Finding a Consensus for PCOS

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Roy Homburg, MD: “My name is Roy Homburg. I am the Professor of Reproductive Medicine at the Free University in Amsterdam. I have with me today Dr. Adam Balen, who is a Consultant Gynaecologist and Obstetrician at the Leeds General Infirmary, which is part of Leeds University.

We are going to talk about a very hot issue and that is finding a consensus for the diagnosis of the polycystic ovaries. This has come up very much lately because there was a consensus meeting in Rotterdam where the idea was to unify the criteria that we have so that we will all be talking about the same thing, which is very important both for clinical and particularly for scientific purposes. Adam, I am going to ask you first of all, what were your impressions from the meeting? Did we succeed in the aim?”

Adam Balen, MD: “I think it was an extremely interesting meeting. There was some excellent interaction and great discussion. There’s no doubt that historically there have been some differences, most noticeably I suppose, the differences that have been expressed as the transatlantic divide and the inclusion of the ultrasound criteria for polycystic ovaries.

What I thought was most interesting was actually hearing about the practical approach to the management of the woman and the likelihood that it may just be simply the fact that in the United States many women go and see a reproductive physician or an endocrinologist, whereas in Europe and Australia it’s often the gynaecologist. There are those of us of course as gynaecologists and infertility specialists who have developed an interest in the syndrome and embrace the endocrinological aspects as well.”

Roy Homburg, MD: “I think you are quite right in emphasising that Polycystic Ovary Syndrome has gone way beyond being just a gynaecological curiosity. It’s now really part of a multi-system endocrinopathy.

Now I suppose that one of the basic summaries and really the headlines of the meeting were that it was decided that if we have two out of three criteria it would be good for the diagnosis of the PCOS. An irregularity of the period, either oligoamenorrhoea, which means really chronic anovulation, the appearance of polycystic ovaries, and hyperandrogenism, which could be either clinical or endocrinal, that is to say laboratory evidence, and we decided that two out of three would make the diagnosis. Do you think that there’s going to be a chance of this being accepted worldwide which would, of course, be a great advance for us?”

Adam Balen, MD: “I very much hope so. I mean there are naturally going to be some people who may feel a little bit uncomfortable. I think that the strength of having this syndrome being recognised as two out of the three criteria is not so proscriptive. Particularly we didn’t get too bogged down on looking at levels of testosterone or classification of hirsuitism other than recognising that signs of hyperandrogenism are subjective and depends both on the symptoms of the individual woman, the assessment by the physician and ethnic and racial differences as well, which we all recognise.

I feel that the syndrome as we have presented it is all encompassing and that’s the strength. When it comes to specific research studies, as long as the researcher is clearly identifying and quantifying the group of patients they are dealing with, then you can make the right conclusions. I think that was one of the other pleas from the meeting was that people when writing about their patient groups simply provide an absolutely clear definition of what they mean.”

Roy Homburg, MD: “Yes, I agree with you. Now, I think that if this consensus is accepted, and I really believe it will be, it’s going to be presented, is being presented by Adam here initially. It will be presented at the ASRM, the American meeting and it is going to be published in both Human Reproduction and Fertility and Sterility, so I think we have a good chance of it being accepted. This is a golden opportunity of course certainly to get the scientific angle right, especially with things when we are looking for the phenotype to match the genotype. If we’re looking for the genes, that overall group of genes, that almost certainly cause PCOS then we must be all talking about the same thing. I think this is going to be a great advance.”

Adam Balen, MD: “One of the points that came out in the discussion we were having this afternoon was the whole issue of whether we will be detecting more women with polycystic ovaries now that we’ve included ultrasound in the diagnosis. I personally feel that’s probably not going to be the case because certainly in our practice we use ultrasound but I think the implications for the patient who may have an ultrasound scan for whatever reason and is then found to have polycystic ovaries causes some disquiet because the question then is posed what should you say to that individual?”

Roy Homburg, MD: “Yes but I think we should distinguish, and it might help to clarify this, that I think we both believe that there is a condition where you may have polycystic ovaries but not the syndrome. In that case it might be a question of what do you say to the patient? My own inclination, if she has no clinical signs or symptoms, you probably not need say anything, unless maybe she’s obese and advise her to not put on too much weight.”

Adam Balen, MD: “I disagree slightly with you there because I would, and I’m sure you would, if you see something on the scan you’d actually tell them what you’ve seen, but there may be an opportunity to suggest that it is appropriate to watch lifestyle matters such as diet and exercise even in the slim women in whom you see polycystic ovaries because we all know that with a gain in weight the syndrome will be expressed.

Of course, we still don’t know enough about the evolution of the condition, but there was an interesting study presented this morning from Rome on the growth hormone secretion in response to food, and the effect on opioides and the suggestion, without going into all the details because it’s quite a complex study, they did find differences in opioid tone, in the slim women, posing the possibility that there may be already some inherent difference in satiety and appetite, how you enjoy your food, that may predispose the slim women with polycystic ovaries to be more likely to gain weight. That’s still conjecture, I appreciate that.”

Roy Homburg, MD: “Yes, it also works the opposite way around. It seems to me, and I think there’s good proof of this that it’s much more difficult to get PCOS women to slim. They have great difficulty cutting down their intake. I think it’s probably worth mentioning the work of Rob Norman in Adelaide, who has proved very clearly that changing lifestyle can greatly affect the fertility potential and I think everybody should take notice of this sort of advice.”

Adam Balen, MD: “And furthermore that it’s the lifestyle changes of exercise and diet that have been shown to be far superior to drugs such as metformin, which whilst it may well have a valuable role, and of course the consensus meeting didn’t deal with treatment, there is this sort of world wide view really isn’t there, that everybody is prescribed metformin.”

Roy Homburg, MD: “Yes, which is pretty typical of what goes on without any really very good evidence-based medicine this is what’s happened. I want to go back to the point we mentioned before about widening the diagnostic criteria. The question was asked is that going to increase expenses, is that going to increase the examinations we do? My personal point of view is it’s much better to catch these women who eventually, if not now, will need treatment. So I’m quite pleased that we have slightly broadened the criteria for inclusion.”

Adam Balen, MD: “It also presents the opportunity to study the cohort long-term.”

Roy Homburg, MD: “Exactly. Any thoughts of what’s going to be? Is it going to be okay? Are we going to manage to get this through?”

Adam Balen, MD: “I’m sure it will be through. I think it was fairly warmly received today.”

Roy Homburg, MD: “Today was very well received.”

Adam Balen, MD: “It is quite, well I wouldn’t say outstanding, but certainly the PCOS parts of this meeting have been packed. Every session has been completely packed.”

Roy Homburg, MD: “Yes, they always are and I think this is a very good indication of how important it was to get a consensus, to get absolute guidelines of what we mean and if we do this to packed houses every time then I think we’ll do it in the end.”

Adam Balen, MD: “Yes.”

Roy Homburg, MD: “Anything else you want to add?”

Adam Balen, MD: “I could talk about the ultrasound and I don’t think you want me to go into the details, but we have defined what we mean by a polycystic ovary as detected by ultrasound now. And because ultrasound is part of the criteria it is something that can be quantified and there have been many correlations performed between the various ultrasound measurements and both signs, symptoms and endocrine disturbances in PCOS. It is quite difficult to synthesise all the literature but in summary we feel that a polycystic ovary is one that has at least 12 follicles between 2 and 9 mm in diameter and/or an ovarian volume of greater than 10 ml. There are various other criteria which I don’t think time allows me to go through but that’s the nuts and bolts.”

Roy Homburg, MD: “Yes, I agree and certainly by narrowing these criteria down I think people will feel very much more comfortable. So we’re going to have definite criteria for ultrasound and for the actual diagnosis itself. Not only that, I think we’ve made it quite plain that we don’t need any sophisticated endocrine examinations. Maybe a simple testosterone would do: probably confirm the diagnosis if we exclude other causes of hyperandrogenemia, and it also would make the endocrine work up very much simpler.”

Adam Balen, MD: “Yes, this is all about taking a pragmatic approach to the management of this common condition.”

Roy Homburg, MD: “Yes, do you think it’s going to change the treatment in any way? Or isit just going to broaden the indications?”

Adam Balen, MD: “No, I think it may make people more aware about providing appropriate advice to their patients but I don’t think it’s going to affect the management. That of course will be addressed in our meeting on Anovulation Induction in London next April. “

Roy Homburg, MD: “Tell us about that more.”

Adam Balen, MD: “The 22nd and 23rd of April at the RCOG in London next year is going to be an ESHRE two-day meeting, state-of-the-art, Anovulation Induction for Anovolitrium Fertility. This is a joint venture between RCOG and ESHRE and I think it’s going to be a very popular meeting. It’s not a consensus meeting but there will be a publication arising from it.”

Roy Homburg, MD: “Great! Thank you.”

Adam Balen, MD: “Thank you very much.”