FERTILITY
When to start additional therapy. If regular menses do not occur within 3 months on metformin alone, I add additional therapy as indicated.
A new way to define PCOS
Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81:19–25.
The addition of ultrasonographic criteria for the diagnosis has effectively nearly doubled the prevalence of PCOS in the United States—and justifies the use of ultrasound to make the diagnosis.
In conjunction with the shift toward metformin as first-line therapy for ovulation induction in women with PCOS, it is important that ObGyns incorporate the latest clinical criteria for the diagnosis of PCOS.
3 clinical indicators
The “Rotterdam Criteria” from the 2003 Consensus Conference require 2 out of 3 clinical indicators to make the diagnosis:
- Oligo- or anovulation,
- Clinical and/or biochemical signs of hyperandrogenism, and
- Polycystic ovaries as evidenced on ultrasound or histology. Ultrasound criteria for polycystic ovaries are specific: increased stroma-to-follicle ratio with multiple subcapsular early antral follicles.
It is also important to note that the diagnosis is primarily clinical, not biochemical, thereby shifting the emphasis to history, physical examination and ultrasound. It also requires the exclusion of other endocrinologic diseases such as thyroid or prolactin disorders, Cushing’s syndrome, or adult onset congenital adrenal hyperplasia.
The addition of ultrasonographic criteria for the diagnosis has effectively nearly doubled the prevalence of PCOS in the United States—and justifies the use of ultrasound to make the diagnosis.
When to use ultrasound in the diagnosis of PCOS
If you suspect PCOS but the patient has only oligo/anovulation or evidence of hyperandrogenism, it is quite reasonable to use vaginal ultrasound to establish the diagnosis, if the strict sonographic criteria are met.
If she has both oligo/anovulation and evidence of hyperandrogenism, however, the diagnosis is established and ultrasound is not necessary.
More promise for fertility preservation
Johnson J, Bagley J, Skaznik-Wikiel M, et al. Oocyte generation in adult mammalian ovaries by putative germ cells in bone marrow and peripheral blood. Cell. 2005;122:303–315.
For women interested in preserving their fertility, this finding suggests the possibility of harvesting and storing oogonial stem cells from a simple blood draw.
In a follow-up from Jonathan Tilly’s lab as reported in this column last year, this paper describes the latest advance in the oogonial stem cell story. The authors report that both bone marrow transplantation and peripheral blood transplantation restored oocytes in the ovaries of mice sterilized with chemotherapy. While the reproductive competence of the restored oocytes has not yet been determined, these findings suggest that germ line stem cells may reside in bone marrow and circulate in the blood stream.
Although a great deal of work is required to verify these findings and demonstrate them in humans, they highlight the astounding progress in the field of stem cell biology and emphasize the promise for fertility preservation in the future.
The author reports no financial relationships relevant to this article.
