The Pregnancy in Polycystic Ovary Syndrome Study: baseline characteristics of the randomized cohort including racial effects

POLYCYSTIC OVARY SYNDROME The Pregnancy in Polycystic Ovary Syndrome Study: baseline characteristics of the randomized cohort including racial effects Richard S. Legro, M.D.,a Evan R. Myers, M.D., M.P.H.,b,c Huiman X. Barnhart, Ph.D.,c Sandra A. Carson, M.D.,d Michael P. Diamond, M.D.,e Bruce R. Carr, M.D.,f William D. Schlaff, M.D.,g Christos Coutifaris, M.D., Ph.D.,h Peter G. McGovern, M.D.,i Nicholas A. Cataldo, M.D.,j Michael P. Steinkampf, M.D.,k John E. Nestler, M.D.,l Gabriella Gosman, M.D.,m Linda C. Guidice, M.D., Ph.D.,j and Phyllis C. Leppert, M.D., Ph.D.n for the Reproductive Medicine Networkc a Department of Obstetrics and Gynecology, Pennsylvania State University, Hershey, Pennsylvania; b Department of Obstetrics and Gynecology and c Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina; d Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; e Wayne State University, Detroit, Michigan; f University of Texas Southwestern Medical Center, Dallas, Texas; g University of Colorado, Denver, Colorado; h University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; i University of Medicine and Dentistry of New Jersey, Newark, New Jersey; j Stanford University, Palo Alto, California; k University of Alabama, Birmingham, Alabama; l Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia; m University of Pittsburgh, Pittsburgh, Pennsylvania; and n Reproductive Sciences Branch, National Institute of Child Health and Human Development, Bethesda, Maryland

Objective: To report the baseline characteristics and racial differences in the polycystic ovary syndrome (PCOS) phenotype from a large multicenter clinical trial (PPCOS). Design: Double-blind, randomized trial of three treatment regimens (with extended release metformin or clomiphene citrate). Setting: Academic medical centers. Patient(s): Six hundred twenty-six infertile women with PCOS, aged 18 –39 years, with elevated T levels and oligomenorrhea (exclusion of secondary causes), seeking pregnancy, with ⱖ1 patent fallopian tube, normal uterine cavity, and a partner with sperm concentration ⱖ20 ⫻ 106/mL in ⱖ1 ejaculate. Intervention(s): Baseline characterization. Main Outcome Measure(s): Historical, biometric, and biochemical measures of PCOS. Result(s): There were no significant differences in baseline variables between treatment groups. The overall mean (⫾SD) age of the subjects was 28.1 ⫾ 4.0 years, and the mean body mass index was 35.2 kg/m2 (⫾8.7). Polycystic ovaries (PCOs) were present in 90.3% of the subjects, and the mean volume of each ovary was 10 cm3 or more. Of the subjects, 7% had ovaries that were discordant for PCO morphology. At baseline, 18.3% of the subjects had an abnormal fasting glucose level (⬎100 mg/dL). Asians tended to have a milder phenotype, and whites and African Americans were similar in these measures. Conclusion(s): The treatment groups were well matched for baseline parameters, and we have added further information to the PCOS phenotype. (Fertil Steril威 2006;86:914–33. ©2006 by American Society for Reproductive Medicine.) Key Words: Randomized controlled trial, insulin resistance, ethnicitye, ethnicity, ultrasound, obesity, metabolic syndrome, infertility, metformin, clomiphene, ovulation induction

Received September 22, 2005; revised and accepted March 8, 2006. Supported by National Institutes of Health/National Institute of Child Health and Human Development grants U10 HD27049 (C.C.), U01 HD38997 (E.M.), U10 HD39005 (M.D.), U10 HD27011 (S.C.), U10 HD33172 (M.S.), U10 HD38988 (B.C.), U10 HD38992 (R.L.), U10 HD38998 (W.S.), U10 HD38999 (P.McG.), and U54 HD29834 (University of Virginia Center for Research in Reproduction Ligand Assay and Analysis Core), and General Clinical Research Center grant MO1RR00056 to the University of Pittsburgh and MO1RR10732 and construction grant C06 RR016499 to Pennsylvania State University. Reprint requests: Richard S. Legro, M.D., Department of Obstetrics and Gynecology, Penn State College of Medicine, M.S. Hershey Medical Center, 500 University Drive, H103, Hershey, PA 17033 (FAX: 717-5316286; E-mail: [email protected]).

914

The Pregnancy in Polycystic Ovary Syndrome (PPCOS) study is a randomized clinical trial sponsored by the National Institutes of Health/National Institute of Child Health and Human Development (NIH/NICHD), conducted at 12 centers in the United States. The trial rationale (1) and sample size calculation (2) have been described previously. Briefly, the purpose of the trial is to determine the method of ovulation induction most likely to result in live birth in infertile women with polycystic ovary syndrome (PCOS). Because both reproductive and metabolic abnormalities have been implicated in the etiology of PCOS, agents were chosen that have either primarily reproductive effects (clomiphene citrate [CC]) or metabolic effects (metformin) to address these

Fertility and Sterility姞 Vol. 86, No. 4, October 2006 Copyright ©2006 American Society for Reproductive Medicine, Published by Elsevier Inc.

0015-0282/06/$32.00 doi:10.1016/j.fertnstert.2006.03.037

issues. Live birth, rather than ovulation, was chosen as the primary outcome of the trial, as ovulation is a surrogate outcome for pregnancy, and because efficacy measured by ovulation potentially may differ from efficacy measured by pregnancy or live birth (1). A recent trial in women with PCOS (3) that reported much higher pregnancy rates (PRs) and fecundity with metformin after ovulation than with CC supports this approach. This report describes the methods used in this study and summarizes the baseline demographic and biomedical characteristics of the randomized cohort of patients. This report also examines markers of hyperandrogenism and insulin resistance according to ethnicity and race to better characterize the PCOS phenotype in the United States. MATERIALS AND METHODS Study Design The PPCOS study is a double-blind, double-dummy randomized trial with three treatment arms: [1] the extended release form of metformin HCl (Glucophage XR) plus placebo, [2] CC plus placebo, or [3] metformin plus CC, administered during 30 weeks. The primary hypothesis is that combined treatment with metformin and CC is more likely to result in a live birth than single agent/placebo therapy. This hypothesis has been suggested by an important small multicenter trial that examined ovulation as a primary endpoint (4) and by small trials that examined PRs as primary endpoints (5). A meta-analysis of these trials showed that therapy with a combination CC and metformin conferred a significant benefit in terms of increasing the PR (6). Patients were randomly assigned to one of three treatment arms by means of an interactive voice system and stratified based on study site and previous exposure to either of the study drugs. Patients received either metformin plus placebo, metformin plus CC, or CC plus placebo. Anovulatory patients had a withdrawal bleed induced with a course of oral medroxyprogesterone acetate (MPA) before the initiation of study medication. Each subject received a medication package on a monthly basis that consisted of a bottle M (metformin or placebo) and a bottle C (CC or placebo). Patients randomized to the metformin arm began daily doses at one pill (either 500 mg extended release metformin or placebo), which was increased in a stepwise fashion during the first 3 weeks until patients were taking a total dose of 2,000 mg/d. Patients in the combined treatment arm (metformin plus CC) received the same dosage of metformin, and received an initial dose of 50 mg of CC on days 3–7 of each treatment cycle on-study. Patients randomized to the CC arm received the same CC dose plus placebo from bottle M. The CC dose was increased on a treatment cycle basis (every 5 weeks of anovulation or after every withdrawal bleed after an ovulation) in non- or poor responders. Study drugs metformin (Glucophage XR) plus identical placebo were provided by Bristol Myers Squibb Fertility and Sterility姞

(New York, NY). Overencapsulated CC tablets (Teva Pharmaceuticals, North Wales, PA) and matching placebo capsules were packaged and tested by a commercial pharmacy supply company (CTS, Inc., Research Triangle Park, NC), specifically for this study. All patients had P levels measured weekly in local laboratories. If two consecutive elevated P levels (⬎5 ng/mL) were noted, a pregnancy test was also checked on a weekly basis until positive or until menses occurred. The dose of bottle C was maintained if ovulation was noted and deemed adequate by the site primary investigator. If a patient had consecutive P levels below the cutoff for 5 weeks, the dose of bottle C was increased by one tablet per day (or 50 mg) for the 5-day course. If the patient remained anovulatory, the daily dose of CC was increased in 50-mg increments each treatment cycle until the maximum recommended dose of three tablets per day for 5 days (or 150 mg/d of CC) was given. Subjects would stay on the maximum daily treatment cycle dose of CC (150 mg/d for 5 days) until the end of the study. Withdrawal bleeds were scheduled at the discretion of the site’s primary investigator. Routine ultrasonography for follicular and endometrial response was not included in the protocol. All medication was discontinued upon a positive pregnancy test. Pregnant patients were then followed, and serial serum hCG levels were measured until an ultrasound examination could document fetal viability. Patients were then referred to their obstetricians for prenatal care. Copies of patients’ obstetrical records, including delivery records, were reviewed by the investigators to obtain birth outcomes. PPCOS was designed with an intention-to-treat analysis plan. The primary outcome of the trial is the proportion of live birth in each treatment arm. The original sample size was 678 (2) to detect a 15% absolute difference in live birth rates. Because of drug supply logistics, the sample size was later reduced to 626 after the Data Safety and Monitoring Board reviewed the blinded data in November 2004. The final sample size of 626 randomized subjects will provide adequate power (80%) to detect a 15% absolute difference in live birth rates between treatment arms based on new assumptions consistent with the observed blinded data available in November 2004. Secondary outcomes include singleton live birth rate, abortion rate, time to pregnancy, and ovulation rate, as well as baseline factors that predict ovulation or pregnancy. The study is not powered to definitively address these secondary outcomes. The study opened to accrual in November of 2002 and completed enrollment in December of 2004. The last patient enrolled finished medication in August of 2005. We are currently awaiting outcomes on all of the ongoing pregnancies from the medication phase of the study. Participants Individuals were recruited from the clinical and referral practices of the investigators in the study, and by means of 915

advertisements and web-based solicitations. A screening questionnaire was administered to determine eligibility based on medical history. The patient then presented for an on-site evaluation and gave written informed consent to participate in the study consistent with the guidelines of each center’s institutional review board. We classified patients as having PCOS based on unexplained hyperandrogenic chronic anovulation, using the 1990 National Institutes of Health criteria (7): oligomenorrhea with a history of eight or fewer spontaneous menses per year and hyperandrogenemia based on an elevated testosterone (T) level documented within the previous year in the outpatient setting (using local laboratory results and a predetermined cutoff level for elevated T that varied from site to site). Other diagnoses such as PRL excess, thyroid disease, and nonclassic congenital adrenal hyperplasia were excluded in all patients before randomization. Patients with more severe phenotypes were screened completely for the presence of androgen-secreting tumors or Cushing’s syndrome. Other infertility factors were excluded by requiring patients to have a normal uterine cavity and ⱖ1 patent fallopian tube (documented by sonohysterography, hysterosalpingography, or diagnostic hysteroscopy and laparoscopy with chromopertubation of the fallopian tubes), and a current partner with a recent semen analysis demonstrating a sperm count ⱖ20 ⫻ 106/mL. Ultrasound criteria were not included in the diagnostic criteria, as this study was designed and initiated before publication of the Rotterdam criteria (8, 9). However, our diagnostic criteria, which mandate two of the three cardinal features of the syndrome, fully qualify for the identification of PCOS, even within this proposed revised diagnostic schema. Procedures Patients were required to fast overnight before their baseline evaluation. Standardized interviewer-administered questionnaires were used to obtain self-reported data on personal medical history, employment, education, family income, infertility and pregnancy history, gynecological history, smoking status, medications, drug or alcohol use, and family medical history. Race and ethnicity were self-reported. Biometric variables, including height, weight, body mass index (BMI), blood pressure, waist circumference, and acne presence and severity were recorded. Hirsutism was scored by using the modified Ferriman-Gallwey method (10). Fasting blood was obtained to measure levels of T, sex hormonebinding globulin (SHBG), proinsulin, insulin, and glucose. Blood samples were collected and processed at each PPCOS site in accordance with the standardized manual of operations. Serum and plasma were stored at ⫺20°C before being shipped to the Ligand Assay & Analysis Core Laboratory at the University of Virginia. Safety analyses from this baseline phlebotomy consisting of a liver and renal profile and complete blood count were performed in local laboratories. 916

Legro et al.

PPCOS baseline characteristics

A transvaginal ultrasound of the pelvis was obtained at the baseline visit. Polycystic ovary morphology, according to the criteria of Adams et al. (11), was determined by the site’s primary investigator on review of the films or during performance of the ultrasound. Ovarian size was obtained by measuring the largest plane of the ovary in two dimensions and then turning the vaginal probe 90 degrees to obtain a third measurement. Volume of the ovary was calculated by using the formula for an ellipsoid (length ⫻ height ⫻ width ⫻ ␲/6) (12), and the size of the largest follicle (or cyst) on each ovary (mean diameter of two measures from the largest plane) was noted. After the baseline visit, patients returned each month for a visit consisting of a limited physical examination (but no ultrasound examination) and a repeat fasting blood measurement until completion of the study or until pregnancy was confirmed. Measurements All samples were analyzed in duplicate for each hormone and assays were performed by the University of Virginia Center for Research and Reproduction Ligand Assay and Analysis Core Laboratory. Testosterone was measured by RIA (Coat-a-Count Kit; Diagnostic Products Corp., Los Angeles, CA); assay sensitivity ⫽ 10 ng/dL; intraassay coefficient of variation (CV) ⫽ 5.0% and interassay CV ⫽ 8.2%. Sex hormone-binding globulin and insulin were measured by chemiluminescent two-site assays (Immulite; Diagnostic Products Corp.; sensitivity ⫽ 0.2 nmol/L and 2.6 ␮IU/mL, respectively; intraassay CV ⫽ 2.4% and 3.3%, respectively; interassay CV ⫽ 5.2% and 8.3%, respectively). Proinsulin was measured by RIA (Linco Research, St. Charles, MO); sensitivity ⫽ 6.0 pmol/L; intraassay CV ⫽ 10.1% and interassay CV ⫽ 10.4%. Glucose was measured by the glucose oxidase method (Olympus AU 640, Olympus Inc, Melville, NY; intraassay CV ⫽ 2.0% and interassay CV ⫽ 3.2%). The free androgen index was calculated from measurable values for total T and SHBG, as previously described (13), using the following equation: Free androgen index ⫽ total testosterone (nmol/L)/SHBG (nmol/L) ⫻ 100. Liver and renal function tests as well as complete blood counts were performed according to local protocols at each site. Data Management and Analyses All data entry, data management, and analyses were coordinated at the Data Coordinating Center at the Duke Clinical Research Institute. Categorical variables are presented as a frequency and percentage within each group. A ␹2 test was used for testing differences among the three treatment groups. A Fisher’s exact test was used if the frequency was small. The mean and standard deviation within each group is displayed for all continuous variables. A Wilcoxon rank sum test was used for testing difference between two groups, and Vol. 86, No. 4, October 2006

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TABLE 1 Demographic characteristics by treatment arm.

Age N Mean ⫾ SD Body mass index (kg/m2) N Mean ⫾ SD ⬍30 30–34 Equal to or greater than 35 Blood pressure (mm Hg) N Systolic Diastolic Hirsutism N Mean ⫾ SD FG ⬍ 8 FG 8–16 FG ⬎ 16 Ethnicity Not Hispanic or Latino Hispanic or Latino Race White Black or African American Asian American Indian or Alaska Native Native Hawaiian or other Pacific Islander Legro. PPCOS baseline characteristics. Fertil Steril 2006.

Clomiphene citrate (n ⴝ 209)

Metformin XR (n ⴝ 208)

Combined clomiphene and metformin (n ⴝ 209)

All patients (n ⴝ 626)

P value across 3 treatment groups

209 27.9 ⫾ 4.0

208 28.1 ⫾ 4.0

209 28.3 ⫾ 4.0

626 28.1 ⫾ 4.0

.691

209 34.2 ⫾ 8.4 65/209 (31.1%) 48/209 (23.0%) 96/209 (45.9%) 206 121.8 (12.8) 77.3 (9.2)

625 35.2 ⫾ 8.7 179/625 (28.6%) 135/625 (21.6%) 311/625 (49.8%) 616 122.1 (13.6) 76.9 (9.9)

208 14.3 ⫾ 8.0 36/208 (17.3%) 96/208 (46.2%) 76/208 (36.5%)

209 14.4 ⫾ 7.4 41/209 (19.6%) 82/209 (39.2%) 86/209 (41.1%)

626 14.4 ⫾ 7.9 121/626 (19.3%) 262/626 (41.9%) 243/626 (38.8%)

156/209 (74.6%) 147/208 (70.7%) 53/209 (25.4%) 61/208 (29.3%)

159/209 (76.1%) 50/209 (23.9%)

462/626 (73.8%) 164/626 (26.2%)

147/208 (70.7%) 140/207 (67.6%) 37/208 (17.8%) 40/207 (19.3%) 5/208 (2.4%) 5/207 (2.4%) 21/208 (10.1%) 27/207 (13.0%) 1/208 (0.5%) 0

148/208 (71.2%) 32/208 (15.4%) 7/208 (3.4%) 24/208 (11.5%) 0

435/623 (69.8%) 109/623 (17.5%) 17/623 (2.7%) 72/623 (11.6%) 1/623 (0.2%)

209 207 36.0 ⫾ 8.9 35.6 ⫾ 8.5 57/209 (27.3%) 57/207 (27.5%) 42/209 (20.1%) 45/207 (21.7%) 110/209 (52.6%) 105/207 (50.7%) 205 205 121.9 (14.2) 122.6 (13.9) 76.1 (10.6) 77.2 (9.7) 209 14.7 ⫾ 8.2 44/209 (21.1%) 84/209 (40.2%) 81/209 (38.8%)

.116 .723

.876 .274

.803 .602

.433 .932

917

918 Legro et al.

TABLE 2 Selected infertility and medical history.

PPCOS baseline characteristics Vol. 86, No. 4, October 2006

How long has the patient been attempting conception (months)? N Mean ⫾ SD Patient had a diagnosis of infertility Ovulatory dysfunction Tubal factor Endometriosis Uterine or male factor Unexplained Patient had prior therapy for infertility Prior conception Prior live birth Prior loss Previous study drug exposure None Metformin only Clomiphene citrate only Metformin and clomiphene citrate Hypertension Thyroid dysfunction Other chronic medical condition Patient had history of smoking Current smoker Stopped Patient had history of alcohol use Currently using No current alcohol use Patient had history of psychiatric disorder Legro. PPCOS baseline characteristics. Fertil Steril 2006.

Clomiphene citrate (n ⴝ 209)

Metformin XR (n ⴝ 208)

Combined clomiphene and metformin (n ⴝ 209)

All patients (n ⴝ 626)

208 41.4 ⫾ 39.4 169/209 (80.9%) 168/209 (80.4%) 0 0 0 1/209 (0.5%) 116/209 (55.5%) 77/209 (36.8%) 33/209 (15.8%) 53/209 (25.4%)

208 39.0 ⫾ 31.9 165/208 (79.3%) 161/208 (77.4%) 3/208 (1.4%) 5/208 (2.4%) 0 1/208 (0.5%) 111/208 (53.4%) 66/208 (31.7%) 33/208 (15.9%) 40/208 (19.2%)

208 40.7 ⫾ 36.0 163/209 (78.0%) 161/209 (77.0%) 2/209 (1.0%) 1/209 (0.5%) 0 2/209 (1.0%) 116/209 (55.5%) 67/209 (32.1%) 28/209 (13.4%) 45/209 (21.5%)

624 40.4 ⫾ 35.8 497/626 (79.4%) 490/626 (78.3%) 5/626 (0.8%) 6/626 (1.0%) 0 4/626 (0.6%) 343/626 (54.8%) 210/626 (33.5%) 94/626 (15.0%) 138/626 (22.0%)

89/209 (42.6%) 14/209 (6.7%) 67/209 (32.1%) 39/209 (18.7%) 12/209 (5.7%) 13/209 (6.2%) 12/209 (5.7%) 88/209 (42.1%) 43/209 (20.6%) 45/209 (21.5%) 138/209 (66.0%) 73/209 (34.9%) 65/209 (31.1%) 37/209 (17.7%)

87/208 (41.8%) 16/208 (7.7%) 68/208 (32.7%) 37/208 (17.8%) 14/208 (6.7%) 17/208 (8.2%) 8/208 (3.8%) 80/208 (38.5%) 29/208 (13.9%) 51/208 (24.5%) 147/208 (70.7%) 71/208 (34.1%) 76/208 (36.5%) 35/208 (16.8%)

86/209 (41.1%) 24/209 (11.5%) 53/209 (25.4%) 46/209 (22.0%) 13/209 (6.2%) 15/209 (7.2%) 8/209 (3.8%) 79/209 (37.8%) 35/209 (16.7%) 44/209 (21.1%) 131/209 (62.7%) 82/209 (39.2%) 49/209 (23.4%) 38/209 (18.2%)

262/626 (41.9%) 54/626 (8.6%) 188/626 (30.0%) 122/626 (19.5%) 39/626 (6.2%) 45/626 (7.2%) 28/626 (4.5%) 247/626 (39.5%) 107/626 (17.1%) 140/626 (22.4%) 416/626 (66.5%) 226/626 (36.1%) 190/626 (30.4%) 110/626 (17.6%)

P value across 3 treatment groups

.961 .768 .658 .215 .020 1.000 .880 .467 .724 .314 .370

.916 .742 .566 .626 .197 .220 .508 .934

FIGURE 1 Circulating hormone levels by treatment group in randomized cohort.

Legro. PPCOS baseline characteristics. Fertil Steril 2006.

a Kruskal-Wallis test was used for testing differences among the groups of three or more. All analyses were performed by using the Statistical Analysis System, version 8.2 (SAS Institute, Cary, NC). Baseline characteristics of randomized participants were examined by treatment group assignment and by race/ ethnicity (racial groups: Caucasian, African American, Asian, American Indian; ethnic groups: Latino or nonLatino). One patient was a Pacific Islander; due to the limited sample size we are not reporting her characteristics separately. For the purpose of examining ethnic and racial differences in abnormalities of markers of insulin action, we arbitrarily defined cutoffs for normal and abnormal based on normal ranges or on published data. For white blood cell counts (WBCs) and liver transaminases (alanine aminotransferase [ALT] or aspartate aminotransferase [AST]) levels we used the cutoffs for normal as determined in each local laboratory (only elevated levels were qualified as abnormal), for others we used cutoffs that have been suggested in the literature and summarized in a recent review (14). A homeostasis model assessment of insulin sensitivity was calFertility and Sterility姞

culated according to the formula of [insulin (␮U/mL) ⫻ glucose (nmol/L)]/22.5. RESULTS Clinical and Demographic Characteristics More than 4,000 potential participants were screened, of whom 1,313 gave consent for further study. Of these, 626 patients passed the eligibility screens and were randomly assigned to one of three treatment arms. The overall distribution by age, race, ethnicity, biometric variables, and medical history variables is found in Table 1. The overall mean (⫾SD) age of the subjects was 28.1 ⫾ 4.0 years and the mean BMI was 35.2 kg/m2 (⫾8.7). Almost 30% of the participants belonged to a US minority racial group, and 26% to a minority ethnic group. More than 80% (80.7%) of the subjects had hirsutism (as defined by a Ferriman-Gallwey score ⱖ8). There were no significant differences in baseline variables between treatment groups. Selected items from the infertility and medical history are summarized in Table 2. Participating patients typically had a longstanding history of infertility, with a mean duration of 40.4 (⫾35.8) months noted. Ovulatory dysfunction secondary to PCOS was the attributed factor in close to 80% of all patients, although other infertility factors had been detected in a minority. The difference noted in endometriosis history between treatment groups is due to its relative rarity in our population. There were no uterine or male factor infertility noted, as these were exclusion criteria. More than half (54.8%) of the patients had received prior treatment of infertility, and 58.1% had some prior exposure to CC or metformin, with 19.5% exposed to both drugs, although we are uncertain whether they were given concurrently in the past (as in the third treatment arm of the protocol). Approximately one-third (33.5%) of patients reported a prior conception, and 22% reported a prior pregnancy loss. Participating patients were overall in good health. Approximately 6% (6.2%) had a history of hypertension, and 7% a history of thyroid dysfunction. Seventeen percent were current smokers and 22% had a history of smoking. Almost 18% (17.6%) reported a history of a psychiatric disorder. Baseline androgen, SHBG, insulin, and proinsulin were comparable among groups with no significant differences (Fig. 1). The ovaries were visualized on transvaginal ultrasound examination in 97% of patients (Table 3). Ninety percent of patients had PCO morphology as determined by increased number of small follicles and increased stroma. One percent or less had hyperthecotic ovaries, defined as increased stroma without the increased number of small follicles. Approximately 9% (8.7% and 9.6% for left and right ovaries, respectively) of patients did not meet the criteria for PCO morphology. Overall 21.2% of the subjects had a follicle ⬎10 mm in diameter. The mean volume of both ovaries exceeded 10 cm3. 919

920 Legro et al.

TABLE 3 Transvaginal ultrasound results by treatment arm.

PPCOS baseline characteristics Vol. 86, No. 4, October 2006

Left ovary Not visualized Right ovary Not visualized Morphology Left: Normal PCO Hyperthecotic Right: Normal PCO Hyperthecotic Left and right ovaries with PCO Left or right ovaries with PCO Neither ovary with PCO Left ovarian volume (cm3) N Mean ⫾ SD Right ovarian volume (cm3) N Mean ⫾ SD Right ovary larger than the left Left ovary larger than the right Patients with at least one follicle ⬎ 10 mm Size of largest follicle (mm) N Mean ⫾ SD

Clomiphene citrate (n ⴝ 209)

Metformin XR (n ⴝ 208)

Combined clomiphene and metformin (n ⴝ 209)

All patients (n ⴝ 626)

P value across 3 treatment groups

4/209 (1.9%)

6/208 (2.9%)

1/209 (0.5%)

11/626 (1.8%)

.153

2/209 (1.0%)

3/208 (1.4%)

1/209 (0.5%)

6/626 (1.0%)

.544

18/205 (8.8%) 185/205 (90.2%) 2/205 (1.0%) 24/205 (11.7%) 181/205 (88.3%) 0 174/202 (86.1%) 192/208 (92.3%) 16/208 (7.7%)

17/201 (8.5%) 181/201 (90.0%) 3/201 (1.5%) 15/203 (7.4%) 185/203 (91.1%) 3/203 (1.5%) 177/197 (89.9%) 189/207 (91.3%) 18/207 (8.7%)

18/205 (8.8%) 186/205 (90.7%) 1/205 (0.5%) 20/207 (9.7%) 187/207 (90.3%) 0 181/204 (88.7%) 192/208 (92.3%) 16/208 (7.7%)

53/611 (8.7%) 552/611 (90.3%) 6/611 (1.0%) 59/615 (9.6%) 553/615 (89.9%) 3/615 (0.5%) 532/603 (88.2%) 573/623 (92.0%) 50/623 (8.0%)

.946

205 10.9 ⫾ 6.9

197 11.2 ⫾ 6.1

205 11.2 ⫾ 6.2

607 11.1 ⫾ 6.4

.476

204 11.8 ⫾ 6.9 115/209 (55.0%) 85/209 (40.7%) 43/209 (20.6%)

200 11.8 ⫾ 5.9 103/208 (49.5%) 88/208 (42.3%) 46/208 (22.1%)

204 12.5 ⫾ 8.1 118/209 (56.5%) 83/209 (39.7%) 44/209 (21.1%)

608 12.0 ⫾ 7.0 336/626 (53.7%) 256/626 (40.9%) 133/626 (21.2%)

.482 .623 .605 .942

195 7.5 ⫾ 5.2

200 7.8 ⫾ 6.2

195 7.6 ⫾ 4.8

590 7.7 ⫾ 5.4

.677

Legro. PPCOS baseline characteristics. Fertil Steril 2006.

.126

.502 .911

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TABLE 4 Demographic characteristics by race and ethnicity. Race Ethnicity

Age (y) N Mean ⫾ SD Body mass index (kg/m2) N Mean ⫾ SD Less than 30 30–34 ⱖ35 Blood pressure (mm Hg) N Systolic Diastolic Hirsutism N Mean ⫾ SD FG ⬍ 8 FG 8–16 FG ⬎ 16

Caucasian (n ⴝ 435)

African American (n ⴝ 109)

Asian (n ⴝ 17)

435 28.2 ⫾ 3.9

109 27.9 ⫾ 4.3

17 30.4 ⫾ 3.0

434 109 17 35.4 ⫾ 8.8 36.0 ⫾ 8.4 29.1 ⫾ 6.3 123/434 (28.3%) 27/109 (24.8%) 11/17 (64.7%) 85/434 (19.6%) 25/109 (22.9%) 2/17 (11.8%) 226/434 (52.1%) 57/109 (52.3%) 4/17 (23.5%)

426 122.2 ⫾ 13.7 77.6 ⫾ 9.9

108 123.6 ⫾ 12.6 76.8 ⫾ 10.5

435 109 14.5 ⫾ 8.0 13.9 ⫾ 7.5 91/435 (20.9%) 19/109 (17.4%) 172/435 (39.5%) 54/109 (49.5%) 172/435 (39.5%) 36/109 (33.0%)

Legro. PPCOS baseline characteristics. Fertil Steril 2006.

American Indian P value or Alaska Native across (n ⴝ 72) race 72 27.6 ⫾ 4.1

72 34.3 ⫾ 8.0 21/72 (29.2%) 23/72 (31.9%) 28/72 (38.9%)

17 111.4 ⫾ 9.1 73.1 ⫾ 6.8

72 122.5 ⫾ 15.0 74.4 ⫾ 9.2

17 12.5 ⫾ 7.2 4/17 (23.5%) 8/17 (47.1%) 5/17 (29.4%)

72 15.1 ⫾ 8.2 11/72 (15.3%) 28/72 (38.9%) 33/72 (45.8%)

.041

.020 .004

.010 .011

.503 .325

Latino (n ⴝ 164)

Not Latino (n ⴝ 462)

164 27.5 ⫾ 4.2

462 28.3 ⫾ 3.9

164 461 34.9 ⫾ 8.3 35.3 ⫾ 8.8 46/164 (28.0%) 133/461 (28.9%) 48/164 (29.3%) 87/461 (18.9%) 70/164 (42.7%) 241/461 (52.3%)

164 120.5 ⫾ 14.7 74.2 ⫾ 9.9

452 122.7 ⫾ 13.2 77.8 ⫾ 9.7

164 462 15.3 ⫾ 7.4 14.1 ⫾ 8.0 22/164 (13.4%) 99/462 (21.4%) 71/164 (43.3%) 191/462 (41.3%) 71/164 (43.3%) 172/462 (37.2%)

P value across ethnicity

.020

.340 .018

.051 ⬍.001

.065 .062

921

TABLE 5 Selected infertility and medical history by race and ethnicity. Race African American (n ⴝ 109)

Caucasian (n ⴝ 435) How long has the patient been attempting conception (months)? N Mean ⫾ SD Patient had a diagnosis of infertility Ovulatory dysfunction Tubal factor Endometriosis Uterine or male factor Unexplained Patient had prior therapy for infertility Prior conception Prior live birth Prior loss Previous study drug exposure None Metformin only Clomiphene citrate only Metformin and clomiphene citrate Hypertension Thyroid dysfunction Other chronic medical condition Patient had history of smoking Current smoker Stopped Patient had history of alcohol use Currently using No current alcohol use Patient had history of psychiatric disorder

American Indian or Alaska Native (n ⴝ 72)

Asian (n ⴝ 17)

435 40.4 ⫾ 36.4 369/435 (84.8%) 365/435 (83.9%) 2/435 (0.5%) 5/435 (1.1%) 0 2/435 (0.5%) 249/435 (57.2%) 145/435 (33.3%) 67/435 (15.4%) 86/435 (19.8%)

108 17 34.3 ⫾ 33.3 24.3 ⫾ 25.2 76/109 (69.7%) 13/17 (76.5%) 74/109 (67.9%) 13/17 (76.5%) 2/109 (1.8%) 0 1/109 (0.9%) 0 0 0 2/109 (1.8%) 0 60/109 (55.0%) 7/17 (41.2%) 38/109 (34.9%) 6/17 (35.3%) 17/109 (15.6%) 2/17 (11.8%) 32/109 (29.4%) 4/17 (23.5%)

72 49.7 ⫾ 34.6 44/72 (61.1%) 43/72 (59.7%) 1/72 (1.4%) 0 0 0 31/72 (43.1%) 25/72 (34.7%) 10/72 (13.9%) 19/72 (26.4%)

168/435 (38.6%) 42/435 (9.7%) 129/435 (29.7%) 96/435 (22.1%) 31/435 (7.1%) 39/435 (9.0%) 19/435 (4.4%) 194/435 (44.6%) 81/435 (18.6%) 113/435 (26.0%) 310/435 (71.3%) 176/435 (40.5%) 134/435 (30.8%) 88/435 (20.2%)

47/109 (43.1%) 10/17 (58.8%) 11/109 (10.1%) 0 36/109 (33.0%) 6/17 (35.3%) 15/109 (13.8%) 1/17 (5.9%) 7/109 (6.4%) 0 2/109 (1.8%) 2/17 (11.8%) 6/109 (5.5%) 1/17 (5.9%) 36/109 (33.0%) 3/17 (17.6%) 19/109 (17.4%) 1/17 (5.9%) 17/109 (15.6%) 2/17 (11.8%) 75/109 (68.8%) 8/17 (47.1%) 33/109 (30.3%) 4/17 (23.5%) 42/109 (38.5%) 4/17 (23.5%) 14/109 (12.8%) 2/17 (11.8%)

39/72 (54.2%) 4/72 (5.6%) 20/72 (27.8%) 9/72 (12.5%) 3/72 (4.2%) 3/72 (4.2%) 3/72 (4.2%) 18/72 (25.0%) 6/72 (8.3%) 12/72 (16.7%) 31/72 (43.1%) 20/72 (27.8%) 11/72 (15.3%) 9/72 (12.5%)

Legro. PPCOS baseline characteristics. Fertil Steril 2006.

Characteristics of Participants by Racial/Ethnic Group Asians tended to be older and lighter than other racial groups and Latinos were younger and thinner than non-Latinos (Table 4). Asians and Latinos also had lower BMIs compared to other groups. Blood pressure tracked with weight in a similar pattern. There were no significant racial differences in body hair distribution, although Latinos were more hirsute than non-Latinos. Although medical history components were generally more comparable among groups (Table 5), Caucasians had the longest mean period of infertility followed by Native Americans, African Americans, and Asians. Testosterone levels tended to be highest in Caucasians and African Americans and lowest in Asians and Native Americans in terms of racial groups, and lower in Latinos in terms 922

Legro et al.

PPCOS baseline characteristics

of ethnic groups, and there was a significant difference across race in both total T and free androgen index (Table 6). Overall, a substantial number had normal total T levels as determined by the core laboratory, ranging from 29.2% in African Americans to 64.7% in Asians with a level of T ⬍ 50 ng/dL. A larger percentage had normal free androgen indices (Table 6). There were no racial or ethnic differences in glucose, insulin, proinsulin, or SHBG levels. We examined markers of insulin resistance for racial or ethnic differences and defined categorical cutoffs of normal or abnormal (Table 7). There was a significant racial effect noted for waist circumference, although this appeared to be due to the lower measures in Asians. African Americans and Native Americans had a higher prevalence Vol. 86, No. 4, October 2006

TABLE 5 Continued. Ethnicity P value across race

⬍.001 ⬍.001 ⬍.001 .281 1.000 .280 .114 .928 .777 .142 .072

.629 .018 .754 ⬍.001 .216 ⬍.001 .008 .080

Latino (n ⴝ 164)

Not Latino (n ⴝ 462)

163 49.3 ⫾ 39.6 122/164 (74.4%) 120/164 (73.2%) 1/164 (0.6%) 2/164 (1.2%) 0 0 88/164 (53.7%) 60/164 (36.6%) 24/164 (14.6%) 37/164 (22.6%)

461 37.2 ⫾ 33.9 375/462 (81.2%) 370/462 (80.1%) 4/462 (0.9%) 4/462 (0.9%) 0 4/462 (0.9%) 255/462 (55.2%) 150/462 (32.5%) 70/462 (15.2%) 101/462 (21.9%)

72/164 (43.9%) 11/164 (6.7%) 58/164 (35.4%)

190/462 (41.1%) 43/462 (9.3%) 130/462 (28.1%)

23/164 (14.0%) 7/164 (4.3%) 7/164 (4.3%) 8/164 (4.9%) 48/164 (29.3%) 18/164 (11.0%) 30/164 (18.3%) 90/164 (54.9%) 43/164 (26.2%) 47/164 (28.7%) 19/164 (11.6%)

99/462 (21.4%) 32/462 (6.9%) 38/462 (8.2%) 20/462 (4.3%) 199/462 (43.1%) 89/462 (19.3%) 110/462 (23.8%) 326/462 (70.6%) 183/462 (39.6%) 143/462 (31.0%) 91/462 (19.7%)

P value across ethnicity

⬍.001 .070 .069 1.000 .655 .577 .734 .339 .873 .853 .075

.209 .076 .772 .002 .012 ⬍.001 .002 .015

Legro. PPCOS baseline characteristics. Fertil Steril 2006.

of abnormal values (81.5% and 81.9%, respectively) and a slightly higher mean level was noted in African Americans for mean waist circumference than other racial groups (104.4 cm for African Americans). Hyperinsulinemia and insulin resistance as diagnosed by homeostatic models were common among all racial and ethnic groups, although Asians tended to have more normal levels. African Americans and Caucasians tended to have comparable levels of insulin, glucose, proinsulin, and homeostatic values obtained from these measures (ratios and homeostasis model assessment). The highest prevalence of abnormal fasting glucose levels (ⱖ100 mg/dL) was found in African Americans (25.5%) and the lowest in Asians (5.7%). Fertility and Sterility姞

Although WBC and liver transaminases were obtained as safety laboratories, elevated levels of these measures have been associated with insulin resistance. It is in these values that we found the most noticeable racial and ethnic differences (Table 7). African Americans had the lowest levels of ALT and AST compared to Caucasians and Native Americans (P⬍.0001). Both Caucasians and Native Americans had a high prevalence of elevated levels of ALT (13.8% and 25.4%, respectively) compared to other groups. Ethnicity may have also contributed to this stratification as a significantly higher prevalence was noted for ALT among Latinos (19.9% vs. 10.1% for non-Latinos, P⫽.002). Mean WBC levels also showed a significant racial effect (P⫽.001), with the lowest levels among African Americans. 923

924 Legro et al.

TABLE 6 Baseline laboratory measurements by race and ethnicity (including distributions for testosterone levels). Race Ethnicity

PPCOS baseline characteristics

Caucasian (n ⴝ 435)

Vol. 86, No. 4, October 2006

Total testosterone (ng/dL) N Mean ⫾ SD ⱕ50 50–100 101–150 ⬎150 Free androgen index N Mean ⫾ SD ⱕ10 11–20 21–30 ⬎30 Glucose (mg/dL) N Mean ⫾ SD Insulin (␮U/mL) N Mean ⫾ SD Proinsulin (pmol/L) N Mean ⫾ SD SHBG (nmol/L) N Mean ⫾ SD

AfricanAmerican (n ⴝ 109)

Asian (n ⴝ 17)

American Indian P value or Alaska Native across (n ⴝ 72) race

422 106 17 62.7 ⫾ 29.4 65.6 ⫾ 27.2 50.5 ⫾ 19.7 159/422 (37.7%) 31/106 (29.2%) 11/17 (64.7%) 222/422 (52.6%) 64/106 (60.4%) 6/17 (35.3%) 34/422 (8.1%) 9/106 (8.5%) 0 7/422 (1.7%) 2/106 (1.9%) 0

68 52.9 ⫾ 24.7 39/68 (57.4%) 26/68 (38.2%) 3/68 (4.4%) 0

422 106 17 9.7 ⫾ 6.9 9.3 ⫾ 6.8 7.3 ⫾ 3.6 260/422 (61.6%) 73/105 (69.5%) 13/17 (76.5%) 129/422 (30.6%) 24/105 (22.9%) 4/17 (23.5%) 27/422 (6.4%) 7/105 (5.7%) 0 6/422 (1.4%) 2/105 (1.9%) 0

68 8.5 ⫾ 6.0 47/68 (69.1%) 17/68 (25.0%) 3/68 (4.4%) 1/68 (1.5%)

.003 .026

.390 .861

Latino (n ⴝ 164)

Not Latino (n ⴝ 462)

163 445 59.7 ⫾ 28.1 62.9 ⫾ 28.8 72/163 (44.2%) 164/445 (36.5%) 79/163 (48.5%) 238/445 (53.8%) 10/163 (6.1%) 36/444 (8.1%) 2/163 (1.2%) 7/444 (1.6%) 163 445 9.1 ⫾ 6.0 9.7 ⫾ 7.0 102/163 (62.6%) 284/445 (63.8%) 53/163 (32.5%) 123/445 (27.6%) 6/163 (3.7%) 31/445 (7.0%) 2/163 (1.2%) 7/445 (1.6%)

P value across ethnicity

.260 .416

.538 .378

422 88.8 ⫾ 16.7

106 90.9 ⫾ 21.8

17 82.9 ⫾ 14.7

68 87.4 ⫾ 13.0

.376

163 86.3 ⫾ 15.5

445 89.9 ⫾ 17.9

.122

424 22.2 ⫾ 25.9

106 27.2 ⫾ 34.7

17 15.9 ⫾ 15.0

68 22.4 ⫾ 15.6

.159

163 21.9 ⫾ 21.1

447 23.4 ⫾ 28.4

.611

424 24.2 ⫾ 24.1

105 25.8 ⫾ 23.6

17 21.3 ⫾ 26.5

68 27.4 ⫾ 36.7

.382

163 25.4 ⫾ 28.2

446 24.7 ⫾ 24.8

.518

424 30.1 ⫾ 19.7

106 30.3 ⫾ 13.5

17 29.0 ⫾ 18.3

68 26.8 ⫾ 13.4

.157

163 28.5 ⫾ 15.0

447 30.1 ⫾ 19.1

.706

Legro. PPCOS baseline characteristics. Fertil Steril 2006.

We noted a significant racial effect in the distribution of PCO morphology, with whites tending to have the lowest prevalence (87.9% for the right ovary and 87.8% for the left ovary) compared to other racial groups (P⫽.007) (Table 8). Both racial and ethnic effects were noted with ovarian volume (P⬍.0001 for left ovarian volume, P⫽.04 for right ovarian volume), with Asians and Native American having lower volumes, and also Latinos (P⫽.001). DISCUSSION Patient Characteristics and Diagnostic Criteria Our goal at baseline was to recruit a study population that was well balanced by treatment arm and that reflected the racial and ethnic diversity of the US population. Our treatment groups were well matched for baseline historic, demographic, and biochemical variables of interest in the study. The mean age of patients on this study was 28 years. The patient population was clearly obese with a mean BMI of 35.2, and was more ethnically and racially diverse than US census distributions. Whether this limits the generalizability of our data, or this reflects the larger racial and ethnic population distribution of PCOS, is unknown. Unfortunately, there are no US population-wide data on the demographics of PCOS. A recent large regional phenotyping series from the United States reported on 316 women with signs and symptoms of oligomenorrhea and hyperandrogenism consistent with PCOS and found similar mean BMIs (approximately 35), and comparable body fat distributions, as well as circulating levels of T and insulin (15). The mean age and BMI for this study were similar to the largest comparable multicenter trial in women with PCOS in the United States which was a dose-ranging trial of troglitazone as an ovulation induction agent. That study reported on 304 women, where age per treatment group ranged from 29 to 30 years of age and BMI from 35 to 38 (16). Participants in multicenter trials of PCOS in the United States tend to be heavier by BMI and slightly older than participants in multicenter trials of metformin and CC that have been conducted outside the United States (3, 17). There are no similarly sized multicenter trials from outside the United States, which may involve alternate diagnostic criteria to use as a comparative yardstick for baseline characteristics. However, large cases series of women with PCOS or results from large phenotyping studies, identified primarily by ultrasound (combined with symptoms), provide some basis for comparison. Balen et al. (18) from England reported on 1,741 consecutive patients with PCOS who weighed substantially less (mean BMI 25.4, with 5th to 95th percentile: 19.0 –38.6) than our subjects and unlike ours, 30% had regular menses, although androgen levels were comparable to our subjects. Powell et al. (19) also from England reported on 386 women with PCOS, similarly diagnosed, in a report that Fertility and Sterility姞

contained both isolated cases and familial probands. The BMI in the two groups of women with PCOS ranged around 27.0 (geometric mean SD range was 20.5–34.2), mean T was comparable at 64 ng/dL (range 35–94 ng/dL), and glucose slightly lower at approximately 85.5 mg/dL (SD range 74.2– 99.4 mg/dL). A follow-up phone survey of 346 Dutch women with PCOS found a mean self reported BMI of 24.4 (range 18.8 –55.1) (20). These results suggest that BMI is substantially less with corresponding improvement in related parameters in other populations. Because these were collected over time in single or regional centers, they may also not reflect changes in the PCOS phenotype over time or the devastating and relatively rapid effects of the obesity epidemic in developed lands. Patients in our study were recruited on the basis of hyperandrogenemia (based on elevated T levels) and oligomenorrhea. Hyperandrogenemia noted in an outside laboratory was not necessarily confirmed by the core laboratory. This could be due to the variability of circulating T levels, as the qualifying and baseline samples were usually measured at different times (21), but is more likely indicative of the variability between assays for T, none of which is universally accepted (22). Another problem with T assays is the poor standardization in the female ranges of hyperandrogenemia (50 –150 ng/mL), which is slightly below the male range of hypogonadism, which many of these assays were developed to detect (23). Of note, a recent published report showed that the method used to measure T for this study (Coat-a-Count Kit; Diagnostic Products Corp.) is one of the most accurate and reliable methods commercially available (24). Nonetheless, the elevated levels of T (total or free androgen index) in the majority of subjects is biochemical evidence of hyperandrogenism in these subjects (8, 9), and putative evidence against a hypothalamic, hypogonadal etiology for the oligo-ovulation in study patients. Our identification of patients based on local cutoff values was also intended to identify a representative sample of women with PCOS based on current practice guidelines in the United States (25). We did not include ovarian morphology or volume as eligibility criteria for the study. More stringent requirements for the ultrasound determination of the PCO have recently been proposed that require a larger number of follicles in a single ultrasound plane than were used for this study (12 vs.10) and also incorporate ovarian volume cutoffs (26). We could not universally apply these criteria, because many study patients had dominant follicles or cysts (⬎10 mm) that confound volume cutoffs per these guidelines. We also did not perform follicle counts as this study was started before publication of the Rotterdam criteria, although subsequent publications have already recommended revising these ultrasound criteria for PCO (27). The ultrasound definition of a PCO remains a shifting target and such guidelines remain at the lowest level of evidence-based medicine (i.e., expert opinion). 925

TABLE 7 Safety laboratory and markers of insulin resistance at baseline by race and ethnicity. Race

All (N ⴝ 626) Waist circumference (cm) N Mean ⫾ SD Abnormal ⱖ88 cm WBC (103/␮L) N Mean ⫾ SD Abnormal by local cutoffs ALT (U/L) N Mean ⫾ SD Abnormal by local cutoffs AST (U/L) N Mean ⫾ SD Abnormal by local cutoffs Glucose (mg/dL) N Mean ⫾ SD ⬍100 100–125 ⬎125 Insulin (␮U/mL) N Mean ⫾ SD Abnormal ⬎20 ␮U/mL Proinsulin (pmol/L) N Mean ⫾ SD Proinsulin to insulin ratio N Mean ⫾ SD Glucose to insulin ratio N Mean ⫾ SD Abnormal ⬍ 4.5 HOMA N Mean ⫾ SD Abnormal ⱖ 3.8

Caucasian (n ⴝ 435)

African American (n ⴝ 109)

Asian (n ⴝ 17)

American Indian or Alaska Native (n ⴝ 72)

623 433 108 17 72 102.5 ⫾ 19.6 103.0 ⫾ 19.7 104.4 ⫾ 21.4 89.8 ⫾ 13.1 99.7 ⫾ 15.3 479/623 (76.9%) 329/433 (76.0%) 88/108 (81.5%) 9/17 (52.9%) 59/72 (81.9%) 626 7.5 ⫾ 3.3 28/626 (4.5%)

435 7.6 ⫾ 3.7 21/435 (4.8%)

109 6.7 ⫾ 2.1 3/109 (2.8%)

17 7.7 ⫾ 1.9 1/17 (5.9%)

72 7.4 ⫾ 2.0 3/72 (4.2%)

626 27.0 ⫾ 14.4 77/608 (12.7%)

435 28.2 ⫾ 14.7 58/419 (13.8%)

109 21.4 ⫾ 9.7 1/108 (0.9%)

17 21.1 ⫾ 9.3 1/17 (5.9%)

72 29.3 ⫾ 16.3 18/71 (25.4%)

626 22.1 ⫾ 8.1 19/626 (3.0%)

435 22.4 ⫾ 8.5 15/435 (3.4%)

109 20.5 ⫾ 6.4 1/109 (0.9%)

17 19.9 ⫾ 4.9 0

72 22.5 ⫾ 7.8 2/72 (2.8%)

608 422 106 17 68 89.0 ⫾ 17.4 88.8 ⫾ 16.7 90.9 ⫾ 21.8 82.9 ⫾ 14.7 87.4 ⫾ 13.0 497/608 (81.7%) 349/422 (82.7%) 79/106 (74.5%) 16/17 (94.1%) 59/68 (86.8%) 93/608 (15.3%) 61/422 (14.5%) 21/106 (19.8%) 1/17 (5.9%) 9/68 (13.2%) 18/608 (3.0%) 12/422 (2.8%) 6/106 (5.7%) 0 0 610 424 106 17 68 23.0 ⫾ 26.6 22.2 ⫾ 25.9 27.2 ⫾ 34.7 15.9 ⫾ 15.0 22.4 ⫾ 15.6 239/610 (39.2%) 163/424 (38.4%) 44/106 (41.5%) 3/17 (17.6%) 31/68 (45.6%) 609 24.9 ⫾ 25.8

424 24.2 ⫾ 24.1

105 25.8 ⫾ 23.6

17 21.3 ⫾ 26.5

68 27.4 ⫾ 36.7

609 1.3 ⫾ 0.8

424 1.3 ⫾ 0.8

105 1.2 ⫾ 0.7

17 1.2 ⫾ 0.5

68 1.3 ⫾ 1.2

608 422 106 7.4 ⫾ 9.2 7.7 ⫾ 10.4 6.6 ⫾ 5.2 243/608 (40.0%) 162/422 (38.4%) 43/106 (40.6%)

17 68 8.3 ⫾ 5.1 6.3 ⫾ 6.0 3/17 (17.6%) 37/68 (54.4%)

608 422 106 5.5 ⫾ 8.4 5.3 ⫾ 8.1 6.7 ⫾ 11.4 286/608 (47.0%) 193/422 (45.7%) 55/106 (51.9%)

17 68 3.5 ⫾ 3.6 5.0 ⫾ 3.7 3/17 (17.6%) 37/68 (54.4%)

Legro. PPCOS baseline characteristics. Fertil Steril 2006.

926

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PPCOS baseline characteristics

Vol. 86, No. 4, October 2006

TABLE 7 Continued.

Ethnicity P value across race

Latino (n ⴝ 164)

Not Latino (n ⴝ 462)

P value across ethnicity

.014 .138

164 101.2 ⫾ 16.7 131/164 (79.9%)

459 103.0 ⫾ 20.5 348/459 (75.8%)

.258 .285

.001 .712

164 7.3 ⫾ 1.9 3/164 (1.8%)

462 7.5 ⫾ 3.7 25/462 (5.4%)

.703 .038

164 30.1 ⫾ 15.9 32/161 (19.9%)

462 25.9 ⫾ 13.7 45/447 (10.1%)

.002 .002

164 23.3 ⫾ 9.2 7/164 (4.3%)

462 21.6 ⫾ 7.7 12/462 (2.6%)

.058 .294

163 86.3 ⫾ 15.5 143/163 (87.7%) 19/163 (11.7%) 1/163 (0.6%)

445 89.9 ⫾ 17.9 354/445 (79.6%) 74/445 (16.6%) 17/445 (3.8%)

.159 .309

163 21.9 ⫾ 21.1 62/163 (38.0%)

447 23.4 ⫾ 28.4 177/447 (39.6%)

.611 .727

.382

163 25.4 ⫾ 28.2

446 24.7 ⫾ 24.9

.518

.469

163 1.3 ⫾ 0.9

446 1.3 ⫾ 0.8

.776

.204 .046

163 6.6 ⫾ 5.6 72/163 (44.2%)

445 7.6 ⫾ 10.2 171/445 (38.4%)

.231 .202

.123 .072

163 4.9 ⫾ 5.4 76/163 (46.6%)

445 5.7 ⫾ 9.2 210/445 (47.2%)

.990 .902

⬍.001 ⬍.001

.077 .577

.376 .293

.122 .025

Legro. PPCOS baseline characteristics. Fertil Steril 2006.

Fertility and Sterility姞

927

TABLE 8 Transvaginal ultrasound results by race and ethnicity. Race

Left ovary Not visualized Right ovary Not visualized Morphology Left: Normal PCO Hyperthecotic Right: Normal PCO Hyperthecotic Left and right ovaries with PCO Left or right ovaries with PCO Neither ovary with PCO Left ovarian volume (cm3) N Mean ⫾ SD Right ovarian volume (cm3) N Mean ⫾ SD Right ovary larger than the left Left ovary larger than the right Patients with ⱖ1 follicle ⬎10 mm Size of largest follicle (mm) N Mean ⫾ SD

Caucasian (n ⴝ 435)

African American (n ⴝ 109)

Asian (n ⴝ 17)

American Indian or Alaska Native (n ⴝ 72)

9/435 (2.1%)

2/109 (1.8%)

0

1/72 (1.4%)

6/435 (1.4%)

0

0

0

1/17 (5.9%) 16/17 (94.1%) 0 2/17 (11.8%) 15/17 (88.2%) 0 13/16 (81.3%) 16/16 (100.0%) 0

0 70/71 (98.6%) 1/71 (1.4%) 1/72 (1.4%) 71/72 (98.6%) 0 61/63 (96.8%) 64/64 (100.0%) 0

17 7.7 ⫾ 5.3

70 8.7 ⫾ 4.3

47/423 (11.1%) 4/106 (3.8%) 372/423 (87.9%) 102/106 (96.2%) 4/423 (0.9%) 0 49/425 (11.5%) 6/108 (5.6%) 373/425 (87.8%) 102/108 (94.4%) 3/425 (0.7%) 0 359/416 (86.3%) 97/104 (93.3%) 386/432 (89.4%) 104/107 (97.2%) 46/432 (10.6%) 3/107 (2.8%) 419 11.6 ⫾ 6.7 421 12.1 ⫾ 6.7 215/435 (49.4%) 193/435 (44.4%) 101/435 (23.2%) 405 7.7 ⫾ 5.6

107 11.3 ⫾ 6.1

105 17 13.4 ⫾ 9.2 10.9 ⫾ 5.5 63/109 (57.8%) 12/17 (70.6%) 40/109 (36.7%) 5/17 (29.4%) 19/109 (17.4%) 4/17 (23.5%) 103 7.6 ⫾ 5.5

17 6.8 ⫾ 4.7

72 10.1 ⫾ 4.3 47/72 (65.3%) 23/72 (31.9%) 9/72 (12.5%) 72 7.7 ⫾ 4.4

Legro. PPCOS baseline characteristics. Fertil Steril 2006.

One concern about the ultrasound evaluation is that the interobserver and intraobserver coefficient of variation for PCO parameters have not been validated in large multicenter trials for PCOS, including this current trial where these measures were not obtained. Nonetheless, ⬎90% of the patients had ultrasound evidence of PCO morphology on at least one ovary, and 8% had bilateral normal morphology, very similar to a smaller recent US study that examined the prevalence of PCO among women with unexplained hyperandrogenic chronic anovulation very similar to the diagnostic guidelines of this study (28). As has been reported in the past (29), ovaries can be discordant for polycystic morphology and this appears more common than previously reported and was noted in approximately 7% of study subjects. These data support the concept that PCO morphology is very common, but not invariant, among women with PCOS according to the 1990 NIH diagnostic criteria. One of the interesting findings of this study was the significantly larger mean ovarian volumes of the right ovary 928

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PPCOS baseline characteristics

compared to the left ovary (in all treatment, racial, and ethnic groups), although the absolute difference (approximately 10%) may be of little clinical significance. However, at least one group has identified the left ovary has having greater sensitivity in diagnosing PCOS compared to the right ovary (30). The differences in ovarian volume may be due to anatomic differences in venous drainage between the two ovaries with the left ovarian vein usually draining into the left renal vein, and the right ovarian vein usually draining into the inferior vena cava, with the left ovary more prone to venous stasis due to this anatomic variation and perhaps over time some atrophy. This would be analogous to the increased incidence of varicoceles and smaller testicular volumes in the left testicle (31). A smaller right ovarian volume has been detected in peripubertal girls before the onset of regular cycles and thus regular follicular development, which may confound the ability to detect this difference in the cycling adult ovary (32). In that sense women with PCOS and infreVol. 86, No. 4, October 2006

TABLE 8 Continued. Ethnicity P value across race

.007

.063

.011 ⬍.001

⬍.001

Latino (n ⴝ 164)

Not Latino (n ⴝ 462)

P value across ethnicity

3/164 (1.8%)

8/462 (1.7%)

1.000

1/164 (0.6%)

5/462 (1.1%)

1.000

13/160 (8.1%) 144/160 (90.0%) 3/160 (1.9%) 14/162 (8.6%) 147/162 (90.7%) 1/162 (0.6%) 141/158 (89.2%) 150/164 (91.5%) 14/164 (8.5%)

40/451 (8.9%) 408/451 (90.5%) 3/451 (0.7%) 45/453 (9.9%) 406/453 (89.6%) 2/453 (0.4%) 391/445 (87.9%) 423/459 (92.2%) 36/459 (5.8%)

.394

158 10.0 ⫾ 6.2

449 11.5 ⫾ 6.4

.001

.895

.642 .780

.040 .028 .033 .232

162 10.8 ⫾ 5.5 95/164 (57.9%) 61/164 (37.2%) 27/164 (16.5%)

446 12.5 ⫾ 7.5 241/462 (52.2%) 195/462 (42.2%) 106/462 (22.9%)

.007 .212 .231 .067

.687

159 7.4 ⫾ 4.6

431 7.7 ⫾ 5.7

.912

Legro. PPCOS baseline characteristics. Fertil Steril 2006.

quent follicular development (approximately 20% with evidence of a follicle ⬎10 mm) may be more like peripubertal girls. From the design of this study and the lack of serial ultrasound monitoring we are unable to determine whether these follicles/cysts were functional, but the lack of ultrasound evidence for cyclic ovarian development in the overwhelming majority of subjects at baseline (approximately 80% did not have a follicle ⬎10 mm in diameter) suggests that a history of oligomenorrhea accurately reflects chronic anovulation. PCOS and Prior Medical History Our patient population had a history of prolonged infertility, with a mean duration approaching 3.5 years. Therefore, based on a diagnosis of infertility as failure to conceive after a 12-month period of attempting, this was a severely affected population. The majority of patients received some form of infertility therapy in the past. Nearly 60% of patients had Fertility and Sterility姞

previously taken one or both of the study drugs. Attempting to study a drug-naïve population might have been considered preferable in some ways, but such a population would not have been reflective of the larger US population of patients with PCOS, and would have substantially prolonged the recruitment period. Each study patient received an active treatment in double-blinded, double-dummy fashion. There is a potentially substantial placebo ovulation effect noted in prior blinded studies with insulin-sensitizing agents (16, 33), suggesting the possibility of further benefit in our doubleblinded study beyond that previously experienced with openlabel treatment. Patients were also stratified at randomization according to prior drug exposure. The higher incidence of prior exposure to metformin compared with CC among study patients may be due to the widespread use of metformin for improving signs and symptoms of PCOS other than anovulatory infertility (the primary indication for using CC). However, this is 929

a notably high prevalence for the use of a medication (metformin) that does not have an Food and Drug Administration indication for such PCOS-related indications as anovulatory infertility, treatment of hirsutism or acne, or weight loss. This may reflect the paucity of effective treatments for PCOS or may be indicative of a willingness among clinicians to prescribe medication in the absence of definitive evidence. The data we present on the prevalence of other disorders in a PCOS population are intriguing. Given the most commonly proposed hypothesis for the cause of endometriosis due to retrograde menstruation (34), endometriosis is relatively and appropriately rare among study patients (1%) with a history of chronic anovulation. This is well below population estimates in an infertile population (35). Smoking is common among study patients, with a prevalence similar to that seen in the Troglitazone in PCOS trial (21%–23% per treatment arm in that trial) (16). The reasons for such a high prevalence of smoking among women with PCOS were not obtained (Is this a perceived appetite suppressant among an obese population?). However, smoking is an additional infertility risk factor in an already challenged population, and smoking cessation is an important goal for further treatment intervention in this population (36). Finally, multiple studies have used validated and nonvalidated survey methods to document psychic stress and diminished quality of life in women with PCOS (37, 38). We found a high prevalence (approaching 20%) of previous self-reported psychiatric disease among study patients, suggesting that this is an important part of the medical history in women with PCOS and one that should be specifically queried. It is also possible that some of this reflects on the longstanding history of infertility in these patients (⬎3 years) and other chronic stigmata of PCOS such as obesity, hirsutism, and menstrual disorders, and their subsequent deleterious effects on quality of life. PCOS and Insulin Resistance Polycystic ovary syndrome is believed to be exacerbated by underlying insulin resistance (39). Ethnicity and race have been shown to affect parameters of insulin action in population-based studies (40), with minority populations more likely to exhibit metabolic abnormalities (41). Small studies of PCOS have suggested there are racial differences in reproductive phenotypes, for instance, Asians with comparable levels of circulating T, but minimal hirsutism (42). Race and ethnicity have also been shown to influence insulin action in women with PCOS (43). However, these studies have been limited by selection bias and small sample size. Because hyperandrogenemia was a selection criterion for this study and markers of insulin resistance were not, and because the secondary aims of this study are to examine the predictive effect of markers of insulin resistance on outcomes, we have focused on these in our baseline article. 930

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PPCOS baseline characteristics

We examined a variety of biometric and biochemical abnormalities associated with the insulin resistance syndrome, including traditional measures of insulin and glucose (44), and nontraditional measures such as elevated levels of WBC and serum transaminases (ALT/AST) (45, 46). We did not measure lipid concentrations on study patients and are unable to determine the prevalence of the metabolic syndrome (47), which is reported to be highly prevalent among women with PCOS (48, 49). The prevalence of abdominal obesity, extrapolated from waist circumference, approached 20% in most racial groups. The lower prevalence in Asians may be an effect of the small sample size (n ⫽ 17). Similarly, whereas most patients (approximately 60%) showed evidence of insulin resistance with either fasting insulin levels or homeostatic models, a substantial minority did not, and biochemical evidence of insulin resistance cannot be viewed as a cornerstone of the phenotype (14, 50). We could not determine the best test of insulin resistance in the population (51), as we did not intensively characterize insulin action, but note that even intensive studies do not invariably document insulin resistance in women with PCOS (39, 44). The most clinically concerning aspect of our cutoffs is the high prevalence (approximately 18%) of impaired fasting glucose in our population, which exceeds the reported approximate 5% prevalence in a cohort of 250 women with PCOS (based on the prior 1997 American Diabetes Association higher cutoff of 110 mg/dL) (52, 53). Because this is one of the strongest risk factors for the development of type 2 diabetes mellitus (54) and by association the development of cardiovascular disease (55, 56), this is perhaps the most clinically relevant abnormality noted in our patients. Despite having no prior history of diabetes, and a value lower at their prior on-site screening, 3% of the subjects had baseline fasting blood glucose levels consistent with a diagnosis of type 2 diabetes (⬎125 mg/dL) when tested in the central laboratory. This is most likely due to the fluctuation of glucose levels around this cutoff in this high risk population for type 2 diabetes. These abnormalities may also potentially identify poor responders to ovulation induction, as well as those at risk for pregnancy loss and complications, although the eventual power of our study to detect these is limited. Nontraditional markers of insulin resistance include those indicative of systemic inflammation. Nonalcoholic fatty liver disease is an inclusive term for steatosis of the liver both with and without signs of injury such as inflammation and fibrosis and, like PCOS, represents a diagnosis of exclusion (57). Nonalcoholic fatty liver disease occurs in the presence of minimal alcohol intake, and 64% of our subjects had no history of current alcohol use. This condition is commonly associated with insulin resistance syndrome (58). It can be suspected on the basis of unexplained elevations in transaminases, and especially ALT levels, with a 90% positive predictive value (59). Vol. 86, No. 4, October 2006

Our data suggest that nonalcoholic fatty liver disease may be more common in Caucasians and Latinos than other groups. However, the prevalence of elevated ALT or AST levels in our subjects is similar to that reported in the larger US population (5.4%) based on Third National Health and Nutrition Examination Survey prevalence data (60). We did not perform hepatic ultrasounds or other diagnostic tests to further characterize the prevalence of nonalcoholic fatty liver disease at baseline, and a substantial proportion of subjects with nonalcoholic fatty liver disease have normal liver tests (20%–30%) based on living liver donor data (61). Thus, we may be underestimating the number of subjects affected with nonalcoholic fatty liver disease.

John Buster, M.D., Paula Amato, M.D., Melissa Torres, R.N.; Pennsylvania State University: William C. Dodson, M.D., C. Gnatuk, M.D., Jamie Ober, R.N.; UMDNJ: D. Heller, M.D., J. Colon, M.D., G. Weiss, M.D., A. Solnica, R.N.; University of Colorado: K. Gattin, R.N., S. Hahn, R.N.; University of Texas, Southwestern: M. Roark, R.N.C.; University of Alabama: R. Blackwell, M.D., V. Willis, R.N., L. Love, B.S.N., R.N.; University of Pittsburgh: K. Laychak, R.N.; Virginia Commonwealth University: M. Nazmy, M.D., D. Stovall, M.D.; University of Virginia: W. Evans, M.D.; Stanford University: K. Turner, R.N.C., N.P.; University of California San Diego: J. Chang, M.D., P. Malcolm, R.N.; Denver Health Medical Center: C. Coddington, M.D.; Kaiser Permanente: K. Faber, M.D. The authors also acknowledge the substantial contributions of the Ligand Assay and Analysis Core Laboratory at the University of Virginia Center for Research and Reproduction under the direction of Dan Hasenleider.

Elevated WBC counts have been associated with lowgrade chronic inflammation and also have been associated with insulin resistance and an increased risk for developing type 2 diabetes mellitus (45). An elevation in WBC levels above normal limits appears to be relatively uncommon among our subjects (⬍5%).

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Conclusions The data obtained at baseline in study subjects randomized to the PPCOS protocol indicate that the study has recruited an appropriate cohort with which to test the trial questions, and that this recruitment was conducted in a timely and uniform fashion. Women in the United States who are evaluated for PCOS on the basis of a history of chronic anovulation and elevated circulating androgen levels are an obese group of women with body fat in a centripetal distribution, who have accompanying metabolic abnormalities including elevated glucose and insulin levels. These data suggest that screening for these abnormalities, even with fasting levels alone has a high yield (approximately 20% with abnormal fasting glucose levels). The bulk of these women also have PCO based on morphology or increased volume. The lack of ultrasound evidence for cyclic ovarian development in the overwhelming majority of subjects at baseline (approximately 80% did not have a follicle ⬎10 mm in diameter) suggests that a history of oligomenorrhea accurately reflects chronic anovulation. We have added further information to the demographics and components of the PCOS phenotype in a US population. Race and ethnicity influence the phenotype to a mild degree, and there is evidence of racial effects on safety laboratories affected by insulin resistance. We eagerly await the outcome of this study. Acknowledgments: In addition to the authors, other investigators of the National Cooperative Reproductive Medicine Network were as follows: University of Pennsylvania: K. Barnhart, M.D., L. Mastroianni Jr., M.D., V. LiVolsi, M.D., L. Martino, M.S.N., C.R.N.P., K. Timbers, M.S.N., C.R.N.P., R. Brown, M.S.N, C.R.N.P.; Duke University: L. Lambe, B.A., R. DeWire, R.N., H. Yang, Ph.D., E. Martinez, R.N., C. Bodine, B.S.N., R. Brown, B.A., R. Oliverio, R.N.; Wayne State University: E. Puscheck, M.D., K. Ginsburg, M.D., K. Collins, M.S., M. Brossoit, A.A., R. Leach, M.D., F. Yelian, M.D., Ph.D., M. Perez, B.S.; Baylor College of Medicine:

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