Autoimmune thyroiditis (AIT) had been diagnosed about 1 year earlier during a workup for fatigue. Antithyroglobulin antibodies were detected at a level of 286 IU/mL (reference range, less than 40 IU/mL). Thyroid replacement therapy was unnecessary because the thyroid-stimulating hormone and free thyroxine levels were normal and have remained normal; the fatigue, which was probably caused by a self-limited viral infection, resolved.
Review of the patient's clinical symptoms and MRI findings pointed to a diagnosis of polycystic ovary syndrome (PCOS).
Daily hormonal therapy with combination estrogen and progesterone(Drug information on progesterone) was prescribed, and lifestyle changes, which included increased physical activity and a more nutritious diet, were initiated. The patient's pain, menstrual irregularity, and mood swings abated within 3 months.
POLYCYSTIC OVARIES: AN OVERVIEW
PCOS is characterized by chronic anovulation, hyperandrogenism, and polycystic-appearing ovaries. The PCOS diagnosis is determined by a constellation of clinical, laboratory, and radiological findings in a female patient of reproductive age.
In a review by Porter,1 the controversies involved in diagnosing PCOS are described, along with the criteria established in 1990 by the NIH and in 2003 by the Rotterdam workshop.2 The NIH diagnostic criteria for PCOS required all of the following:
- Chronic anovulation.
- Clinical or biochemical evidence of hyperandrogenism.
- Lack of another endocrine disorder.
The Rotterdam criteria required 2 of 3 criteria:
- Anovulation.
- Hyperandrogenism or polycystic ovaries on ultrasonogram.
- Lack of another endocrine disorder.
The Rotterdam definition potentially includes more patients (ie, those without androgen excess).
The associated clinical findings and symptoms of PCOS include menstrual irregularity, infertility, effects secondary to excess androgens (hirsuitism, male-pattern alopecia, acne), obesity, fatigue, and acanthosis nigricans. PCOS may affect up to 10% of premenopausal women. It may be on the rise in adolescents because of the increasing obesity epidemic in children.3
Laboratory findings in a patient with PCOS may include hyperinsulinemia and elevated levels of luteinizing hormone (LH), testosterone,dehydroepiandrosterone sulfate (DHEAS), 17 hydroxyprogesterone (17-OHP), and estrone(Drug information on estrone). Insulin resistance also goes hand-in-hand with PCOS.4
Transvaginal ultrasonography is the radiological study of choice to evaluate the ovaries for the number of follicles, size, and stroma.5 According to Adams and colleagues,6 polycystic ovaries are identified by the presence of 8 or more peripheral follicular cysts (10 mm or smaller) and increased central ovarian stroma. In most instances, an ultrasonogram is not needed for diagnosis and an MRI scan is typically not included in the workup of a patient with suspected PCOS; however, MRI can provide very clear images of polycystic ovaries, as shown in Figures 1 and 2.
Yoo and colleagues7 concluded that compared with ultrasonography, MRI provides greater delineation of the structural components of the ovary in obese girls with PCOS. On MRI, a functional cyst would appear as a single dominant cyst as opposed to multiple cysts involving both ovaries, which are seen in patients with PCOS.
Prompt recognition and treatment of PCOS in the young adolescent is essential for abatement of symptoms. The goal of therapy is to restore menstrual cycles and reduce signs of hyperandrogenism. Current interventions include lifestyle modifications (increased exercise, weight reduction), oral contraceptives, and metformin(Drug information on metformin) for those patients with insulin resistance.8
AUTOIMMUNE THYROIDITIS AND PCOS
The association of PCOS and AIT has been described mainly in women in the third decade of life or older.9-11 In a prospective multicenter study that included one 16-year-old patient, Janssen and colleagues10 revealed a 3-fold higher prevalence of AIT in patients with PCOS compared with age-matched controls. Elevated levels of thyroperoxidase or thyroglobulin antibodies were found in 47 (26.9%) of 175 patients with PCOS compared with only 14 (8.3%) of 168 controls.10 More than 40% of patients with PCOS also had hypoechoic tissue typical of AIT on ultrasonograms of the thyroid. The thyroid findings correlated to some degree with an increased estrogen to progesterone(Drug information on progesterone) ratio.10 Janssen and colleagues10 suggest screening all patients with PCOS for thyroid dysfunction and thyroid-specific autoantibodies even when there is no evidence of overt thyroid dysfunction; however, this practice is not widely recommended.
The Rotterdam definition potentially includes more patients (ie, those without androgen excess).
The associated clinical findings and symptoms of PCOS include menstrual irregularity, infertility, effects secondary to excess androgens (hirsuitism, male-pattern alopecia, acne), obesity, fatigue, and acanthosis nigricans. PCOS may affect up to 10% of premenopausal women. It may be on the rise in adolescents because of the increasing obesity epidemic in children.3
Laboratory findings in a patient with PCOS may include hyperinsulinemia and elevated levels of luteinizing hormone (LH), testosterone,dehydroepiandrosterone sulfate (DHEAS), 17 hydroxyprogesterone (17-OHP), and estrone(Drug information on estrone). Insulin resistance also goes hand-in-hand with PCOS.4
Transvaginal ultrasonography is the radiological study of choice to evaluate the ovaries for the number of follicles, size, and stroma.5 According to Adams and colleagues,6 polycystic ovaries are identified by the presence of 8 or more peripheral follicular cysts (10 mm or smaller) and increased central ovarian stroma. In most instances, an ultrasonogram is not needed for diagnosis and an MRI scan is typically not included in the workup of a patient with suspected PCOS; however, MRI can provide very clear images of polycystic ovaries, as shown in Figures 1 and 2.
Yoo and colleagues7 concluded that compared with ultrasonography, MRI provides greater delineation of the structural components of the ovary in obese girls with PCOS. On MRI, a functional cyst would appear as a single dominant cyst as opposed to multiple cysts involving both ovaries, which are seen in patients with PCOS.
Prompt recognition and treatment of PCOS in the young adolescent is essential for abatement of symptoms. The goal of therapy is to restore menstrual cycles and reduce signs of hyperandrogenism. Current interventions include lifestyle modifications (increased exercise, weight reduction), oral contraceptives, and metformin(Drug information on metformin) for those patients with insulin resistance.8
AUTOIMMUNE THYROIDITIS AND PCOS
The association of PCOS and AIT has been described mainly in women in the third decade of life or older.9-11 In a prospective multicenter study that included one 16-year-old patient, Janssen and colleagues10 revealed a 3-fold higher prevalence of AIT in patients with PCOS compared with age-matched controls. Elevated levels of thyroperoxidase or thyroglobulin antibodies were found in 47 (26.9%) of 175 patients with PCOS compared with only 14 (8.3%) of 168 controls.10 More than 40% of patients with PCOS also had hypoechoic tissue typical of AIT on ultrasonograms of the thyroid. The thyroid findings correlated to some degree with an increased estrogen to progesterone(Drug information on progesterone) ratio.10 Janssen and colleagues10 suggest screening all patients with PCOS for thyroid dysfunction and thyroid-specific autoantibodies even when there is no evidence of overt thyroid dysfunction; however, this practice is not widely recommended.