A comprehensive review of the new FIGO classification of ovulatory disorders.

BACKGROUND: The World Health Organization (WHO) system for the classification of disorders of ovulation was produced 50 years ago and, by international consensus, has been updated by the International Federation of Gynecology and Obstetrics (FIGO). OBJECTIVE AND RATIONALE: This review outlines in detail each component of the FIGO HyPO-P (hypothalamic, pituitary, ovarian, PCOS) classification with a concise description of each cause, and thereby provides a systematic method for diagnosis and management. SEARCH METHODS: We searched the published articles in the PubMed database in the English-language literature until October 2022, containing the keywords ovulatory disorders; ovulatory dysfunction; anovulation, and each subheading in the FIGO HyPO-P classification. We did not include abstracts or conference proceedings because the data are usually difficult to assess. OUTCOMES: We present the most comprehensive review of all disorders of ovulation, published systematically according to the logical FIGO classification. WIDER IMPLICATIONS: Improving the diagnosis of an individual's ovulatory dysfunction will significantly impact clinical practice by enabling healthcare practitioners to make a precise diagnosis and plan appropriate management.

Hyperandrogenism.

Hyperandrogenism is a common condition encountered by pediatric and adolescent physicians. Most girls with hyperandrogenism represent physiological pubertal variation; pathology may be present in a substantial minority. Systematic evaluation is essential to avoid unnecessary work-up in physiological causes while not missing pathological causes. Polycystic ovarian syndrome (PCOS), unexplained, persistent hyperandrogenism of ovarian origin, is the most common form in adolescent girls. The high prevalence of physiological peripubertal hirsutism, anovulation, and polycystic ovarian morphology results in mislabeling many girls as having the polycystic ovarian syndrome, a disorder with lifelong implications. The use of strict criteria of age-specific anovulation, hyperandrogenism, and duration is essential to reduce their stigmatization. The exclusion of secondary causes by screening tests (cortisol, thyroid profile, prolactin, and 17OHP) is essential before undertaking treatment for PCOS. Lifestyle measures, estrogen-progesterone preparations, antiandrogens, and metformin are the cornerstone of managing the disorder.

[PCOS - desire for children and pregnancy]. / PCOS ­ Kinderwunsch und Schwangerschaft.

Polycystic ovary syndrome (PCOS) is diagnosed according to the Rotterdam criteria, where two of the following three criteria must be met: Anovulation, hyperandrogenism, and characteristic morphology by sonography. Women diagnosed with PCOS are at higher risk for diabetes and impaired glucose tolerance. Therefore, these women should be carefully counselled about lifestyle measures and improvements in fertility and pregnancy outcomes. Some women benefit from metformin, which needs to be clarified by off-label use. For fertility, mild stimulation is possible in women with unovulatory cycles, whereas women with PCOS need to be monitored more closely for the development of gestational diabetes, preeclampsia or hypertension during pregnancy.

Female Pelvic Conditions: Polycystic Ovary Syndrome.

It is estimated that polycystic ovary syndrome (PCOS) affects about 10% of women of reproductive age in the United States. Principal risk factors include obesity and a family history of PCOS. A diagnosis of PCOS should be considered in women with irregular or absent menstrual cycles, issues related to hyperandrogenism, or infertility. The Rotterdam diagnostic criteria require two of the following three factors: oligo- or anovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries identified on ultrasonography. Laboratory tests are recommended to rule out other conditions and factors, including thyroid conditions, hyperprolactinemia, atypical congenital adrenal hyperplasia, and tumors. The mainstays of treatment are lifestyle changes to achieve weight loss and combination oral contraceptives (COCs). (PCOS is an off-label use of COCs.) A weight loss of 5% to 10% has been shown to decrease PCOS symptoms. Medical or surgical management of obesity may be indicated. COCs provide endometrial protection and help manage acne and hirsutism. (Hirsutism is an off-label use of COCs. Acne is an off-label use of some COCs.) Routine acne treatments also are used. Hirsutism may improve with topical cosmetic treatments, spironolactone, or finasteride. (Hirsutism is an off-label use of spironolactone and finasteride.) Infertility is a common issue in patients with PCOS. The aromatase inhibitor letrozole is the first-line treatment for PCOS-related anovulation. Gonadotropin-releasing hormone analogues also are used to induce ovulation. (This is an off-label use of letrozole and gonadotropin-releasing hormone analogues.).

The Prevalence of Polycystic Ovary Syndrome, Its Phenotypes and Cardio-Metabolic Features in a Community Sample of Iranian Population: Tehran Lipid and Glucose Study.

Objectives: The aim of the present study was to evaluate the prevalence of polycystic ovary syndrome (PCOS), its phenotypical and cardio-metabolic features in a community sample of the Iranian population in comparison to healthy eumenorrheic, non-hirsute women without polycystic ovaries. The second aim was to assess the cardio-metabolic characteristics of women who suffered from one criteria of PCOS compared to those healthy eumenorrheic, non-hirsute women. Methods: In this cross-sectional population-based study, a total of 1,960 eligible women, aged (18-45 years) were recruited from the Tehran-Lipid and Glucose-Study participants and were classified as the three groups of (i) women with PCOS by the Rotterdam criteria, (ii) non-PCOS women with one criteria of PCOS and (iii) healthy eumenorrheic, non-hirsute women without polycystic ovaries morphology (PCOM) as the control group. Further PCOS women were extended to four phenotypes of hyperandrogenism, oligo-anovulation, polycystic ovaries (phenotype A), hyperandrogenism, oligo/anovulation (phenotype B), hyperandrogenism, polycystic ovaries (phenotype C) and oligo-anovulation, polycystic ovaries (phenotype D). Cardio-metabolic profiles and the prevalence of comorbidities of metabolic syndrome (MetS) and lipid abnormalities were compared among these groups linear, and the median regression models adjusted for age and body mass index. Results: The prevalence of PCOS according to the diagnostic criteria of the NIH, Rotterdam and AE-PCOS Society were 13.6, 19.4, and 17.8, respectively. Among those who met the Rotterdam criteria, 23.9, 46.3, 21.6, and 8.2% had phenotypes A, B, C, and D, respectively. Among the remaining 1,580 women who did not fulfil the PCOS criteria, 108 (6.8%) suffered from only oligo/anovulation, 332 (21%) only hyperandrogenism/hyperandrogenemia, 159 (16.2%) only PCOM in ultrasound and 981 (62%) were healthy eumenorrheic, non-hirsute women without PCOM. The study revealed that some adiposity indices and lipid abnormalities in PCOS phenotypes with hyperandrogenism (A, B, and C) were worse than in healthy women. By contrast, women with phenotype D did not differ from the healthy ones in terms of adiposity and lipid abnormalities. However, the respective values for other cardio-metabolic profiles and MetS rates in different phenotypes of PCOS were similar to the healthy women. Only the prevalence of MetS in phenotype A was significantly higher than in the healthy women. There were no statistically significant differences between participants with one criteria of PCOS and healthy counterparts in terms of most adiposity indexes, cardio-metabolic factors, and comorbidity of MetS and its components. However, women with hyperandrogenism had a significantly higher level of the waist to height ratio (WHtR) and hypertriglyceridemia than their healthy counterparts. Conclusion: PCOS, mainly classical phenotypes A and B, are common among Iranian women of reproductive age. Women with PCOS who had androgen excess exhibited the worst lipid profile, and those who had full three criteria of the syndrome exhibited the higher rate of MetS. However, women with only ovulatory dysfunction and only PCOM had similar cardio-metabolic characteristics, compared to healthy subjects. These data suggest that routine screening for metabolic disturbances may be needed in the prevention of cardio-metabolic disorders in patients with more serious phenotypes of PCOS.

Polycystic Ovarian Syndrome Treated with Individualized Homeopathy: A Case Report.

Introduction: Polycystic ovarian syndrome (PCOS) is a polygenic, multifactorial, syndromic disorder with reproductive, endocrine, and metabolic dysfunction seen in reproductive aged women (12-45 years). The exact cause is not known may involve increased luteinizing hormone, increased insulin levels, and a defect in androgen synthesis. The symptoms include anovulation, irregular menses, and hyperandrogenism. It is clinically manifested by hirsutism, acne, and androgenic alopecia. Health care practitioners continue to seek a cure for PCOS as it is increasing in frequency and is one of the major causes of anovulatory infertility. Methods: The case was recorded in the gynaecological department at the Homoeopathic Medical College and Research Centre. An 18- year-old female patient with PCOS was treated with individualised homeopathy (iHOM) medicine between 26th September 2019 and 26th November 2020. During the follow-up visits, treatment outcomes were assessed. To assess whether the changes were due to homoeopathic medicine, an assessment using the modified Naranjo criteria was performed. Results: Over an observational period of 1 year, beneficial result from iHOM medicine was seen. This treatment method can be used by the physicians in the treatment of PCOS as a complementary health practice. Conclusion: Considering the multi-factorial aetiology of PCOS, iHOM medicine with lifestyle modification is helpful in treating PCOS.

Hyperandrogenic Anovulation: Differential Diagnosis and Evaluation.

Hyperandrogenic anovulation refers to the constellation of disorders that present in women with irregular menses, hirsutism and/or acne across the lifespan. Understanding the clinical signs and symptoms of each diagnosis in the differential and laboratory testing to confirm or exclude a diagnosis allows a clinician to appropriately counsel and treat the patient.

A patient-specific model combining antimüllerian hormone and body mass index as a predictor of polycystic ovary syndrome and other oligo-anovulation disorders.

OBJECTIVE: To determine whether a patient-specific predictive model combining antimüllerian hormone (AMH) levels and body mass index (BMI) can aid in the diagnosis of polycystic ovary syndrome (PCOS) and other ovulatory dysfunction disorders (OVDYS) among infertile women. DESIGN: Retrospective cohort study. SETTING: Academic fertility center. PATIENT(S): One thousand and ten infertile women undergoing 3,160 intrauterine insemination (IUI) cycles, stratified by diagnosis in three groups: PCOS, OVDYS, and other etiologies. INTERVENTION(S): Ovulation induction followed by IUI or ultrasound-monitored natural cycles. MAIN OUTCOME MEASURE(S): The probability of either PCOS or OVDYS diagnosis based on AMH levels alone and a patient-specific predictive model that combines serum AMH and patient's BMI. RESULT(S): Median and interquartile range (IQR) for the serum AMH levels (ng/mL) were the highest in women with PCOS, and lowest in those with other infertility causes. Overall, for every 1 ng/mL increase in AMH, the odds of PCOS and OVDYS versus other causes increased by 55% and 24%, respectively. Postestimation from multivariate logistic regression models showed that PCOS diagnosis can be predicted with lower AMH values in women with a higher BMI compared with the AMH values predicting PCOS in normal-weight or underweight patients. The receiver operating characteristic curves reinforced these findings, and the best cutoffs for PCOS diagnosis were 7.5, 4.4, and 4.1 ng/mL for women belonging to the BMI groups 18.5-24.9, 25.0-29.9, and ≥30.0 kg/m2, respectively. CONCLUSION(S): Taking into account AMH and BMI, we developed a model that predicts the probability of an oligo-anovulation diagnosis, thus facilitating patient-specific counseling in the infertility setting.

Ultrasonographic and biochemical assessments as early prediction of polycystic ovarian syndrome in obese women.

BACKGROUND: Polycystic ovary syndrome (PCOS) is considered as a common cause of hormonal disturbance and obesity. The diagnosis of PCOS was done by different methods including clinical signs as anovulation, hyperandrogenism, biochemical markers and ultrasounographic investigation. This study investigated comparative outcomes of ultrasonographic and biochemical markers for early prediction of PCOS in obese women. SUBJECTS AND METHODS: Seventy-five patients were clinically diagnosed with obese, PCOS and obese with PCOS and twenty-five normal age matched subjects were enrolled as control. Abdominal and transvaginal ultrasonographic for assessment of ovarian properties. In addition, BMI, serum free testosterone, dehydroepiandrosterone (DHEA), insulin, glycosylated hemoglobin (HbA1c) and LDL-c levels were evaluated. RESULT: In obese patients with PCOs (20%) ovaries revealed normal appearance in morphology while the rest (80%) showed PCOs in the form of cysts of 2-8 mm in diameter peripherally arranged around stroma. A significant elevation of free testosterone, DHEA and insulin in obese with or without PCOS compared with obese group (p<0.001). A positive correlation with hormonal abnormalities of increased HA1c, LDL-c, free testosterone, DHEA and insulin compared with obese only. CONCLUSION: According to our study findings, ovarian morphology combined with biochemical markers is more reliable for early prediction and diagnosis of PCOS for interpretation and management.

Use of exogenous gonadotropins for ovulation induction in anovulatory women: a committee opinion.

This document reviews gonadotropin treatment for ovulation induction in anovulatory women and outlines the recommended pretreatment evaluation, indications, treatment regimens, and complications of gonadotropin treatment. It replaces the document with a similar name, last published in 2008 (Fertil Steril 2008;90:S7-12).

Use of AMH in the Differential Diagnosis of Anovulatory Disorders Including PCOS.

Since the historical use of gonadotrophin and estradiol levels to define the different anovulatory disorders has shown some limitations, the use of other markers such as anti-müllerian hormone (AMH) has been proposed. This review addresses the role of AMH in the differential diagnosis of anovulatory disorders, especially focusing on its value in the prognostic characterization of their severity. Current limitations and future clinical applications are discussed.

Pre-ovulatory follicular temperature in bi-ovular cows.

In a previous study on monovular cows, follicles revealed a mean antral (follicular fluid) temperature 1.54°C cooler than rectal temperatures in ovulating cows, whereas no such temperature differences were detected in non-ovulating cows. The present study adds to our previous work, this time considering 24 bi-ovular cows (one follicle per ovary). In order to increase the number of pre-ovulatory follicles failing to ovulate, this study was performed under heat-stress conditions. Follicular temperatures of the ovulating follicles (n = 31) were 0.93°C significantly cooler (P < 0.0001) than rectal temperatures, whereas no significant differences in temperature were found in non-ovulating follicles (n = 17). Eight cows became pregnant. The results of the present study indicate that, similar to those in monovular cows, pre-ovulatory follicles in bi-ovular cows were cooler than deep rectal temperatures and those temperature gradients were not found in follicles showing ovulation failure.

Biomarkers in abnormal uterine bleeding†.

Abnormal uterine bleeding (AUB) is an extremely common problem and represents a clinical area of unmet need. It has clinical implications and a high cost for the healthcare system. The PALM-COEIN acronym proposed by FIGO may be used as a foundation of care; it improves the understanding of the causes of AUB, and in doing so facilitates effective history taking, examination, investigations, and management. Heavy menstrual bleeding, a subset of AUB, is a subjective diagnosis and should be managed in the context of improving the woman's quality of life. Available evidence suggests that there is poor satisfaction with standard treatment options often resulting in women opting for major surgery such as hysterectomy. Such women would benefit from a tailored approach, both for diagnosis and treatment, highlighting the deficiency of biomarkers in this area. This article focuses on the causes of AUB as per the PALM-COEIN acronym, the researched biomarkers in this area, and the potential pathogenetic mechanisms. In the future, these approaches may improve our understanding of AUB, thereby enabling us to direct women to most suitable current treatments and tailor investigative and treatment strategies to ensure best outcomes, in keeping with the principles of personalized or precision medicine.

Oligo-anovulation is not a rarer feature in women with documented endometriosis.

OBJECTIVE: To study the prevalence of oligo-anovulation in women suffering from endometriosis compared to that of women without endometriosis. DESIGN: A single-center, cross-sectional study. SETTING: University hospital-based research center. PATIENT (S): We included 354 women with histologically proven endometriosis and 474 women in whom endometriosis was surgically ruled out between 2004 and 2016. INTERVENTION: None. MAIN OUTCOME MEASURE(S): Frequency of oligo-anovulation in women with endometriosis as compared to that prevailing in the disease-free reference group. RESULTS: There was no difference in the rate of oligo-anovulation between women with endometriosis (15.0%) and the reference group (11.2%). Regarding the endometriosis phenotype, oligo-anovulation was reported in 12 (18.2%) superficial peritoneal endometriosis, 12 (10.6%) ovarian endometrioma, and 29 (16.6%) deep infiltrating endometriosis. CONCLUSION(S): Endometriosis should not be discounted in women presenting with oligo-anovulation.

Anti-müllerian hormone in the pathophysiology and diagnosis of polycystic ovarian syndrome.

PURPOSE OF REVIEW: Polycystic ovarian syndrome (PCOS) is the most common cause of chronic anovulation and hyperandrogenism in young women and represents a true public health concern and an economic burden. RECENT FINDINGS: The pathophysiology of PCOS is still not fully understood, but progresses have been made and the relationships between anti mullerian hormone (AMH), follicle stimulating hormone, luteinizing hormone, E2 and androgens have been explored. The follicle excess plays a central role in the syndrome and AMH is definitively a major component of this phenomena. SUMMARY: The aim of this chapter is to present the recent work studying the role of AMH in the pathophysiology of PCOS and to discuss the improvement that serum AMH assay brings in the diagnosis of PCOS.

Understanding variation in prevalence estimates of polycystic ovary syndrome: a systematic review and meta-analysis.

BACKGROUND: Polycystic ovary syndrome (PCOS) prevalence estimates vary when different diagnostic criteria are applied. Lack of standardization of individual elements within these criteria may contribute to prevalence differences. OBJECTIVE AND RATIONALE: A systematic review of studies reporting prevalence of PCOS, using at least one of the National Institutes of Health (NIH), Rotterdam or Androgen Excess Society (AE-PCOS) criteria, was conducted. The aim was to investigate the impact on prevalence reporting of different definitions of the clinical elements for PCOS diagnosis. SEARCH METHODS: A systematic search of Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Emcare and BIOSIS was conducted. The search was limited to English language and studies published between January 1990 and January 2018. Included articles needed to define PCOS by at least one of the NIH, Rotterdam or AE-PCOS criteria, be of an unselected population and be published as a full text article. Risk-of-bias was assessed. OUTCOMES: A total of 21 studies met the inclusion criteria. The random-effects pooled prevalence of PCOS in studies that used the NIH criteria (7% [95% CI: 6-7%]), was significantly different from that identified in studies that used the Rotterdam criteria (12% [95% CI: 10-15%], P < 0.0001) but not studies that used the AE-PCOS criteria (10% [95% CI: 6-13%], P = 0.075). The pooled estimates for Rotterdam and AE-PCOS were not significantly different from each other (P = 0.201). Pooled prevalence estimates were compared between studies separated on the basis of: oligo-amenorrhoea vs oligo-amenorrhoea plus short cycles, clinical androgen excess requiring hirsutism vs any clinical androgen excess, use of different versions and cut-offs for the Ferriman-Gallwey (F-G) score, and inclusion vs non-inclusion of oral contraceptive users. There were no statistically significant differences for any of these comparisons. There was insufficient information to allow subgroup analyses of definitions of polycystic ovaries. WIDER IMPLICATIONS: Inclusion of ovarian morphology results in statistically significantly higher pooled prevalence estimates for PCOS. Heterogeneity in prevalence estimates for PCOS reflect the broad clinical spectrum of the condition, lack of standardization of the elements within each set of diagnostic criteria and the use of a range of diagnostic cut-offs, as well as potential differences between study populations. The use of different definitions for anovulation and clinical androgen excess did not appear to contribute to differences in the estimated prevalence of PCOS in this study. However, as the number of studies in most of the comparison groups was small, real differences may have been missed. Uncertainty surrounding the diagnosis of PCOS urgently needs to be addressed in order to provide clinicians and their patients with greater diagnostic certainty, and hence reduce inappropriate labelling and the potential psychological harm that may accompany misdiagnosis.

C-Reactive protein in relation to fecundability and anovulation among eumenorrheic women.

OBJECTIVE: To assess systemic inflammation in relation to fecundability and anovulation. DESIGN: Prospective cohort study among participants in the Effects of Aspirin in Gestation and Reproduction trial who were assigned to the placebo. SETTING: Academic medical centers. PATIENT(S): Healthy eumenorrheic women (n = 572), 18-40 years of age, with one or two pregnancy losses, attempting spontaneous pregnancy. INTERVENTION(S): Baseline serum high-sensitivity C-reactive protein (hsCRP) values <10 mg/L were categorized into tertiles. MAIN OUTCOME MEASURE(S): Discrete Cox proportional hazards models estimated the fecundability odds ratio (FOR) and 95% confidence interval (CI) and adjusted for potential confounders. Log-binomial regression estimated the risk ratio (RR) and 95% CI of anovulation. The algorithm to define anovulation used data on urinary concentrations of hCG, pregnanediol-3-glucuronide, and LH as well as fertility monitor readings. RESULT(S): Higher hsCRP was associated with reduced fecundability but not with an increased risk of anovulation. CONCLUSION(S): Among healthy women attempting pregnancy after one or two pregnancy losses, we found preliminary evidence that systemic inflammation is associated with reduced fecundability, but not independently from adiposity. Sporadic anovulation did not appear to drive this association. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT00467363.

Estudio y tratamiento de la anovulación en el síndrome de ovarios poliquísticos (2017) / Study and treatment of anovulation in polycystic ovary syndrome (2017)

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