Book Review

Polycystic Ovary Syndrome: A Guide to Clinical Management

N Engl J Med 2005; 353:2625December 15, 2005

Article

Polycystic Ovary Syndrome: A Guide to Clinical Management
By Adam H. Balen, Gerard S. Conway, Roy Homburg, and Richard S. Legro. 211 pp., plus index, illustrated. Abingdon, England, Taylor & Francis, 2005. $149.95. ISBN: 1-84214-211-9

Seventy years ago, two North American gynecologists, Stein and Leventhal, published the first clear clinical description of what is now called the polycystic ovary syndrome in infertile women who were usually obese and hirsute, had irregular menstrual cycles, and had large ovaries with multiple peripheral cysts. Removal of part of the ovary by wedge resection led to a restoration of fertility in the majority of women with this disorder. The presentation of the syndrome with infertility has now been augmented by the discovery of insulin resistance, hyperlipidemia, and features of the metabolic syndrome in many patients. These findings have led to new treatments, including the administration of insulin-sensitizing drugs.

Photomicrograph of a Tissue Specimen from a Woman with Polycystic Ovary Syndrome.

New investigative techniques have failed to reveal an underlying cause for the syndrome, despite the presence of hyperandrogenism and characteristic results on ovarian ultrasonography in most patients. Transatlantic disagreement over the diagnostic features of the polycystic ovary syndrome has been reflected in the importance placed by clinicians on the clinical, endocrinologic, and ultrasonographic findings at presentation. The recommendations of a National Institutes of Health conference on the syndrome 15 years ago indicated that the diagnosis should be made when hyperandrogenism and anovulation coincided with exclusion of other causes, such as late-onset congenital adrenal hyperplasia, Cushing's syndrome, and other causes of irregular menstrual cycles. International and European studies have demanded consideration of polycystic morphology as being mandatory for diagnosis. Ultimately, a consensus conference in Rotterdam, the Netherlands, in 2003 published a definition of the polycystic ovary syndrome that called for the presence of two of three features — ultrasonographic features, anovulation, and hyperandrogenism — with the exclusion of other causes. This definition has not been universally accepted, particularly in the United States, where the role of ultrasonography is debated.

Polycystic Ovary Syndrome is the best attempt so far to integrate conflicting views of this syndrome into an understanding that will help the general physician, endocrinologist, dermatologist, gynecologist, and radiologist in treating patients. The book describes the controversies underlying the definition of the disorder, the theories regarding its familial origins, the multiple clinical presentations, and the reproductive and metabolic sequelae. Traditional and newer forms of treatment are described, including the widespread use of metformin, the new wonder drug that restores ovulation and fertility in many women while improving metabolic sequelae with few serious side effects.

It is difficult to determine the genetic origins of a condition if the definition of the disease is not universally agreed on, because the cardinal investigative measurements are so unreliable and the clinical presentation is so variable, even within families. Yet the polycystic ovary syndrome is the most common hormonal condition in women between menarche and menopause, and it has enormous potential economic consequences because of the associated obesity and increased risk of diabetes mellitus. A sensible understanding of the syndrome is essential, and this book crosses the geographic and disciplinary divisions that have bedeviled practitioners for so long. It highlights the fundamental features of a fascinating and critically important clinical and metabolic affliction of young women that has proven, serious long-term consequences.

Robert J. Norman, M.D.
University of Adelaide, Woodville, SA 5011, Australia