endocrine signs of hyperandrogenemia as obligatory criteria for PCOS diagnosis. This consensus was recently revised during the 2003 Rotterdam meeting (published simultaneously in both F&S and HR in January 2004), where the occurrence of polycystic ovaries was added to the diagnostic criteria, along with the statement that patients needed to score positive for only 2 out of 3 criteria. This approach (also applied for the diagnosis of the metabolic syndrome) underlines that PCOS concerns a heterogeneous syndrome, with no single feature being mandatory for the diagnosis. It was recognized that that the clinical assessment of hyperandrogenemia is subjective and that good assays to measure free and biologically active testosterone is only available in few laboratories worldwide. Important endocrine features associated with PCOS, including elevated LH and impaired glucose tolerance, are not involved in the diagnosis.
|NIH||NIH extension||Novel phenotypes (Rotterdam criteria)|
For the gynecologist focusing on anovulatory infertility, PCOS is part of the spectrum of WHO type 2 anovulation, characterized by normal serum FSH and E2 concentrations. It is generally believed that PCOS patients present with poor reproductive outcome following infertility therapies. However, this contention is largely based on retrospective and uncontrolled observations. Recent longitudinal follow up studies from our own group showed that cumulative singleton birth rates up to 75% can be achieved with conventional approaches for ovulation induction (involving clomiphene citrate as first line, and exogenous gonadotropinsd as second line) followed by IVF. Recent novel approaches for ovulation induction such as insulin sensitizing agents, aromatase inhibitors, laparoscopic ovarian surgery procedures and IVF involving single ET all need further evaluation in PCOS.
PCOS women frequently present with metabolic abnormalities such as insulin resistance, dislipidemia and hypertension, even at young age. Therefore, currently much attention is shifted towards the assessment of increased health risks of PCOS women later in life, such as type 2 diabetes and cardiovascular disease. Unfortunately, sufficiently powered studies with a sufficient duration of follow-up are extremely scare so far.
03 - 07 May 2008
European Society of Endocrinology