1. Introduction

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder among women of reproductive age but often unrecognized condition. It was first described by Stein and Leventhal in 1935 as women with polycystic ovaries, amenorrhea, and hirsutism [1]. One in

© 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

15 women worldwide is affected by this syndrome [2]. There is actually no consensus on diagnostic criteria and the figures may change.

Most women with PCOS have infertility or subfertility and other metabolic alterations such as insulin resistance, dyslipidemia, hyperinsulinemia, and obesity. Despite the etiology of the syndrome is still far from being elucidated, it could be considered the result of concurrent endocrine modifications, lifestyle factors, and genetic background. In particular, accumulating evidence suggests that insulin resistance and compensatory hyperinsulinemia play a pivotal pathogenic role in the hyperandrogenism of many PCOS phenotypes, which in turn have a clear detrimental effect on chronic anovulation [3].

There has been considerable controversy about specific diagnostic criteria when all classic features (hirsutism, irregular menstrual cycles, obesity, and a classic ovarian morphology by transvaginal ultrasonography) are not evident.

2.1.1. Detecting of ovulatory dysfunction

Table 1. Diagnostic criteria for PCOS.

Ovulatory dysfunction (oligo- or amenorrhea)

2.1.2. Measurement of androgens

duced from both adrenal and ovarian.

and a cycle length of up to 40 days can be considered normal.

The definition of ovulatory dysfunction is not clear. If the menstrual cycle length is longer than 35 days, it is assumed that chronic anovulation is present and that special tests are not needed. A 30–35 day cycle can also be anovulatory. Measurement of serum progesterone in the midluteal stage (Days 21–22) is the best way to evaluate ovulation. Progesterone levels > 2.5 ng/mL may indicate ovulation but values of ≥7 ng/mL are needed for normal luteal function [7]. Three consecutive measurements with a total serum value of ≥15 ng/mL indicate normal luteal function. Alternatives to progesterone measurement such as baseline body temperature schedules, urinary luteinizing hormone (LH) kits, or timed endometrial biopsy may be suggested, but do not provide sufficient information about the luteal phase. The cycle time for oligomenorrhea is ≥35 days in adult women. The threshold value during puberty is higher

PCOS morphology Not required Two of three required Either ovulatory dysfunction

Hyperandrogenism Required Two of three required Required

NIH 1990 criteria Rotterdam criteria [5] AE-PCOS Society criteria

Required Two of three required Either ovulatory dysfunction

or PCOS morphology required

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Controversies in Polycystic Ovary Syndrome http://dx.doi.org/10.5772/intechopen.72513

or PCOS morphology required

In women, the androgen source is the adrenal cortex and the ovaries. Testosterone is produced from the ovary, DHEA-S is produced from the adrenal gland, and androstenedione is pro-

The issue of which serum androgen should be measured for diagnosis of PCOS remains controversial. Free testosterone (T) levels are more sensitive than the measurement of total T for establishing the existence of androgen excess. The normal value of total testosterone level is 20–60 ng/dl. In cases with PCOS, the total testosterone level is generally lower than 150 ng/dl. If the total testosterone level is higher than 150 ng/dl, testosterone-secreting adrenal tumor, ovarian tumor, or ovarian hypertrophy should be suspected. In patients using oral contracep-

Direct analog RIA measurement in commercial laboratories is notoriously inaccurate. Ideally, it should be determined through equilibrium dialysis techniques. Consequently, if the clinician is uncertain regarding the quality of the free-T assay, it may be preferable to rely on calculated free T, which has a good concordance and correlation with free T as measured by equilibrium dialysis methods [8]. Value of measuring levels of androgens other than T (dehydroepiandrosterone sulfate, androstenedione) in patients with PCOS is relatively insignificant. If dehydroepiandrostenedione sulfate (DHEAS) levels are higher than 700 μg/dL, adrenal tumors should be suspected. DHEAS levels may also increase in cases with LOCAH (late-onset congenital

tives, total androgen levels should be measured 8–12 weeks after drug withdrawal.

adrenal hyperplasia), Cushing's disease, adrenal adenomas as well as PCOS.

Research for PCOS in the last decade has brought new important insights for the evaluation and treatment of this disorder. Unclear points for diagnosis and treatment and proper approach to PCOS-related diseases will be discussed in this chapter.
