Letters to the Editor
5.
have one or more elevated androgens (most commonly free T), the remaining have normal levels and we suggest the term “normoandrogenemic PCOS” for them. The role of AR activity mediated by the CAG repeat polymorphism in the pathogenesis of PCOS is an active area of research and the authors could have mentioned this evolving concept. In a study conducted in 250 south Indian women with PCOS and 299 controls, AR microsatellite variation seemed to account for hyperandrogenicity in obese PCOS patients to a large extent.[6] Whether this is similar to AR hypersensitivity observed in patients with idiopathic hirsutism needs further research. Though the authors mention the risk of metabolic syndrome in PCOS patients, we suggest that the addition of a simple noninvasive radiological investigation like carotid intima media thickness (CIMT) in the list of work-up of patients with PCOS would encourage early cardiovascular screening and interventions to control modifiable cardiovascular risk factors.[7]
Sidharth Sonthalia, Jyotirmaya Bharti Consultant Dermatologist, Skinnocence, The Skin Clinic, Gurgaon, Haryana, India Address for correspondence: Dr. Sidharth Sonthalia, Skinnocence, The Skin Clinic, C-2246, Sushant Lok-1, Block-C, Gurgaon-122 009, Haryana, India E-mail: [email protected]
REFERENCES 1. 2. 3. 4. 5.
6.
7.
154
Madnani N, Khan K, Chauhan P, Parmar G. Polycystic ovarian syndrome. Indian J Dermatol Venereol Leprol 2013;79:310-21. Ságodi L, Barkai L. Diagnostic difficulties of polycystic ovarian syndrome in adolescent girls. Orv Hetil 2013;154:136-42. Vanky E, Isaksen H, Moen MH, Carlsen SM. Breastfeeding in polycystic ovary syndrome. Acta Obstet Gynecol Scand 2008;87:531-5. Thatcher SS, Jackson EM. Pregnancy outcome in infertile patients with polycystic ovary syndrome who were treated with metformin. Fertil Steril 2006;85:1002-9. Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004;19:41-7. Dasgupta S, Sirisha PV, Neelaveni K, Anuradha K, Reddy AG, Thangaraj K, et al. Androgen receptor CAG repeat polymorphism and epigenetic influence among the south Indian women with polycystic ovary syndrome. PLoS One 2010;5:e12401. Meyer ML, Malek AM, Wild RA, Korytkowski MT, Talbott EO. Carotid artery intima-media thickness in polycystic ovary syndrome: A systematic review and meta-analysis. Hum Reprod Update 2012;18:112-26.
Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.129398 PMID: 129398
Polycystic ovarian syndrome: A review Sir, The topic of polycystic ovarian syndrome (PCOS) is vast and complex with many gray areas. It is extremely difficult to include all aspects of this condition in an article but we have tried to present as much data as possible. We appreciate the comments made after reading our article and give the following explanations. 1.
We agree with the reader that the diagnosis of PCOS in adolescence is indeed difficult. In the proposed diagnostic criteria for PCOS, no particular consideration has been given to the adolescent age group. Menstrual irregularity is common in the early years after menarche and oligo-anovulation may be normal.[1] Clinical hyperandrogenism (HA) may be less common in younger women.[2] Biochemical HA is the most consistent biochemical abnormality in PCOS but there are no widely accepted normal values for adolescents.[3] Further, laboratory assays used to measure testosterone concentrations vary widely between laboratories. Compounding these limitations is the paucity of normative data for testosterone concentrations from population-based studies on adolescents.[4] Ovarian appearance in the early post-menarchal years may differ from that seen in adult women. It is not well defined how a multifollicular appearance may differ from polycystic ovarian (PCO) morphology.[5] We agree that for diagnosing PCOS in an adoloscent, menstrual irregularity lasting for over two years and accurate assessment of hyperandrogenic and metabolic features should be given preference as diagnostic features over the ultrasound detected Overian morphology.
Indian Journal of Dermatology, Venereology, and Leprology | March-April 2014 | Vol 80 | Issue 2
Letters to the Editor
2.
3.
4.
5.
It has been mentioned in the article that metformin can be used throughout pregnancy and it is indeed safe. The apparent lack of teratogenicity has earned it an FDA pregnancy category B classification. If a pregnant woman has evidence of virilization then one should think of luteoma of pregnancy as a possible cause. Eruption of acne or hirsutism during lactational amenorrhoea is rarely due to PCOS and one needs to look for other causes. As such, PCOS is a diagnosis of exclusion! The sex hormone-binding globulin (SHBG) levels can be measured in patients with PCOS and are usually low. However, SHBG levels vary according to ethnicity and age. Moreover, the assays for SHBG are not standardized. Measuring SHBG levels in all patients of PCOS is not the current clinical practice. The validity of free androgen index (FAI) as an accurate reflector of free testosterone levels has been questioned and additional data are required to support its use.[6] It has been recommended that free testosterone should be used only in those patients who have signs of hyperandrogenism in the presence of normal levels of testosterone. In a recent systematic review, polymorphism of the androgen receptor gene seems to be a promising biomarker for PCOS because shorter repeats may be linked to the disorder. However, further studies are needed to understand the association fully.[7] Though measurement of carotid artery intimamedia thickness is a simple non-invasive test for cardiovascular screening, PCOS occurs in 2nd-3rd decade and unless other risk factors are present, it should not be performed routinely. Even highy specific C-reactive protein (hsCRP) is a good, reliable and clinically practical biomarker for cardiovascular screening in PCOS patients.
Nina Madnani, Kaleem Khan, Phulrenu Chauhan1, Parmar1 Departments of Dermatology and 1Endocrinology, P. D. Hinduja National Hospital, Mahim, Mumbai, Maharashtra, India Address for correspondence: Dr. Nina Madnani, Department of Dermatology, P.D. Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai - 400 016, Maharashtra, India. E-mail: [email protected]
REFERENCES 1. 2.
3.
4. 5. 6.
7.
Apter D, Vihko R. Premenarcheal endocrine changes in relation to age at menarche. Clin Endocrinol (Oxf) 1985;22:753-60. Rosenfield RL, Ghai K, Ehrmann DA, Barnes RB. Diagnosis of the polycystic ovary syndrome in adolescence: Comparison of adolescent and adult hyperandrogenism. J Pediatr Endocrinol Metab 2000;13:1285-9. Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, et al. Task Force on the Phenotype of the Polycystic Ovary Syndrome of The Androgen Excess and PCOS Society. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: The complete task force report. Fertil Steril 2009;91:456-88. Khan U. Polycystic ovary syndrome in adolescents. J Pediatr Adolesc Gynecol 2007;20:101-4. Holm K, Laursen EM, Brocks V, Müller J. Pubertal maturation of the internal genitalia: An ultrasound evaluation of 166 healthy girls. Ultrasound Obstet Gynecol 1995;6:175-81. Miller KK, Rosner W, Lee H, Hier J, Sesmilo G, Schoenfeld D, et al. Measurement of free testosterone in normal women and women with androgen deficiency: Comparison of methods. J Clin Endocrinol Metab 2004;89:525-33. Lin LH, Baracat MC, Maciel GA, Soares JM Jr, Baracat EC. Androgen receptor gene polymorphism and polycystic ovary syndrome. Int J Gynaecol Obstet 2013;120:115-8.
Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.129399 PMID: 129399
Delleman syndrome or Haberland syndrome? Sir, We read the article by Nocito et al.[1] with interest and wish to make the following observations: 1.
The authors have described a dermoid cyst over the iris impairing patient’s vision in the left eye. We disagree as the location of dermoid is on the cornea and limbus, rather than iris. Iris is the intraocular pigmented structure of eye, which regulates the entry of light into the eye. Authors also state that patient is having a blue-gray dermoid cyst over the right eye sclera. We disagree with the diagnosis in the right eye since the color of dermoid ranges from yellow to gray to pink rather than blue-gray.[2] It seems
Indian Journal of Dermatology, Venereology, and Leprology | March-April 2014 | Vol 80 | Issue 2
155
Copyright of Indian Journal of Dermatology, Venereology & Leprology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
5.
have one or more elevated androgens (most commonly free T), the remaining have normal levels and we suggest the term “normoandrogenemic PCOS” for them. The role of AR activity mediated by the CAG repeat polymorphism in the pathogenesis of PCOS is an active area of research and the authors could have mentioned this evolving concept. In a study conducted in 250 south Indian women with PCOS and 299 controls, AR microsatellite variation seemed to account for hyperandrogenicity in obese PCOS patients to a large extent.[6] Whether this is similar to AR hypersensitivity observed in patients with idiopathic hirsutism needs further research. Though the authors mention the risk of metabolic syndrome in PCOS patients, we suggest that the addition of a simple noninvasive radiological investigation like carotid intima media thickness (CIMT) in the list of work-up of patients with PCOS would encourage early cardiovascular screening and interventions to control modifiable cardiovascular risk factors.[7]
Sidharth Sonthalia, Jyotirmaya Bharti Consultant Dermatologist, Skinnocence, The Skin Clinic, Gurgaon, Haryana, India Address for correspondence: Dr. Sidharth Sonthalia, Skinnocence, The Skin Clinic, C-2246, Sushant Lok-1, Block-C, Gurgaon-122 009, Haryana, India E-mail: [email protected]
REFERENCES 1. 2. 3. 4. 5.
6.
7.
154
Madnani N, Khan K, Chauhan P, Parmar G. Polycystic ovarian syndrome. Indian J Dermatol Venereol Leprol 2013;79:310-21. Ságodi L, Barkai L. Diagnostic difficulties of polycystic ovarian syndrome in adolescent girls. Orv Hetil 2013;154:136-42. Vanky E, Isaksen H, Moen MH, Carlsen SM. Breastfeeding in polycystic ovary syndrome. Acta Obstet Gynecol Scand 2008;87:531-5. Thatcher SS, Jackson EM. Pregnancy outcome in infertile patients with polycystic ovary syndrome who were treated with metformin. Fertil Steril 2006;85:1002-9. Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004;19:41-7. Dasgupta S, Sirisha PV, Neelaveni K, Anuradha K, Reddy AG, Thangaraj K, et al. Androgen receptor CAG repeat polymorphism and epigenetic influence among the south Indian women with polycystic ovary syndrome. PLoS One 2010;5:e12401. Meyer ML, Malek AM, Wild RA, Korytkowski MT, Talbott EO. Carotid artery intima-media thickness in polycystic ovary syndrome: A systematic review and meta-analysis. Hum Reprod Update 2012;18:112-26.
Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.129398 PMID: 129398
Polycystic ovarian syndrome: A review Sir, The topic of polycystic ovarian syndrome (PCOS) is vast and complex with many gray areas. It is extremely difficult to include all aspects of this condition in an article but we have tried to present as much data as possible. We appreciate the comments made after reading our article and give the following explanations. 1.
We agree with the reader that the diagnosis of PCOS in adolescence is indeed difficult. In the proposed diagnostic criteria for PCOS, no particular consideration has been given to the adolescent age group. Menstrual irregularity is common in the early years after menarche and oligo-anovulation may be normal.[1] Clinical hyperandrogenism (HA) may be less common in younger women.[2] Biochemical HA is the most consistent biochemical abnormality in PCOS but there are no widely accepted normal values for adolescents.[3] Further, laboratory assays used to measure testosterone concentrations vary widely between laboratories. Compounding these limitations is the paucity of normative data for testosterone concentrations from population-based studies on adolescents.[4] Ovarian appearance in the early post-menarchal years may differ from that seen in adult women. It is not well defined how a multifollicular appearance may differ from polycystic ovarian (PCO) morphology.[5] We agree that for diagnosing PCOS in an adoloscent, menstrual irregularity lasting for over two years and accurate assessment of hyperandrogenic and metabolic features should be given preference as diagnostic features over the ultrasound detected Overian morphology.
Indian Journal of Dermatology, Venereology, and Leprology | March-April 2014 | Vol 80 | Issue 2
Letters to the Editor
2.
3.
4.
5.
It has been mentioned in the article that metformin can be used throughout pregnancy and it is indeed safe. The apparent lack of teratogenicity has earned it an FDA pregnancy category B classification. If a pregnant woman has evidence of virilization then one should think of luteoma of pregnancy as a possible cause. Eruption of acne or hirsutism during lactational amenorrhoea is rarely due to PCOS and one needs to look for other causes. As such, PCOS is a diagnosis of exclusion! The sex hormone-binding globulin (SHBG) levels can be measured in patients with PCOS and are usually low. However, SHBG levels vary according to ethnicity and age. Moreover, the assays for SHBG are not standardized. Measuring SHBG levels in all patients of PCOS is not the current clinical practice. The validity of free androgen index (FAI) as an accurate reflector of free testosterone levels has been questioned and additional data are required to support its use.[6] It has been recommended that free testosterone should be used only in those patients who have signs of hyperandrogenism in the presence of normal levels of testosterone. In a recent systematic review, polymorphism of the androgen receptor gene seems to be a promising biomarker for PCOS because shorter repeats may be linked to the disorder. However, further studies are needed to understand the association fully.[7] Though measurement of carotid artery intimamedia thickness is a simple non-invasive test for cardiovascular screening, PCOS occurs in 2nd-3rd decade and unless other risk factors are present, it should not be performed routinely. Even highy specific C-reactive protein (hsCRP) is a good, reliable and clinically practical biomarker for cardiovascular screening in PCOS patients.
Nina Madnani, Kaleem Khan, Phulrenu Chauhan1, Parmar1 Departments of Dermatology and 1Endocrinology, P. D. Hinduja National Hospital, Mahim, Mumbai, Maharashtra, India Address for correspondence: Dr. Nina Madnani, Department of Dermatology, P.D. Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai - 400 016, Maharashtra, India. E-mail: [email protected]
REFERENCES 1. 2.
3.
4. 5. 6.
7.
Apter D, Vihko R. Premenarcheal endocrine changes in relation to age at menarche. Clin Endocrinol (Oxf) 1985;22:753-60. Rosenfield RL, Ghai K, Ehrmann DA, Barnes RB. Diagnosis of the polycystic ovary syndrome in adolescence: Comparison of adolescent and adult hyperandrogenism. J Pediatr Endocrinol Metab 2000;13:1285-9. Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, et al. Task Force on the Phenotype of the Polycystic Ovary Syndrome of The Androgen Excess and PCOS Society. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: The complete task force report. Fertil Steril 2009;91:456-88. Khan U. Polycystic ovary syndrome in adolescents. J Pediatr Adolesc Gynecol 2007;20:101-4. Holm K, Laursen EM, Brocks V, Müller J. Pubertal maturation of the internal genitalia: An ultrasound evaluation of 166 healthy girls. Ultrasound Obstet Gynecol 1995;6:175-81. Miller KK, Rosner W, Lee H, Hier J, Sesmilo G, Schoenfeld D, et al. Measurement of free testosterone in normal women and women with androgen deficiency: Comparison of methods. J Clin Endocrinol Metab 2004;89:525-33. Lin LH, Baracat MC, Maciel GA, Soares JM Jr, Baracat EC. Androgen receptor gene polymorphism and polycystic ovary syndrome. Int J Gynaecol Obstet 2013;120:115-8.
Access this article online Quick Response Code:
Website: www.ijdvl.com DOI: 10.4103/0378-6323.129399 PMID: 129399
Delleman syndrome or Haberland syndrome? Sir, We read the article by Nocito et al.[1] with interest and wish to make the following observations: 1.
The authors have described a dermoid cyst over the iris impairing patient’s vision in the left eye. We disagree as the location of dermoid is on the cornea and limbus, rather than iris. Iris is the intraocular pigmented structure of eye, which regulates the entry of light into the eye. Authors also state that patient is having a blue-gray dermoid cyst over the right eye sclera. We disagree with the diagnosis in the right eye since the color of dermoid ranges from yellow to gray to pink rather than blue-gray.[2] It seems
Indian Journal of Dermatology, Venereology, and Leprology | March-April 2014 | Vol 80 | Issue 2
155
Copyright of Indian Journal of Dermatology, Venereology & Leprology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
