Journal of Hepatology
Volume 47, Issue 3 , Pages 313-315, September 2007

Need for liver evaluation in polycystic ovary syndrome☆

Department of Clinical Medicine, University of Palermo, Via delle Croci 47, 90139 Palermo, Italy

published online 05 July 2007.

Associate Editor: Y.M. Deugnier

Article Outline

 

Medicine is changing and requires a more in-depth knowledge also in fields that were previously considered completely different and dedicated to other specialists. A good example of this general trend is the paper by Cerda et al. [1] that shows a high prevalence of nonalcoholic fatty liver disease (NAFLD) in women with Polycystic Ovary Syndrome (PCOS). The authors studied 41 young women with PCOS and found that 17 patients (41%) had NAFLD. In addition, 7 patients with NAFLD had increased aminotransferase levels raising the possibility of a transition to nonalcoholic steatohepatitis (NASH).

Other reports have shown similar data recently [2], [3], [4], [5]. It is time therefore that doctors caring for patients with liver diseases start to collaborate with the specialists (gynecologists, endocrinologists), who generally treat patients with PCOS and vice versa.

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1. PCOS: a common disorder in young women 

In the past, PCOS was considered an uncommon disorder determining infertility in some particular women who also were obese and hirsute [6]. However, after well-defined diagnostic criteria (chronic anovulation and clinical or androgen excess) were established [7], it has emerged that the syndrome is very common and in all epidemiological studies its prevalence has ranged between 5 and 7% of premenopausal women [8], [9]. New, more extensive diagnostic criteria have been adopted [10], [11] and PCOS may be diagnosed in patients with ovulatory cycles who have hyperandrogenism (clinical or biologic) and polycystic ovaries (ESHRE/ASRM and AES criteria) (Table 1) and in patients who have chronic anovulation, polycystic ovaries but no androgen excess (ESHRE/ASRM criteria) [10], [11], too. Using these new criteria, prevalence of PCOS is still higher and probably near 10% of young women [12].

Table 1. Androgen excess society criteria for diagnosis of PCOS
Hyperandrogenism
Clinical (hirsutism, or acne or androgenic alopecia)
or
Biological (increased serum testosterone or free androgen index or dehydroepiandrosterone sulfate)

+

Chronic anovulation
(oligomenorrhea or amenorrhea or normal menses with low serum progesterone level in day 22–24 of the cycle)

or

Polycystic ovaries at the ultrasound
(US finding of at least 12 follicles of 2–9mm in a whole ovary and/or increased ovarian volume)

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2. PCOS: an important cause of metabolic syndrome in young women 

The interest in PCOS has markedly increased after the finding that insulin resistance [13] and abdominal obesity [14] are essential features of the syndrome. Because of these characteristics, a large number of women with PCOS present with metabolic syndrome. In the USA, metabolic syndrome affects 40–50% of women with PCOS [15], [16] with a prevalence that is about 7 times that of the female population of similar age. In Mediterranean countries (Italy), mostly because of differences in body weight [17], metabolic syndrome in PCOS is less common than in USA but still four times more common than in the young female population [18]. In addition, even when metabolic syndrome is not found, a constellation of single metabolic and cardiovascular risk factors (LDL-cholesterol, HDL-cholesterol, triglycerides, C-reactive proteins, homocysteine) is found in most patients [18], [19] indicating that almost all women with PCOS present some metabolic alteration. All these data suggest that PCOS is the most common cause of metabolic syndrome and related disorders in young women.

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3. PCOS and liver diseases 

Obesity but in particular metabolic syndrome seems to be the main cause of NAFLD [20], [21]. In addition, the single components of metabolic syndrome are very common in patients with fatty liver: low HDL-cholesterol levels and/or hypertriglyceridemia are found in more than 75% of patients with NAFLD [22] while hypertension is an independent predictor for NASH [23]. Therefore, it has been suggested that NAFLD has to be considered one element of the metabolic syndrome [24].

Because of the role of PCOS in determining metabolic syndrome in young women, it is not surprising that NAFLD is very common in patients with this ovarian disorder. In this issue, Cerda et al. [1] report that 41% of PCOS women present NAFLD. In other studies, the prevalence of NAFLD in women with PCOS was also higher (55%) [5].

Being PCOS the most common cause of metabolic syndrome in young women, it may be hypothesized that PCOS is an important cause of NAFLD in these subjects.

However, the available data are still scarce and several issues regarding the association between PCOS and liver diseases need to be clarified. In particular, we need to know whether a screening for NAFLD is needed only in PCOS patients with the full metabolic syndrome or whether it has to be performed in patients having single characters of the syndrome, too. Because increased abdominal fat is present in 30–40% of normoweight women with PCOS [14], we need to know whether NAFLD is increased in lean PCOS patients, too. It is probable because Gambarin-Gelwan et al. reported that 39% of PCOS patients with NAFLD were lean [5]. Finally, because women with PCOS present increased inflammatory factors and altered adipokines, it has to be established whether PCOS patients with NAFLD are at higher risk for NASH.

Until more data are available, we suggest to assess serum aminotransferase, GGT and alkalin phosphatase levels and to search for steatosis, at least by US examination, in all PCOS women having metabolic syndrome. On the contrary, in young women with NAFLD, the existence of PCOS should be always suspected and investigated.

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References 

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☆ The authors declare that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.

PII: S0168-8278(07)00360-1

doi:10.1016/j.jhep.2007.06.009

Journal of Hepatology
Volume 47, Issue 3 , Pages 313-315, September 2007

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