The Role of Sonographic Markers of Ovarian Morphology Versus Hirsutism Indices in the Prediction of Serum Total Testosterone in Hirsute Women

Conclusion: Sonographic markers particularly ovarian dimensions, ovarian volume, ovarian area, stromal echogenicity and ovarian echogenicity are good predictors of total testosterone levels in women with hirsutism whether having regular or irregular menstrual cycles. They are better predictor of total testosterone levels than other Sonographic markers namely number of follicles of different sizes , stroma to ovary ratio and stromal echogenicity index. They are much more sensitive predictors of total testosterone than hirsutism scores whether regional or total scores.

Male-pattern hair growth is the most commonly accepted clinical indicator of androgen status (Azziz, R., et al., 2004). A typical hair growth is commonly quantified using the modified Ferriman-Gallwey (mFG) scoring system, which rates hair growth on nine androgen-sensitive regions of the body using a 0-4 scale (Ferriman, D. and Gallwey, J.D., 1961). The utility of all nine regions in the prediction of androgen excess remains a topic of debate (Api, M., et al., 2009 andCook, H., et al., 2011). This notion has merit because a more focused approach involving a subset of regions with the greatest sensitivity to androgen levels could help to obviate some of the subjectivity associated with hirsutism scoring (Derksen, J., et al., 1993 andHines, G.,et al 2001). Uncertainty in the utility of hirsutism scores stems from findings of poor agreement in hirsutism scores (Clark, N.M et al., 2014 andKiddy, D.S et al., 1990), as well as the known influence of age (Rashidi, H et al., 2013), race and ethnicity (Escobar-Morreale, H.F et al., 2012 andJavorsky, E et al., 2014 ), and adiposity (Clark, N.M et al., 2014 andKiddy, D.S et al., 1990)) on male-pattern hair growth. Although hirsutism has shown better sensitivity for biochemical hyperandrogenism compared with acne or alopecia (Azziz, R., 2003 andKarrer-Voegeli, S.,et al., 2009), its specificity is low because idiopathic hirsutism occurs in 5%-15% of the general population  and in up to 50% of all mild hirsutism cases studied (Reingold, S.B. and Rosenfield, R.L., 1987). The advent of more standardized approaches to measure serum androgens provides an opportunity to revisit the utility of hirsutism scores to reflect androgen levels.
In view of the improved resolution afforded by the latest imaging systems (Jayaprakasan, K., et al., 2008, Lujan, M.E., et al., 2010and Lujan, M.E et al., 2008, there is growing evidence supporting an expanded role for ovarian ultrasonography in the clinical evaluation of androgen excess (Christ, J.P., et al., 2014) .
The objective of this study was to assess the ability of sonographic markers of ovarian morphology versus mFG scores to predict total testosterone (T) levels in women. In this study, we enrolled women with hirsutism and then divide them regarding to their cycle regularity to assess any impact of menstrual cycle status on these relationships. We tried to test the hypnosis whether sonographic markers or hirsutism indices would be more predictive to the testosterone levels in hirsute women.  Table (2) shows the correlation between hirsutism scores and total testosterone of study participants with regular and irregular menstrual cycles. There were no correlation between any of the hirsutism score and total testosterone of study participants with regular and irregular menstrual cycles.  Table (3) shows the correlation between sonographic markers and total testosterone of study participants with regular and irregular menstrual cycles. There were correlations between ovarian dimensions, ovarian volume, ovarian area, stromal echogenicity and ovarian echogenicity and total testosterone in both groups. However, there were no correlations between 2-5 FNPO, 6-9 FNPO and 2-9 FNPO, stroma to ovary ratio & stromal echogenicity index and total Testosterone in both groups There were correlation between the three ovarian dimensions, ovarian volume, Ovarian Area, stromal echogenicity and ovarian echogenicity and Total Testosterone. However, there were no correlations between 2-5 mm FNPO, 6-9 mm FNPO, 2-9 mm FNPO, stroma to ovary ratio & stromal echogenicity index and Total Testosterone.

Discussion
In this current Study, there were no correlation between any of the demographic characteristics in either of the regular and irregular cycle and Total Testosterone. These findings are in accordance with those of Vanden  Brink H, et al., 2016, who did not find any correlation between age, weight, height, body mass index and total testosterone level in their study participants.
In this current study, there were no correlation between any of the Hirsutism score and total testosterone of study participants with regular and irregular menstrual cycles. The findings regarding this issue are very In this current Study, There were no correlations between Hirsutism scores and Total Testosterone of all study participants. However, there were some association between Hirsutism scores (upper lip, chin and lower abdomen (r of ≥ 0.3 ‹ 0.5). These findings are in agreement with those of Vanden Brink H, et al., 2016who noted that regional mFG scores were more predictive of total testosterone compared to the total mFG score. However, neither regional nor total mFG scores predicted total testosterone to any significant degree in either women with regular or irregular menstrual cycles. Our results are not completely in agreement with Api, M, et al., 2009 who concluded that the mFG scoring system was found to be clinically useful and the upper lip was observed to have the highest score of androgen sensitive area of the body as well as the highest inter-observer variability and that the cut-off value to establish the diagnosis of hirsutism should be population-specific. Also, our results are not completely in agreement with Rashidi H. et al., 2013 who concluded that evaluating terminal hair growth on chin or lower abdomen for predicting hirsutism seems to be an acceptable screening method.

The Role of Sonographic Markers of Ovarian Morphology Versus Hirsutism Indices in the Prediction of Serum Total Testosterone in Hirsute Women
In this current Study, There were correlation between the three ovarian dimensions, ovarian volume, ovarian area, stromal echogenicity and ovarian echogenicity in all study participants and Total Testosterone. However, there were no correlations between 2-5 mm FNPO, 6-9 mm FNPO, 2-9 mm FNPO, stroma to ovary ratio & stromal echogenicity ratio index and Total Testosterone. Our results were not in agreement with those of Fulghesu A.M., et al., 2007, who reported that Stroma to ovary ratio was found to be the best significant predictor of elevated Testosterone level. However, our results are more in agreement with those of Vanden Brink H, et al., 2016who concluded that sonographic markers may serve as a clinical biomarker for androgen status in instances where access to high-performance assays is more limited. The ability of ovarian morphology to predict total testosterone levels was modified by menstrual cycle status and that their findings support the use of ultrasonography as a potentially informative tool in the detection of hyperandrogenemia in women with regular menstrual cycles, where other clinical indicators of androgen excess may not necessarily be present.