Ultrasound Diagnosis of Polycystic Ovarian Syndrome: Current Guidelines, Criticism and Possible Update

Research Article

Austin J Obstet Gynecol.2017; 4(2): 1073.

Ultrasound Diagnosis of Polycystic Ovarian Syndrome: Current Guidelines, Criticism and Possible Update

Fulghesu AM, Canu E*, Porru C and Cappai A

Department of Scienze Chirurgiche, University of Cagliari, Cagliari, Italy

*Corresponding author: Elena Canu, Department of Scienze Chirurgiche, University of Cagliari, Cagliari, Italy

Received: August 29, 2017; Accepted: October 25, 2017; Published: November 01, 2017

Abstract

The US diagnosis of PCOS is still an open problem. The frequency of over diagnosis in particular phase of reproductive age, the contrasting guidelines and the technological advances lead to be a difficult charge for the sonographer. Follicle number and disposition and ovarian volume represents most used criteria, but other aspects as stromal study and ovarian vascularization could help. On the other hand, recently, the introduction of Anti-mullerian hormone assay introduced a support for US diagnosis.

Keywords: PCOS; US; FNPS; FNPO; S/A ratio

Abbreviations

AFC: Antral follicular count; AMH: Anti-mullerian hormone; FNPO: Follicle number per ovary; FNPS: Follicle number per section; LH: Luteinizing hormone; PCO: Polycystic Ovary; PCOM: Polycystic Ovarian Morphology PCOS: Polycystic Ovary Syndrome; S/A: Stroma/Area (Ovarian stromal area to total ovarian area); TA: Transabdominal; TV: Transvaginal; US: Ultrasonography, Ultrasonographic

Introduction

Body text

Definition: Polycystic ovarian syndrome is the most common female endocrine disorder, affecting 5-10% of women in the reproductive age [1]. PCOS has a wide variety of clinical manifestations: from alterations of the menstrual cycle secondary to ovulatory dysfunction, to dermatological manifestations, such acne and hirsutism, to metabolic alterations, often accompanied by ultrasound features of polycystic ovaries [2].

From the introduction in the current clinical practice of the first clinical screening of gynecological health in young women and the use of the pelvic ultrasound as routine exam, the diagnosis of PCOS are increased to the point that it is calculated that every four healthy girls, at least one was diagnosed of PCOS [3].

The definition of polycystic ovarian syndrome represents a clinical debate between specialists interested to pelvic ultrasound and/or gynecological endocrinology and constitutes a discussion topic in the literature.

Stein and Leventhal [4] discovered in 1935 the existence of a precise association between some clinical elements (infertility, amenorrhea, hirsutism and obesity) and the morphology of the ovaries: increased volume and pearly appearance and texture. From 1935 many other definitions have been proposed and the two main used by authors in the last twenty years are those of the NIH/NICHD (National Institute of Health/National Institute of Child Health and Human Development) of 1990 [5] and that of the Consensus of Rotterdam (2003) [6].

The definition proposed by NIH/NICHD envisages the presence of clinical hyperandrogenism or hyperandrogenemia, oligo or an ovulation and the exclusion of other disorders that cause hyperandrogenism, as congenital adrenal hyperplasia, androgen secreting neoplasms, hyperprolactinemia and thyroid dysfunction. This definition would exclude the use of ultrasound in diagnosis and this is not supported by many authors.

Current Guidelines

Recent diagnostic criteria proposed by the American Society of Reproductive Medicine (ASRM) and European Society of Human Reproduction and Embryology (ESHRE) in 2003 [7], as well as by the Androgen Excess and PCOS Society in 2006 [8], have reasserted the importance of ovarian morphology to the diagnosis of PCOS.

The consensus establishes, that the diagnosis of PCOS, may be done in the presence of at least two of the following symptoms (excluding other causes of hyperandrogenism):

- Oligoanovulation (oligoamenorrhea)

- Clinical hyperandrogenism and/or biological hyperandrogenemia

- Polycystic ovary morphology at ultrasound

About the phenotype, with the adoption of the Rotterdam criteria, two new subtypes have been introduced (not included in the criteria of the NIH, 1990): in addition to patients with ovulatory problems and hyperandrogenism (both with and without ovary PCO to US examination), fall within the definition of PCOS two other groups of patients, i.e. patients with anovulation and PCO ovary but without signs of hyperandrogenism, and patients with PCO ovary and hyperandrogenism but with normal ovulatory cycles.

Ultrasonographic features of polycystic ovaries and clinical correlates

From Consensus, ovarian ultrasound evaluation becomes a crucial stage in the diagnostic work-up of PCOS. The introduction of endovaginal probes with excellent sharpness of the image made possible to study more precisely both the size and the ovarian morphology, also in obese patients, in which the transabdominal scan was not sufficiently reliable.

For more than 15 years sonographic criteria to define the polycystic ovary was heavily influenced by the definition of Adams et al [9]: multiple follicles (n> 10) of small size (average diameter 2-8 mm) arranged in the subcortical seat around a hyperechogenic stroma and with enlarged volume ovaries (> 8ml).

In 2003, the Consensus Conference of Rotterdam [6], considering the literature, redefined the sonographic criteria of polycystic ovaries:

- Presence of at least 12 follicles in each ovary: the calculation must take account of all the follicles present, from the inner edge to the outer one, regardless of their arrangement and, for a more exhaustive study, different sections produced on different planes must be evaluated (Figure 1);