Jan. 28, 2004 — The European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) cosponsored the Rotterdam polycystic ovary syndrome (PCOS) consensus workshop group to revise the guidelines for diagnosis and management that the National Institutes of Health released in 1990. The revised guidelines are published in the January issue of Fertility and Sterility.

"PCOS remains a syndrome and no constellation of findings or set criteria can exclusively be used for a clinical diagnosis or for inclusion in clinical research," Robert Schenken, MD, president-elect of ASRM, says in a news release. "Further studies are needed to assess risk levels based on different diagnostic criteria."

The Rotterdam panel concluded that PCOS encompasses a broader variety of manifestations of ovarian dysfunction than those included in the original diagnostic criteria defined by the National Institutes of Health in 1990. Although the cardinal features are hyperandrogenism and polycystic ovary morphology, no single criterion is sufficient for clinical diagnosis.

Other clinical manifestations may include menstrual irregularities, signs of androgen excess, obesity, insulin resistance, elevated serum luteinizing hormone (LH) levels, and increased risk of type 2 diabetes, cardiovascular events, and endometrial cancer.

To be diagnosed with PCOS by the Rotterdam criteria, a woman must have two of the following three manifestations: irregular or absent ovulation, elevated levels of androgenic hormones, and/or enlarged ovaries containing at least 12 follicles each. Other conditions with similar signs, such as androgen-secreting tumors or Cushing's syndrome, must be ruled out. Polycystic ovaries with normal ovarian function and without hyperandrogenism should not be considered PCOS without further workup.

"This is by no means a final definition of the syndrome," says Robert Rebar, MD, executive director of ASRM. "While the clarification of diagnostic criteria might improve the ability of clinicians and researchers to discuss PCOS, the way the criteria are framed — as two out of three required for diagnosis — may cause some confusion."

The panel recommended that women with PCOS be evaluated for metabolic syndrome with measurements for abdominal obesity, triglycerides, high-density lipoproteins, hypertension, and fasting and two-hour glucose tolerance.

"More research is needed to clarify the way the risks of PCOS relate to the individual patient's manifestation of the syndrome," Dr. Rebar concludes.

NV Organon and ESHRE/ASRM sponsored this symposium.

Fertil Steril. 2004;81:19-25

Clinical Context

Study Highlights

• The group working on the consensus guidelines differentiated research according to the goals of the study (ie, treatment of hirsutism vs. treatment of infertility). Family studies were also reviewed.
• PCOS should be excluded from other disorders in which hirsutism and menstrual irregularities are prominent, such as congenital adrenal hyperplasia, Cushing's syndrome, and androgen-secreting tumors. Additionally, it is reasonable to check ethinyl estradiol, follicle-stimulating hormone (FSH), and prolactin levels in these women. However, thyroid disorders in PCOS patients are not more common than in other young women, and thyroid-stimulating hormone assays are unnecessary unless otherwise clinically indicated.
• Hirsutism is the best clinical marker of hyperandrogenism, although different degrees of hirsutism should be expected based on ethnicity. Standardized screening tools for hirsutism are not commonly used but should be considered. Acne is a more variable marker of hyperandrogenism.
• The best measures of objectively measuring hyperandrogenism are free testosterone levels or the free testosterone index. However, not all patients with PCOS have elevated circulating androgen levels, and not all circulating androgens will be accounted for with these tests. Routine measurement of androstenedione and dehydroepiandrosterone levels cannot be recommended at this time.
• Polycystic ovaries are defined as those found on ultrasound to contain 12 or more follicles measuring 2 to 9 mm in diameter and/or have an increased volume of 10 mL or greater. Only one ovary meeting these criteria is necessary to meet the definition of polycystic ovaries. Women found to have incidental polycystic ovaries on an ultrasound performed for another indication should not be considered to have PCOS unless there is corroborating clinical evidence of the syndrome.
• Insulin resistance can occur in up to 50% of patients with PCOS, so the consensus group recommends oral glucose tolerance tests for all PCOS patients.
• LH levels are frequently elevated in women with PCOS, especially when compared with FSH. LH/FSH ratios can be elevated in up to 95% of women with PCOS if women with recent ovulation are excluded. The clinical implications of this abnormality are unclear. Although some research has suggested lower fertility rates and higher miscarriage rates for women with high LH levels, other studies have contradicted this data. LH levels do not need to be checked routinely in patients with PCOS.
• Women with PCOS are at increased risk for diabetes, and this risk is increased if the patient has anovulatory vs. ovulatory PCOS. However, PCOS has not been definitely linked to an increased risk of cardiovascular disease, endometrial cancer, or death.

Pearls for Practice

• PCOS is characterized by obesity, menstrual irregularities, signs of excess androgenism, and glucose intolerance.
• PCOS remains a diagnosis of exclusion that is made both clinically and with ancillary testing. Monitoring PCOS patients for glucose intolerance and diabetes is critical.

CME Test