Ultrasonographic criteria in the diagnosis of polycystic ovary syndrome: a systematic review and diagnostic meta-analysis.
Level 1 - systematic review of randomized trials
Systematic review and diagnostic meta-analysis of diagnostic accuracy studies
PubMed 37804097 · doi:10.1093/humupd/dmad027
What was done
A systematic review and bivariate diagnostic meta-analysis of studies published between January 1990 and June 2023 evaluating ultrasound markers for polycystic ovary syndrome (PCOS). Evaluated markers included follicle number per ovary (FNPO), follicle number per single cross-section (FNPS), ovarian volume (OV), and stromal features. Risk of bias was assessed with QUADAS-2 and QUADAS-C. Of 31 included studies, 24 contributed to meta-analysis (20 adult studies with 3,883 controls and 3,859 PCOS cases; 4 adolescent studies with 210 controls and 268 PCOS cases).
What was found
In adult women, FNPO demonstrated the highest diagnostic accuracy, with pooled sensitivity of 84% (95% CI: 81-87%), specificity of 91% (95% CI: 86-94%), and AUC of 0.905. OV showed sensitivity of 81% (95% CI: 76-86%), specificity of 81% (95% CI: 75-86%), and AUC of 0.856. FNPS had sensitivity of 81% (95% CI: 70-89%), specificity of 83% (95% CI: 75-88%), and AUC of 0.870. In adolescents, limited data suggested OV as a potential marker. Due to heterogeneity and methodological variations, the meta-analysis could not establish optimal quantitative cutoff thresholds.
Why it matters
The findings support FNPO as the primary ultrasonographic criterion for polycystic ovarian morphology in adult PCOS evaluation, with OV and FNPS serving as acceptable secondary alternatives when full follicle counts cannot be obtained.
Limits
Most included studies had high risk of bias regarding patient selection (non-consecutive or non-randomized sampling) and index test conduct (lack of pre-specified threshold comparisons). Significant heterogeneity remained unexplained by age, BMI, ultrasound technology, or threshold subgroups, preventing the identification of precise diagnostic cutoffs. Evidence in adolescent populations was limited to only four studies. Geographic variations in accuracy were present and potentially confounded by differences in diagnostic criteria and baseline patient characteristics.
Cited by
- supports In PCOS, a polycystic ovary appearance on ultrasound is characterized by seeing 20 or more follicles arranged in a 'string of pearls' pattern.