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Transvaginal Ultrasound Appearance of the Ovary in Infertile Women with Oligomenorrhea: Association with Clinical and Endocrine Profiles

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Transvaginal Ultrasound Appearance of the Ovary in Infertile Women with Oligomenorrhea: Association with Clinical and Endocrine Profiles Vol. 9, No. 2, 2004 Middle East Fertility Society Journal © Copyright Middle East Fertility Society Transvaginal ultrasound appearance of the ovary in infertile women with oligomenorrhea: association with clinical and endocrine profiles Ahmed Aboul Nasr, M.D. Hesham Gaber, M.D. Hesham Hamzah, M.D. Omniah Azzam, M.D. Zakaria Abou El Maaty, M.D. Department of Obstetrics & Gynecology, Cairo University, Cairo, Egypt ABSTRACT Objective: to assess the morphological findings of the ovary based on transvaginal ultrasound in infertile oligomenorrheic women and their predictivity for endocrine signs of polycystic ovary syndrome Design: prospective controlled trial Setting: Kasr El-Aini Hospital Participants: Fifty women were recruited and divided into two groups: Group I: 30 patients suffering from primary or secondary infertility with oligomenorrhea. Group II: 20 apparently normal parous women non-hirsute, non-obese, with normal menstrual rhythm and normal serum concentration of LH as control. Interventions: All women were examined by transvaginal sonography, assessed for dody mass index and hirsutism. Blood withdrawal was performed for hormone estimates. Main Outcome measures: Ovarian follicle number, volume, stromal width, cross sectional area, roundness index and uterine width / ovarian length. Estimates of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and total testosterone were performed. Results: All the ultrasonographic criteria for PCOS diagnosis showed highly statistically significant difference between the study and control group (P =0.0001). The hormonal characteristics in the form of high LH, LH/FSH ratio >3 and high testosterone showed statistically significant difference between study and control group (P<0.05). Polycystic ovaries could be observed in 20% of normal control population. About half of the patients in the study group were hirsute. There was statistically significant difference between hirsute and non-hirsute subgroups as regards the ultrasonographic criteria (P<0.05) but not the hormonal ones. There was no statistically significant difference between obese and non-obese patients in the study group as regards all ultrasonographic criteria except for increased cross sectional area (P=0.025) The mean stromal width as a single test and mean stromal width and/or mean roundness index as a combined test appear to be the most valuable sonographic parameters as screening test to predict endocrine abnormalities characteristic for PCOS diagnosis. Conclusion: A wide spectrum of ultrasonographic ovarian findings can be demonstrated in PCOS, extending from apparently normal to markedly enlarged cystic ovaries. In addition some women show sonographic signs of PCO without hyperandrogenemia, others are hyperandrogenemic without clinical symptoms and without typical sonographic PCOS signs. Amongst all sonographic signs abnormal ovarian stroma alone or in combination was the most sensitive one in prediction for endocrine profiles. Keywords: Oligomenorrhea, PCOS, infertility, transvaginal ultrasound. Hyperandrogenaemia. Oligomenorrhea is usually defined by menstrual definition is, however, arbitrary and does not intervals between 6 weeks and 6 months. This necessarily reflect important distinctions, indeed, they can be misleading (1). Therefore, Contact address: Hesham Al-Inany, 8 Moustapha Hassanin st, oligomenorrhea includes a spectrum of conditions Manial, Cairo 11451, Egypt E-mail: [email protected] ranging from virtual normality at one end to the 140 Aboul Nasr et al. TVS of the ovary: clinical & endocrine profiles MEFSJ same causes as amenorrhea at the other. The main intercycle variability of less than 5 days. Hair difference appears to be in the frequency of growth was assessed clinically using scoring polycystic ovaries, which ultrasound and endocrine system described by Ferriman and Gallway. studies show account for about 90% of cases of Nonhirsutism was defined by a score of 5 or less oligomenorrhea and 33% of amenorrhea, although and unequivocal hirsutism by a score of 12 or more often without the classical syndrome, including to avoid any overlap with normal variation in hair hirsutism and obesity (1). It is also recognized, ngrowth. Obesity was defined as body-mass index however that, many women with polycystic greater than 25 kg/m2. None of the women had ovaries are endocrinologically normal. In one been pregnant in the previous year or received population-based study of 190 women, no hormonal therapy in the preceding 6 month. Each differences in menstrual cycle pattern or prior patient was scanned with a transvaginal endoprobe fertility were found between women with (Siemens, 5 MHz). The scans were undertaken polycystic ovaries and those with normal appearing within the first 5 days of the menstrual cycle of ovaries (2). those with normal menstrual rhythm and at random Oligomenorrhea may alternatively be used as a in those with oligomenorrhea. The maximum functional marker for PCOS. Biochemical longitudinal and transverse diameters of each evidence of androgen excess was reported in 40% ovary were measured and volume was calculated of non-hirsute oligo-ovulatory women in one study according to the formula: Volume= 0.5xd1xd2xd3 Allen et al. (3), whereas in another report, 90% of (d1,2,3= diameters of the ovary in 3 perpendicular women with oligomenorrhea were considered to planes).. When possible, the maximum transverse have PCOS on the basis of concomitant hirsutism, diameter of brightly echogenic stromal tissue was estrogen status and luteinizing hormone (LH) to measured. Follicular diameter was calculated as follicle-stimulating hormone (FSH) ratio (1). the mean of the maximum measurement in 3 Because of the broad spectrum of clinical perpendicular planes. The number and distribution presentation of PCOS, including eumenorrhoeic in each ovary of follicles up to 10 mm were non-hirsute women troubled only by recurrent recorded. Cross sectional area of the ovary was miscarriage, and because of the lack of any reliable calculated from the formula= length x width x #/4. simple tests, assessment of ovarian morphology Roundness index = ovarian width/ovarian length. has assumed critical importance for the The mean measurements of both ovaries were used categorization of women with ovarian disorder (4). for comparison. Also the uterine width/ovarian The aim of this study is to determine the range of length was recorded. appearances of the ovary in infertile Hormonal assessment: oligomenorrheic patients and apparently normal Blood was analyzed for follicle-stimulating women using high-resolution transvaginal hormone (FSH), luterinizing hormone (LH) and ultrasonography and to investigate the predictive total testosterone (T) concentrations. The samples value of polycystic ovaries for endocrine signs of were taken in the early follicular phase in the polycystic ovary syndrome (PCOS). women with normal menstrual rhythm, and at random in the women with oligomenorrhea. In those with oligomenorrhea the venous sampling MATERIALS AND METHODS was ultimately timed retrospectively from any ensuring period to ensure that the blood had not Two consecutive series of young women (21-35 been taken during the preovulatory phase. Serum years) were recruited for study prospectively; one LH and FSH concentrations were determined by group with oligomenorrhea and elevated serum specific radioimmunoassays (RIA) using concentration of LH and a control group of polyclonal rabbit antisera (WRB/F87 for LH and apparently normal women (non-hirsute, non-obese, M93/6873 for FSH; Pharmacia Diagnostic), normal menstrual rhythm and normal serum standardized against international reference concentrations of LH). Normal menstrual rhythm preparations. Following ether extraction, (T) was was defined as cycle length of 21-35 days and measured by specific RIA using polycolonal anti- Vol. 9, No. 2, 2004 Aboul Nasr et al. TVS of the ovary: clinical & endocrine profiles 141 Table 1. The demographic characteristics of the infertile oligomenorrheic patients (n = 30) Oligomenorrheic group Control group P. value (n = 30) Age (years) 26.13 ± 4.04 29.35 ± 3.25 NS (21 to 35) (25 - 35 years) Body mass index (kg /m2) 31.02 ± 4.79 28 ±2.16 <0.05 (24.34 to 39.04) (24.44 to 31.22) Infertility duration (years) 3.30 ± 2.74 None (1 to 10) LH (mIU/ml) 10.86 ± 4.42 5.2 ± 2.4 < 0.05* LH / FSH 3.53 ± 1.20 1.05 ± 0.89 < 0.05* Testosterone (ng/dL) 84.46 ± 25.18 46.6 ± 18.2 < 0.05* Data are mean ± SD and range value. sera (HP/5/55/1A sheep anti serum, University of Microsoft Excel version 7 and SPSS (Statistical Surrey, Guildford). Package for the Social Science) statistical program. The study was approved by the local Ethics Statistical analysis Committee of Obstetrics and Gynecology Department of Kasr El-Aini Hospital. Data were statistically represented in terms of range, mean, standard deviation (SD), median and percentages. Comparison between different groups RESULTS in the present study was done using Student t test for comparing parametric data. For comparing The background characteristics of our non-parametric data, Chi square (2) test was participants are presented in Table I. There was a performed. Yates correction was used instead statistically significant difference between different when the frequency is less than 10. Accuracy was transvaginal criteria in the 2 groups (Table 2). represented using the terms sensitivity, specificity, There was no statistically significant difference positive predictive value, and negative predictive between obese and
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