To the Editor:
I have read with interest the extensive revision and establishment of criteria for the polycystic ovary syndrome (PCOS) by The Androgen Excess and PCOS Society (1). Certainly I agree with most of the concepts stated, but I would like to point out some with which I disagree:
1. I think more stress should have been put on the criteria to define each symptom and analytical data instead of widely analyzing their prevalence (which naturally will depend on the concept and the cataloguing criteria). I am referring to the definition of the criteria to consider hyperandrogenemia, hirsutism, oligo-anovulation, polycystic ovaries, ovulatory and menstrual dysfunction, gonadotropic abnormalities (FSH/LH), hyperinsulinemia, insulin resistance, etc.
2. One piece of information of great interest for physicians and patients is the label of “polycystic ovaries,” derived from the frequently wrong echographic observation showing multifolicular ovaries that are sometimes observed just with a transabdominal echography. In my opinion, to see the ovarian morphology the transabdominal echography is of little utility and therefore it should be done transvaginally (if that is not possible, it could be done transrectally with identical results). Besides, as PCOS is typically a gynecologic pathology, I think the transvaginal echography should be done by the same physician (the gynecologist) who examines the patient, assesses the available data, gives a diagnosis and establishes treatment.
3. Regarding the criteria proposed for the diagnosis of PCOS, in my opinion they should all be met for this diagnosis to be established (that is, not an “and/or” but “and”). I don´t think we can speak of PCOS (whatever the type) without: 1) hirsutism, even if it is light in the middle line, intermammary, periareolar; 2) increased androgens (∆4-A and/or T), at least in the upper normal limits (i.e. 0.6-0.8 ng/mL of testosterone or 4-4.5 ng/mL of ∆4A); 3) oligo-anovulation, at least presence of a certain common menstrual delay and in some cycles, anovulation or evident delay in the ovulation; 4) polycystic ovaries observed through transvaginal echography, with the typical form (peripheric crown of follicles smaller than 6-8mm) or with thick ovaries (with hyperthecosis) generally related to insulin resistance; and 5) alteration of the relation FSH/LH in the 3rd-4th day of the cycle. When any of these criteria are missing, the need for the exclusion of other related disorders is even more imperative.
4. In the article, the possibility of other forms of PCOS or related disorders is considered. In 1999, we described a group of heterogeneous disorders that seem to be related to this pathology (2). This group included: 1) simple nonhyperandrogenic obesity, 2) typical nonhyperinsulinemic PCOS, and 3) insulin-resistant PCOS. However, despite the wide number of references in the “complete task force report,” that paper has not been mentioned.
Pedro Acién, MD, PhD
Service of Obstetrics and Gynecology
San Juan University Hospital
Department/Division of Gynecology
School of Medicine
Miguel Hernández University
Campus of San Juan
1. Azziz R, Carmina E, Dewailly D, et al. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril 2009;91:456-88.
2. Acién P, Quereda F, Matallín P, Villarroya E, López-Fernández JA, Acién M, et al. Insulin, androgens, and obesity in women with and without polycystic ovary syndrome: a heterogeneous group of disorders. Fertil Steril 1999;72:32-40.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.03.110
The Authors Respond:
We greatly appreciate Dr. Acien’s interest in the Task Force’s report (1). He firstly suggests that “more stress should have been put on the criteria to define each symptom and analytical data instead of widely analyzing their prevalence.” We fully agree that, while much emphasis has been placed on arriving at a uniform definition of PCOS, of equal or even greater importance is the need to clearly and accurately define the specific phenotypic features used in the definitions. Although not the aim of our Task Force, we did make an effort to discuss throughout the pitfalls and limitations of each of the diagnostic criteria discussed (assessment of ovulatory dysfunction, measures of androgen levels, exclusion of related disorders, etc.). Further details on these important questions were discussed elsewhere (2).
Secondly, Dr. Acien notes that the assessment of ovarian morphology by “transabdominal echography is of little utility and therefore it should be done transvaginally.” While transvaginal ultrasonography is clearly superior to transabdominal imaging, we should note that not all patients tolerate a vaginal (rectal) examination, and are able to tolerate a transabdominal exam. The results of transabdominal sonography greatly depend on the degree of the patient’s obesity and are superior for assessment of ovarian size than follicle number. While it is true that it is preferable that the ultrasound is performed by the examining physician, this is not always practical or possible. In fact, the results of the evaluation will primarily depend on the skill of the sonographer, be it a radiologic technician, radiologist, or clinician. There, while we agree that transvaginal sonography has a greater value than transabdominal imaging, we cannot agree that the latter is “of little utility.” Likewise, we respectfully disagree that PCOS is a gynecologic pathology. PCOS is a life-long reproductive-metabolic disorder, whose impact is felt and should be understood and managed by a broad spectrum of practitioners.
Thirdly, the correspondent notes that, in his opinion, all features of PCOS must be present for the diagnosis to be made (i.e., hirsutism, hyperandrogenemia, oligo-anovulation, polycystic ovaries, and alteration of the relation FSH/LH in the 3rd-4th day of the cycle). Surprisingly, he feels that need for “the exclusion of other related disorders is even more imperative” when “any of these criteria are missing.” We disagree. PCOS clearly has a heterogeneous presentation, and exclusion of related disorders should be made in all patients suspected of the disorder, regardless of their phenotypic presentation. The correspondent is referred to the text of the report for further responses to this statement (1).
We apologize that we did not include the correspondent’s own publication in our task force report. However, we should note that many other reports were not included, particularly if they did not report the prevalence of the features of PCOS being evaluated (e.g., menstrual or ovulatory dysfunction, hirsutism, hyperandrogenemia). Of note, a “total of 527 articles were initially available for this review, although additional studies (crossreferences and those published in 2006) were also considered” and only a fraction of these were actually included. We appreciate Dr. Acien’s interest in the report.
Ricardo Azziz, M.D., M.P.H.a
Enrico Carmina, M.D.b
Didier Dewailly, M.D.c
Evanthia Diamanti-Kandarakis, M.D.d
Hector F. Escobar-Morreale, M.D., Ph.D.e
Walter Futterweit, M.D.f
Onno E. Janssen, M.D.g
Richard S. Legro, M.D.h
Robert J. Norman, M.D.i
Ann E. Taylorj
Selma F. Witchel, M.D.k
for the The Androgen Excess and PCOS Society
aCedars-Sinai Medical Center and The David Geffen School of Medicine at UCLA
Los Angeles, California
bUniversity of Palermo
cLille University Hospital
dUniversity of Athens Medical School
eHospital Ramon y Cajal
fMount Sinai School of Medicine
New York, New York
gUniversity of Essen
hPennsylvania State University School of Medicine
iUniversity of Adelaide
kChildren’s Hospital of Pittsburgh
1. Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, Janssen OE, Legro RS, Norman RJ, Taylor AE, Witchel SF; and Task Force on the Phenotype of the Polycystic Ovary Syndrome of The Androgen Excess and PCOS Society. The Androgen Excess and PCOS Society Criteria for the Polycystic Ovary Syndrome: The Complete Task Force Report. Fertil Steril 91:456-88, 2009.
2. Azziz R. Diagnosing the diagnosis: Why we must standardize the defining features of PCOS. Ann Clin Biochem 45:3-5, 2008.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.03.111