text:
Nana suddenly disappeared. It
was a fresh plunge, an escapade, a flight into barbarous
regions. Before her departure she had treated
herself to a new sensation: she had held a sale
and had made a clean sweep of everything house,
furniture, jewelry, nay, even dresses and linen.
Prices were cited the five days' sale
produced more than six hundred thousand francs.
For the last time Paris had seen her in a fairy piece.
It was called Mélusine, and it played at the Theatre
de la Gaite, which the penniless Bordenave had taken
out of sheer audacity. Here she again found herself
in company with Prulliere and Fontan. Her part
was simply spectacular, but it was the great attraction
of the piece, consisting, as it did, of three poses
PLASTIQUES, each of which represented the same dumb
and puissant fairy. Then one fine morning amid
his grand success, when Bordenave, who was mad after
advertisement, kept firing the Parisian imagination
with colossal posters, it became known that she must
have started for Cairo the previous day. She had
simply had a few words with her manager. Something
had been said which did not please her; the whole
thing was the caprice of a woman who is too rich to
let herself be annoyed. Besides, she had indulged
an old infatuation, for she had long meditated visiting
the Turks.
Months passed she began
to be forgotten. When her name was mentioned
among the ladies and gentlemen, the strangest stories
were told, and everybody gave the most contradictory
and at the same time prodigious information.
She had made a conquest of the viceroy; she was reigning,
in the recesses of a palace, over two hundred slaves
whose heads she now and then cut off for the sake
of a little amusement. No, not at all! She
had ruined herself with a great big nigger! A
filthy passion this, which had left her wallowing
without a chemise to her back in the crapulous debauchery
of Cairo. A fortnight later much astonishment
was produced when someone swore to having met her
in Russia. A legend began to be formed:
she was the mistress of a prince, and her diamonds
were mentioned. All the women were soon acquainted
with them from the current descriptions, but nobody
could cite the precise source of all this information.
There were finger rings, earrings, bracelets, a REVIERE
of phenomenal width, a queenly diadem surmounted by
a central brilliant the size of one's thumb.
In the retirement of those faraway countries she began
to gleam forth as mysteriously as a gem-laden idol.
People now mentioned her without laughing, for they
were full of meditative respect for this fortune acquired
among the barbarians.
One evening in July toward eight o'clock,
Lucy, while getting out of her carriage in the Rue
du Faubourg Saint-Honore, noticed Caroline Hequet,
who had come out on foot to order something at a neighboring
tradesman's. Lucy called her and at once
burst out with:
"Have you dined? Are you
disengaged? Oh, then come with me, my dear.
Nana's back."
The other got in at once, and Lucy continued:
"And you know, my dear, she may be dead while
we're gossiping."
"Dead! What an idea!"
cried Caroline in stupefaction. "And where
is she? And what's it of?"
"At the Grand Hotel, of smallpox. Oh, it's
a long story!"
Lucy had bidden her coachman drive
fast, and while the horses trotted rapidly along the
Rue Royale and the boulevards, she told what
had happened to Nana in jerky, breathless sentences.
"You can't imagine it.
Nana plumps down out of Russia. I don't
know why some dispute with her prince.
She leaves her traps at the station; she lands at
her aunt's you remember the old thing.
Well, and then she finds her baby dying of smallpox.
The baby dies next day, and she has a row with the
aunt about some money she ought to have sent, of which
the other one has never seen a sou. Seems the
child died of that: in fact, it was neglected
and badly cared for. Very well; Nana slopes, goes
to a hotel, then meets Mignon just as she was thinking
of her traps. She has all sorts of queer feelings,
shivers, wants to be sick, and Mignon takes her back
to her place and promises to look after her affairs.
Isn't it odd, eh? Doesn't it all
happen pat? But this is the best part of the
story: Rose finds out about Nana's illness
and gets indignant at the idea of her being alone
in furnished apartments. So she rushes off, crying,
to look after her. You remember how they used
to detest one another like regular furies!
Well then, my dear, Rose has had Nana transported
to the Grand Hotel, so that she should, at any rate,
die in a smart place, and now she's already
passed three nights there and is free to die of it
after. It's Labordette who told me all about
it. Accordingly I wanted to see for myself "
"Yes, yes," interrupted
Caroline in great excitement "We'll go
up to her."
They had arrived at their destination.
On the boulevard the coachman had had to rein in his
horses amid a block of carriages and people on foot.
During the day the Corps Legislatif had voted for war,
and now a crowd was streaming down all the streets,
flowing along all the pavements, invading the middle
of the roadway. Beyond the Madeleine the sun had
set behind a blood-red cloud, which cast a reflection
as of a great fire and set the lofty windows flaming.
Twilight was falling, and the hour was oppressively
melancholy, for now the avenues were darkening away
into the distance but were not as yet dotted over
by the bright sparks of the gas lamps. And among
the marching crowds distant voices swelled and grew
ever louder, and eyes gleamed from pale faces, while
a great spreading wind of anguish and stupor set every
head whirling.
"Here's Mignon," said Lucy.
"He'll give us news."
Mignon was standing under the vast
porch of the Grand Hotel. He looked nervous and
was gazing at the crowd. After Lucy's first
few questions he grew impatient and cried out:
"How should I know? These
last two days I haven't been able to tear Rose
away from up there. It's getting stupid,
when all's said, for her to be risking her life
like that! She'll be charming if she gets
over it, with holes in her face! It'll
suit us to a tee!"
The idea that Rose might lose her
beauty was exasperating him. He was giving up
Nana in the most downright fashion, and he could not
in the least understand these stupid feminine devotions.
But Fauchery was crossing the boulevard, and he, too,
came up anxiously and asked for news. The two
men egged each other on. They addressed one another
familiarly in these days.
"Always the same business, my
sonny," declared Mignon. "You ought
to go upstairs; you would force her to follow you."
"Come now, you're kind,
you are!" said the journalist. "Why
don't you go upstairs yourself?"
Then as Lucy began asking for Nana's
number, they besought her to make Rose come down;
otherwise they would end by getting angry.
Nevertheless, Lucy and Caroline did
not go up at once. They had caught sight of Fontan
strolling about with his hands in his pockets and
greatly amused by the quaint expressions of the mob.
When he became aware that Nana was lying ill upstairs
he affected sentiment and remarked:
"The poor girl! I'll
go and shake her by the hand. What's the
matter with her, eh?"
"Smallpox," replied Mignon.
The actor had already taken a step
or two in the direction of the court, but he came
back and simply murmured with a shiver:
"Oh, damn it!"
The smallpox was no joke. Fontan
had been near having it when he was five years old,
while Mignon gave them an account of one of his nieces
who had died of it. As to Fauchery, he could speak
of it from personal experience, for he still bore
marks of it in the shape of three little lumps at
the base of his nose, which he showed them. And
when Mignon again egged him on to the ascent, on the
pretext that you never had it twice, he violently
combated this theory and with infinite abuse of the
doctors instanced various cases. But Lucy and
Caroline interrupted them, for the growing multitude
filled them with astonishment.
"Just look! Just look what
a lot of people!" The night was deepening, and
in the distance the gas lamps were being lit one by
one. Meanwhile interested spectators became visible
at windows, while under the trees the human flood
grew every minute more dense, till it ran in one enormous
stream from the Madeleine to the Bastille. Carriages
rolled slowly along. A roaring sound went up
from this compact and as yet inarticulate mass.
Each member of it had come out, impelled by the desire
to form a crowd, and was now trampling along, steeping
himself in the pervading fever. But a great movement
caused the mob to flow asunder. Among the jostling,
scattering groups a band of men in workmen's
caps and white blouses had come in sight, uttering
a rhythmical cry which suggested the beat of hammers
upon an anvil.
"To Ber-lin!
To Ber-lin! To Ber-lin!"
And the crowd stared in gloomy distrust yet felt themselves
already possessed and inspired by heroic imaginings,
as though a military band were passing.
"Oh yes, go and get your throats
cut!" muttered Mignon, overcome by an access
of philosophy.
But Fontan thought it very fine, indeed,
and spoke of enlisting. When the enemy was on
the frontier all citizens ought to rise up in defense
of the fatherland! And with that he assumed an
attitude suggestive of Bonaparte at Austerlitz.
"Look here, are you coming up with us?"
Lucy asked him.
"Oh dear, no! To catch something horrid?"
he said.
On a bench in front of the Grand Hotel
a man sat hiding his face in a handkerchief.
On arriving Fauchery had indicated him to Mignon with
a wink of the eye. Well, he was still there;
yes, he was always there. And the journalist
detained the two women also in order to point him out
to them. When the man lifted his head they recognized
him; an exclamation escaped them. It was the
Count Muffat, and he was giving an upward glance at
one of the windows.
"You know, he's been waiting
there since this morning," Mignon informed them.
"I saw him at six o'clock, and he hasn't
moved since. Directly Labordette spoke about
it he came there with his handkerchief up to his face.
Every half-hour he comes dragging himself to where
we're standing to ask if the person upstairs
is doing better, and then he goes back and sits down.
Hang it, that room isn't healthy! It's
all very well being fond of people, but one doesn't
want to kick the bucket."
The count sat with uplifted eyes and
did not seem conscious of what was going on around
him. Doubtless he was ignorant of the declaration
of war, and he neither felt nor saw the crowd.
"Look, here he comes!" said Fauchery.
"Now you'll see."
The count had, in fact, quitted his
bench and was entering the lofty porch. But the
porter, who was getting to know his face at last, did
not give him time to put his question. He said
"She's dead, monsieur, this very minute."
Nana dead! It was a blow to them
all. Without a word Muffat had gone back to the
bench, his face still buried in his handkerchief.
The others burst into exclamations, but they were
cut short, for a fresh band passed by, howling, "A
Berlin! A Berlin! A Berlin!"
Nana dead! Hang it, and such a fine girl too!
Mignon sighed and looked relieved, for at last Rose
would come down. A chill fell on the company.
Fontan, meditating a tragic rôle, had assumed a look
of woe and was drawing down the corners of his mouth
and rolling his eyes askance, while Fauchery chewed
his cigar nervously, for despite his cheap journalistic
chaff he was really touched. Nevertheless, the
two women continued to give vent to their feelings
of surprise. The last time Lucy had seen her was
at the Gaite; Blanche, too, had seen her in Mélusine.
Oh, how stunning it was, my dear, when she appeared
in the depths of the crystal grot! The gentlemen
remembered the occasion perfectly. Fontan had
played the Prince Cocorico. And their
memories once stirred up, they launched into interminable
particulars. How ripping she looked with that
rich coloring of hers in the crystal grot! Didn't
she, now? She didn't say a word: the
authors had even deprived her of a line or two, because
it was superfluous. No, never a word! It
was grander that way, and she drove her public wild
by simply showing herself. You wouldn't
find another body like hers! Such shoulders as
she had, and such legs and such a figure! Strange
that she should be dead! You know, above her tights
she had nothing on but a golden girdle which hardly
concealed her behind and in front. All round
her the grotto, which was entirely of glass, shone
like day. Cascades of diamonds were flowing down;
strings of brilliant pearls glistened among the stalactites
in the vault overhead, and amid the transparent atmosphere
and flowing fountain water, which was crossed by a
wide ray of electric light, she gleamed like the sun
with that flamelike skin and hair of hers. Paris
would always picture her thus would see
her shining high up among crystal glass like the good
God Himself. No, it was too stupid to let herself
die under such conditions! She must be looking
pretty by this time in that room up there!
"And what a lot of pleasures
bloody well wasted!" said Mignon in melancholy
tones, as became a man who did not like to see good
and useful things lost.
He sounded Lucy and Caroline in order
to find out if they were going up after all.
Of course they were going up; their curiosity had increased.
Just then Blanche arrived, out of breath and much exasperated
at the way the crowds were blocking the pavement,
and when she heard the news there was a fresh outburst
of exclamations, and with a great rustling of skirts
the ladies moved toward the staircase. Mignon
followed them, crying out:
"Tell Rose that I'm waiting
for her. She'll come at once, eh?"
"They do not exactly know whether
the contagion is to be feared at the beginning or
near the end," Fontan was explaining to Fauchery.
"A medical I know was assuring me that the hours
immediately following death are particularly dangerous.
There are miasmatic exhalations then. Ah, but
I do regret this sudden ending; I should have been
so glad to shake hands with her for the last time.
"What good would it do you now?" said
the journalist.
"Yes, what good?" the two others repeated.
The crowd was still on the increase.
In the bright light thrown from shop-windows and beneath
the wavering glare of the gas two living streams were
distinguishable as they flowed along the pavement,
innumerable hats apparently drifting on their surface.
At that hour the popular fever was gaining ground
rapidly, and people were flinging themselves in the
wake of the bands of men in blouses. A constant
forward movement seemed to sweep the roadway, and the
cry kept recurring; obstinately, abruptly, there rang
from thousands of throats:
"A Berlin! A Berlin! A Berlin!"
The room on the fourth floor upstairs
cost twelve francs a day, since Rose had wanted something
decent and yet not luxurious, for sumptuousness is
not necessary when one is suffering. Hung with
Louis XIII cretonne, which was adorned with a pattern
of large flowers, the room was furnished with the
mahogany commonly found in hotels. On the floor
there was a red carpet variegated with black foliage.
Heavy silence reigned save for an occasional whispering
sound caused by voices in the corridor.
"I assure you we're lost.
The waiter told us to turn to the right. What
a barrack of a house!"
"Wait a bit; we must have a
look. Room number 401; room number 401!"
"Oh, it's this way:
405, 403. We ought to be there. Ah, at last,
401! This way! Hush now, hush!"
The voices were silent. Then
there was a slight coughing and a moment or so of
mental preparation. Then the door opened slowly,
and Lucy entered, followed by Caroline and Blanche.
But they stopped directly; there were already five
women in the room; Gaga was lying back in the solitary
armchair, which was a red velvet Voltaire. In
front of the fireplace Simonne and Clarisse were now
standing talking to Lea de Horn, who was seated, while
by the bed, to the left of the door, Rose Mignon, perched
on the edge of a chest, sat gazing fixedly at the body
where it lay hidden in the shadow of the curtains.
All the others had their hats and gloves on and looked
as if they were paying a call: she alone sat there
with bare hands and untidy hair and cheeks rendered
pale by three nights of watching. She felt stupid
in the face of this sudden death, and her eyes were
swollen with weeping. A shaded lamp standing on
the corner of the chest of drawers threw a bright
flood of light over Gaga.
"What a sad misfortune, is it
not?" whispered Lucy as she shook hands with
Rose. "We wanted to bid her good-by."
And she turned round and tried to
catch sight of her, but the lamp was too far off,
and she did not dare bring it nearer. On the bed
lay stretched a gray mass, but only the ruddy chignon
was distinguishable and a pale blotch which might
be the face. Lucy added:
"I never saw her since that
time at the Gaite, when she was at the end of the
At this Rose awoke from her stupor
and smiled as she said:
"Ah, she's changed; she's changed."
Then she once more lapsed into contemplation
and neither moved nor spoke. Perhaps they would
be able to look at her presently! And with that
the three women joined the others in front of the fireplace.
Simonne and Clarisse were discussing the dead woman's
diamonds in low tones. Well, did they really
exist those diamonds? Nobody had seen
them; it must be a bit of humbug. But Lea de Horn
knew someone who knew all about them. Oh, they
were monster stones! Besides, they weren't
all; she had brought back lots of other precious property
from Russia embroidered stuffs, for instance,
valuable knickknacks, a gold dinner service, nay,
even furniture. "Yes, my dear, fifty-two
boxes, enormous cases some of them, three truckloads
of them!" They were all lying at the station.
"Wasn't it hard lines, eh? to
die without even having time to unpack one's
traps?" Then she had a lot of tin, besides something
like a million! Lucy asked who was going to inherit
it all. Oh, distant relations the aunt,
without doubt! It would be a pretty surprise
for that old body. She knew nothing about it yet,
for the sick woman had obstinately refused to let
them warn her, for she still owed her a grudge over
her little boy's death. Thereupon they were
all moved to pity about the little boy, and they remembered
seeing him at the races. Oh, it was a wretchedly
sickly baby; it looked so old and so sad. In
fact, it was one of those poor brats who never asked
to be born!
"He's happier under the ground,"
said Blanche.
"Bah, and so's she!" added Caroline.
"Life isn't so funny!"
In that gloomy room melancholy ideas
began to take possession of their imaginations.
They felt frightened. It was silly to stand talking
so long, but a longing to see her kept them rooted
to the spot. It was very hot the lamp
glass threw a round, moonlike patch of light upon the
ceiling, but the rest of the room was drowned in steamy
darkness. Under the bed a deep plate full of
phenol exhaled an insipid smell. And every few
moments tiny gusts of wind swelled the window curtains.
The window opened on the boulevard, whence rose a
dull roaring sound.
"Did she suffer much?"
asked Lucy, who was absorbed in contemplation of the
clock, the design of which represented the three Graces
as nude young women, smiling like opera dancers.
Gaga seemed to wake up.
"My word, yes! I was present
when she died. I promise you it was not at all
pleasant to see. Why, she was taken with a shuddering
fit "
But she was unable to proceed with
her explanation, for a cry arose outside:
And Lucy, who felt suffocated, flung
wide the window and leaned upon the sill. It
was pleasant there; the air came fresh from the starry
sky. Opposite her the windows were all aglow
with light, and the gas sent dancing reflections over
the gilt lettering of the shop signs.
Beneath these, again, a most amusing
scene presented itself. The streams of people
were discernible rolling torrentwise along the sidewalks
and in the roadway, where there was a confused procession
of carriages. Everywhere there were vast moving
shadows in which lanterns and lampposts gleamed like
sparks. But the band which now came roaring by
carried torches, and a red glow streamed down from
the direction of the Madeleine, crossed the mob like
a trail of fire and spread out over the heads in the
distance like a vivid reflection of a burning house.
Lucy called Blanche and Caroline, forgetting where
she was and shouting:
"Do come! You get a capital view from this
They all three leaned out, greatly
interested. The trees got in their way, and occasionally
the torches disappeared under the foliage. They
tried to catch a glimpse of the men of their own party
below, but a protruding balcony hid the door, and
they could only make out Count Muffat, who looked
like a dark parcel thrown down on the bench where he
sat. He was still burying his face in his handkerchief.
A carriage had stopped in front, and yet another woman
hurried up, in whom Lucy recognized Maria Blond.
She was not alone; a stout man got down after her.
"It's that thief of a
Steiner," said Caroline. "How is it
they haven't sent him back to Cologne yet?
I want to see how he looks when he comes in."
They turned round, but when after
the lapse of ten minutes Maria Blond appeared, she
was alone. She had twice mistaken the staircase.
And when Lucy, in some astonishment, questioned her:
"What, he?" she said.
"My dear, don't you go fancying that he'll
come upstairs! It's a great wonder he's
escorted me as far as the door. There are nearly
a dozen of them smoking cigars."
As a matter of fact, all the gentlemen
were meeting downstairs. They had come strolling
thither in order to have a look at the boulevards,
and they hailed one another and commented loudly on
that poor girl's death. Then they began
discussing politics and strategy. Bordenave, Daguenet,
Labordette, Prulliere and others, besides, had swollen
the group, and now they were all listening to Fontan,
who was explaining his plan for taking Berlin within
a week.
Meanwhile Maria Blond was touched
as she stood by the bedside and murmured, as the others
had done before her:
"Poor pet! The last time
I saw her was in the grotto at the Gaite."
"Ah, she's changed; she's
changed!" Rose Mignon repeated with a smile of
gloomiest dejection.
Two more women arrived. These
were Tatan Nene and Louise Violaine. They had
been wandering about the Grand Hotel for twenty minutes
past, bandied from waiter to waiter, and had ascended
and descended more than thirty flights of stairs amid
a perfect stampede of travelers who were hurrying
to leave Paris amid the panic caused by the war and
the excitement on the boulevards. Accordingly
they just dropped down on chairs when they came in,
for they were too tired to think about the dead.
At that moment a loud noise came from the room next
door, where people were pushing trunks about and striking
against furniture to an accompaniment of strident,
outlandish syllables. It was a young Austrian
couple, and Gaga told how during her agony the neighbors
had played a game of catch as catch can and how, as
only an unused door divided the two rooms, they had
heard them laughing and kissing when one or the other
was caught.
"Come, it's time we were
off," said Clarisse. "We shan't
bring her to life again. Are you coming, Simonne?"
They all looked at the bed out of
the corners of their eyes, but they did not budge
an inch. Nevertheless, they began getting ready
and gave their skirts various little pats. Lucy
was again leaning out of window. She was alone
now, and a sorrowful feeling began little by little
to overpower her, as though an intense wave of melancholy
had mounted up from the howling mob. Torches
still kept passing, shaking out clouds of sparks,
and far away in the distance the various bands stretched
into the shadows, surging unquietly to and fro like
flocks being driven to the slaughterhouse at night.
A dizzy feeling emanated from these confused masses
as the human flood rolled them along a dizzy
feeling, a sense of terror and all the pity of the
massacres to come. The people were going wild;
their voices broke; they were drunk with a fever of
excitement which sent them rushing toward the unknown
"out there" beyond the dark wall of the
Lucy turned round. She leaned
her back against the window, and her face was very
"Good God! What's to become of us?"
The ladies shook their heads.
They were serious and very anxious about the turn
events were taking.
"For my part," said Caroline
Hequet in her decisive way, "I start for London
the day after tomorrow. Mamma's already
over there getting a house ready for me. I'm
certainly not going to let myself be massacred in
Her mother, as became a prudent woman,
had invested all her daughters' money in foreign
lands. One never knows how a war may end!
But Maria Blond grew vexed at this. She was a
patriot and spoke of following the army.
"There's a coward for
you! Yes, if they wanted me I should put on man's
clothes just to have a good shot at those pigs of Prussians!
And if we all die after? What of that? Our
wretched skins aren't so valuable!"
Blanche de Sivry was exasperated.
"Please don't speak ill
of the Prussians! They are just like other men,
and they're not always running after the women,
like your Frenchmen. They've just expelled
the little Prussian who was with me. He was an
awfully rich fellow and so gentle: he couldn't
have hurt a soul. It's disgraceful; I'm
ruined by it. And, you know, you mustn't
say a word or I go and find him out in Germany!"
After that, while the two were at
loggerheads, Gaga began murmuring in dolorous tones:
"It's all over with me;
my luck's always bad. It's only a
week ago that I finished paying for my little house
at Juvisy. Ah, God knows what trouble it cost
me! I had to go to Lili for help! And now
here's the war declared, and the Prussians'll
come and they'll burn everything. How am
I to begin again at my time of life, I should like
to know?"
"Bah!" said Clarisse.
"I don't care a damn about it. I shall
always find what I want."
"Certainly you will,"
added Simonne. "It'll be a joke.
Perhaps, after all, it'll be good biz."
And her smile hinted what she thought.
Tatan Nene and Louise Violaine were of her opinion.
The former told them that she had enjoyed the most
roaring jolly good times with soldiers. Oh, they
were good fellows and would have done any mortal thing
for the girls. But as the ladies had raised their
voices unduly Rose Mignon, still sitting on the chest
by the bed, silenced them with a softly whispered
"Hush!" They stood quite still at this
and glanced obliquely toward the dead woman, as though
this request for silence had emanated from the very
shadows of the curtains. In the heavy, peaceful
stillness which ensued, a void, deathly stillness
which made them conscious of the stiff dead body lying
stretched close by them, the cries of the mob burst
But soon they forgot. Lea de
Horn, who had a political salon where former ministers
of Louis Philippe were wont to indulge in delicate
epigrams, shrugged her shoulders and continued the
conversation in a low tone:
"What a mistake this war is!
What a bloodthirsty piece of stupidity!"
At this Lucy forthwith took up the
cudgels for the empire. She had been the mistress
of a prince of the imperial house, and its defense
became a point of family honor with her.
"Do leave them alone, my dear.
We couldn't let ourselves be further insulted!
Why, this war concerns the honor of France. Oh,
you know I don't say that because of the prince.
He was just mean! Just imagine, at night
when he was going to bed he hid his gold in his boots,
and when we played at bezique he used beans, because
one day I pounced down on the stakes for fun.
But that doesn't prevent my being fair.
The emperor was right."
Lea shook her head with an air of
superiority, as became a woman who was repeating the
opinions of important personages. Then raising
her voice:
"This is the end of all things.
They're out of their minds at the Tuileries.
France ought to have driven them out yesterday.
Don't you see?"
They all violently interrupted her.
What was up with her? Was she mad about the emperor?
Were people not happy? Was business doing badly?
Paris would never enjoy itself so thoroughly again.
Gaga was beside herself; she woke
up and was very indignant.
"Be quiet! It's idiotic!
You don't know what you're saying.
I I've seen Louis Philippe's
reign: it was full of beggars and misers, my dear.
And then came '48! Oh, it was a pretty disgusting
business was their republic! After February I
was simply dying of starvation yes, I, Gaga.
Oh, if only you'd been through it all you would
go down on your knees before the emperor, for he's
been a father to us; yes, a father to us."
She had to be soothed but continued with pious fervor:
"O my God, do Thy best to give
the emperor the victory. Preserve the empire
to us!"
They all repeated this aspiration,
and Blanche confessed that she burned candles for
the emperor. Caroline had been smitten by him
and for two whole months had walked where he was likely
to pass but had failed to attract his attention.
And with that the others burst forth into furious
denunciations of the Republicans and talked of exterminating
them on the frontiers so that Napoleon III, after
having beaten the enemy, might reign peacefully amid
universal enjoyment.
"That dirty Bismarck there's
another cad for you!" Maria Blond remarked.
"To think that I should have
known him!" cried Simonne. "If only
I could have foreseen, I'm the one that would
have put some poison in his glass."
But Blanche, on whose heart the expulsion
of her Prussian still weighed, ventured to defend
Bismarck. Perhaps he wasn't such a bad sort.
To every man his trade!
"You know," she added, "he adores
"What the hell has that got
to do with us?" said Clarisse. "We
don't want to cuddle him, eh?"
"There's always too many
men of that sort!" declared Louise Violaine
gravely. "It's better to do without
'em than to mix oneself up with such monsters!"
And the discussion continued, and
they stripped Bismarck, and, in her Bonapartist zeal,
each of them gave him a sounding kick, while Tatan
Nene kept saying:
"Bismarck! Why, they've
simply driven me crazy with the chap! Oh, I hate
him! I didn't know that there Bismarck!
One can't know everybody."
"Never mind," said Lea
de Horn by way of conclusion, "that Bismarck
will give us a jolly good threshing."
But she could not continue. The
ladies were all down on her at once. Eh, what?
A threshing? It was Bismarck they were going to
escort home with blows from the butt ends of their
muskets. What was this bad Frenchwoman going
to say next?
"Hush," whispered Rose, for so much noise
hurt her.
The cold influence of the corpse once
more overcame them, and they all paused together.
They were embarrassed; the dead woman was before them
again; a dull thread of coming ill possessed them.
On the boulevard the cry was passing, hoarse and wild:
Presently, when they were making up
their minds to go, a voice was heard calling from
the passage:
"Rose! Rose!"
Gaga opened the door in astonishment
and disappeared for a moment. When she returned:
"My dear," she said, "it's
Fauchery. He's out there at the end of the
corridor. He won't come any further, and
he's beside himself because you still stay near
that body."
Mignon had at last succeeded in urging
the journalist upstairs. Lucy, who was still
at the window, leaned out and caught sight of the
gentlemen out on the pavement. They were looking
up, making energetic signals to her. Mignon was
shaking his fists in exasperation, and Steiner, Fontan,
Bordenave and the rest were stretching out their arms
with looks of anxious reproach, while Daguenet simply
stood smoking a cigar with his hands behind his back,
so as not to compromise himself.
"It's true, dear,"
said Lucy, leaving the window open; "I promised
to make you come down. They're all calling
us now."
Rose slowly and painfully left the chest.
"I'm coming down; I'm
coming down," she whispered. "It's
very certain she no longer needs me. They're
going to send in a Sister of Mercy."
And she turned round, searching for
her hat and shawl. Mechanically she filled a
basin of water on the toilet table and while washing
her hands and face continued:
"I don't know! It's
been a great blow to me. We used scarcely to be
nice to one another. Ah well! You see I'm
quite silly over it now. Oh! I've
got all sorts of strange ideas I want to
die myself I feel the end of the world's
coming. Yes, I need air."
The corpse was beginning to poison
the atmosphere of the room. And after long heedlessness
there ensued a panic.
"Let's be off; let's
be off, my little pets!" Gaga kept saying.
"It isn't wholesome here."
They went briskly out, casting a last
glance at the bed as they passed it. But while
Lucy, Blanche and Caroline still remained behind, Rose
gave a final look round, for she wanted to leave the
room in order. She drew a curtain across the
window, and then it occurred to her that the lamp
was not the proper thing and that a taper should take
its place. So she lit one of the copper candelabra
on the chimney piece and placed it on the night table
beside the corpse. A brilliant light suddenly
illumined the dead woman's face. The women
were horror-struck. They shuddered and escaped.
"Ah, she's changed; she's
changed!" murmured Rose Mignon, who was the
last to remain.
She went away; she shut the door.
Nana was left alone with upturned face in the light
cast by the candle. She was fruit of the charnel
house, a heap of matter and blood, a shovelful of
corrupted flesh thrown down on the pillow. The
pustules had invaded the whole of the face, so that
each touched its neighbor. Fading and sunken,
they had assumed the grayish hue of mud; and on that
formless pulp, where the features had ceased to be
traceable, they already resembled some decaying damp
from the grave. One eye, the left eye, had completely
foundered among bubbling purulence, and the other,
which remained half open, looked like a deep, black,
ruinous hole. The nose was still suppurating.
Quite a reddish crush was peeling from one of the
cheeks and invading the mouth, which it distorted
into a horrible grin. And over this loathsome
and grotesque mask of death the hair, the beautiful
hair, still blazed like sunlight and flowed downward
in rippling gold. Venus was rotting. It seemed
as though the poison she had assimilated in the gutters
and on the carrion tolerated by the roadside, the
leaven with which she had poisoned a whole people,
had but now remounted to her face and turned it to
The room was empty. A great despairing
breath came up from the boulevard and swelled the


text:
Walking into the Chopin Theatre to attend a performance of Theatre Y's Macbeth is a bit of a trip. In addition to the Scottish Play, the Chopin is currently home to a production of The Nutcracker, that family-friendly holiday classic. In keeping with The Nutcracker's holiday theme, the lobby of the Chopin is decorated in ribbons, glitter, and evergreens for Christmas; when I arrived on the Friday after Election Day, the pleasant pop tones of the Jackson 5 Christmas Album floated through the lobby's festive air. Amid all of this holiday cheer, though, was a prominent display covered in dripping blood to advertise Theatre Y's Macbeth.
That audience members must walk through a dizzying Christmas scene to enter the dark black-box theater where Macbeth is being staged may amount to nothing more than a scheduling coincidence, but the resulting sense of cognitive dissonance perfectly matches Theatre Y's disorientating take on Shakespeare's Scottish Play. The product of a yearlong collaboration between Theatre Y's independent, mission-driven company and French theater luminary Georges Bigot, this Macbeth imagines Shakespeare's bloody tragedy as a surreal nightmare. Amplifying the text's major themes—How do we know what we know? Can we trust our own senses? Are we in charge of our actions, or is control an illusion?—the production offers a deliberately "non-realist" take on the play that fundamentally blurs kitsch and high art, comedy and tragedy, audience and actor.
The play begins, of course, with witches. In this production, these three sisters are truly weird. They add substantially to the sense of unreality, of time out of place. As a spectator, it is difficult to know whether one is meant to laugh at them or cower in fear. They roar and screech and twist their bodies into unnatural shapes, but also dance flirtatiously to a doo-wop tune while displaying their bodies provocatively—for in a nod to Europe's radical FEMEN activists, these witches appear nearly nude from the waist up. They wear bikini tops that reveal female symbols painted across their torsos (at the post-election performance I attended, the word "nasty" was scrawled across the ribs of one weird sister). Like members of FEMEN, though, these women expose their bodies not to entice but to terrify men. They wear sloppy cut-off jean shorts and long, unkempt hair that they gleefully twist across their chins into beards when Banquo insults their looks.
In Act 1, one of the witches is heavily pregnant, making it all the more shocking when she smears blood across her mouth and body. When the weird sisters reappear in Act 4, she has evidently delivered the pregnancy, signaling the "delivery" of Macbeth's malevolent ambition into the world. In a horrifying parody of maternity, the witches in this act proceed to use a baby carriage as a cauldron in which they stew such ingredients as the "maw and gulf / Of the ravin'd sea-salt shark," the "liver of a blaspheming Jew," and the "finger of a birth-strangled babe / Ditch-deliver'd by a drab." They take turns showing their "apparitions" to the increasingly desperate and violent Macbeth in this carriage-cauldron, thrusting pagan statues puppet-like out from under the pram's bonnet and ventriloquizing them in voices that are alternately silly and scary. The confused combination of Halloween horror-kitsch, aggressive sexuality, twisted violence, and total unpredictability makes these witches all the more frightening—and advances the disorienting atmosphere that infuses the whole play.
The production further amplifies its sense of nightmarish unreality by conscripting the audience into the performance, framing the viewer not only as a participant in the play, but also as responsible for its outcome. While the performers do interact physically and verbally, acting out Macbeth's political and interpersonal drama according to the dictates of language and plot, they deliver most (indeed, almost all) of their lines in the form of direct address to the audience. Accordingly, we as viewers are treated as complicit in the play's bloody conspiracies and strange turns. Upon receiving her husband's letter near the end of Act 1, for instance, Katie Stimpson's captivating Lady Macbeth stretches luxuriously on her bed and speaks to the audience as if we are the absent Macbeth, staring directly into the eyes of the closest viewers to engender a powerful sense of intimacy. In the staging of the scene, we become her spousal co-conspirator. Yet when Macduff passes Malcolm's test of loyalty, the prince speaks to the spectators, not his thane; instead of murderous conspirators, the audience become saviors of "good truth and honor." By the end, it becomes difficult to discern if we spectators have been cast as heroes or enemies. We have, it seems, taken on both—even all—roles at once. Indeed, in the final battle scene, Macbeth and Macduff deliver not only their lines to the audience, but blows as well. Rather than battling each other, the two actors perform their fight choreography side by side, aiming each violent strike and every vengeful word at the crowd of viewers.
The feeling of being responsible for the play's events but unable to respond—whether by talking back to Lady Macbeth or defending oneself from Macduff and Macbeth's blows—augments the nightmarish unreality of the play as a whole. After all, if we cannot even be sure what role we play as mere audience members, how can we trust anything we see, hear, or otherwise perceive? By means of this disorienting effect, Theatre Y and Georges Bigot's production foregrounds one of Macbeth's most unsettling questions. The play doubts not merely whether we can control the reality we live in, but whether we can identify what is "real" at all. Theatre Y refuses to give a straightforward answer either way, suggesting instead that there may be more power—if less comfort—in the asking.
Rebecca L. Fall is a visiting assistant professor in the Department of English at Northwestern University, where she teaches courses on Renaissance literature and media history. She is currently writing a book on nonsense writing, clownish language and silly jokes in sixteenth- and seventeenth-century English literature. Her research has been supported by several nationally competitive fellowships, including the Mellon/ACLS and Mellon-CES Dissertation Completion Fellowships. Rebecca holds a PhD and an MA in English from Northwestern University, and a BA in English from the University of Virginia.

subset: commoncrawl


text:
The Horsa Glider was a glider used by the British in Call of Duty and Call of Duty: United Offensive.
Call of Duty Edit
Jack Evans is flown in on a Horsa Glider above Benouville along with a platoon of British troops. The glider lands hard, hitting a stream and charging through a wooded area. They stop meters away from the German line. Three gliders crash near Pegasus Bridge and remain there until the next day.
There is also a crashed Horsa near the Stables in the Call of Duty on the Bocage map.
Call of Duty: United OffensiveEdit
Horsa Gliders are seen on the Bocage map in the stables.
Trivia Edit
- In the map Bocage, a dead cow is under the Horsa Glider. This is a reference to the joke in the credits that says at the end "No cows were harmed in the making of this game."
Community content is available under CC-BY-SA unless otherwise noted.


text:
Thu 22 Aug 2019
Sat 24 Aug 2019
Barbican Centre, Silk Street,London, EC2Y 8DS
The multi award-winning production of Tim Rice and Andrew Lloyd Webber's Jesus Christ Superstar is back in London at the Barbican.Playing just 60 performances at the Barbican following two sell-out seasons at Regent's Park Open Air Theatre, this 'gorgeous, thrilling, heavenly musical' (Guardian) is 'an almighty revelation' (Daily Telegraph).The new cast of Jesus Christ Superstar includes: Robert Tripolino and Ricardo Afonso in the iconic roles of Jesus and Judas, with Sallay Garnett as Mary. Matt Cardle** plays the role of Pilate, with Cavin Cornwall and Nathan Amzi as Caiaphas and Annas.At the Barbican from July 2019, book your Jesus Christ Superstar tickets today!Please note: *Suitable for ages 10+. This production contains some violence and an onstage depiction of the crucifixion.**Matt Cardle will not perform on the following days: Friday 12 July, Saturday 13 July (evening), Tuesday 30 July or Wednesday 31 July.


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SuperJet 2020
A legend - but for competition use only!
Rider and legendary machine in perfect harmony. At one with each other and with the water. It's how races are won.
The impressive power and acceleration of the race-bred 2-stroke engine is combined with a sleek, ultra-light hull. Supreme agility and control is the SuperJet's trademark, with the ability to out-carve rival racers by diving deeper and turning harder into turns.
Its unique ergonomic design - with spring-assisted steering pole and handlebar - leads the rider naturally into a comfortable lean-forward position, the ideal stance for competition riding. Your SuperJet is ready and waiting. But please be aware that it is sold for closed course and competition use only.
High-performance 2-stroke engine
The SuperJet is powered by a high-performance, two-cylinder, 701cc Yamaha marine engine. Two 38mm Mikuni® carburators feed this world-class power plant, for excellent throttle response throughout the RPM range. Loop-charged combustion distributes the fuel/air mixture more evenly, for better combustion, performance and fuel economy.
Lightweight, deep-strake hull with wide front section
Perfectly balanced to give ultra-tight cornering ability and to maximise its blistering straight-line speeds, the SuperJet's lightweight, deep-strake hull features moulded-in sponsons. Positioned well forward, they increase the water surface area, allowing you to turn easily, while giving the SuperJet great stability.
Optimised intake duct pump and ride-plate position
To increase dynamic stability and straight-line running performance within the limited space of the hull, the ride plate is positioned far aft – effectively lengthening the waterline. The pump itself is also positioned far aft, providing stable pump performance even in choppy water.
Hyper-Flow jet pump and adjustable steering nozzle
The SuperJet 144mm Hyper-Flow jet pump propulsion system is designed to maximise water flow for high performance. The SuperJet pump configuration provides excellent hook-up and smooth acceleration.
Race-developed stainless steel impeller
The SuperJet's stainless steel impeller was developed with the feedback from racers. Fluid analysis technology was used to realise its super-efficient, high-performance design – a design that's world famous for delivering superior acceleration and speed.
Spring-assisted steering pole
The spring assisted steering pole and handlebars have been specially designed to provide a riding position that allows you to get the most out of the SuperJet – a machine built for winning. The result is a forward-leaning riding position that is hugely popular with pro racers and which offers the most comfortable stance for competition.


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I recently looked at 500 completed Trello cards and estimated processing time with the Kanban board and without it. For example, if a card had status updates over several weeks, we assumed that those updates would have happened with meetings or email updates without Trello. Similar approaches were taken for other tasks like event planning and customer followups. If there was no way of estimating the improvement, we conservatively assumed there was none.
This methodology gave us the following results. While it is not a full time/motion study, it gave us clear indication where the biggest impact of the kanban approach is.
The results assume the following 3 key criteria for all tasks and boards:
- All team members collaborate on each other's boards and tasks
- Each card has a due date and owner(s) assigned
- Each team member follows up on notifications or tasks due
Here are the savings we found:
- Typical project status updates – up to 70% time saved
( Traditional project update meetings: 1 hour a week – Trello updates 5-10 minutes per week through comments and alerts) Assuming 100 project boards – 83 hours a week can be saved
- Searching through email for contextual information – up to 60% time saved
This is harder to quantify but finding all project or task related information is almost impossible in Outlook as it is conversation based and not project based- Typical search estimated at 10-12 hours a week, vs Trello search less than 1-2 hours a week as most information is project based – however multiple boards may need to be searched for related content
- Finding reference documents – a wash
Trello is not a better or worse repository of documents
- Keeping people in the loop, managing overlapping tasks – order of magnitude. Traditional email or reporting systems have no easy way of showing what others are working on. In Trello I always know what everyone is doing, especially if the rule is that unless it is recorded in Trello it does not count.
The capability is clearly there, but sometimes people do not record every action or forget to check for overlapping activities. This can be made easy through the many web services integrations with Trello (Zapier or IFTTT) and also through in-Trello automation through powerups like Butler. Will cover those in a later post.


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A person who feels loyalty to a nation, cause, or person feels a sense of allegiance, commitment, dedication toward them.
Loyalty is — you guessed it! — the quality of being loyal. People demonstrate their loyalty to a sports team by cheering for it, win or lose. People demonstrate their loyalty to a political party by voting only for the people of that party. Brand loyalty is the notion (or hope) that once consumers identify strongly with a particular brand or product, like a car or computer, they'll stick with that brand or maker when it comes time to buy new products.


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PhotonStar SmartNemesis LED
Issue 54 Apr / May 2010
One of the products that created a lot of interest at this year's ARC Show was PhotonStar's new SmartNemesis LED downlight. David Morgan puts it through its paces.
PhotonStar is a new LED luminaire company started by former directors of the high tech LED chip design company, Mesophotonics. The LED division of Mesophotonics was sold to Luxtaltek, a Taiwanese LED manufacturer in 2007 and PhotonStar was formed soon afterwards.
The founders of PhotonStar, Dr James Mckenzie and Dr Majd Zoorob, are both physicists with long experience in photonics optics and LED design. They were joined by a number of other highly qualified scientists from Southampton University to complete the development team. With this highly qualified technical capability in place, the company has concentrated on the performance and efficiency aspects of LED lighting, developing a range of downlights and accent lights. These incorporate PhotonStar's LED light engine and control design.
It would appear that the initial PhotonStar products utilised industry standard LV halogen luminaire components into which their LED light engine and thermal management components were fitted. The company has now taken over Architectural Lighting and Controls, another Southampton-based lighting firm, enabling them to widen the product range to include specials and other products better suited to the lighting design market.
The latest PhotonStar product - which was launched at London's ARC 2010 Show - is the high-power SmartNemesis downlight that incorporates a variety of clever technical innovations to optimise efficiency and performance.
SmartNemesis is designed as a replacement for commercial twin lamp compact fluorescent downlights. The bezel diameter of 183mm is typical for this category of downlight and is much larger than the MR16 replacement LED downlights now available from many suppliers. The highest power version (56 watts) delivers over 3,200 lumens in a very cool, 6500K colour temperature. In warm white, 2700K, it provides 2,600 lumens. The light engine developed for the SmartNemesis utilises 32 top flux bin Cree LEDs for the 56W version and 24 top flux bin Cree LEDs for the 42W version.
This LED light engine incorporates a diffusing screen but no individual collimating lenses. Optical control is achieved via the specular vacuum metalised moulded reflector and a wide distribution is produced with this combination.
To maximise energy savings and improve sustainability each SmartNemesis incorporates a light sensor that monitors the light level on the working plane and maintains a pre-set level by dimming down to take advantage of available daylight via a micro processor controlled dimmer in the driver. The dimmer can reduce light levels to below 1% in 0.5% steps and is also used to maintain a safe LED operating temperature if the ambient temperature rises above a pre-set limit. The target light level is set with the aid of a hand held controller so that each downlight can be set to maintain an individual lighting level. The driver includes dimming control via DALI, DMX or 0 – 10V.
PhotonStar claims an efficiency level of up to 73 lumens per watt for this product when the daylight sensor is activated. When used with occupancy sensors this, they claim, enables energy savings of up to 70% when compared to standard CFL downlights.
The test sample I was shown for this review was unfortunately not left with me for direct comparison with CFL or other LED downlights so I cannot comment on the relative energy performance of the SmartNemesis. My impression of the light output and light pattern was that the light output was powerful but that the light pattern on the floor was not completely uniform with some darker areas visible. This may have been an issue with this pre-production sample or a more fundamental design issue.
Although PhotonStar claim that the optics provide glare-free illumination, this is only true when viewed from normal viewing angles. When on full power, a direct view of the LED light engine is a painful experience for the eyes. With the increasing output from ever smaller LED emitters, glare is becoming more of an issue and the traditional reflector cone downlight may need to evolve to reduce this hazard. The surface brightness of a CFL lamp is much lower than that for a high power LED light engine so a direct view of the light source is not a significant problem. Some useful luminous intensity figures provided by PhotonStar compares CDM and CFL downlights from Zumtobel and Philips with the PhotonStar LED downlight. This shows the levels to be roughly three times higher for their LED downlight than for the CFL equivalent. As a comparison the CDM figures are around eight times higher than the CFL levels but reflectors for these lamps often incorporate a two cone design to reduce this problem.
As would be expected given PhotonStar's technical capability, thermal management of the LED light engine has been given a high priority. The LED Light engine is cooled with the aid of a large passive die-cast aluminium heat sink that extends sideways for optimum cooling. The same size heat sink is used for both wattages so that in the 56 watt version the recommended safe ambient temperature in the ceiling drops to only 35ºC and the L70 lifespan falls to 45,000 hours. As previously mentioned, the downlight incorporates an onboard thermal sensor in the light engine so that if the ambient temperature rises above a pre-set limit the light output is reduced to keep the LED array working at a safe level. PhotonStar's markets include a number of countries in the Middle East so an effective and sophisticated thermal management system is essential for these applications.
To remove any additional heat sources from the LED array, the driver and power supply are remote which allows the separate 24 volt DC power supply to run a number of downlights.
The overall quality and attention to detail in the design of the SmartNemesis should appeal to the target specification market. However, the indicated price seems quite high when compared to downlights from some of the major brands incorporating the Philips Fortimo light engine, which some may say has a higher perceived brand value in the market. The LED downlight market is clearly going to be a highly competitive and volatile one over the next few years as the increasing number of players try to gain volume sales on the basis of their performance figures and ever lower prices.
PhotonStar has followed a logical path in defining the performance of this range around that of existing CFL products but there seems to be an unresolved issue with the potential for glare and the rather harsh quality of light created from most high power LED downlights. Their focus on achieving high efficiency and high reliability is certainly to be commended but it is a pity that a more creative use of LED technology and optical control has not been considered in the development of this range.
I look forward to seeing future PhotonStar products that may combine high levels of efficiency with a more mellow, softer lighting effect.
© David Morgan Associates 2010. David Morgan runs David Morgan Associates, a London-based international design consultancy specialising in luminaire design and development.
Email: firstname.lastname@example.com
Web: www.dmadesign.co.uk Tel: +44 (0)20 8340 4009
The views expressed in this article are entirely those of David Morgan and not necessarily those of mondo*arc.


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The kitchen is one of the most important places in the house where energy efficiency can make a big difference. There are many little ways to cut down on electricity use, but collectively these thoughtful steps add up to some sweet savings when the electric bill arrives. Like any recipe, follow each step and the end result could save you enough each month to go out for a great dinner!
It's Too Hot to Cook – Cutting Electricity Consumption
Nobody wants to be in a hot kitchen on a scorching day even when the air conditioning is running strong. Ideally, however, it's best to avoid cooking on such days. By running the oven and stove, you wind up infusing more heat into the home. This added heat requires your air conditioning to run even harder to compensate for the added warmth. Instead, try to cook outdoors on the grill when the weather is especially warm. Or, opt for more salads and sandwiches. If you use the stovetop, try to make something that cooks quickly.
Don't Run the Dishwasher until It's Full
By only running the dishwasher when it's completely filled, you may cut down this appliance's annual use in half. Not only will you save on electricity, you'll conserve water too! It isn't energy efficient to wash only half loads at one time. You'll use less electricity by waiting to run the dishwasher until it is completely full.
Keep Tabs on Your Refrigerator Temperature
During an energy audit, most experts will advise homeowners to keep their refrigerator set at 5°C. Homeowners can monitor this temperature by using a refrigerator thermometer to insure that the thermostat of the appliance runs true. Other fridge tips: don't place hot food in the refrigerator because the appliance has to work harder to cool it off, don't keep the refrigerator door open any longer than absolutely necessary as it allows cold air to escape, and check to make sure the seals of the refrigerator and freezer doors are vacuum tight when closed.
Boil Only What You Need
It's common for people to fill their kettle or pans with far more water than is necessary. In order to bring larger volumes of water to boil, it requires more energy to do the job. Instead, measure accurate amounts of water so you only boil what you need. Cutting electricity consumption in this way can add up to a significant energy savings in a year's time.
Buy Energy Efficient Appliances
While it may not be cost effective or reasonable for someone to replace all older appliances at once, when it does come time to replace refrigerators, dishwashers, ovens, microwaves, etc…be sure to purchase energy efficient models. Read several product reviews in order to make the best purchase. These energy efficient models have been designed to run far more efficiently than the appliances of ten years ago. By the time you add all the energy saved from each step listed here, you can see how much energy could conceivably be conserved. Not only will your kitchen be more eco-friendly, now that you are cutting electrity consumption, your electric bill will cost you less too!
image source Natasha Risinger is a stay-at-home mom on a tight budget. She is always looking for great ways to save money and then she shares her findings with others by blogging on the Internet. Visit the www.texaselectricityproviders.com to get more ideas about saving money on your electricity bills.


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Consensus has recently been reached by international pediatric subspecialty societies that otherwise unexplained persistent hyperandrogenic anovulation using age- and stage-appropriate standards are appropriate diagnostic criteria for polycystic ovary syndrome (PCOS) in adolescents. The purpose of this review is to summarize these recommendations and discuss their basis and implications. Anovulation is indicated by abnormal uterine bleeding, which exists when menstrual cycle length is outside the normal range or bleeding is excessive: cycles outside 19 to 90 days are always abnormal, and most are 21 to 45 days even during the first postmenarcheal year. Continued menstrual abnormality in a hyperandrogenic adolescent for 1 year prognosticates at least 50% risk of persistence. Hyperandrogenism is best indicated by persistent elevation of serum testosterone above adult norms as determined in a reliable reference laboratory. Because hyperandrogenemia documentation can be problematic, moderate-severe hirsutism constitutes clinical evidence of hyperandrogenism. Moderate-severe inflammatory acne vulgaris unresponsive to topical treatment is an indication to test for hyperandrogenemia. Treatment of PCOS is symptom-directed. Cyclic estrogen-progestin oral contraceptives are ordinarily the preferred first-line medical treatment because they reliably improve both the menstrual abnormality and hyperandrogenism. First-line treatment of the comorbidities of obesity and insulin resistance is lifestyle modification with calorie restriction and increased exercise. Metformin in conjunction with behavior modification is indicated for glucose intolerance. Although persistence of hyperandrogenic anovulation for ≥2 years ensures the distinction of PCOS from physiologic anovulation, early workup is advisable to make a provisional diagnosis so that combined oral contraceptive treatment, which will mask diagnosis by suppressing hyperandrogenemia, is not unnecessarily delayed.
- combined oral contraceptive
- dehydroepiandrosterone sulfate
- functional ovarian hyperandrogenism
- luteinizing hormone
- nonclassic congenital adrenal hyperplasia
- polycystic ovary morphology
- polycystic ovary syndrome
- sex hormone binding globulin
Polycystic ovary syndrome (PCOS) is the most common cause of chronic hyperandrogenic anovulation and the single most common cause of infertility in young women.1 It is also a risk factor for metabolic syndrome-related comorbidities and for impaired well-being and mortality.2 Considerable evidence suggests that PCOS has diverse causes, arising as a complex trait with contributions from both heritable and environmental factors that affect ovarian steroidogenesis.3,4 Insulin-resistant hyperinsulinism, in part related to coexistent obesity, is the most common nonsteroidogenic factor. The complex interactions generally mimic an autosomal dominant trait with variable penetrance: the disorder is correlated in identical twins5; about half of sisters are hyperandrogenic, and half of these also have oligo-amenorrhea and thus PCOS6,7; and polycystic ovaries appear to be inherited as an autosomal dominant trait.7,8 Three percent to 35% of mothers have PCOS,9,10 and metabolic syndrome prevalence is high in parents and siblings.11–13
Primary functional ovarian hyperandrogenism (FOH) accounts for the vast majority of PCOS. Ovarian androgenic function tests show that most have 17-hydroxyprogesterone hyperresponsiveness to gonadotropins in the absence of a steroidogenic block (typical FOH) and subnormal dexamethasone-suppressibility of testosterone; a minority have only the latter abnormality (atypical FOH)1,14 A related adrenal androgenic hyperresponsiveness to adrenocorticotropin (primary functional adrenal hyperandrogenism) is often associated with FOH: it is the sole source of androgen in a small PCOS subset.
The syndrome was first described by Stein and Leventhal.15 Over the past 25 years, internationally accepted diagnostic criteria have been developed for adults based on various combinations of otherwise unexplained hyperandrogenism, anovulation, and a polycystic ovary, which are all encompassed by Rotterdam consensus criteria.16–18 These criteria generate 4 phenotypes, which fall on a spectrum of decreasing specificity and severity in Table 1.1
These diverse criteria have been problematic when applied to adolescents. Anovulatory cycles are frequent in adolescents. The common signs of adult hyperandrogenism are less reliable in adolescents than in adults: hirsutism is in a developmental phase, and acne vulgaris is common. Testosterone serum levels rise during anovulatory cycles; there is a paucity of reliable norms for androgen levels in adolescent girls, and the extent to which adolescent hyperandrogenism predicts adult hyperandrogenism is unclear. Furthermore, polycystic ovary morphology by adult standards is common in normal adolescents.
Recent Endocrine Society clinical guidelines suggest that adolescent PCOS be diagnosed using the National Institutes of Health–based criteria of otherwise unexplained hyperandrogenism and persistent anovulatory menstrual abnormality.19 Because the evidence presented to support this conclusion was meager, the Pediatric Endocrine Society invited representatives of international pediatric, adult, and reproductive endocrinology, adolescent medicine, and adolescent gynecology subspecialty societies to appoint experts to define appropriate criteria for the diagnosis of PCOS in adolescence. Their consensus supported the criteria of persistent hyperandrogenic oligo-anovulatory menstrual abnormality based on age- and stage-appropriate standards, as summarized in Table 2.4 The purpose of this review is to use these consensus criteria as a point of reference to address common misconceptions that stand as a barrier to the early diagnosis and treatment of PCOS.
Evidence of an Abnormal Degree of Anovulation in Adolescents
Physiologic adolescent anovulation is a well-known phenomenon: the greater length of menstrual cycles and greater degree of menstrual irregularity in adolescents than adults is due to their higher frequency of anovulatory cycles.4,20–24 However, there is a widespread misconception that any degree of amenorrhea or menstrual irregularity is acceptable. Rather, normal adolescent menstrual cyclicity differs only slightly from that of reproductive-age adults: cycles shorter than 19 days or longer than 90 days are abnormal at any stage, 75% of menstrual cycles range from 21 to 45 days during the first postmenarcheal (gynecologic) year, and 95% of girls achieve 21- to 40-day adult menstrual cyclicity by their fifth gynecologic year.
Thus, most adolescent anovulation is asymptomatic, with cyclic menstrual bleeding usually occurring at 21- to 45-day intervals even in the first postmenarcheal year (Fig 1). This paradox arises because immature cyclic ovarian function is usually occurring during these intervals.23,24 Most normal adolescent menstrual cycles that are not normally ovulatory by standard criteria have hormonal evidence of luteal insufficiency (Fig 1), which signifies antecedent ovulation with immature corpus luteum formation.24 Serum hormonal changes during normal adolescent menstrual cycles confirm that substantial but immature cyclic follicular development occurs in such girls and some aluteal adolescents.23,25
An abnormal menstrual bleeding pattern ("symptomatic adolescent anovulation") is almost always the result of anovulatory cycles and cause for concern if persistent.3,23 The various manifestations of an abnormal degree of adolescent anovulation, that is, uterine bleeding patterns that occur in <5% of adolescents, are summarized in Table 3. Symptomatic adolescent anovulation has an overall long-term persistence rate of approximately one-third (Fig 2).26
However, the risk for ongoing anovulation is greater for hyperandrogenemic anovulatory adolescents than for nonhyperandrogenemic ones. Among girls evaluated for abnormal menstrual bleeding without clinical signs of hyperandrogenism, approximately half have elevated androgen levels.27,28 Reevaluation of such patients has shown that hyperandrogenemia resolves in approximately half and that PCOS is the single most common cause of residual ongoing menstrual disorder.29–32 Furthermore, in the presence of clinical evidence of hyperandrogenism, for example, hirsutism or serious acne, hyperandrogenic oligo-anovulation (ie, PCOS) persisted for ≥3 years in ≥80%.31,33 Indeed, in a small series of adolescents with elevated free testosterone and documented FOH, follow-up showed that all still had PCOS as young adults.33 Thus, the actuarial curve describing the prognosis for symptomatic anovulation seems to comprise 2 components: 1 for hyperandrogenemic cases, half of which persist, and another for nonhyperandrogenemic cases, few of which persist (Fig 2). The transient cases are due to physiologic anovulation. The persistent hyperandrogenemic cases are mostly PCOS, and the persistent nonhyperandrogenic cases have some form of hypogonadism.
In summary, uterine bleeding at intervals more frequent than 19 days or less frequent than 90 days is abnormal even in the first postmenarcheal year (Table 3). In the absence of clinical evidence of an endocrine disorder, persistent abnormal menstrual bleeding for 1 year carries an approximately 50% risk of ongoing menstrual irregularity, and approximately half of the ongoing cases will have PCOS. However, if clinical evidence of PCOS is present, such as hirsutism, the risk of ongoing hyperandrogenic menstrual abnormality is high.
Clinical and Biochemical Evidence of Hyperandrogenism in Adolescents
The development of sexual hair (terminal hair that develops in a malelike pattern) and most sebaceous glands is dependent on androgen.34 Hirsutism is considered clinical evidence of hyperandrogenism and equivalent to biochemical evidence of hyperandrogenism in all adult criteria for PCOS (Table 1) because documentation of hyperandrogenemia can be problematic.35 However, this criterion is controversial because mild hirsutism is due to ethnic or familial factors rather than hyperandrogenemia half of the time, in contrast to moderate-severe hirsutism, which is usually due to hyperandrogenemia.36 On the other hand, hyperandrogenemia is variably accompanied by hirsutism: little more than half of hyperandrogenemic PCOS patients are hirsute.1
Clinical Evidence of Hyperandrogenism
Hirsutism is defined as excessive sexual hair.4,35 Sexual hair growth is commonly graded by the Ferriman-Gallwey score (Fig 3): a total score of 8 to 15 defines mild hirsutism, 16 to 24 moderate hirsutism, in the general US adult population.35
Hirsutism must be distinguished from hypertrichosis, which is defined as generalized excessive vellus hair growth distributed in a nonsexual pattern, for example, predominantly on forearms or lower legs. This hair growth is not due to androgen excess. It may have an ethnic/hereditary, basis or may result from malnutrition or certain medications, such as phenytoin or cyclosporine.
The meager normative data that exist in adolescence suggest that an adult level of hirsutism is achieved by 2 years after menarche or 15 years of age37,38: upper lip scores of 3 to 4 increased over the course of puberty to reach an adult prevalence of <3% in Black and White US adolescents by the second postmenarcheal year (Fig 4).
Acne, rather than hirsutism, may be the only pilosebaceous manifestation of hyperandrogenism.39 Comedonal acne is common in adolescent girls, but inflammatory acne that is moderate or severe (ie, >10 facial lesions, Table 4) is uncommon during the perimenarcheal years.40 Girls with acne that is persistent and poorly responsive to topical dermatologic therapy are ordinarily treated by combined oral contraceptive (COC) pills, which lower ovarian androgen production, or the systemic retinoid Accutane.41 Because COC therapy thus masks the hyperandrogenism of underlying PCOS, it is recommended that patients with moderate-severe inflammatory acne unresponsive to topical treatments be assessed for hyperandrogenemia before instituting systemic medical treatments.
Biochemical Evidence of Hyperandrogenism
Documentation of hyperandrogenism requires reliable assays with well-defined normal ranges.4,42,43 Measurements of total and/or free testosterone are recommended to initiate documentation of hyperandrogenemia.35,44 Elevated serum free testosterone is the single most sensitive indicator of hyperandrogenemia because the bioactive portion of the serum testosterone is the free fraction. Sex hormone binding globulin (SHBG) serum concentrations govern the fraction of testosterone that is free; they are lowered by obesity and androgen excess itself. The cost-effectiveness of routinely measuring more androgens than total and free testosterone has not been documented, although androstenedione may be considered45 and dehydroepiandrosterone sulfate (DHEAS) is widely used to assess adrenal hyperandrogenism. Although dihydrotestosterone generated in target tissue mediates most testosterone effects, its serum level is of little diagnostic value.36
However, accurate determinations of total and free testosterone concentrations are often problematic. Diurnal rhythm, phase of menstrual cycle, and SHBG concentrations are biological variables that influence total testosterone concentrations. Methodological problems regarding testosterone determinations abound. Most notably, the multichannel platform assays now commonly used by hospital laboratories lack sensitivity, specificity, and accuracy for testosterone, although they are good for SHBG and DHEAS measurement. Some direct assays of total testosterone are also inaccurate, but others are as accurate as the postchromatographic radioimmunoassays that have been available only through specialty laboratories or the tandem mass spectrometry methods that are beginning to supplant them.14,46,47 The reliable free testosterone assays calculate the free testosterone concentration as the product of the total testosterone and the fraction that is free from SHBG binding (free testosterone = total testosterone × percent free testosterone).48 The most common methods calculate percent free testosterone from the SHBG concentration or determine the percent free testosterone by dialysis. Free testosterone assays are less well standardized than total testosterone assays, which has limited their usefulness.
The criteria used to define hyperandrogenemia in adolescent girls are confounded by developmental considerations. However, shortly after menarche, serum testosterone of adolescents attains adult levels (Fig 5).1,4 Thus, adult testosterone levels are an appropriate criterion on which to base a diagnosis of hyperandrogenemia.
However, testosterone levels increase as adolescent anovulatory cycles lengthen.4 Thus, the few available data suggest that prolonged physiologic anovulation accounts for the half of hyperandrogenemic anovulatory cycles that resolve during adolescence, as discussed in the previous section.29–33
In summary, biochemical evidence of hyperandrogenism, as indicated by persistent elevation of serum total and/or free testosterone levels above adult norms and determined by a reliable reference laboratory, provides the clearest support for the presence of hyperandrogenism in an adolescent girl with symptoms of PCOS. In most such laboratories, the upper limit approximates 55 ng/dL for total testosterone and 9 pg/mL for free testosterone. However, an elevated androgen level should not be considered evidence of hyperandrogenism in an otherwise asymptomatic adolescent with anovulatory symptoms unless the hyperandrogenemia and anovulation persist. In the absence of the availability of reliable androgen assays, moderate-severe hirsutism constitutes clinical evidence of hyperandrogenism. Moderate-severe inflammatory acne vulgaris unresponsive to topical medications is an indication to test for hyperandrogenemia.
The Quandary of Polycystic Ovary Morphology in Adolescence
Histopathologically, the polycystic ovary is characterized by an excessive number of small antral follicles that are arrested before the preovulatory stage of development (which accounts for the polycystic appearance), ovarian enlargement, capsular thickening, and thecal-stromal hyperplasia and luteinization.1 Ultrasonographically, polycystic ovary morphology (PCOM) has been defined in adults by consensus criteria as an ovary with a volume >10.0 mL by a simplified formula or a small antral follicle (2–9 mm diameter) count ≥12 per ovary.17,49 However, it has become apparent that these criteria are problematic in young adults, particularly because the newer high-definition vaginal imaging techniques show that small antral follicle counts up to 24 are normal.50,51
Adult PCOM criteria are especially problematic when applied to adolescents. For one thing, an accurate antral follicle count cannot be defined by the abdominal ultrasonographic approach necessary in virginal adolescents.51 For another, even if an accurate follicle count is obtained by magnetic resonance imaging, the adult criteria for PCOM overlap with criteria for a multifollicular ovary, which is defined by the presence of ≥6 follicles of 4- to 10-mm diameter without increase in ovarian volume and is known to be a normal variant unrelated to hyperandrogenism.4 Furthermore, although data vary considerably, current data suggest that ovarian volume is slightly larger in adolescents than in adults.1,4 Consequently, one-third to half of normal adolescents meet adult criteria for PCOM.52 Until further research establishes definitive criteria, current evidence suggests that a mean ovarian volume >12 cc (or single ovary >15 cc) be considered enlarged in adolescents.1,4,52
PCOM is variably related to hyperandrogenism in adults.1 On one hand, it is absent in 5% to 20% of adult PCOS.1,18,53 On the other, PCOM is a common finding among healthy women. Many of these women have mild PCOS features, that is, irregular menstrual cycles and/or hirsutism. When care has been taken to exclude those with such symptoms, approximately one-quarter of apparently normal adults with PCOM have mild subclinical androgenic ovarian dysfunction that is in the PCOS range (Fig 6); it has been postulated that these are carriers of PCOS or at risk for PCOS.
In summary, the uncertainty about appropriate criteria for PCOM in adolescents is too great to use PCOM as a diagnostic criterion in adolescents.
The Role of Insulin Resistance and Metabolic Syndrome in the Diagnosis of PCOS
Insulin resistance out of proportion to that conferred by obesity is variously reported in one- to two-thirds of PCOS subjects.54–56 Obesity prevalence likewise varies widely among populations, averaging approximately 50%.57 The insulin resistance of PCOS seems to be associated with increased abdominal fat depots independent of BMI,58 and superimposed excess adiposity further increases all fat depots and insulin resistance.55,59
Metabolic syndrome, a cluster of glucose abnormalities, central (android) obesity, hypertension, and dyslipidemia, is the variable result of insulin resistance interacting with obesity and age.60,61 Its prevalence is highest in obese subjects.4 It is present in ∼25% of adolescents with PCOS.11,62–64 The comorbidity of metabolic syndrome makes PCOS a risk factor for the early development of type 2 diabetes mellitus, sleep-disordered breathing, and ultimately, the threat of cardiovascular disease.
The insulin resistance of PCOS primarily involves insulin's glucose-metabolic effects.65 Other insulin actions are unaffected in PCOS, with resultant compensatory insulin-resistant hyperinsulinism. The compensatory hyperinsulinemia accounts for acanthosis nigricans and synergizes with gonadotropins to aggravate ovarian androgen excess.66 Severe insulin-resistant hyperinsulinemia causes pseudo-Cushing's syndrome and pseudo-acromegaly.67
In summary, although insulin resistance and obesity are commonly associated with PCOS, they are not necessarily present and so are not diagnostic criteria.4 However, the presence of obesity and/or signs of insulin-resistant hyperinsulinism such as acanthosis nigricans should alert the physician to the possibility of PCOS and its metabolic syndrome–related comorbidities.
Diagnostic Procedures to Exclude Non-PCOS Causes of Hyperandrogenic Anovulation
PCOS consensus criteria all consider the disorder to be a diagnosis of exclusion. Although the differential diagnosis of PCOS is fairly long (Table 5),68 most disorders other than physiologic adolescent anovulation are uncommon to rare. All guidelines recommend screening for nonclassic congenital adrenal hyperplasia (NCCAH), which is the most likely disorder to mimic PCOS although it accounts for only ∼5% of hyperandrogenic anovulation.4,19 Otherwise, guidelines differ on specific recommendations for approaching the workup. Most recommend screening for hypothyroidism because it causes menstrual irregularity and coarsening of hair (rather than true hirsutism69). Some recommend screening all hyperandrogenic women for hyperprolactinemia; most endocrinologists find it to be rare, but it has been reported in as many as 16% of young women presenting with PCOS symptoms.69,70 Other disorders are undeniably rare, including the only life-threatening disorder in the differential diagnosis, androgen-secreting tumor, the prevalence of which is 0.2%. The central adiposity and hirsutism of PCOS often raise concern for Cushing's syndrome, which rarely presents as PCOS. Some rare disorders are clinically subtle early on but easy to screen for (eg, insulin-like growth factor-I for acromegaly).
The approach to the differential diagnosis begins with a thorough medical history and physical examination. Because PCOS is but 1 of many causes of anovulation and only approximately half of hyperandrogenic patients have cutaneous signs of hyperandrogenism, the initial evaluation often includes determination of the serum gonadotropins luteinizing hormone (LH) and follicle-stimulating hormone (FSH).3,23 Low LH suggests a hypogonadotropic disorder of neuroendocrine origin, whereas high FSH suggests primary ovarian failure. A pregnancy test is indicated in any sexually mature teenager with amenorrhea.
The initial endocrinologic hyperandrogenism workup typically includes serum total testosterone, free testosterone, SHBG, DHEAS, and an early morning serum 17-hydroxyprogesterone level. Beyond that, the workup is individualized. For patients for whom cost is a major consideration, a minimalist approach is reasonable in which the clinical findings guide additional hormone determinations such as thyrotropin, prolactin, insulin-like growth factor-I, and serum or urinary cortisol. For others, economy of time justifies initiating studies with this full endocrine screening panel. Clinical or laboratory findings or patient preferences may dictate a more complete endocrinologic evaluation for rare disorders (Table 5) in some cases.3,71
The 8 am 17-hydroxyprogesterone level requires interpretation; normal random values do not completely exclude NCCAH because of marked diurnal variation. An 8 am value >200 ng/dL (6.0 nmol/L) is suggestive of NCCAH, although it is also compatible with recent ovulation or tumoral hyperandrogenism.72 This cutoff displayed 92% to 98% sensitivity in detecting NCCAH73,74 and 12% to 25% specificity in discriminating it from PCOS.75,76 Thus, unless the 17-OHP level achieves a diagnostic level (>1000 ng/dL = 30 nmol/L), an adrenocorticotropic hormone test is recommended to confirm the diagnosis of NCCAH.74
Pelvic ultrasonography is seldom necessary for diagnosis because criteria for PCOM in adolescence are uncertain, as discussed earlier. However, it is indicated if clinical findings are suggestive of a virilizing tumor (eg, rapid progression, clitoromegaly, pelvic mass, or a total testosterone level >200 ng/dL) or disorder of sex development. In the absence of tumor, ultrasonography can be reassuring evidence that the "cysts" of PCOS are not tumor-related.
Currently the only certain way to differentiate the hyperandrogenemia of PCOS from that of physiologic adolescent anovulation is by the persistence of PCOS into adulthood. This is particularly problematic in cases with otherwise asymptomatic, but hyperandrogenemic, adolescents with abnormal menstrual bleeding patterns: the data reviewed here indicate that approximately half of these will remit and the other half persist as PCOS. The distinction is less problematic in cases with menstrual irregularity with symptomatic hyperandrogenism, that is, moderate-severe hirsutism or inflammatory acne: the foregoing data reviewed here indicate that the great majority (perhaps all) will persist as PCOS.
It may be possible to make the distinction between PCOS and physiologic adolescent anovulation early by testing ovarian androgenic function to diagnose the presence of FOH.33 Further research will be necessary to test this possibility. Two kinds of tests are available (Fig 6). A dexamethasone androgen-suppression test is the most sensitive, but least specific, of these tests: elevated testosterone post-dexamethasone indicates a nonadrenal source, which is usually ovarian. The more specific test determines whether 17-hydroxyprogesterone hyperresponds to gonadotropins (indicative of typical FOH): this involves administering either a test dose of gonadotropin-releasing hormone agonist or of human chorionic gonadotropin and determining the 17-hydroxyprogesterone level 20 to 24 hours later.
Making a positive diagnosis of FOH by testing ovarian androgenic function also makes possible another distinction that is seldom made but has practical implications: determining whether PCOS is due to simple obesity, a category of PCOS considered "pseudo-PCOS." Excess adiposity itself suppresses ovulation (via LH suppression) and causes hyperandrogenemia (via adipose tissue formation of testosterone from androstenedione).77 Neither an ovarian nor adrenal source of hyperandrogenism was demonstrable by ovarian androgenic function tests in ∼10% of our PCOS cases (National Institutes of Health criteria), and the great majority of these were obese.1,14,78 These cases were generally characterized by mild elevation of serum free testosterone, normal total testosterone, normal LH, and normal ovarian volume.
A fasting lipid panel and oral glucose tolerance test are advisable for early detection of diabetes mellitus and metabolic syndrome in PCOS patients with obesity or family risk factors. Obese PCOS patients should also be screened for sleep-disordered breathing. Evaluation for metabolic syndrome should also be considered in primary relatives in view of the familial component(s) of PCOS.
Principles of Treatment of Adolescent PCOS
The treatment of PCOS is symptomatic and is individualized according to patient complaints and goals. The main considerations in treating adolescent PCOS are menstrual irregularity, cutaneous manifestations of hyperandrogenism, and the comorbidities of metabolic syndrome.
Cyclic administration of estrogen-progestin in the form of combined COC pills is the first-line medical treatment of most adolescents.23,79 COCs normalize endometrial cycling, thereby protecting against endometrial carcinoma, and inhibit ovarian function, thereby normalizing serum androgens. These actions make them optimal both for treating abnormal uterine bleeding and as adjuncts to cosmetic and topical treatments for hirsutism and acne. Progestin monotherapy is the major alternative to COCs for the control of menstrual irregularity for those opposed to or with contraindications for (eg, thromboembolic risk) COCs. However, hyperandrogenism antagonizes the effects of female hormones on the neuroendocrine system and endometrium, so irregular bleeding may persist and androgens are not well suppressed.
Comorbidities related to obesity and insulin resistance require separate management consideratons.19,80,81 Lifestyle modification with calorie restriction and increased exercise is paramount, but sustained weight loss is difficult to achieve. Insulin-lowering treatments, whether weight reduction or drug treatment, have an ∼50% probability of improving menstrual cyclicity but a negligible effect on hirsutism. Well-controlled studies indicate that metformin monotherapy offers no advantage over lifestyle modification with regard to weight reduction or menstrual frequency. Since it may have additive clinical and biochemical effects, metformin is most effective in combination with a behavioral weight-reduction program.82–84 The only clear indication for metformin is abnormal glucose tolerance. Other applications require further evaluation.85 More detailed discussion of these treatments and higher-tier patient management considerations can be found elsewhere.3,68,71
Consensus has recently been reached by international pediatric subspecialty societies that otherwise unexplained persistent hyperandrogenic anovulation using age- and stage-appropriate standards are appropriate diagnostic criteria for PCOS in adolescents (Table 2).4 Two aspects of these criteria warrant further discussion.
The consensus group urged great caution before labeling hyperandrogenic adolescents as having PCOS if the menstrual abnormality has not persisted for 2 years or more. Before that point in time, they recommended that such girls be considered to be "at-risk for PCOS" (ie, assigned a provisional diagnosis) to avoid misdiagnosing physiologic pubertal changes as PCOS. They coupled this recommendation with one for frequent longitudinal reevaluations. These recommendations place a high value on the accuracy of diagnosis.
Notably, the recommendations specify that initiation of a diagnostic workup should not be unnecessarily delayed. Workup within 2 years may be necessary so that medical treatment that would mask hyperandrogenemia and anovulatory symptoms, particularly COCs, is not unnecessarily delayed. Thus, initiation of diagnostic testing is advisable within 1 year if treatment is required to control abnormal menstrual bleeding or comorbidities or if symptoms suggestive of PCOS coexist (eg, development of hirsutism, moderate inflammatory acne resistant to topical therapy, acanthosis nigricans). Excessive uterine bleeding may mandate emergency evaluation early in the course. Primary amenorrhea should be evaluated when recognized.
The practitioner should also recognize that menstrual abnormalities may not be the chief complaint. Indeed, anovulatory symptoms may not be the initial symptom but may emerge a year or more after presentation for obesity, hirsutism, or acanthosis nigricans.33 Thus, these complaints should trigger consideration of an early appropriate workup. If PCOS is suspected in such a patient, specific ovarian androgenic function testing to document FOH may be particularly helpful.
In adolescents in whom a provisional diagnosis of PCOS has been made, the recommendation for longitudinal reevaluation requires withdrawing COC for ∼3 months when the patient is gynecologically mature (eg, at graduation from high school) to determine persistence of hyperandrogenic anovulation; this maneuver should be coupled with contraceptive counseling because the infertility of PCOS is relative, not absolute.
The helpful suggestions of Drs Laura Torchen and Christine Yu are appreciated.
- Accepted June 25, 2015.
- Address correspondence to Robert L. Rosenfield, MD, Section of Adult and Pediatric Endocrinology, Metabolism, and Diabetes, University of Chicago Medical Center, 5841 S. Maryland Ave (MC-5053), Chicago, IL 60637. E-mail: robros{at}peds.bsd.uchicago.edu
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: The author's research related to this article was supported in part by the Eunice Kennedy Shriver National Institutes of Child and Human Development/National Institutes of Health through cooperative agreement (U54-041859) as part of the Specialized Cooperative Centers Program in Reproduction and Infertility Research, HD-39267, and RR-00055 and UL1RR024999 from the National Center for Research Resources. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
POTENTIAL CONFLICTS OF INTEREST: The author has indicated he has no conflicts of interest to disclose.
- Copyright © 2015 by the American Academy of Pediatrics


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