Doppler study of uterine and ovarian vasculature during different phases of the menstrual cycle in Polycystic ovarian disease

Transcription

1 Doppler study of uterine and ovarian vasculature during different phases of the menstrual cycle in Polycystic ovarian disease A Thesis Submitted to the Faculty of Medicine at Cairo University For Fulfillment of Master Degree in Obstetrics and Gynecology By Hebat Allah Mohamed Ebrahim M.B., B.Ch. (2006) Faculty of Medicine Cairo University Supervised by Prof. Maged Ahmed Abd El Raauf Professor of obstetrics and gynecology Faculty of Medicine Cairo University Prof. Soha Talaat Hamed Professor of radiology Faculty of Medicine Cairo University Dr. Ahmed Mahmoud Hussin Lecturer of obstetrics and gynecology Faculty of Medicine Cairo University 2012

2 Firstly, I wish to express my sincere gratitude to Allah Allah who gave me the ability and patience to finish this work. I would like to express my deep appreciation and gratitude to Prof. Maged Ahmed Abd El Raauf, Professor of Obstetrics & Gynecology Faculty of Medicine, Cairo university, for his wise guidance, meticulous supervision, beneficial remarks, valuable instructions,for his continuous encouragement and great help throughout the work. Special thanks and gratitude to Prof. Soha Talaat Hamed professor of Radiology Faculty of Medicine Cairo university,, who her been kind enough to spare no effort and time to advice and supervise me and gave her experience to assist, in every possible way to accomplish his work. I would like to express my utmost t gratitude to Dr. Ahmed Mahmoud Hussin Lecturer of Obstetrics & Gynecology Faculty of Medicine Cairo university, for his encouragement, his kind supervision, that helped me too much to accomplish this work. Hebat Allh Mohamed Ebrahim

3 Parents, Family And Sheraz

4 CONTENTS Page Introduction 1 Aim of the Work 3 Review of Literature 4 o Anatomy of the ovary 4 o Polycystic ovary syndrome 5 o Etiology of polycystic ovary disease. 8 o Pathogenesis.10 o Long term health risks of polycystic ovary disease 11 o Diagnosis of Polycystic ovary diseas 12 o Management of PCOD 18 o Normal ultrasonography of the uterus and ovaries 24 o Ultrasonographic diagnosis of PCOD 29 o Doppler ultrasound 30 Patients and Methods 36 Illustrated cases 40 Results.. 48 Discussion Summary. 68 Conclusion 71 References.. 72 Arabic Summary 81

5 LIST OF FIGURES No. Title Page 1 Endovaginal ultrasonography normal appearance ofthe uterus. 2 Transabdominal ultrasonography uterus normal aspect, anteverted-anteflexed. Uterine measurements on a sagittal view (length, width) Transabdominal ultrasonography evaluation of uterine 26 thickness in a transverse view. 4 Endovaginal ultrasonography uterine cavity line Endovaginal ultrasonography endometrium 27 thickness(double layer). 6 Endovaginal ultrasonography endometrium thickness(single layer) Endovaginal ultrasonography ovarian 28 measurementson a) sagittal view (length, width); b) transverse view. 8 Endovaginal ultrasonography normal appearance of 28 the ovary. 9 Polycystic Ovary by Ultrasound Ovarian artery blood flow Uterine artery blood flow Uterine artery blood flow in PCO Ovarian artery blood flow in PCO Ultrasound of normal ovary Ultrasound of PCO case Endometrial thickness in follicular phase in control 41 group. 17 Endometrial thickness in preovulatory phase in control 41 group. 18 Endometrial thickness in follicular phase in control 41 group. 19 Uterine artery in follicular phase in control group Uterine artery in preovulatory phase in control group. 42

6 No. Title Page 21 Uterine artery in luteal phase in control group Ovarian artery in follicular phase in control group Ovarian artery in preovulatory phase in control group Ovarian artery in luteal phase in control group Uterine artery in follicular phase before induction in PCO group. 26 Uterine artery in follicular phase after induction in PCO group. 27 Uterine artery in preovulatory phase before induction in PCO group. 28 Uterine artery in preovulatory phase after induction in PCO group. 29 Ovarian artery in follicular phase before induction in PCO group. 30 Ovarian artery in follicular phase after induction in PCO group. 31 Ovarian artery in preovulatory phase before induction in PCO group. 32 Ovarian artery in preovulatory phase after induction in PCO group. 33 Comparison between cases and controls as regard FSH and LH. 34 Comparison between study and control groups as regard ovarian volume. 35 Comparison between cases (before and after induction) and controls as regard uterine artery Doppler indices infollicular phase. 36 Comparison between cases and controls as regard uterine artery Doppler indices in preovulatory phase. 37 Comparison between cases (before and after induction) and controls as regard Ovarian artery Doppler indices in folliculare phase. 38 Comparison between cases (before and after induction) and controls as regard Ovarian artery Doppler indices in preovulatory phase. 39 Comparison between cases and controls as regard endometrial thickness in preovulatory phase

7 No. Title Page 40 Comparison between different phases in menstruation in normal females as regard Uterine artery Doppler indices. 41 Comparison between different phases in menstruation in normal females as regard Ovarian artery Doppler indices. 42 The correlation of the Endometrial thickness and Uterine PI. 43 The correlation of the Endometrial thickness and Uterine RI. 44 The correlation of the Endometrial thickness and Ovarian PI. 45 The correlation of the Endometrial thickness and Ovarian RI

8 LIST OF TABLES No. Title Page 1 Criteria for defining PCOS. 6 2 Suggested diagnostic evaluation for PCOS Comparison between cases and controls as regard age 48 distribution. 4 Comparison between cases and controls as regard BMI Comparison between cases and controls as regard FSH 49 and LH. 6 Comparison between study and control groups as regard 50 ovarian volume. 7 Comparison between cases and controls as regard uterine 51 artery Doppler indices in follicular phase. 8 Comparison between cases and controls as regard uterine 52 artery Doppler indices in preovulatory phase. 9 Comparison between cases and controls as regard ovarian 53 arteries Doppler indices in follicular phase. 10 Comparison between cases and controls as regard ovarian 54 arteries Doppler indices in preovulatory phase. 11 Comparison between cases and controls as regard 55 endometrial thickness in preovulatory phase. 12 Comparison between different phases in menstruation in 56 normal females as regard Uterine artery Doppler indices. 13 Comparison between different phases in menstruation in 57 normal females as regard Ovarian artery Doppler indices. 14 Correlation between Endometrial thickness and different Doppler indices. 58

9 ABBREVIATIONS 17 HP 17 hydroxy progesterone enzyme 21-OH 21 hydroxy progesterone enzyme 2D Two dimensional A 4 Androstenedione ACTH Adrenocorticotrophin Hormone AI Aromatase Inhibitors ASRM American Society for Reproductive Medicine AUC Area Under Curve BMI Body Mass Index camp Cyclic Adenosine Mono-Phosphate CC Clomiphene Citrate DHEA Dehydroepiandrosterone DHEAS Dehydroepiandiosterone Sulfate DHT Dihydrotestosterone DM Diabetes Mellitus E1 Estrone E2 Estradiol ESHRE European Society for Human Reproduction and Embryology FSH Follicular Stimulating Hormone GnRH Gonadotrophin Releasing Hormone hcg human Chorionic Gonadotrophin HDL High Density Lipoproteins hmg human menopausal Gonadotrophins ICSI Intra-Cytoplasmic Sperm Injection IVF In Vitro fertilization IVM In Vitro Maturation LDL Low Density lipoprotein LH Luteinizing Hormone LOD Laparoscopic Ovarian Diathermy mfg Modified Ferriman and Gallway score MG Mean Grayness mrna Messenger Ribonucleic Acid NCAII Non-classic Congenital Adrenal Hyperplasia NIH National Institute of Health OGTT Oral Glucose tolerance Test OHSS Ovarian Hyper stimulation Syndrome

10 OS OV P4 PCO PCOS PI PPCOS RCT rfsh RI SHBH T TA TSH TV US UER US W WAIR Ovarian Stroma Ovarian Volume Progesterone Polycystic Ovary Polycystic Ovarian Syndrome Pulsatility index Pregnancy in Polycystic Ovarian Syndrome Randomized Controlled Trial recombinant Fol1icular Stimulating Hormone Resistance index Sex Hormone Binding Globulin Testosterone Transabdominal Thyroid Stimulating Hormone Transvaginal Ultrasound Ultrasound Examination Route United states Wan Waist to Hip Ratio

11 Abstract Comparative study between two groups: 30 cases diagnosed to have polycystic ovarian disease and the second group included 50 fertile ovulatory women. Methods: Doppler analysis of the uterine arteries and ovarian stromal blood flow was performed by trans vaginal ultrasound in control group and PCO group before and after induction of ovulation. Results: Ovarian volume was significantly higher in cases than control with increased level of LH and in cases of PCO. The endometrial thickness in preovulatory phase was significantly higher in PCO cases after induction with PCO cases before induction but No statistically significant correlation was found between Endometrial thickness and any of uterine or ovarian Doppler artery indices in PCO cases after ovulation induction. The PI and RI of the ovarian arteries were significantly higher in follicular phase than in preovulatory phase and in preovulatory phase than luteal phase in control group. The RI of the uterine arteries was significantly higher in follicular phase than in preovulatory phase and also in preovulatory phase than in luteal phase in control group. The PI and RI of the ovarian arteries in follicular and preovulatory phases were significantly higher in patients with PCO disease than in control women. And The PI of the uterine arteries was significantly higher in patients with PCO disease than in control women. The PI of the ovarian arteries in follicular and preovulatory phases and RI in follicular phase were significantly higher in PCO cases before induction than in PCO cases after induction.the PI of the uterine arteries in follicular and preovulatory phases was significantly higher in patients with PCO cases before induction than in PCO cases after induction. Conclusion: Doppler examination may be useful for the evaluation of PCOS patients, in addition to conventional hormonal parameters that may contribute to a better understanding of the complex pathophysiology of PCO, and in the study of hemodynamic changes in the uterine and ovarian arteries during the menstrual cycle in women with normal ovaries. Keywords Polycystic ovarian disease Ultrasound Color Doppler

12 INTRODUCTION Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders affecting female fertility (Kousta et al., 1999). Most investigators would agree that the blood flow and the vascular pattern of an organ are directly related to the organ's morphology and function. Therefore, the clinician may consider an ability to detect alterations in an organ's blood flow and vascular pattern a valuable tool in evaluating organic and functional anomalies (Pan et al., 2002). Polycystic ovary disease (PCOD) is one of the most common endocrine disorders affecting female fertility, although its etiology remains unknown. The finding of polycystic ovaries (PCO) is more common, with 22% of the younger female population showing a PCOlink pattern on ultrasound scanning of the ovaries (Battaglia et al., 2003). Stein and Leventhal (1935) described several women presenting with oligoamenorrhoea combined with the presence of bilateral polycystic ovaries established during surgery. In case polycystic ovaries is diagnosed by morphology in women with oligo-anovulation, not all the features which are believed to be associated with polycystic ovary disease need to be present (Goudas et al., 1997). Likewise, with the use of transvaginal ultrasound it has become evident that women with oligoamenorrhoea, obesity and hirsutism do not all have the typical polycystic ovary morphology (Balen et al., 1995). The occurrence of a considerable heterogeneity in clinical symptoms and endocrine features associated with polycystic ovary disease implies that some women with polycystic ovary on ultrasound scan may even exhibit none of the other features of polycystic ovary disease (Broekmans et al., 2006). The criteria for diagnosis and definition of polycystic ovary disease are as heterogeneous as the pathology itself. The predominantly North American definition of polycystic ovary disease recommended that diagnostic criteria should include biochemical evidence of hyperandrogenism and ovarian dysfunction in the absence of other endocrine disorders (Dunaif, 1997). The European definition of polycystic ovary disease requires the sonographic appearance of polycystic ovaries associated with menstrual disturbances and clinical signs of hyperandrogenism. No hormonal parameters are required for the definitive diagnosis (Homburg, 2002).

13 Definition of polycystic ovary disease: At a joint consensus meeting of the American Society of Reproductive Medicine and the European Society of Human Reproduction and Embryology held in Rotterdam, in May 2003, a refined definition of the polycystic ovary disease was agreed. Namely the presence of two out of the following three criteria: (i) oligo- and/or anovulation; (ii) hyperandroginism (clinical and/or biochemical); and (iii) polycystic ovaries, with the exclusion of other etiologies. The morphology of the polycystic ovary has been redefined as an ovary with 12 or more follicles measuring 2-9 mm in diameter and/or increased ovarian volume more than 10 ml (Balen et al., 2005). According to the Rotterdam consensus criteria, additional polycystic ovary disease phenotypes include polycystic ovaries and hyperandrogenism in women with normal menstrual cycles and especially women presenting with polycystic ovaries and anovulation without androgen excess. It remains to be established whether these additional phenotypes present with features associated with long-term health risks: obesity, insulin resistance and the metabolic syndrome (Broekmans et al., 2006). Most investigators would agree that the blood flow and the vascular pattern of an organ are directly related to the organ s morphology and function. Therefore, the clinician may consider an ability to detect alteration in an organ s blood flow and vascular pattern a valuable tool in evaluation of organic and functional anomalies. The ovary is an ideal organ for the application of these techniques, as there is a rapid and controlled sequence of cyclical events involving neoangiogenesis coupled with the significant fluctuations in the local concentration of hormones known to affect the vasculature. (Pan et al., 2002).

14 AIM OF THE WORK 1. Study Dopler hemodynamics changes in ovarian and uterine arteries in different phases of the cycle in normal fertile women. 2. Compare Doppler hemodynamics in ovarian and uterine arteries of PCOD patients with another group of fertile women who have normal ovarian function. 3. Study the effect of ovulation induction by clomiphene citrate on Dopler hemodynamics in ovarian and uterine arteries of PCOD patients.

15 Anatomy of the ovary Gross Anatomy: The ovaries are almond shaped but may vary in size, position, and appearance, depending on the age and the reproductive activities of the individual (DeLancey et al, 1997). The normal adult woman ovaries range from cm long, cm thick, and cm wide, with a weight of 3 8 gm. (kleeman, 2007). The ovary is encapsulated by a thin whitish the tunica albuginea (Tortora et al, 1998). fibrous Capsule called The ovary can be divided into: Outer cortex which consists of a cellular connective tissue stroma in which the ovarian follicles are embedded. Inner medulla which is composed of loose connective tissue which contains blood vessels and nerves (Kleeman, 2007). The ovary is attached by the mesovarium to the posterior surface of the broad ligament. Further support is given by the ovarian ligament proper and the suspensory ligament of the ovary that is continuous with the broad ligament attaching to the pelvic sidewall and in which the ovarian vessels and lymphatics run (Michael et al, 2006). Blood supply of the ovary: The ovarian artery originates from the abdominal aorta, below the level of the renal arteries The ovarian arteries supply the ovaries, uterine tubes, the upper portion of the body and fundus of the uterus, and anastomose with the uterine arteries (Winkler et al, 1986). The ovarian vein is typically single but may be multiple and will fuse forming single vein which accompanies the ovarian artery along its retroperitoneal course. The right vein drains into the inferior vena cava and the left one drains into the left renal vein. (Tukeva et al, 1999). Lymphatic drainage of the ovary: The ovarian lymphatics ascend with the ovarian vessels drain almost exclusively into to the para-aortic lymph nodes, close to the origin of the ovarian arteries (Reynolds et al, 2006). Other small branches drain via the broad ligament to the external, internal, and common iliac groups of nodes (Livengood et al, 2006).

16 POLYCYSTIC OVARIAN DISEASE (A) HISTORICAL BACKGROUND: In 1935, Stein and Leventhall first defined a disorder, which would eventually become known as the polycystic ovary (or ovarian) syndrome (PCOS). These gynecologists described 7 women suffering from infertility and amenorrhea and determined, upon surgical exploration, that these women had enlarged ovaries with several superficial cystic structures. Stein and Leventhall performed ovarian wedge resections on these patients, in the belief that they were removing obstructions or cysts from the ovary, which would allow for normal ovarian function to resume. After the surgery, all women resumed their cyclic menses and 5 conceived (Trivax and Azziz, 2007). In 1945, Stein published a follow-up report in which he added excessive male-pattern hair growth and in contrast to what is known today, obesity to the list of symptoms, and noted that the disorder was overall quite rare. The disorder remains a fertile ground for academic debate and research investigations (Trivax and Azziz, 2007). (B) DEFINING PCOD: Basics: PCOS is a functional disorder of unclear etiology, and, as such, is a diagnosis of exclusion, with other androgen excess and ovulatory disorders of clearly defined etiologies excluded. Androgen excess disorders to exclude are 21-hydroxylase deficient nonclassic adrenal hyperplasia (NCAH), adrenal or ovarian androgen-secreting tumors, disorders of generalized adrenocortical dysfunction (e.g., Cushing s disease), and use or abuse of androgenic or anabolic drugs. (Azziz, 2007). It should be recognized that PCOS is still a syndrome namely a collection of signs and features that characterize a disorder, where no single test is diagnostic. While the disorder is relatively heterogeneous, three features are generally recognized to compose this syndrome, including androgen excess, ovulatory dysfunction, and polycystic ovaries. Androgen excess (or hyperandrogenism) is detectable either by laboratory analysis, generally measuring circulating androgen levels, or by clinical exam, primarily in the form of hirsutism. Ovulatory dysfunction is generally detectable by the presence of clinically evident oligoamenorrhea (Azziz, 2007). SPECIFIC CRITERIA FOR PCOD:

17 To maintain uniformity and lessen ambiguity, three major diagnostic criteria for PCOD have been proposed (Table 1). The first arose from the proceedings of a National Institutes of Health (NIH)/ National Institute of Child Health and Human Development (NICHD) sponsored conference in 1990 (i.e., the NIH 1990 criteria)(zawadski and Duanif, 1992). The second criteria were proposed by an expert conference sponsored by the European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) in 2003 in Rotterdam. (The Rotterdam ESHRE/ASRM, 2004). The most recent criteria was defined by a task force of the Androgen Excess Society (AES) in 2006 (AES, 2006). Table (1): Criteria for defining PCOS (quoted from Trivax and Azziz, 2007) NIH 1990 (3): To include all the following: Clinical hyperandrogenism and/or hyerandrogenemia Chronic anovulation Exclusion of related disorders ESHRE/ASRM (Rotterdam) 2003: To include two of the following. in addition to exclusion of related disorders: Oligo-anovulation Hyperandrogenism and/or hyerandrogenemia Exclusion of related disorders AES 2006 (6): To include two of the following: Hyperandrogenism (hirsutism and/or hyerandrnemia) Ovarian dysfunction (oligo-anovulation and/or polycystic ovaries) Exclusion of related disorders EPIDEMIOLOGY OF PCOD: Polycystic ovary disease (PCOD) is one of the most common endocrine disorders affecting female fertility, although its etiology remains unknown. The finding of polycystic ovaries (PCO) is more common, with 22% of the younger female population showing a PCOlink pattern on ultrasound scanning of the ovaries (Battaglia et al., 2003). DIFFERENTIAL DIAGNOSIS OF PCOD: PCOS remains a diagnosis of exclusion, and it is useful to exclude other potential etiologies that can present with the triad of polycystic ovaries, hyperandrogenism, and chronic anovulation. It is important to note that the presence of one of these signs or symptoms alone presents a much wider differential diagnosis (Legro, 2007).

18 Other than PCOS, other potentially serious causes of hyperandrogenism include such disorders as Cushing s syndrome and an androgen-secreting tumor (ACOG, 2002). These disorders are acquired and are often preceded by a period of normal menses without symptoms of hyperandrogenism. In contrast, PCOS presents in the postmenarche and tends to affect women throughout much of their reproductive life. As Cushing s syndrome has an extremely low prevalence in the population (1 2 per million) (Tsigos and Chrousos,1996). Nonetheless, the presence of clinical signs more commonly found in Cushing s syndrome, such as ecchymoses, proximal muscle weakness, centripetal reddened striae, facial rubor and swelling, and perhaps hypertension and glucose intolerance, should signal the need for screening tests. Cortisol excess can be screened for with a 24-h urine collection for free cortisol (Legro, 2007). Androgen secreting tumors are rare in this age group, are usually ovarian in origin, tend to have markedly elevated circulating androgen levels above the usual PCOS range, and are associated with a comparatively rapid onset of symptoms which frequently progress to frank virilization with clitoromegaly, breast atrophy, and voice changes (Waggoner et al., 1999; Lobo, 1991). Virilization is rarely, if ever, associated with PCOS, and this clinical presentation should always trigger a search for other causes, including anabolic steroid abuse (Legro, 2007). A disorder that can present peripubertally in a similar indolent fashion as PCOS is 21-hydroxylase (21-OH) deficient nonclassic congenital adrenal hyperplasia (NCAH), also known as late-onset congenital adrenal hyperplasia. NCAH is a homozygous recessive disorder due to mutations in the CYP21gene, which results in an abnormal (or absent) 21-OH activity and a shift toward the overproduction of androgens (Legro, 2007). Overall, between 1 and 8% of women with androgen excess have CYP21 deficient (Azziz et al., 1994). Other rare situations that may present with hyperandrogenic chronic anovulation are thyroid disease and hyperprolactinemia (Legro, 2007). Although the evidence linking thyroid disease to hyperandrogenism is weak. A TSH level is easily obtained. The case for measuring prolactin is more complex. About 20 30% of women with PCOS have been reported to have mildly elevated prolactin levels (Luciano et al., 1984). ETIOLOGY OF POLYCYSTIC OVARY DISEASE

19 1- Hereditary Factors of PCOD: Polycystic ovary disease runs in families and a number of genetic abnormalities appear to result in features of the syndrome and account for the heterogeneity of the symptoms (Balen, 2004). 2- Endocrinological Causes of PCOD: (A) Adrenal Abnormalities: Adrenal androgen excess in polycystic ovary disease may be heterogeneous in etiology, whereas 17, 20 lyase hyperactivity appears to be an intrinsic adrenal disorder, adrenal androgen hyper-responsiveness to adrenocorticotropic hormone (ACTH) may be ovarian induced. Adrenogenital syndrome (adrenal hyperplasia) can cause polycystic ovary disease (Speroff et al., 2005). (B) Ovarian Abnormalities: The proposed mechanism is through abnormal activation of ovarian enzymes especially 17 α-hydroxylase and lyase which catalyses the conversion of progesterone into 17α-OH progesterone then to androstenedione (Speroff et al., 2005). (C) Hypothalamic-pituitary Abnormalities: Exaggerated gonadotropin releasing hormone (GnRH) pulsatility results in hyper-secretion of luteinising hormone (LH), which has effects both on ovarian androgen production and oocyte development. Disturbed ovarian-pituitary and hypothalamic feedback accentuates the gonadotropin abnormalities (Balen, 2004). (D) Metabolic factors: 1. Obesity: Haq et al. (2007) performed a study included 508 women with polycystic ovary disease. They concluded that the highest rate of abnormal clinical and biochemical features of polycystic ovary disease were seen in obese women with body mass index BMI above 30 (68.5%). These obese women need more attention for their appropriate management. 2. Hyperinsulinemia:

20 Insulin resistance and compensatory hyperinsulinemia are the major pathophysiology of polycystic ovary disease (Weerakiet et al., 2007). Disturbances in insulin metabolism are also linked to disturbed levels of leptin (regulatory peptide secreted from fat cells to affect the CNS), Ghrelin (gastric peptide) and growth hormone which enter the pool of polycystic ovary etiology (Speroff et al., 2005). 3. Abnormal Estrogen Clearance and Metabolism: The clearance and metabolism of estrogen can be impaired by other pathologic conditions, such as thyroid or hepatic disease; it is for this reason that a careful history and physical examination are important elements in the differential diagnosis of anovulation. Both hyperthyroidism and hypothyroidism can cause persistent anovulation by altering not only metabolic clearance but also peripheral conversion rates among the various steroids (Speroff et al., 2005). 4. Growth Hormone and Insulin-like growth factor: Women of normal weight with polycystic ovary disease and hyperinsulinemia presented high growth hormone (GH) levels in response to the l-dopa test. This suggested that the action of GH and insulin-like growth factor-1 (IGF-1) might be responsible for the elevation in LH and the consequent hyperandrogenic anovulation observed in normal weight women with polycystic ovary disease. ( Premoli et al.,2005). (E) Psychological Stress: The participation of stress as an etiological factor for ovarian pathologies in patients with polycystic ovary disease give strong support for participation of sympathetic nerves in the ovary function both in normal and pathological status. Psychological stress may be associated with elevated levels of urinary 3-methoxy-4-hydroxyl-phenoglycerol (MHPG) excretion and platelet serotonin. As MHPG correlated with LH, and MHPG correlated to DHEA-S, Greiner et al.,(2005) hypothesized that psychological stress and neurotransmitter levels may be linked to some of the hormonal derangement, including inappropriate gonadotropin secretion and elevated adrenal androgen levels in women with polycystic ovarian disease (Greiner et al., 2005).