PCOS: What is the Diagnostic Criteria?

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Hans van der Slikke, MD, PhD: “We are at ESHRE 2003 in Madrid, Spain and we have here Dr. Basil Tarlatzis from Greece and Dr. Bart Fauser from Holland and they talk this afternoon about the new guidelines for PCO and PCOS. Welcome gentlemen! Could you give a little summary, in a few words, of the main diagnostic criteria and nomenclature you talked about?”

Bart CJM Fauser, MD, PhD: “Now the three criteria that will appear in the new guidelines are the clinical picture of abnormal ovarian function: 

1) oligoamenorrhoea
2) any form of hyperandrogenemia, either clinical, being hirsutism, acne or endocrine which means the hormonal diagnosis of high androgen levels, and 
3) the ultrasound picture of polycystic ovaries. 

Those three are the major criteria but it’s important to realise that in order to make the diagnosis it doesn’t need to fulfil all three criteria but only two out of three. That makes it into a heterogeneous, so if you have polycystic ovaries and hyperandrogenemia you don’t need to have cycle abnormalities for the diagnosis. Or if you have cycle abnormalities and polycystic ovaries you don’t need hyperandrogenemia for the diagnosis. 

So I think that’s a real advancement in terms of way you are thinking because as gynaecologists usually we are not used to that kind of thinking although in other specialties that’s pretty common. Indeed I think it’s the ultimate: it’s a syndrome. We know that not a single symptom or sign is mandatory for the diagnosis and that’s usually still how our mind works. We want to see it in black and white. It should be there or it shouldn’t but here sometimes it can be but it doesn’t have to.”

Hans van der Slikke, MD, PhD: “This is important because it’s not a disease of importance for gynaecologists only but it is a serious disease for long-life diabetes, cardiovascular disease maybe?”

Bart CJM Fauser, MD, PhD: “Yes! Right! Therefore they may visit a cardiologist, they may visit an endocrinologist, a medical endocrinologist, paediatrician if they are relatively early with their complaints, a dermatologist because of hirsutism, so they have very different phenotypes. And depending on age, indeed they may go on with obesity problems, and signs of early diabetes. 

The key issue and the problem is, and the major controversy has been, the ultrasound. That started in the UK. All the first papers were from the United Kingdom, and they were widely accepted I think in major parts of the world, except North America and that still is the case. It’s still clear, and what we’ve done now is try to unify in order to make something workable for everyone. Clearly now too we got criticised this afternoon because some people were saying, “Yes but ultrasound should be mandatory. I would never diagnose a PCOS without the ultrasound picture.” And two weeks ago in the US there were quite some complaints, people there were saying, “We don’t need ultrasound at all.” So it’s interesting. Now you see we all have our own perceptions and world and cultural things and if we can really get it to work, get it on paper supported by all the participants and then get it published I do believe it’s a clear step forward.”

Hans van der Slikke, MD, PhD: “Dr Tarlazis? How many Americans participated in this workshop?”

Basil C Tarlatzis, MD, PhD: “Approximately 10, almost half of the participants, and they were the leading figures working in the field. Of course we had very intense discussions because, as Professor Fauser said, the problem is that they have focused mainly on the menstrual ovulatory irregularities and the high androgens, but we know that, as I said, the phenotype PCOS is variable, so you may have high androgens without menstrual irregularities but on an ultrasound, polycystic ovaries. 

And then, if this woman gains a few kilograms or pounds, she becomes irregular in her menses. Hence, the syndrome is there, but you may see it at a different phase in her life. Therefore, we tried to be as inclusive as possible, namely to include all possible phenotypic disorders in order to be able to understand what is happening with the disease and move forward to its aetiology. Obviously, that was the difficulty. When such a thing is being proposed, as Professor Fauser said, you face opposition from both sides. I mean, those who have been used to use ultrasound only, they say, “Why do you need all these androgen measurements and stuff?” If on the other hand, you speak with the American colleagues who have been used to use only the blood measurements and very elaborate endocrine tests, they say, “Why do you need the ultrasound?” The fact that the complaints come from both sides means that we are on the right track. 

The second thing that we tried to do, and which will hopefully appear on the paper, was to set criteria, because indeed both the measurement of the androgens but also the ultrasonographic evaluation of the ovaries, have pitfalls. Thus, in the paper we will put some guidelines again on how we should determine ultrasonographically that an ovary is polycystic and the same we will try to do for the androgen determinations”.

Hans van der Slikke, MD, PhD: “Actually there was a clear consensus there which I think already is a step forwards.”

Basil C Tarlatzis, MD, PhD: “Indeed, and ultrasonography, ovarian volume should be the feature because it is simple and the current equipment, can automatically calculate ovarian volume, if you properly measure the three dimensions. Thus, we can have a more objective measurement. And for the androgens we will also have some guidelines on which tests to use and what are their limitations.”

Hans van der Slikke, MD, PhD: “It’s going to help it and I think it’s going to stimulate certain developments and it’s certainly going to put more emphasis on certain androgen assays which will be developed further as being the most reliable marker.”

Basil C Tarlatzis, MD, PhD: “It is extremely important to be as precise as possible, because trying to diagnose such a variable syndrome with tests that are not objective and accurate, you can imagine, ends up in chaos.”

Hans van der Slikke, MD, PhD: “Not only for treatment but also for science and for evidence based medicine.”

Associate Professor Basil C Tarlatzis, MD, PhD: “Absolutely.”

Bart CJM Fauser, MD, PhD: “And for advances in the field because you can, obviously you can build a house with bricks and stones but if the foundation is not good then it’s not going to work after all. And that’s the fear obviously that people are doing so many different things and later on you have to start from scratch again. So now we try to work on the foundation to make that more solid. From there on we can build again.”

Hans van der Slikke, MD, PhD: “It’s very good. I congratulate you both on the results of these beautiful consensus.”

Bart CJM Fauser, MD, PhD: “Don’t be too early!”

Hans van der Slikke, MD, PhD: “And where can we find it?”

Bart CJM Fauser, MD, PhD: “It’s going to be published both in Fertility and Sterility and Human Reproduction at the same time.”

Associate Professor Basil C Tarlatzis, MD, PhD: “Hopefully by the end of the year.”

Bart CJM Fauser, MD, PhD: “By the end of the year.”

Hans van der Slikke, MD, PhD: “This will be great. Thank you both very much.”