938
British Journal of Obstetrics and Gynaecology November 1992, Vol. 99
CORRESPONDENCE
References
References
Duley L. (1922)Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean. Br J Obstet Gynuecol99,541-553. Fiander A. (1991) Maternal mortality in developing countries: an example from Northern Ghana. J Obstet Gynuecol 11,339-341.
Conway G. S., Honour J. W. & Jacobs H. S. (1989)Heterogeneity of the polycystic ovary syndrome: clinical, endocrine and ultrasound features in 556 patients. Clin Endocrinol30,459470. El Tabbakh G. H., Lotfy I., Azab I., Rahman H. A,, Southren A. L. & Aleem F. A. (1986) Correlation of the ultrasonic appearance of the ovaries in polycystic ovarian disease and the clinical, hormonal, and laparoscopic findings. Am J Obstet Gynecol 154, 892-895. Faure N., Prat X., Bastide A. & Lemay A. (1989) Assessment of ovaries by magnetic resonance imaging in patients with polycystic ovarian syndrome. H u m Reprod 4,468-472. Orsini L. F., Venturoli S.. Lorusso R., Pluchinotta V., Paradisi R. & Bovicelli L. (1 985) Ultrasonic findings in polycystic ovarian disease. Fertil Steril43, 709-714. Robinson S., Rodin D. A,, Deacon A,, Wheeler M. J. & Clayton R. N. (1992) Which hormone tests for the diagnosis of polycystic ovary syndrome? Br J Obstet 99,232-238.
Which hormone tests for the diagnosis of polycystic ovary syndrome? Dear Sir, In their report of endocrine findings in women with polycystic ovary syndrome (PCOS), Robinson el a/. (1992) refer to ultrasound as the gold standard for the diagnosis of PCOS, and suggest that hormone investigation should be used to provide confirmatory evidence. While pelvic ultrasonography has proved to be an invaluable method for the study of women with polycystic ovaries (PCO). we believe its application in routine clinical practice is not without problems. The characterization of ovarian morphology using ultrasound requires considerable expertise and experience beyond the comparatively simple requirements for the diagnosis of ovarian tumours and for the monitoring of follicular growth. Orsini et al. (1985) reported that only one third of 16 patients with laparoscopically-diagnosed PCO had evidence of increased follicularity at transabdominal ultrasonography. El Tabbakh et a/. (1986)similarly studied 20 women with laparoscopically-diagnosed PCO and found that no follicles were discernible in 11 cases. Studies comparing pelvic ultrasonography with magnetic resonance imaging for the examination of ovarian morphology in women with PCOD diagnosed biochemically also indicated that abdominal ultrasound fails to reveal many of the smaller follicles (Faure et al. 1989). This difficulty in defining small follicles helps to explain the differences in the criteria used to diagnose PCO reported by different groups. Apart from any limitation of ultrasonography in the definition of ovarian morphology, it must be remembered that the method is limited to the morphology of the ovary. The finding of PCO is misleading in a small proportion of cases because the true cause of oligo-amenorrhoea will be overriding any disorder that might occur due to (pre-existing) PCO. We, and others (Conway erul. 1989), have found PCO at scan in women with hypothalmic disorder related to weight loss, and hyperprolactinaemia due to a pituitary adenoma. The danger of largely basing the diagnosis of PCOS on ovarian ultrasonography is the possibility of overlooking serious conditions such as anorexia nervosa. which may be difficult to detect in practice. Robert Fox University of Bristol Department of Obstetrics and Gynaecology Bristol Maternity Hospitul Southwell Street, Brisrol
Authors’ reply Dear Sir, We were interested in the letter by Robert Fox, and agree that the use of pelvic ultrasonography in routine clinical practice can be problematical. However, we have found that with well-trained experience ultrasonographers there is little difficulty in differentiating polycystic and normal ovaries. As regards the question of failure of ultrasound to identify PCO in laparoscopically diagnosed cases the correspondents have not cited a recent publication from Saxton etal. (BrJ Ohsf Gynaecoll990,97,695-699),cited in our report, which showed a very good (91 YO)specificity of ultrasound. This is even more evident with routine use of transvaginal ultrasound. We believe that ultrasound, in experienced hands, can be used as the gold standard for defining ovarian morphology. Nevertheless, we agreed with the view expressed that not all women with oligomenorrhoea. hirsuitism and biochemical hyperandogenism who clinically are classified as polycystic ovary syndrome will have polycystic morphology of the ovaries. We accept that hyperprolactinacmia may produce a similar morphological appearance on ultrasound but this rarely causes diagnostic difficulty since the biochemical findings are of low oestradiol and testosterone levels, which is also true for hypothalamic amenorrhoea. Therefore, if all features, clinical, biochcmical. and ultrasound are taken together there is little difficulty in distinguishing PCOS from other causes of oligo-amenorrhoea. We clearly state that in our study hyperprolactinaemia was excluded, and none of the subjects presented with weight loss related amenorrhoea. R. N. Clayton Professor of Medicine Consultant Physician/Endocrinologi.~t North Stafjordshire Royal Infirmmry Drpurtment of Endocrinology and Diabetes Mellitiis Stoke-on-Trent ST4 7LN
British Journal of Obstetrics and Gynaecology November 1992, Vol. 99
CORRESPONDENCE
References
References
Duley L. (1922)Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean. Br J Obstet Gynuecol99,541-553. Fiander A. (1991) Maternal mortality in developing countries: an example from Northern Ghana. J Obstet Gynuecol 11,339-341.
Conway G. S., Honour J. W. & Jacobs H. S. (1989)Heterogeneity of the polycystic ovary syndrome: clinical, endocrine and ultrasound features in 556 patients. Clin Endocrinol30,459470. El Tabbakh G. H., Lotfy I., Azab I., Rahman H. A,, Southren A. L. & Aleem F. A. (1986) Correlation of the ultrasonic appearance of the ovaries in polycystic ovarian disease and the clinical, hormonal, and laparoscopic findings. Am J Obstet Gynecol 154, 892-895. Faure N., Prat X., Bastide A. & Lemay A. (1989) Assessment of ovaries by magnetic resonance imaging in patients with polycystic ovarian syndrome. H u m Reprod 4,468-472. Orsini L. F., Venturoli S.. Lorusso R., Pluchinotta V., Paradisi R. & Bovicelli L. (1 985) Ultrasonic findings in polycystic ovarian disease. Fertil Steril43, 709-714. Robinson S., Rodin D. A,, Deacon A,, Wheeler M. J. & Clayton R. N. (1992) Which hormone tests for the diagnosis of polycystic ovary syndrome? Br J Obstet 99,232-238.
Which hormone tests for the diagnosis of polycystic ovary syndrome? Dear Sir, In their report of endocrine findings in women with polycystic ovary syndrome (PCOS), Robinson el a/. (1992) refer to ultrasound as the gold standard for the diagnosis of PCOS, and suggest that hormone investigation should be used to provide confirmatory evidence. While pelvic ultrasonography has proved to be an invaluable method for the study of women with polycystic ovaries (PCO). we believe its application in routine clinical practice is not without problems. The characterization of ovarian morphology using ultrasound requires considerable expertise and experience beyond the comparatively simple requirements for the diagnosis of ovarian tumours and for the monitoring of follicular growth. Orsini et al. (1985) reported that only one third of 16 patients with laparoscopically-diagnosed PCO had evidence of increased follicularity at transabdominal ultrasonography. El Tabbakh et a/. (1986)similarly studied 20 women with laparoscopically-diagnosed PCO and found that no follicles were discernible in 11 cases. Studies comparing pelvic ultrasonography with magnetic resonance imaging for the examination of ovarian morphology in women with PCOD diagnosed biochemically also indicated that abdominal ultrasound fails to reveal many of the smaller follicles (Faure et al. 1989). This difficulty in defining small follicles helps to explain the differences in the criteria used to diagnose PCO reported by different groups. Apart from any limitation of ultrasonography in the definition of ovarian morphology, it must be remembered that the method is limited to the morphology of the ovary. The finding of PCO is misleading in a small proportion of cases because the true cause of oligo-amenorrhoea will be overriding any disorder that might occur due to (pre-existing) PCO. We, and others (Conway erul. 1989), have found PCO at scan in women with hypothalmic disorder related to weight loss, and hyperprolactinaemia due to a pituitary adenoma. The danger of largely basing the diagnosis of PCOS on ovarian ultrasonography is the possibility of overlooking serious conditions such as anorexia nervosa. which may be difficult to detect in practice. Robert Fox University of Bristol Department of Obstetrics and Gynaecology Bristol Maternity Hospitul Southwell Street, Brisrol
Authors’ reply Dear Sir, We were interested in the letter by Robert Fox, and agree that the use of pelvic ultrasonography in routine clinical practice can be problematical. However, we have found that with well-trained experience ultrasonographers there is little difficulty in differentiating polycystic and normal ovaries. As regards the question of failure of ultrasound to identify PCO in laparoscopically diagnosed cases the correspondents have not cited a recent publication from Saxton etal. (BrJ Ohsf Gynaecoll990,97,695-699),cited in our report, which showed a very good (91 YO)specificity of ultrasound. This is even more evident with routine use of transvaginal ultrasound. We believe that ultrasound, in experienced hands, can be used as the gold standard for defining ovarian morphology. Nevertheless, we agreed with the view expressed that not all women with oligomenorrhoea. hirsuitism and biochemical hyperandogenism who clinically are classified as polycystic ovary syndrome will have polycystic morphology of the ovaries. We accept that hyperprolactinacmia may produce a similar morphological appearance on ultrasound but this rarely causes diagnostic difficulty since the biochemical findings are of low oestradiol and testosterone levels, which is also true for hypothalamic amenorrhoea. Therefore, if all features, clinical, biochcmical. and ultrasound are taken together there is little difficulty in distinguishing PCOS from other causes of oligo-amenorrhoea. We clearly state that in our study hyperprolactinaemia was excluded, and none of the subjects presented with weight loss related amenorrhoea. R. N. Clayton Professor of Medicine Consultant Physician/Endocrinologi.~t North Stafjordshire Royal Infirmmry Drpurtment of Endocrinology and Diabetes Mellitiis Stoke-on-Trent ST4 7LN
