Aviva SopherPediatric Endocrinology, Aviva Sopher
- Aviva Sopher
- United States of America
From the Authors (Pereira-Eshraghi et al):
We thank Dr Martin for her comments. Indeed, we do agree that young women with irregular menstrual cycles should be labelled as “at risk” for polycystic ovary syndrome (PCOS) for at least two years post menarche, if not for longer.
PCOS is often unrecognized and underdiagnosed, especially in younger patients, despite its relatively high prevalence. One large population-based study in the United States reports that approximately 50% of adolescents with symptoms indicative of PCOS remain undiagnosed. (1) One explanation for the difficulty in diagnosing PCOS is the fragmented diagnostic process, which reflects the multiple systems affected in this disorder. Patients are often evaluated by physicians of different specialties who are working in parallel rather than collaboratively. For example, patients may see a dermatologist for hirsutism and acne, a gynecologist for irregular menses, and a psychologist or psychiatrist for depression or anxiety.
As Dr. Martin states, “Long-term consequences of untreated PCOS are serious, such as insulin resistance, cardiovascular disease, hyperlipemia, infertility, endometrial hyperplasia and endometrial cancer”. Knowing whether or not an adolescent or young adult is at risk for or has PCOS is invaluable in screening for and helping to prevent these disorders. In this age of personalized medicine, we disagree with the “chief complaint” approach that Dr. Martin has proposed, which will likely lead to a delay in diagnosis.
In contrast, an earlier diagnosis of PCOS and identification of those at risk for PCOS can expedite screening for comorbidities and prevention of their onset and progression. For example, an oral glucose tolerance test is not indicated in overweight adolescents who do not have PCOS (2), whereas it is in those with a potential diagnosis of PCOS it is. (3),This is relevant since PCOS is a disorder of insulin resistance for which metformin, an insulin sensitizer, can be an important component of the treatment plan. Treatment with metformin may lead to improvement or resolution of many of the metabolic findings associated with PCOS including non-alcoholic fatty liver disease (NAFLD), hypertriglyceridemia and insulin resistance, and has also been shown to regulate menstrual cycles.(4)
Earlier confirmation of diagnosis of PCOS particularly in patients “at risk” will allay some of the mental strain on adolescents and young adults who are experiencing symptoms. Affected adolescents may wonder why their menses are irregular and why they have more hair on their bodies than their peers. A confirmed diagnosis can be comforting and will help guide treatment.
Importantly, there is an imbalance in the amount of money spent on diagnosis compared to the amountspent on treatment of PCOS and its comorbidities. Patients with PCOS require life-long medical care to both treat PCOS symptoms and to mitigate long-term health complications. (5) The estimated annual cost of PCOS in women of reproductive age in the United States is $4.3 billion dollars; however, only 2 % of this sum is used in for diagnosis.(6) Individuals with PCOS report dissatisfaction with the diagnostic process due to the multiple visits to different physicians and the amount of time until a diagnosis is made (7). The prolonged length of time
used to diagnose patients with PCOS is even more pronounced in adolescents and young adults. Whereas MRI is more expensive than ultrasound, it may be more cost-effective to perform an MRI if it is a better modality for arriving at a more definitive diagnosis.
Showing that MRI is a potential tool for the evaluation ovarian morphology in non-obese adolescents and young female will allow us to extrapolate the results to patients with obesity. Whereas the opposite would not be necessarily appropriate. Besides providing clarity of images, MRI is not operator-dependent as is ultrasound.
Finally, if this modality is found to be useful and cost-effective, radiologists can learn how to interpret scans as they frequently learn different protocols as new technologies emerge.
1: March WA, Moore VM, Willson KJ, Phillips DI, Norman RJ, Davies MJ. The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Hum Reprod. 2010;25(2):544-551.
3:Teede HJ, Misso ML, Costello MF, Docras A, Laaven J, Moran L, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril 2018;110: 364–79.
4: Moghetti P, Castello R, Negri C, Tosi F, Perrone F, Caputo M, Zanolin E, Muggeo M. Metformin effects on clinical features, endocrine and metabolic profiles, and insulin sensitivity in polycystic ovary syndrome: a randomized, double-blind, placebo-controlled 6-month trial, followed by open, long-term clinical evaluation. J Clin Endocrinol Metab. 2000 Jan;85(1):139-46. doi: 10.1210/jcem.85.1.6293. PMID: 10634377.
5: Fauser BC, Tarlatzis BC, Rebar RW, et al. Consensus on women's health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil Steril. 2012;97(1):28-38.e25.
6: Azziz R, Marin C, Hoq L, Badamgarav E, Song P. Health care-related economic burden of the polycystic ovary syndrome during the reproductive life span. J Clin Endocrinol Metab. 2005;90(8):4650-4658.
7: Gibson-Helm M, Teede H, Dunaif A, Dokras A. Delayed Diagnosis and a Lack of Information Associated With Dissatisfaction in Women With Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2017;102(2):604-612.