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‘Paradigm shift’ needed to prevent metabolic dysfunction in PCOS
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AUSTIN, Texas — An early and definitive diagnosis of polycystic ovary syndrome is crucial for moving beyond treating symptoms to reducing metabolic risks, according to a speaker at the American Association of Clinical Endocrinologists Annual Scientific and Clinical Congress.
That move requires better defining of diagnostic criteria and clearing up confusion about the nature of PCOS, Jennifer Glueck, MD, assistant professor in the division of endocrinology at Rush University Medical Center in Chicago, said here.
“The more uniform recognition of the Rotterdam criteria as the way to diagnosis PCOS and the importance of focusing on different phenotypes of PCOS will help improve delays in diagnosis and help disseminate the correct information to patients about their metabolic and reproductive risks,” Glueck told Endocrine Today.
The diagnostic criteria for PCOS have been a source of confusion for clinicians and patients, Glueck said. The history has been marked by a series of expert consensus conferences that focused on syndrome features according to the clinical viewpoint of the participants, with endocrinologists elevating chronic anovulation and hyperandrogenism, and OB-GYN physicians highlighting ovarian morphology, for example.
A consensus conference convened at NIH in 2012, comprised of endocrinologists, cardiologists, and OB-GYN and internal medicine physicians, recommended adopting the criteria of the 2003 Rotterdam conference. These criteria specify that a diagnosis of PCOS may be made when a woman presents with any two of the following: oligo- or anovulation, clinical or biochemical evidence of hyperandrogenism, and polycystic ovarian morphology.
“They also made the important caveat that you really have to distinguish what phenotype you’re talking about both for research purposes, but also for clinical care because the different phenotypes do confer different risks for patients reproductively and metabolically,” Glueck said.
Most women diagnosed with PCOS present with the “classic” symptoms of hyperandrogenism and ovulation dysfunction, which is also the phenotype with the greatest metabolic risks, according to Glueck.
In this group of women, 30% to 40% have impaired glucose tolerance, 10% have type 2 diabetes before age 40 years and 30% to 40% have metabolic syndrome. In other phenotypes, particularly in women with regular periods, these metabolic abnormalities are less severe. Women without hyperandrogenism are “relatively healthier compared to all the other phenotypes,” Glueck said.
But what most clinicians may not know, is that “there is an increased risk of metabolic complications in women with PCOS regardless of BMI, and the increased risk is present at a relatively young age compared to women without PCOS,” Glueck told Endocrine Today.
Anti-Müllerian hormone (AMH) may soon serve as an aid in the diagnosis of PCOS, according to Glueck. Researchers are exploring threshold levels to define PCOS and are working to develop a standard assay. AMH levels are two to four times higher in women with PCOS compared with women without the syndrome, she said.
“[AMH] is a great biomarker for the increase in growing follicles in PCOS and therefore may soon replace ovarian ultrasound when diagnosing PCOS,” Glueck told Endocrine Today. “We’re not quite there yet. AMH can discriminate true normal controls from women with any of the PCOS phenotypes; however, the threshold remains specific for the method and clinical setting.”
Glueck said she currently measures a patient’s AMH level to help with diagnosis when evidence of hyperandrogenism or ovarian dysfunction is missing.
Women seek treatment for the clinical symptoms of hyperandrogenism and abnormal ovulation and may not understand that insulin resistance and metabolic syndrome are associated with the PCOS, Glueck said.
“There is a need for a paradigm shift in the way that we treat these patients, away from just treating PCOS as an issue of irregular periods and birth control pills and stopping there, but [rather] focusing in on the importance of an early and more definitive diagnosis ... [so patients] can understand their metabolic risks and partnering with them earlier so we can prevent the metabolic issues rather than trying to treat them,” she said. – by Jill Rollet
Reference:
Glueck J. What’s New in PCOS? Presented at: AACE Annual Scientific and Clinical Congress; May 3-7, 2017; Austin, Texas.
Disclosures: Glueck reports no relevant financial disclosures.