Polycystic ovary syndrome: it is always bilateral?

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1 Ultrasound Obstet Gynecol 1999;14: Polycystic ovary syndrome: it is always bilateral? C. Battaglia, G. Regnani, F. Petraglia*, M. R. Primavera, M. Salvatori and A. Volpe Department of Obstetrics and Gynecology, University of Modena; *Department of Surgical Science, University of Udine, Italy Key words: PCOS, DOPPLER, ULTRASOUND, HIRSUTISM, MENSTRUAL DISORDERS ABSTRACT Objective To evaluate whether patients with unilateral polycystic ovary showed different ovarian and uterine blood flow from those with bilateral polycystic ovaries, and to investigate whether there was a correlation between the ultrasonographic aspect and different hormonal parameters. Design An observational study. Subjects Sixteen patients with unilateral polycystic ovary and twenty patients with bilateral polycystic ovaries underwent clinical, biochemical, gray-scale and color Doppler ultrasonographic evaluation. Methods The following parameters were evaluated: hormonal (luteinizing hormone (LH), follicle stimulating hormone (FSH), LH/FSH concentration ratio, estradiol, prolactin, androstenedione, testosterone), clinical (body mass index, Ferriman Gallwey score), ultrasonographic (ovarian volume, number and distribution of subcapsular follicles, stromal score) and Doppler (uterine artery and intraparenchymal vessel pulsatility index, ovarian stromal vascularization), in oligomenorrheic patients in the early follicular phase (cycle days 3 5) or in amenorrheic patients at random. Results Significantly higher androstenedione plasma levels and LH/FSH concentration ratios were observed in bilateral polycystic ovaries. In unilateral polycystic ovaries, gray-scale and color Doppler ultrasonography showed different features in the affected and the unaffected ovary, similar to the appearance of a polycystic and normal ovary, respectively. Conclusion Polycystic ovary syndrome does not predetermine a single ultrasonographic and Doppler pattern. INTRODUCTION Polycystic ovary syndrome (PCOS) is one of the most widely discussed and controversial areas in gynecological endocrinology. The etiology of the syndrome is uncertain, because of the wide spectrum of disorders encompassed by the diagnosis 1 3. Minimal signs of hyperandrogenism in lean, normally menstruating women, and obesity, severe hirsutism and oligo- or amenorrhea (as originally described by Stein and Leventhal 4 ) represent opposite poles of the clinical spectrum in this condition. Despite the vast amount of clinical, laboratory and experimental data that have been accumulated, the pathogenesis of PCOS remains a subject of speculation. The heterogeneity of clinical and endocrine features remains a confounding factor in the investigation of PCOS patients Assessment of ovarian morphology by means of ultrasound is currently employed as a substitute for histological examination in the diagnosis of polycystic ovaries. The ultrasound criteria for diagnosis of PCOS have been established: enlarged ovary with multiple small follicles arranged around an echogenic stroma. However, the number of small follicles reported as necessary to establish the diagnosis of PCOS has varied: above five 12, more than ten 13 and at least The ultrasonographic parameters have been shown to be strictly correlated with histopathological findings 15. Furthermore, Yoshino and coworkers showed that ultrasonographic parameters were correlated with androstenedione, luteinizing hormone (LH) and the LH/follicle stimulating hormone (FSH) ratio in PCOS patients 16. Even the ultrasonographic modifications are normally present in both ovaries and most investigators have stressed this bilaterality both at laparoscopy 2 and histologically 15,21,22 ; however, some cases of unilateral polycystic ovaries have been described Correspondence: Dr C. Battaglia, Department of Obstetrics and Gynecology, University of Modena, Via del Pozzo, 71, 411 Modena, Italy ORIGINAL PAPER 183 Received Revised Accepted

2 Transvaginal color Doppler facilitates the detection of small vessels in the utero-ovarian circulation and the measurement of impedance to flow in this vascular tree. We recently showed 26, and Zaidi 27 and Aleem 28 and colleagues successively confirmed, that in patients with PCOS significant changes occur within the intraovarian vessels. Furthermore, uterine artery resistance was shown to be increased in PCOS. The aim of this observational study was to evaluate whether PCOS patients with unilateral or bilateral polycystic ovaries showed differences in their ovarian and uterine blood flow and whether there was a correlation between these findings and specific hormonal parameters. MATERIALS AND METHODS The study protocol was approved by the local Ethics Review Committee. Between June 1994 and November hirsute women (age range years) attending the Gynecological Endocrinology Clinic participated in the study after giving informed consent. Polycystic ovary syndrome was previously suspected on the basis of the following criteria: hirsutism, menstrual disturbances (oligo- or amenorrhea), increased plasma circulating androgens, LH/FSH ratio of > 2.5 and typical ultrasonographic findings (more than five small follicles, ovarian volume > 8 ml and increased ovarian stroma echogenicity) in at least one ovary. Patients were subdivided according to ovarian ultrasonographic findings: women presenting unilateral polycystic ovary (group I; n = 18) and those with bilateral polycystic ovaries (group II; n = 21). Patients were selected to obtain roughly equal numbers in each group. All the patients had acne and/or seborrhea, and hirsutism (Ferriman Gallwey score > 8) 29. None had hypertension (systolic blood pressure > 14 mmhg and/or diastolic blood pressure > 9 mmhg), or was a heavy smoker (more than ten cigarettes/day) or took regular intense exercise. Furthermore, they had not received hormonal therapy for at least 4 months before the study. Patients with ultrasound evidence of multifollicular ovaries (more than five follicles) in which the follicles were > 4 mm in maximum diameter and distributed evenly throughout the ovary and in which there was no increase in stromal echodensity were excluded from the study. Thirty (76%) patients were oligomenorrheic (cycle length > 35 days), and nine (24%) were amenorrheic (no vaginal bleeding for 6 months). The mean body mass index (BMI = weight (kg)/height 2 (m 2 )) was similar in group I (23.2 ± 4.5) and group II (23.8 ± 4.5) patients. Hirsutism was evaluated according the Ferriman Gallwey method. The mean menarchal age was not significantly different between patients of group I (11.1 ± 1.1 years) and those of group II (9.9 ± 1.7 years). Oligomenorrheic patients were studied in the early follicular phase (cycle days 3 5), whereas amenorrheic patients were studied at random. Ultrasonographic and color Doppler analyses, humoral and hormonal assays were performed in all patients. Ultrasound and Doppler examinations Ultrasonographic examination of the ovaries was performed with the use of a 6.5-MHz transvaginal transducer (AU 4 Idea ; ESAOTE, Milan, Italy). Ovarian volume and the number, diameter and distribution of follicles were recorded. The volume was calculated by the formula: V = π/6 D1 D2 D3, where D1 was the longitudinal diameter, D2 the anteroposterior diameter and D3 the transverse diameter of the ovary. Echogenicity of the ovarian stroma was scored as (normal), 1 (moderately increased) or 2 (markedly increased) 3,31. In group I patients, different values were observed between affected and unaffected ovaries, whereas in patients with bilateral polycystic ovaries no significant differences between left and right ovaries were observed, and therefore the average value of both ovaries was used for statistical analysis. Doppler flow measurements of the uterine and intraovarian vessels were performed transvaginally with a 6.5-MHz color Doppler system (AU 4 Idea ). All the patients were in the semirecumbent position and were evaluated between 8. and 11. to exclude effects of circadian rhythmicity on uterine blood flow 32. Furthermore, they rested in a waiting room for at least 15 min before being scanned and completely voided the bladder in order to minimize external effects on pelvic blood flow 33.A 5-Hz filter was used to eliminate low- frequency signals originating from vessel wall movements. Color signals were sought in the stroma at the maximum distance from the surface of the ovary. The ovarian stroma was considered to be avascular if no blood vessels were demonstrated by color Doppler imaging. When several blood vessels were detected inside the ovarian stroma, only the one with the lowest downstream impedance was selected for Doppler measurements. Color flow images of the ascending branches of the uterine arteries were sampled laterally to the cervix in a longitudinal plane. The angle of insonation was always adjusted to obtain maximum color intensity. When good signals were obtained, blood flow velocity waveforms were recorded by placing the sample volume across the vessel and activating the pulsed Doppler mode. The pulsatility index (PI), defined as the difference between the peak systolic and end-diastolic flow divided by the mean maximum flow velocity, was calculated for the ovarian stromal and uterine arteries. For each examination, the mean value of three consecutive waveforms was obtained. No significant differences between the PIs of the left and right uterine arteries were observed in patients with bilateral or unilateral polycystic ovaries, and therefore the average value of both arteries was used. In group I patients, different stromal vascularization was observed between the affected and the unaffected ovary, whereas in patients with bilateral polycystic ovaries the lowest PIs of the stromal arteries were not significantly different between the left and right ovaries, therefore the mean value was utilized for statistical analysis. In the results the PIs have not been corrected for heart rate 34. Ultrasound and color Doppler analyses were performed by a single examiner (C.B.). 184 Ultrasound in Obstetrics and Gynecology

3 Hormonal assay and biochemical evaluation Peripheral blood was obtained from all patients between 8. and 11., after an overnight fast, on the same day that Doppler examination took place, and different hormonal parameters were analyzed. Blood samples were collected and centrifuged, and the plasma was separated and stored at 2 C. Plasma concentrations of LH, FSH, testosterone, androstenedione and estradiol were determined by radioimmunoassay (Radim; Pomezia, Italy). The LH/FSH concentration ratio was calculated. Total plasma cholesterol and triglyceride levels were measured by standard enzymatic methods (Sclavo Diagnostici, Sienna, Italy). High-density lipoprotein (HDL)-cholesterol levels in the supernatant were determined by using enzymatic reagents (Bio Meriaux, Lille, France). Statistical analysis Data are presented as mean ± one standard deviation, unless otherwise indicated. Differences between groups were assessed with analysis of variance (ANOVA) and Student s t test, where indicated. The relationship between parameters was assessed by stepwise multiple linear regression. A probability of.5 was considered as statistically significant. RESULTS Because of hyperprolactinemia, two patients in group I and one patient in group II were excluded from the study. The Ferriman Gallwey score was not significantly different between patients of the studied population (Table 1). The levels of circulating LH, FSH, estradiol and testosterone did not differ between the groups, but plasma androstenedione levels and the LH/FSH concentration ratio were significantly higher in bilateral than unilateral PCOS patients (Table 1). Plasma HDL was significantly lower in group II than group I patients (Table 1). The HDL/total cholesterol ratio was lower in bilateral (21.8%) than in unilateral (27.5%) PCOS patients. The ultrasonographic evaluation showed that patients with unilateral PCOS presented different features (number of small follicles, ovarian volume and echodensity) in the affected and the unaffected ovary, similar to those of a typical polycystic ovary and a normal ovary, respectively (Table 2). On Doppler analysis, elevated resistance within the uterine arteries was observed in all patients. However, this was significantly higher in group II (PI = 3.51 ±.66) than group I (PI = 3.17 ±.57; p <.5). In the unilateral PCOS group, in comparison with bilateral PCOS patients, different PI values were observed at the level of the ovarian stromal arteries in the affected and the unaffected ovary. In Table 1 Clinical, hormonal and humoral findings in patients with unilateral and bilateral polycystic ovaries. The normal range was derived from normo-ovulatory patients of the Gynecological Endocrinology Clinic Ferriman Gallwey score LH (mu/ml) FSH (mu/ml) LH/FSH ratio Estradiol (pg/ml) Testosterone (ng/1 ml) Androstenedione (ng/1 ml) Total cholesterol (mg/1 ml) HDL (mg/1 ml) Triglycerides (mg/1 ml) *p <.5; **p <.1 Unilateral (n = 16) ± ± ± ± ± ± ± ± ± 66.1 Bilateral (n = 2) ± ± ± 1.1* 16.7 ± ± ± 18** ± ± 8.8* 16.5 ± 56.2 range ± 1 < >55 < 175 Table 2 Ultrasonographic findings in patients with unilateral (group I) or bilateral (group II) polycystic ovaries. The normal range was derived from the normo-ovulatory patients of the Gynecological Endocrinology Clinic Group I (n = 16) Ovarian volume (ml) Subcapsular follicles (n) Stromal score (%) 1 2 Affected ovary (a) 12.2 ± ± *p <.1 (b vs. a and b vs. c) Unaffected ovary (b) 7.1 ± 2.7* 5 ± 2.1* * Group II (n = 2) (c) 11.9 ± ± range* Table 3 Intraovarian Doppler findings in patients with unilateral (group I) or bilateral (group II) polycystic ovaries. The normal range was derived from the normo-ovulatory patients of the Gynecological Endocrinology Clinic Ovarian stromal artery PI Visualization (%) Group I (n = 16) Affected ovary (a).77 ±.11 1 Unaffected ovary (b) 1.61 ±.24* 32* Group II (n = 2) (c).76 ±.18 1 range NM NM, not measurable in patients without polycystic ovaries before the 5th day of the menstrual cycle. *p <.1 (b vs. a and b vs. c); PI, pulsatility index Ultrasound in Obstetrics and Gynecology 185

4 addition, in the unaffected ovaries the intraovarian vessels were not visualized in 68% of the cases (Table 3). There was no significant difference in the mean age of patients between the groups. In the whole studied population the mean uterine artery PI values were positively correlated with plasma androstenedione levels (r =.4128; p <.1). DISCUSSION Since the advent of ultrasound scanning an accurate estimation of the prevalence of polycystic ovaries in different study populations has been possible Furthermore, the use of transvaginal probes has shown that ultrasound findings correlate well with laparoscopic measurements and histological features 15,21,22, making it probably the most sensitive index of the marker for PCOS in comparison with the clinical and endocrinological features 2,39. Moreover, as recently demonstrated, Doppler analysis can be a valuable additional tool for the diagnosis of PCOS In the present study, other than confirming the role of Doppler velocimetry in the diagnosis of PCOS, we reported the largest series in the literature to date of unilateral polycystic ovaries. Patients with unilateral PCOS presented lower PI values in uterine arteries associated with lower plasma androstenedione levels and with a lower LH/FSH ratio. The PI in the intraovarian vessels and the percentage of intraovarian vessel visualization presented different values in the affected and the unaffected ovary, the former comparable to typical PCOS and the latter to normal ovary characteristics. Similarly, ultrasonographic evaluation showed significant differences (number of small follicles, ovarian volume and echodensity) between affected and unaffected ovaries. The above data confirm a previous study, in which an analysis was carried out of venous blood obtained by percutaneous retrograde bilateral catheterization of the ovarian veins; in a virilized patient, it was observed that the source of androgens was unilateral and that the histological examination of the excised ovarian tissue showed asymmetric hyperthecosis ovarii 23. This finding adds a further possible confounding factor to the investigation of the syndrome. Given the heterogeneous nature of the clinical and biochemical features of PCOS, it has been suggested that the syndrome represents a range of disorders rather than a single entity. Recent data from both clinical investigations and studies of isolated theca cells implicate a primary ovarian abnormality rather than hypersecretion of androgens as a result of abnormal gonadotropins We speculated that in unilateral PCOS the peripheral expression of ovarian receptors for LH or environmental factors (infections, ovarian vascularization) may limit the morphological and functional features of PCOS to a single ovary. In addition to the abnormalities of the pituitary ovarian axis, PCOS is characterized by significant metabolic abnormalities These include hyperinsulinemia, insulin resistance, reduced thermogenesis and dyslipidemia. In the present study, a total cholesterol/hdl ratio approaching 5 was shown. This condition is apparently associated with a four-fold increased risk of myocardial infarction 48,49. Furthermore, as previously emphasized, increased resistance in uterine arteries has been shown, and a positive correlation with androstenedione has been confirmed 26,34,47,5 52. This supports a possible direct androgen vasoconstrictive effect. The main hypothesis is that androgens favor hypertension and promote atherogenesis. The above findings emphasize that the significance of PCOS for women s health extends far beyond the implications for endocrinological and reproductive functions. From the above data it is possible to conclude that PCOS does not predetermine a single ultrasonographic and Doppler pattern. However, the combined assessment of ovarian morphology by transvaginal ultrasound and color Doppler flow analysis, in both intraovarian and uterine arteries, may provide insight into the pathological state of the disease. Longitudinal studies with careful follow-up are necessary to confirm and expand the above findings. REFERENCES 1. 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