The Combination of Increased Ovarian Volume and Follicle Number is Associated with More Severe Hyperandrogenism in German Women with Polycystic Ovary Syndrome

Introduction

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of reproductive age, with a prevalence of 5 - 10 % depending on their ethnic background ([Asuncion et al., 2000]; [Azziz et al., 2004]). Recently, a controversy of the diagnostic criteria of PCOS has arisen. While both NIH ([Dunaif, 1997]) and Rotterdam ([Carmina, 2004]; [ESHRE/ASRM, 2004]) definitions exclude other pituitary, adrenal and ovarian pathologies, the 1990 NIH criteria include chronic anovulation and hyperandrogenism, but the 2003 Rotterdam consensus meeting introduced polycystic ovaries (PCO) as an additional third criterion, requiring two out of three to diagnose PCOS. To fulfill the new PCO criteria, either 12 or more follicles measuring 2 - 9 mm or an increased ovarian volume greater than 10 ml has to be found on ovarian ultrasound. In a recent survey, gynaecologists were more likely to express that PCO on ultrasound were essential for the diagnosis of PCOS than endocrinologists ([Cussons et al., 2005]). The difficulties in finding a common definition of PCOS reflect the heterogeneity of this syndrome. In addition, data about the significance of polycystic ovaries for endocrine and metabolic characteristics in PCOS women are conflicting. Some researchers found a correlation between ovarian morphology and parameters of insulin resistance ([Adams et al., 2004]; [Pache et al., 1993]), while others failed to find an association of PCO with metabolic risk factors and insulin resistance ([Legro et al., 2005]; [Michelmore et al., 1999]; [Norman et al., 1995]; [Raskauskiene et al., 2005]). In PCOS women presenting with PCO, significantly higher LH to FSH ratios have been described ([Herter et al., 1993]; [Legro et al., 2005]; [van der Westhuizen and van der Spuy, 1996]). In oligomenorrhoic women, ovarian volume as well as follicle number correlated with clinical and biochemical signs of hyperandrogenism ([Pache et al., 1993]). In healthy volunteers without hormonal contraception, testosterone concentrations were found to be significantly higher in women presenting with PCO ([Michelmore et al., 1999]). However, no impact on androgen levels and steroid hormones was detected by other study groups ([Najmabadi et al., 1997]).

The Rotterdam 2003 PCO definition ([Balen et al., 2003]) includes the two main features of PCO, namely an increased number of follicles and an indirect measure of stromal hypertrophy by ovarian volume. The influence of these two factors, either alone or in combination with menstrual cyclicity, clinical signs of hyperandrogenism and fertility is still unclear. Recent studies using the current PCO definition focused only on the biochemical endocrine and metabolic aspects of PCOS and failed to quantify the number of ovarian follicles and its impact on typical clinical PCOS features.

We conducted this study to evaluate the prevalence of PCO in German PCOS women and whether there are clinical and biochemical differences in PCOS with and without PCO. In addition, we were interested in the question whether volume or follicle number or its combination are associated with typical PCOS features like hyperandrogenism or metabolic disturbances.

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