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Original Studies |
Endocrine Section, First Department of Medicine, University of Athens Medical School, Laiko General Hospital, Goudi 115 27 Athens, Greece
Address all correspondence and requests for reprints to: E. Diamanti-Kandarakis, M.D., First Department of Medicine, Laiko General Hospital, 17 Agiou Thoma Street, 115 27 Athens, Greece.
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Abstract |
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 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
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6) and O/M: group N
(n = 108), regular menses and absence of hirsutism; group 1
(n = 56), regular menses and hirsutism; group 2 (n = 10), O/M
and absence of hirsutism; and group 3 (n = 18), O/M and hirsutism.
Body mass index, waist to hip ratio, and mean blood pressure did not
differ among the studied groups. Hormonal profile was assessed by
measuring free testosterone (FT). The prevalence of PCOS, defined by
the presence of O/M and biochemical hyperandrogenism (FT 95th
percentile of the normal women), was estimated to be 6.77% (13 women
of 192). Higher FT levels were observed in group 3 (O/M and
hirsutism) compared with groups N (P < 0.00001)
and 1 (P < 0.0001) and in groups 1 (hirsutism) and
2 (O/M) compared with group N (P < 0.0001 and
P < 0.005, respectively). Sex hormone-binding
globulin levels were lower in women with PCOS and in groups 1 and 3
than those in group N (P < 0.002,
P < 0.02, and P < 0.002,
respectively) independently of the body mass index. The metabolic
profile was investigated by measurements of fasting glucose (FG),
fasting insulin (FI), and estimation of the fasting glucose to insulin
ratio (FG:I ratio). After covariance adjusted for the BMI, FI levels
were higher in group 3 and in women with PCOS than in the normal
(P < 0.005 and P < 0.002,
respectively) and the hirsute (P < 0.05 and
P < 0.02, respectively) women, whereas FG levels
did not differ among the studied groups. The FG:I ratio was lower in
group 3, group 1, and in women with PCOS than in normal women
(P < 0.05). Finally, a high incidence of family
history of diabetes mellitus (P = 0.001) and
menstrual disorders (P = 0.01) was observed in
women with PCOS, in contrast to the normal and hirsute women. In conclusion, PCOS appears to be a particularly common endocrine disorder in the Greek population under study (prevalence, 6.77%); furthermore, it is associated with certain metabolic abnormalities. These data also suggest that the severity of the fasting hyperinsulinemia is associated with the severity of the clinical phenotype of hyperandrogenism independently of obesity.
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The prevalence of PCOS in premenopausal women is estimated to be about 5–10% (1). In the past, most prospective studies attempting to define the prevalence of PCOS used the ultrasonographic appearance of polycystic ovaries as a prerequisite for the diagnosis of PCOS; however, this is not included in the current diagnostic criteria. These studies demonstrated that 21–23% of unselected women appear to be affected (6, 7, 8). In a recent study, using the current criteria for the diagnosis of PCOS, the prevalence of PCOS in a population of unselected U.S. Black and White women was reported to be 4% (9). However, as there are significant ethnic and racial variations in the clinical presentation of PCOS, the frequency of obesity, insulin resistance, and the incidence of diabetes mellitus, it seems reasonable that the prevalence of PCOS could differ among different populations (10, 11).
The current study was undertaken 1) to determine the prevalence of the PCOS in a sample of the population of a Greek island, 2) to identify hormonal and metabolic parameters of women with PCOS and, in particular, among women with clinical signs of hyperandrogenemia, and 3) to investigate associations of the above-mentioned clinical manifestations with family history of diabetes mellitus, menstrual disorders, cardiovascular disease, hirsutism, and premature baldness in male relatives.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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We studied 192 women of reproductive age who lived on the Greek island of Lesbos and accepted our invitation of free medical examination. A large scale informational campaign took place before the study from the local authorities (local TV channel, newspaper, and radio station). All women were offered a free medical examination by an endocrinologist, and no reference was made to the specific disorders being studied. The protocol was approved by the institutional review committee of Bostanion General Hospital in Lesbos. The age of the women finally enrolled in this protocol ranged between 17–45 yr. None of them received oral contraceptives or other drugs that could interfere with the hormonal and metabolic studies. All of them were clinically healthy, none of them suffered from chronic or acute disease, and all were euthyroid according to the clinical evaluation. Postmenopausal women were excluded from the study.
Personal medical history was obtained from every woman according to a
customized preprepared questionnaire. Menstrual cycle history was
carefully detected and included a general review since menarche and a
detailed recall of the last 2- to 3-yr interval. Ovulatory dysfunction
was defined as less than eight cycles per yr, and regular menstrual
cycle as 26–34 days in length. Emphasis was placed upon family history
regarding diabetes mellitus in the first and second degree relatives,
menstrual disorders, hirsutism, and early baldness in male relatives
(father and/or brothers). A family history of menstrual disorders and
hirsutism was positive when oligomenorrhea and/or hirsutism existed
during the youth of the mother according to the report of the studied
women. Physical examination was performed in each person by two
doctors. Obesity was assessed by estimating body mass index (BMI;
weight/height2, kilograms per
m2), with normal ranging between 17–25.9,
overweight between 26–30, and obese over 30.1. Body fat distribution
was assessed by measurements of the waist to hip girth ratio (WHR)
(12). A Ferriman and Gallwey score of 6 or greater (F-G, 6) was
considered hirsutism (13). Additionally, blood pressure was measured in
with subjects in the sitting position, and the mean blood pressure
(MBP) was estimated [MBP = diastolic + (systolic/3)].
According to the history and the physical examination, the subjects under study were divided into four groups. Group N consisted of women with normal menstrual cycles (<35 days) and absence of hirsutism (F-G, <6), group 1 included women with hirsutism and/or acne and regular menstrual cycles, group 2 included women with oligomenorrhea and absence of hirsutism, and, lastly, group 3 included women presenting with oligomenorrhea and hirsutism.
Blood samples were collected between 0800–0900 h and plasma free testosterone (FT; picograms per mL), sex hormone-binding globulin (SHBG; nanomoles per L), LH (units per L), FSH (units per L), fasting insulin (microunits per mL), and glucose (milligrams per dL) were measured. The fasting glucose (FG) to insulin (FI) ratio was estimated (FG:I ratio; milligrams per 10-4 U) and was used as an indicator of insulin sensitivity (14). In the cases of impaired fasting glucose (FG, 110–125 mg/dL), a 75-g oral glucose tolerance test was performed; subjects with overt diabetes mellitus and impaired glucose tolerance were excluded from the above metabolic study. Additionally, serum PRL (nanograms per mL), TSH (microunits per mL), and 17-hydroxyprogesterone (17-OHProg; nanograms per mL) levels were detected in blood samples of women with oligomenorrhea (groups 2 and 3) to exclude other causes of menstrual disorders (15, 16).
Diagnosis of PCOS
PCOS was diagnosed in women presenting with oligomenorrhea (as defined above) and hyperandrogenism; related disorders with similar clinical presentation were excluded (1990 NIH Consensus Conference on the PCOS). Hyperandrogenism was defined as FT levels above the 95th percentile of the levels detected in the group of normal cycling nonhirsute women (group N). The polycystic ovarian morphology detected by ultrasound was not considered an essential criterion for the diagnosis of the syndrome, as it is reported that approximately 20% of normal women could present the above ultrasonographic appearance (6).
Assays
Plasma glucose was determined by the glucose oxidase method (glucose analyzer, Beckman Coulter, Inc., Palo Alto, CA). Blood samples were centrifuged immediately, and serum was stored at -20 C until assayed. Serum insulin levels were measured using the RIA INSULIN-CT kit from CIS-Bio International (Gif-sur-Yvette, France). Duplicate plasma samples were analyzed for FT using the commercially available Coat-A-Count Free Testosterone kit from Diagnostic Products (Los Angeles, CA). The absolute range for FT in ovulating females was nondetectable to 3.9 pg/mL. SHBG serum levels were measured by immunoradiometric assay (IRMA) using the SHBG IRMA 125I (RADIM S.A., Liège, Belgium). PRL was measured using the PRL IRMA kit from MEDGENIX DIAGNOSTICS. 17OHProg levels were measured using a RIA kit from Diagnostics Systems Laboratories, Inc. (Wesbster, TX). LH and FSH were measured using the LHsp and FSH IRMA kits from Biosource Technologies, Inc., Europe S.A. TSH was measured using the human TSH IRMA kit from INCSTAR Corp. (Stillwater, MN). The intra- and interassay coefficients of variation for FT were 4.3% and 5.5%, and 3.2% and 3.4% for low and high levels respectively; for SHBG, they were 5.1% and 5.1%, and 5.6% and 4.6%, respectively; for insulin, they were 8.2% and 8.8%, and 5.4% and 6.4%, respectively; for PRL, they were 4.0% and 7.1%, and 6.4% and 6.8%, respectively; for 17OHProg, they were 9.3% and 9.7%, and 9.5% and 10.8, respectively; for LH, they were 6.5% and 8.8%, and 3.5% and 4.5%, respectively; for FSH, they were 2.7% and 5.3%, and 1.6% and 3.6%, respectively; and for TSH, they were 3.2% and 5.7%, and 3.3% and 4.9%, respectively.
Statistical analysis
Results are reported as the mean ± SE.
Multivariate analysis of covariance, using BMI as a covariant, was
performed. For individual comparisons, Tukey’s test for unequal sample
sizes was used. Regarding family history cross-tabulation of the four
studied groups, residual analysis was performed using
2 as the statistical indicator. The
partitioning of the table referring to family history in women with
PCOS, the normal and the hirsute groups, was performed as described by
Siegel and Castellan (17). Analysis was performed using the
STATISTICA/w software package (version 5.1' 98).
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Results |
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In the studied population, 108 of 192 women had regular menstrual cycles as defined above and no signs of hyperandrogenism (H/A), hirsutism, and/or acne (group N). Fifty-six of 192 women (29%) demonstrated hirsutism with a F-G score ranging from 6–12 and regular menstrual cycles (group 1). Moreover, 18 of 192 women (9.4%) presented moderate to severe hirsutism, with a F-G score ranging from 13–20, and oligomenorrhea (O/M; group 3); 10 of these 18 women presented with acne. In all cases, hirsutism had an onset in adolescence and did not progressively worsen. Additionally, 10 of 192 examined women (5.2%) had menstrual disorders without hirsutism and/or acne (F-G, <6; group 2).
The characteristics (age, BMI, and WHR) of the four groups of the
studied population are shown in Table 1
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No statistically significant differences existed in age (group N,
33.1 ± 0.7; group 1, 31.5 ± 1.0; group 2, 35.0 ± 3.2;
group 3, 24.6 ± 1.1, yr), BMI (group N, 25.9 ± 0.6; group
1, 27.2 ± 0.7; group 2, 28.7 ± 2.7; group 3, 28.9 ±
1.6 kg/m2), or WHR (group N, 0.77 ± 0.01;
group 1, 0.76 ± 0.02; group 2, 0.73 ± 0.01; group 3,
0.77 ± 0.03). MBP (group N, 80.7 ± 1.2; group 1, 79.7
± 1.3; group 2, 88.0 ± 4.4; group 3, 85.7 ± 2.9 mm Hg) did
not differ even after BMI and age were used as covariates.
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The data are summarized in Table 1
. Although the unadjusted mean
values ± SE are displayed in Table 1 and Fig. 1, the P values are taken from
the data after covariance adjusting for changes in the BMI. Women with
hirsutism only (group 1) compared to normal women (group N) showed
higher levels of FT (2.2 ± 0.1 vs. 1.4 ± 0.1
pg/mL; P < 0.0001). Additionally, women with
oligomenorrhea (group 2) showed higher FT levels compared to group N
(FT; 2.7 ± 0.2 vs. 1.4 ± 0.1 pg/mL;
P < 0.005). Women with hirsutism and oligomenorrhea
(group 3) had higher FT levels than those in group 1 (3.5 ± 0.2
vs. 2.2 ± 0.1 pg/mL; P < 0.0001) or
group N (3.5 ± 0.2 vs. 1.4 ± 0.1 pg/mL;
P < 0.00001); no statistically significant difference
was found in FT levels between women of group 3 and women of group 2
(Fig. 1).
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One woman of group N had diabetes mellitus and was not
included in the metabolic studies as well as two obese women, one from
group 1 (hirsutism) and the other from group 3 (hirsutism and O/M), who
showed impaired glucose tolerance. The data are summarized in Table 1.
Although the unadjusted mean ± SE are displayed in
Table 1 and
Figs. 2–4, the P values are taken from the data
after covariance adjusting for changes in the BMI. FG did not differ
among the four groups, whereas FI in group 3 (hirsutism and O/M) was
higher than that in group N (42.4 ± 9.8 vs. 21.9
± 1.5 µU/mL; P < 0.005) or group 1 (hirsutism;
42.4 ± 9.8 vs. 27.1 ± 1.6 µU/mL;
P < 0.05; Fig. 2). The
FG:I ratio was lower in group 3 compared to group N (3.21 ± 0.25
vs. 6.2 ± 0.4 mg/10-4 U;
P < 0.05). Additionally, women with simple hirsutism
(group 1) had a lower FG:I ratio compared to the normal women
(4.45 ± 0.3 vs. 6.2 ± 0.4
mg/10-4 U; P < 0.05; Fig. 3). SHBG levels in women with simple
hirsutism (group 1) were lower than those in group N (44.4 ± 1.9
vs. 56.9 ± 2.7 nmol/L; P < 0.02).
Additionally, SHBG levels in women with hirsutism and oligomenorrhea
(group 3) were lower than those in group N (30.3 ± 4.0
vs. 56.9 ± 2.7 nmol/L; P < 0.002;
Fig. 4). There was a noticeable trend for
an increase in fasting insulin levels and a decrease in the FG:I ratio
and SHBG levels from group N to group 3 (
Figs. 2–4).
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Women with hirsutism and/or oligomenorrhea (groups 2 and 3) who presented with hyperandrogenemia were diagnosed as having PCOS. As defined, none of the subjects suspected of PCOS had evidence of thyroid disease, hyperprolactinemia, Cushing’s syndrome, or androgenic tumor. 21-Hydroxylase deficiency was excluded by measuring 17OHProg; none of the suspected women had an initial level above 2 ng/ml, effectively ruling out the disorder (15). H/A was defined as a FT level above the 95th percentile of the mean value in the normal women (group N; i.e. >3.3 pg/ml). Thirteen women fulfilled the criteria, 2 from group 2 (O/M) and 11 from group 3 (O/M and hirsutism). Therefore, the prevalence of PCOS in the population under study was 6.77% (13 of 192). Moreover, 6 of 56 women from group 1 (10.7%) had H/A according to the above definition. However, as they reported regular menses, they were not included in the estimation of the prevalence of the syndrome.
Anthropometric, hormonal, and metabolic parameters of the PCOS group
The 13 women diagnosed with PCOS were compared to the normal and
hirsute groups (groups N and 1, respectively). Age (24.6 ± 1.8,
yr), BMI (28.6 ± 1.8, kg/m2), WHR
(0.78 ± 0.04), and MBP (81.8 ± 3.6 mm Hg) of the PCOS women
did not differ compared to those in groups N and 1. PCOS women had
higher FI levels (46.3 ± 13.5 µU/mL) compared with groups N and
1 (P < 0.002 and P < 0.02,
respectively), whereas FG levels (108.1 ± 8.9 mg/dL) did not
differ (Fig. 2 and Table 1). The FG:I ratio (3.1 ± 0.3,
mg/10-4 U) and SHBG level (25.7 ± 3.6
nmol/L) were also lower in the PCOS group compared with the normal
group (P < 0.05 and P < 0.002,
respectively; Figs. 3 and 4); these findings were independent of the
BMI. Finally, the LH to FSH ratio (2.0 ± 0.2) did not differ
compared with those in the other groups.
Family history
The observed frequencies of positive family history regarding
diabetes mellitus, menstrual disorders, hirsutism, and early baldness
in male relatives are shown in Table 2.
Women with hirsutism and/or oligomenorrhea (groups 2 and 3) showed a
more frequently positive family history of diabetes mellitus (60% and
66.6%, respectively; P = 0.006) and menstrual
disorders (40% and 33.3%, respectively; P = 0.00001)
compared with the normal and hirsute women (groups N and 1). Women with
hirsutism, regardless of the presence of menstrual irregularities
(groups 1 and 3), more often had a positive family history of hirsutism
(21.4% and 39%, respectively; P = 0.0001) than
nonhirsute women (groups N and 2). A family history of premature
baldness in male relatives was less often observed in group N than in
the rest of the groups (P = 0.04).
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Discussion |
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The incidence of oligomenorrhea (14.6%; 28 of 192) in the studied population may be overestimated because of the definition we used, i.e. less than 8 cycle/yr; this definition was also used in the recent study by Knochenhauer et al. (9). H/A was confirmed in 6.77% of the examined women with oligomenorrhea or oligomenorrhea and hirsutism. The majority of the studied women fulfilling the criteria for PCOS (11 from the overall 13) belonged to the group characterized by the main clinical manifestations of the syndrome (group 3). In this group were included 18 women with oligomenorrhea and hirsutism/or acne. The remaining 7 women, with the clinical manifestations of the syndrome but without proven hyperandrogenemia (normal FT), cannot be entirely excluded from the diagnosis of PCOS, because another nonmeasured androgen could have been elevated. Therefore, the prevalence of PCOS in our sample could have been approximately 10.4% (20 of 192) if another elevated androgen was detected.
PCOS women appeared to have fasting hyperinsulinemia, lower FG/I ratio, and decreased SHBG levels compared with the normal women, independently of the BMI. Insulin resistance in PCOS has been estimated in small groups of women by highly sophisticated methods (i.e. ivGTT, hyperinsulinemic-euglycemic clamps) (1, 3, 23). In this study, for the first time, we used fasting hyperinsulinemia and the FG/I ratio, which have been considered adequate and sensitive screening markers for insulin resistance, to determine in a large sample of premenopausal women the presence of insulin resistance in association with hyperandrogenic manifestations (14, 24). The gradual increase, a dose-dependent-like pattern, of fasting insulin levels from the group of normal women to the group with the clinical and biochemical abnormalities of the syndrome, indicates that the severity of fasting hyperinsulinemia is associated with the severity of the clinical phenotype, independently of the degree of obesity. It is noteworthy that statistical significance is achieved between the group of normal women and the group that presents the full-blown syndrome. The above finding suggests that fasting hyperinsulinemia is a characteristic accompanying feature of PCOS (3, 23). It should also be noted that obesity, defined as a BMI above 30 kg/m2, was observed in 38% (5 of 13) of the women with PCOS, consistent with other reports (4, 9).
Regarding the metabolic studies, in women with idiopathic hirsutism mean FI levels were in between the levels of normal and PCOS women without reaching statistical significance compared to the normal group. Nevertheless, the FG/I ratio was significantly lower in the studied hirsute women compared to normal women. This finding raises the question of whether women with so-called idiopathic hirsutism are a heterogeneous group exhibiting not only a cosmetic problem but subtle metabolic disturbances as well.
The reported incidence of idiopathic hirsutism varies from 5–15% in Caucasian women (13, 25). However, in our study 29% (56 of 192) of the examined women presented with idiopathic hirsutism. This rather impressive percentage could be due to the ethnic variation of the Mediterranean people. The possible role of ethnicity in the prevalence and features of PCOS has been reported in other populations (i.e. Caribbean-Hispanic) (26, 27). Nevertheless, it should be borne in mind that the recruitment of women in the present study was not fully randomized, and that "hairiness" represents for many women a cosmetic problem that merits serious consideration. The studied women with idiopathic hirsutism demonstrated a statistically significant lower SHBG level and higher FT level compared to normal women, although the mean FT value was within the normal range. It should be noted that 10.7% of the studied hirsute women were hyperandrogenemic, with FT levels exceeding the 95th percentile of the normal women. Therefore, idiopathic hirsutism is not a homogeneous clinical and biochemical entity and, instead, may include a variety of disorders in androgen metabolism (28) as well as subclinical metabolic aberrations.
Furthermore, nonhirsute women with oligomenorrhea presented higher FT levels than normal women, independently of BMI. Moreover, two of them had H/A, as defined, and were diagnosed with PCOS. As noted by other investigators, oligomenorrhea seems to be associated with subtle or overt elevations of androgens even in the absence of hirsutism or acne and may present a discrete form of PCOS (29, 30).
It is controversial whether women with PCOS have elevated blood pressure. In the studied population, mean blood pressure, estimated by a random measurement, did not differ in women with PCOS and normal women. This observation is in accordance with other studies focussed on this matter (31).
Regarding family history, we observed a high incidence of family history of menstrual disorders in women with PCOS, in accordance with the general view that PCOS has a strong familial component (10, 32, 33). Another observation was that hirsute women reported a strong family history of hirsutism; it seems that familiar and ethnic aspects should be taken into consideration. Additionally, women with PCOS reported a high, statistically significant incidence of family history of diabetes mellitus compared to normal and hirsute women. This observation may imply that the genetic trait of PCOS is associated with a diabetogene(s), and it should be further examined in large scale studies, focussing on the prevalence of a family history of diabetes mellitus in PCOS. Additionally, a family history of diabetes mellitus could have influenced the metabolic profile in the studied women with PCOS. However, the only supporting evidence on this matter has been provided by insulin secretory abnormalities in women with PCOS and a family history of diabetes mellitus, assessed by sophisticated methods in a study by Erhmann et al. (23). On the other hand, the presence of insulin resistance, which is a distinct feature of PCOS, seems to be independent of the family history of diabetes mellitus up to the third decade of life (34).
In conclusion, in the Greek population studied, PCOS is considered to be a common endocrine disorder, with a prevalence of 6.77%. The metabolic abnormalities, in particular fasting hyperinsulinemia and FG:I ratio, seem to accompany the severity of the clinical phenotype, covering the spectrum of hyperandrogenic disorders in the studied groups of women, independently of obesity. These data also suggest that women with hirsutism and regular menses constitute a heterogeneous group as far as hormonal and metabolic parameters are concerned. Additionally, the incidence as well as the role of family history of diabetes mellitus in women with PCOS should be considered in terms of its possible implication in the pathogenesis of the syndrome.
Received December 30, 1998.
Revised May 19, 1999.
Revised July 28, 1999.
Accepted June 18, 1999.
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R. Wu, S. Fujii, N.K. Ryan, K.H. Van der Hoek, M.J. Jasper, I. Sini, S.A. Robertson, R.L. Robker, and R.J. Norman Ovarian leukocyte distribution and cytokine/chemokine mRNA expression in follicular fluid cells in women with polycystic ovary syndrome Hum. Reprod., February 1, 2007; 22(2): 527 - 535. [Abstract] [Full Text] [PDF]
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S. Nader and E. Diamanti-Kandarakis Polycystic ovary syndrome, oral contraceptives and metabolic issues: new perspectives and a unifying hypothesis Hum. Reprod., February 1, 2007; 22(2): 317 - 322. [Abstract] [Full Text] [PDF]
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M. C Amato, A. Galluzzo, S. Merlino, A. Mattina, P. Richiusa, A. Criscimanna, and C. Giordano Lower insulin sensitivity differentiates hirsute from non-hirsute Sicilian women with polycystic ovary syndrome Eur. J. Endocrinol., December 1, 2006; 155(6): 859 - 865. [Abstract] [Full Text] [PDF]
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 E. CARMINA Ovarian and Adrenal Hyperandrogenism Ann. N.Y. Acad. Sci., December 1, 2006; 1092(1): 130 - 137. [Abstract] [Full Text] [PDF]
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E. DIAMANTI-KANDARAKIS, T. PATERAKIS, and H. A. KANDARAKIS Indices of Low-Grade Inflammation in Polycystic Ovary Syndrome Ann. N.Y. Acad. Sci., December 1, 2006; 1092(1): 175 - 186. [Abstract] [Full Text] [PDF]
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E. DIAMANTI-KANDARAKIS and F. ECONOMOU Stress in Women: Metabolic Syndrome and Polycystic Ovary Syndrome Ann. N.Y. Acad. Sci., November 1, 2006; 1083(1): 54 - 62. [Abstract] [Full Text] [PDF]
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R. Azziz, E. Carmina, D. Dewailly, E. Diamanti-Kandarakis, H. F. Escobar-Morreale, W. Futterweit, O. E. Janssen, R. S. Legro, R. J. Norman, A. E. Taylor, et al. Criteria for Defining Polycystic Ovary Syndrome as a Predominantly Hyperandrogenic Syndrome: An Androgen Excess Society Guideline J. Clin. Endocrinol. Metab., November 1, 2006; 91(11): 4237 - 4245. [Abstract] [Full Text] [PDF]
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X. Chen, D. Yang, L. Li, S. Feng, and L. Wang Abnormal glucose tolerance in Chinese women with polycystic ovary syndrome Hum. Reprod., August 1, 2006; 21(8): 2027 - 2032. [Abstract] [Full Text] [PDF]
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 M. J. Himelein and S. S. Thatcher Depression and Body Image among Women with Polycystic Ovary Syndrome. J Health Psychol, July 1, 2006; 11(4): 613 - 625. [Abstract] [PDF]
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 S.K. Blank, C.R. McCartney, and J.C. Marshall The origins and sequelae of abnormal neuroendocrine function in polycystic ovary syndrome Hum. Reprod. Update, July 1, 2006; 12(4): 351 - 361. [Abstract] [Full Text] [PDF]
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