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Views & Reviews From the Frontline

Bad medicine: polycystic ovary syndrome

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5669 (Published 12 October 2010) Cite this as: BMJ 2010;341:c5669

"Bad Journalism: Polycystic Ovary Syndrome"

Dear Editor:

We read with some considerable concern the views expressed by Dr Des
Spence on Page 838 of the BMJ, 16/10/2010: "Bad Medicine: Polycystic
Ovary Syndrome" and we wish to offer an alternative viewpoint. Whilst
Polycystic Ovary Syndrome (PCOS) is common it does not affect 1/3 of the
population but more in the region of 10-15%, slightly higher in certain
ethnic groups. Between 20-30% of the female population may have polycystic
ovaries on ultrasound scan, but a much smaller proportion have symptoms of
PCOS.

To suggest that the Rotterdam Consensus Workshop on PCOS in 2003 was
"a small group of vested interest specialists, sponsored by a special
interest endocrinology group and a company that manufactures drugs used in
this condition" is totally inaccurate and a distortion of the truth. The
purpose of the working group primarily was to unite experts in the area,
both endocrinologists and gynaecologists, from across Europe and the USA
(representing the leading learned societies in reproductive medicine) to
produce clear guidelines for the diagnosis of PCOS. The reason for this
is because there is some confusion concerning the classification and
diagnosis of this common condition (J Clin Endocrinol Metab 2006; 91:786-
9). Dr Spence concentrates on the Rotterdam criteria but may well be aware
that there are other criteria for diagnosis of PCOS, including the
Androgen Excess Society guidelines where one of the fundamental features
is a raised testosterone manifested either biochemically or clinically
(hirsutism, acne, alopecia). The Rotterdam workshop was an attempt to
bring clarity to the diagnosis of PCOS and provide guidance for non-
experts, such as Dr Spence.

We completely disagree that the condition of PCOS is a myth, but
rather it is complex and chronic condition that displays heterogeneity,
which probably helps to explain why it is so misunderstood. To make a
statement that there is no evidence that PCOS increases cardiovascular
disease is naive given that PCOS women who are enrolled in studies are
usually under the age of 35yr when overt cardiovascular disease is rare.
To date no long-term prospective studies with outcome data are available
and this is an area that requires urgent attention. There is, however,
abundant data examining PCOS women and surrogate markers which predict
cardiovascular disease, including intimal medial thickness (Arterioscler
Thromb Vasc Biol 2000; 20:2414-21) and coronary calcification (J Clin
Endocrinol Metab 2004; 89:5454-61), independent of age and BMI. We are
rather surprised and worried that Dr Spence seems unaware that PCOS women
are at a much higher risk of developing impaired glucose tolerance (40%),
and Type II diabetes (10%) at all weights and at a young age (J Clin
Endocrinol Metab 2005;90:3236-42) both of which carry increased
cardiovascular risk.

It is when PCOS women develop diabetes that the primary diagnosis of
PCOS may be ignored with the women being classified primarily as diabetes
and cardiovascular disease. A recent study reported among postmenopausal
women evaluated for suspected ischemia, clinical features of PCOS and a
raised testosterone, are significantly associated with more angiographic
coronary artery disease and worsening cardiovascular event-free survival
(J Clin Endocrinol Metab 2008; 93:1276-84). Apart from cardiovascular end
-points, what Dr Spence has forgotten to mention is that PCOS women, which
ever diagnostic criteria are applied, have a much higher incidence of
psycho-social problems, and suicide is 7-fold higher than in women who do
not have this condition (Endocr Pract 2009; 15:475-82). To paraphrase Dr
Spence's last sentence 'women have the right to receive a correct
diagnosis and management plan based on sound scientific and medical
knowledge and not bad journalism'.

(1) Harpal S Randeva FRCP, PhD
Senior Lecturer in Medicine
University of Warwick Medical School
Harpal.Randeva@Warwick.ac.uk (Corresponding Author)

(2) Adam Balen FRCOG, MD, FRCOG
Professor of Reproductive Medicine and Surgery
Leeds Teaching Hospitals NHS Trust

(3) Stephen Atkin FRCP, PhD
Professor of Endocrinology & Metabolism
Hull York Medical School

(4) Stephen Franks FRCP, MD, FMedSci
Professor of Reproductive Endocrinology
Imperial College, London

(5) Edward W Hillhouse FRCP, PhD
Professor of Medicine
University of Leeds

Competing interests: No competing interests

31 October 2010
Harpal S Randeva
Senior Lecturer in Medicine
Adam Balen, Stephen Atkin, Stephen Franks & Edward W Hillhouse
University of Warwick Medical School