Abstract
Background: Many clinical and biochemical criteria are used to assess hyperandrogenism in subjects with polycystic ovary syndrome (PCOS). Standard indicators used to confirm hyperandrogenism are based predominantly on western data. Whilst the phenotype of PCOS has ethnic specific variation, specific cutoffs for hyperandrogenism in South Asians have not been defined. Objectives: To evaluate the effectiveness of modified Ferriman-Gallwey score (FG Score), serum total testosterone and free androgen index (FAI) in the assessment of hyperandrogenism in PCOS. Materials and methods: A case control study was conducted on 100 women aged 20-45 years (mean age=30) attending a specialized endocrine clinic in Colombo, Sri Lanka from 1st January 2010 to 1st June 2013. Confirmed cases with PCOS (Rotterdam criteria 2003) were age matched for controls from healthy volunteers. Recommended cut-offs for hyperandrogenism: FG score ≥8, testosterone (T) >3.5 nmol/L and FAI >5 were applied and receiver operating characteristics (ROC) curves were drawn to compare the diagnostic power of each parameter. Results: 50 cases with PCOS and 50 controls were studied. Cases versus controls had significantly greater FG score, testosterone and FAI:median FG=10 vs 3, mean testosterone 2.762±1.78 vs 1.045± 0.40 (p=0.0001), mean FAI 7.31±7.55 vs 3.64±4.87 (p= 0.01);76% cases and 4% controls had FG score ≥8 (p=0.0001), 30% cases had elevated (T) with none among controls (p=0.00001), 43.3% cases and 14.7% controls had FAI ≥5 (p=0.002). The diagnostic power of serum testosterone was greater than that of FAI in subjects with FG score ≥8. Area under the curve (AUC) for T and FAI were 0.832 and 0.766 respectively. Conclusion: Clinical assessment by FG score detects hyperandrogenism in PCOS patients more frequently compared to serum testosterone and free androgen index. A higher detection rate was observed in controls when FAI was used as the indicator, suggesting a possible influence from changes in SHBG concentration. Hence, total testosterone having greater diagnostic power than FAI in confirming hyperandrogenism, is the recommended biochemical test in the diagnostic work up of PCOS. DOI: http://dx.doi.org/10.4038/sjdem.v4i1.7240 Sri Lanka Journal of Diabetes, Endocrinology and Metabolism 2014; 4 : 3-8
Highlights
The polycystic ovary syndrome (PCOS) is the commonest endocrine disorder of women of reproductive age worldwide (1)
Clinical assessment by FG score detects hyperandrogenism in PCOS patients more frequently compared to serum testosterone and free androgen index
A higher detection rate was observed in controls when free androgen index (FAI) was used as the indicator, suggesting a possible influence from changes in sex hormone binding globulin (SHBG) concentration
Summary
The polycystic ovary syndrome (PCOS) is the commonest endocrine disorder of women of reproductive age worldwide (1). According to an editorial published in the British Medical Journal (3), the definition of PCOS by The Androgen Excess and PCOS Society revolves around the presence of hyperandrogenism (clinical and/or biochemical) and ovarian dysfunction (oligo-anovulation) and/or polycystic ovaries with the exclusion of related disorders (4). The Rotterdam 2003 consensus diagnostic criteria require any 2 out of the 3 criteria to be positive and the criteria being oligo-anovulation, clinical and/or biochemical signs of hyperandrogenism, polycystic ovaries and the exclusion of other aetiologies (congenital adrenal hyperplasia, androgen-secreting tumour, Cushing’s syndrome) (5). The FAI is the ratio of the total serum testosterone (TT) concentration to the concentration of sex hormone binding globulin (SHBG) This is referred to as the testosterone free index (TFI) and is typically calculated on a molar/molar basis and re-scaled by a factor of ten, one hundred or one thousand, as shown below (7). Whilst the phenotype of PCOS has ethnic specific variation, specific cutoffs for hyperandrogenism in South Asians have not been defined
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