Polycystic ovarian syndrome: role of imaging in diagnosis.

Polycystic ovarian syndrome (PCOS) is the most common endocrine abnormality in women of reproductive age and carries with it significant health risks, including infertility, endometrial hyperplasia, diabetes, and cardiovascular disease. The workup of PCOS has evolved to include the use of pelvic ultrasonography (US). Ovarian imaging is crucial in the evaluation of patients with suspected PCOS. Although findings of polycystic ovaries are commonly seen at routine US and are frequently not associated with PCOS, awareness of the criteria and definitions used in the diagnosis of PCOS is important, especially in patients who are being evaluated for ovulatory dysfunction or hyperandrogenism. The imaging report should be specific and should include ovarian volumes and antral follicle counts, in addition to other pertinent findings (eg, the presence of a dominant follicle or corpus luteum). Because patients are frequently referred for radiologic imaging as a part of clinical workup, and polycystic ovaries are a common incidental finding in women undergoing US for other gynecologic complaints, radiologists should be aware of the current diagnostic criteria for PCOS, the role of imaging in workup for this abnormality, and the pertinent reporting parameters for pelvic US.

Serum biomarkers for detecting ectopic pregnancy.

Unless an ectopic pregnancy is visible by ultrasound, diagnosis can be a challenge. Differentiating ectopic pregnancies from intrauterine pregnancies can be impossible without intervention or follow-up. This poses a clinical dilemma to the practitioner given the inherent danger to the mother of tubal rupture of an ectopic pregnancy versus the fear of intervening in the case of a desired pregnancy without certainty of diagnosis. Early diagnostic modalities are clearly lacking, and serum biomarkers are currently being investigated as a solution to need for a rapid and accurate test for ectopic pregnancy.

Part 2: Ovarian failure in adolescent cancer survivors should be treated.

Teenage girls who have survived childhood and adolescent cancer are at risk of losing ovarian function as a result of treatment. This iatrogenic complication may compromise their ability to conceive in the future. In addition, the more immediate consequence is interference in the physical, sexual, and psychosocial development of the female adolescent and her ability to "graduate" into young adulthood. This paper lends strong support to meticulous, graduated hormone replacement, mimicking Tanner's stages of pubertal development, to allow smooth transition of adolescent cancer survivors into adulthood.

A disintegrin and metalloprotease protein-12 as a novel marker for the diagnosis of ectopic pregnancy.

OBJECTIVE: To evaluate the performance of a novel biomarker, a disintegrin and metalloprotease-12 (ADAM-12), to differentiate an ectopic pregnancy (EP) from normal intrauterine pregnancies (IUPs). DESIGN: Case-control study. SETTING: Three urban academic centers. PATIENT(S): Women who were seen in the emergency department with pain or bleeding in the first trimester of pregnancy. INTERVENTION(S): Sera from women with diagnosed EP or IUP were evaluated via proteomics and an ADAM-12 dissociation-enhanced lanthanide fluoroimmunoassay. MAIN OUTCOME MEASURE(S): Differences between groups, area under the receiver operating curve, sensitivity, and specificity. RESULT(S): Via a proteomics evaluation, we found a statistically significant decrease in ADAM-12 in the sera of patients with EP, which we confirmed in a larger group of 199 patients (median IUP 18.6 ng/mL versus median EP 2.5 ng/mL with good discrimination between the groups as assessed by receiver operating characteristics [area under the curve = 0.82]). At a low cut-point, the sensitivity was 70% and specificity 84%, but, at a higher cut-point optimizing sensitivity, the ADAM-12 test demonstrated a sensitivity of 97%. CONCLUSION(S): ADAM-12 is a promising marker for the diagnosis of EP in women with symptoms in the first trimester, validating the proteomics findings. Further studies in additional patient populations and in combination with other biomarkers are needed.

Development of a multiple marker test for ectopic pregnancy.

OBJECTIVE: Many serum markers have been proposed to aid in the identification of an ectopic pregnancy, but few have been validated. Most studies have been limited by sample size and design. The goal of this study was to assess putative markers to identify which can be optimally combined. METHODS: We conducted a case-control study using sera from 100 patients with ectopic pregnancy and 100 patients with intrauterine pregnancy who presented to three urban academic centers between September 2000 and April 2009 with first-trimester pain or bleeding. Samples were analyzed for 12 promising biomarkers. Classification tree analysis was used to examine markers simultaneously with the goal of optimizing the accuracy of ectopic pregnancy diagnosis, and validation was performed using bootstrapping. RESULTS: Six of the 12 markers were differentially expressed between those with ectopic pregnancy and intrauterine pregnancy (P<.001) with fair diagnostic properties (area under the curve greater than 0.6) when examined individually (inhibin A, progesterone, activin A, vascular endothelial growth factor [VEGF], pregnancy-specific ß-1-glycoprotein, and pregnancy-associated plasma protein-A). Six additional markers were found to have limited value. Using a two-step diagnostic algorithm with four markers (progesterone, VEGF, inhibin A, activin A), we diagnosed 42% of the sample with perfect specificity and 98% (93-100%) sensitivity. Overall, a single ectopic pregnancy was misclassified, achieving 99% (96-100%) accuracy. CONCLUSION: Evaluating a large number of biomarkers simultaneously demonstrates that most of the putative markers of ectopic pregnancy are not useful. However, a select few can distinguish ectopic pregnancy from intrauterine pregnancy with superior accuracy as part of a multiple marker test. CLINICAL TRIAL REGISTRATION: : ClinicalTrials.gov, www.clinicaltrials.gov, NCT00194168.

Predictors of pregnancy in women with polycystic ovary syndrome.

CONTEXT: Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility. The selection of first-line therapies for ovulation induction is empiric. OBJECTIVE: The aim of the study was to develop a clinically useful predictive model of live birth with varying ovulation induction methods. DESIGN, SETTING, AND PARTICIPANTS: We built four prognostic models from a large multicenter randomized controlled infertility trial of 626 women with PCOS performed at academic health centers in the United States to predict success of ovulation, conception, pregnancy, and live birth, evaluating the influence of patients' baseline characteristics. INTERVENTIONS: Ovulation was induced with clomiphene, metformin, or the combination of both for up to six cycles or conception. MAIN OUTCOME MEASURE: The primary outcome of the trial was the rate of live births. RESULTS: Baseline free androgen index, baseline proinsulin level, interaction of treatment arm with body mass index, and duration of attempting conception were significant predictors in all four models. History of a prior loss predicted ovulation and conception, but not pregnancy or live birth. A modified Ferriman Gallwey hirsutism score of less than 8 was predictive of conception, pregnancy, and live birth (although it did not predict ovulation success). Age was a divergent predictor based on outcome; age greater than 34 predicted ovulation, whereas age less than 35 was a predictive factor for a successful pregnancy and live birth. Smoking history had no predictive value. CONCLUSIONS: A live birth prediction chart developed from basic clinical parameters (body mass index, age, hirsutism score, and duration of attempting conception) may help physicians counsel and select infertility treatments for women with PCOS.