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Polycystic ovary syndrome
Polycystic Ovary Syndrome. | |
Classification and external resources | |
A polycystic ovary (aka PCO) shown on an ultrasound image. PCO is not necessary for diagnosing PCOS, but is a common sign. As many as 30% or more of women with PCOS do not have PCO as a sign.
MedlinePlus | 000369 |
eMedicine | med/2173 ped/2155 radio/565 |
MeSH | D011085 |
Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders among females. PCOS is a complex, heterogeneous disorder of uncertain etiology, but there is strong evidence that it can, to a large degree, be classified as a genetic disease.[1][2][3]
PCOS produces symptoms in approximately 5% to 10% of women of reproductive age (12–45 years old). It is thought to be one of the leading causes of female subfertility[4][5][6] and the most frequent endocrine problem in women of reproductive age.[7]
The principal features are (1) anovulation, resulting in irregular menstruation, amenorrhea, ovulation-related infertility; (2) excessive amounts or effects of androgenic (masculinizing) hormones, resulting in acne and hirsutism; and (3) insulin resistance, often associated with obesity, Type 2 diabetes, and high cholesterol levels.[8] Finding that the ovaries appear polycystic on ultrasound is common, but not an absolute requirement in all definitions of the disorder. The symptoms and severity of the syndrome vary greatly among affected women.
Signs and symptoms[edit]
Common symptoms of PCOS include:
- Menstrual disorders: PCOS mostly produces oligomenorrhea (few menstrual periods) or amenorrhea (no menstrual periods), but other types of menstrual disorders may also occur.[7][9]
- Infertility:[9] This generally results directly from chronic anovulation (lack of ovulation).[7]
- High levels of masculinizing hormones: The most common signs are acne and hirsutism (male pattern of hair growth), but it may produce hypermenorrhea (very frequent menstrual periods), androgenic alopecia (increase hair thining or diffuse hair loss), or other symptoms.[7][10] Approximately three-quarters of patients with PCOS (by the diagnostic criteria of NIH/NICHD 1990) have evidence of hyperandrogenemia.[11]
- Metabolic syndrome:[9] This appears as a tendency towards central obesity and other symptoms associated with insulin resistance.[7] Serum insulin, insulin resistance and homocysteine levels are higher in women with PCOS.[12]
When Asian women are affected with PCOS, they are less likely to develop hirsutism than women of other ethnic backgrounds.[13]
PCOS is a heterogeneous disorder of uncertain etiology.[1][2][9] There is strong evidence that it is a genetic disease. Such evidence includes the familial clustering of cases, greater concordance in monozygotic compared with dizygotic twins and heritability of endocrine and metabolic features of PCOS.[1][2][3]
The genetic component appears to be inherited in an autosomal dominant fashion with high genetic penetrance but variable expressivity in females; this means that each child has a 50% chance of inheriting the predisposing genetic variant(s) from a parent, and if a daughter receives the variant(s), then the daughter will have the disease to some extent.[2][14][15][16] The genetic variant(s) can be inherited from either the father or the mother, and can be passed along to both sons (who may be asymptomatic carriers or may have symptoms such as early baldness and/or excessive hair) and daughters, who will show signs of PCOS.[14][16] The allele appears to manifest itself at least partially via heightened androgen levels secreted by ovarian follicle theca cells from women with the allele.[15] The exact gene affected has not yet been identified.[2][3][17]
The clinical severity of PCOS symptoms appears to be largely determined by factors such as obesity.[3][7]
Not all women with PCOS have polycystic ovaries (PCO), nor do all women with ovarian cysts have PCOS; although a pelvic ultrasound is a major diagnostic tool, it is not the only one.[18] The diagnosis is straightforward using the Rotterdam criteria, even when the syndrome is associated with a wide range of symptoms.
Two definitions are commonly used:
- In 1990 a consensus workshop sponsored by the NIH/NICHD suggested that a patient has PCOS if she has all of the following:[19]
- oligoovulation
- signs of androgen excess (clinical or biochemical)
- other entities are excluded that would cause polycystic ovaries
- In 2003 a consensus workshop sponsored by ESHRE/ASRM in Rotterdam indicated PCOS to be present if any 2 out of 3 criteria are met[20]
- oligoovulation and/or anovulation
- excess androgen activity
- polycystic ovaries (by gynecologic ultrasound)
Other entities are excluded that would cause these.[7][21]
The Rotterdam definition is wider, including many more patients, most notably patients without androgen excess. Critics say that findings obtained from the study of patients with androgen excess cannot necessarily be extrapolated to patients without androgen excess.[22][23]
- Androgen Excess PCOS Society
- In 2006 the Androgen Excess PCOS Society suggested a tightening of the diagnostic criteria to all of:[7]
- excess androgen activity
- oligoovulation/anovulation and/or polycystic ovaries
- other entities are excluded that would cause excess androgen activity
Standard diagnostic assessments[edit]
- History-taking, specifically for menstrual pattern, obesity, hirsutism, and the absence of breast development. A clinical prediction rule found that these four questions can diagnose PCOS with a sensitivity of 77.1% (95% confidence interval [CI] 62.7%–88.0%) and a specificity of 93.8% (95% CI 82.8%–98.7%).[24]
- Gynecologic ultrasonography, specifically looking for small ovarian follicles. These are believed to be the result of disturbed ovarian function with failed ovulation, reflected by the infrequent or absent menstruation that is typical of the condition. In a normal menstrual cycle, one egg is released from a dominant follicle – essentially a cyst that bursts to release the egg. After ovulation the follicle remnant is transformed into a progesterone-producing corpus luteum, which shrinks and disappears after approximately 12–14 days. In PCOS, there is a so-called "follicular arrest", i.e., several follicles develop to a size of 5–7 mm, but not further. No single follicle reaches the preovulatory size (16 mm or more). According to the Rotterdam criteria, 12 or more small follicles should be seen in an ovary on ultrasound examination.[19] The follicles may be oriented in the periphery, giving the appearance of a 'string of pearls'. The numerous follicles contribute to the increased size of the ovaries, that is, 1.5 to 3 times larger than normal.[citation needed]
- Laparoscopic examination may reveal a thickened, smooth, pearl-white outer surface of the ovary. (This would usually be an incidental finding if laparoscopy were performed for some other reason, as it would not be routine to examine the ovaries in this way to confirm a diagnosis of PCOS.)[citation needed]
- Serum (blood) levels of androgens (male hormones), including androstenedione and testosterone may be elevated.[7] Dehydroepiandrosterone sulfate levels above 700-800 µg/dL are highly suggestive of adrenal dysfunction because DHEA-S is made exclusively by the adrenal glands.[25][26] The free testosterone level is thought to be the best measure,[26][27] with ~60% of PCOS patients demonstrating supranormal levels.[11] The Free androgen index (FAI) of the ratio of testosterone to sex hormone-binding globulin (SHBG) is high[7][26] and is meant to be a predictor of free testosterone, but is a poor parameter for this and is no better than testosterone alone as a marker for PCOS,[28] possibly because FAI is correlated with the degree of obesity.[29]
- Some other blood tests are suggestive but not diagnostic. The ratio of LH (Luteinizing hormone) to FSH (Follicle stimulating hormone), when measured in international units, is elevated in women with PCOS. Common cut-offs to designate abnormally high LH/FSH ratios are 2:1[30] or 3:1[26] as tested on Day 3 of the menstrual cycle. The pattern is not very specific and a ratio of 2:1 or higher was present in less than 50% of women with PCOS in one study.[30] There are often low levels of sex hormone binding globulin,[26] particularly among obese or overweight women.[citation needed]
Associated conditions[edit]
- Fasting biochemical screen and lipid profile[26]
- 2-hour oral glucose tolerance test (GTT) in patients with risk factors (obesity, family history, history of gestational diabetes)[7] may indicate impaired glucose tolerance (insulin resistance) in 15–33% of women with PCOS.[26] Frank diabetes can be seen in 65–68% of women with this condition.[citation needed] Insulin resistance can be observed in both normal weight and overweight patients, although it is more common in the latter (and in those matching the stricter NIH criteria for diagnosis); 50–80% of PCOS patients may have insulin resistance at some level.[7]
- Fasting insulin level or GTT with insulin levels (also called IGTT). Elevated insulin levels have been helpful to predict response to medication and may indicate women who will need higher dosages of metformin or the use of a second medication to significantly lower insulin levels. Elevated blood sugar and insulin values do not predict who responds to an insulin-lowering medication, low-glycemic diet, and exercise. Many women with normal levels may benefit from combination therapy. A hypoglycemic response in which the two-hour insulin level is higher and the blood sugar lower than fasting is consistent with insulin resistance. A mathematical derivation known as the HOMAI, calculated from the fasting values in glucose and insulin concentrations, allows a direct and moderately accurate measure of insulin sensitivity (glucose-level x insulin-level/22.5).[citation needed]
- Glucose tolerance testing (GTT) instead of fasting glucose can increase diagnosis of increased glucose tolerance and frank diabetes among patients with PCOS according to a prospective controlled trial.[31] While fasting glucose levels may remain within normal limits, oral glucose tests revealed that up to 38% of asymptomatic women with PCOS (versus 8.5% in the general population) actually had impaired glucose tolerance, 7.5% of those with frank diabetes according to ADA guidelines.[31]
Differential diagnosis[edit]
Other causes of irregular or absent menstruation and hirsutism, such as hypothyroidism, congenital adrenal hyperplasia (21-hydroxylase deficiency), Cushing's syndrome, hyperprolactinemia, androgen secreting neoplasms, and other pituitary or adrenal disorders, should be investigated.[7][21][26] PCOS has been reported in other insulin-resistant situations such as acromegaly.[citation needed]
Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of male hormones (androgens), particularly testosterone, by either one or a combination of the following (almost certainly combined with genetic susceptibility[15]):
- the release of excessive luteinizing hormone (LH) by the anterior pituitary gland[citation needed]
- through high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries are sensitive to this stimulus[9]
Alternatively or as well, reduced levels of sex-hormone binding globulin can result in increased free androgens.[citation needed]
The syndrome acquired its most widely used name due to the common sign on ultrasound examination of multiple (poly) ovarian cysts. These "cysts" are actually immature follicles, not cysts. The follicles have developed from primordial follicles, but the development has stopped ("arrested") at an early antral stage due to the disturbed ovarian function. The follicles may be oriented along the ovarian periphery, appearing as a 'string of pearls' on ultrasound examination.[citation needed]
Women with PCOS experience an increased frequency of hypothalamic GnRH pulses, which in turn results in an increase in the LH/FSH ratio.[32]
A majority of patients with PCOS have insulin resistance and/or are obese. Their elevated insulin levels contribute to or cause the abnormalities seen in the hypothalamic-pituitary-ovarian axis that lead to PCOS. Hyperinsulinemia increases GnRH pulse frequency, LH over FSH dominance, increased ovarian androgen production,[9] decreased follicular maturation, and decreased SHBG binding; all these steps contribute to the development of PCOS.[citation needed] Insulin resistance is a common finding among patients of normal weight as well as overweight patients.[7][12]
In many cases PCOS is characterised by a complex positive feedback loop of insulin resistance and hyperandrogenism. In most cases it can not be determined which (if any) of those two should be regarded causative. Experimental treatment with either antiandrogens or insulin sensitizing agents improves both hyperandrogenism and insulin resistance.[citation needed]
Adipose tissue possesses aromatase, an enzyme that converts androstenedione to estrone and testosterone to estradiol. The excess of adipose tissue in obese patients creates the paradox of having both excess androgens (which are responsible for hirsutism and virilization) and estrogens (which inhibits FSH via negative feedback).[33]
PCOS may be associated with chronic inflammation,[9][34] with several investigators correlating inflammatory mediators with anovulation and other PCOS symptoms.[35][36] Similarly, there seems to be a relation between PCOS and increased level of oxidative stress.[37]
It has previously been suggested that the excessive androgen production in PCOS could be caused by a decreased serum level of IGFBP-1, in turn increasing the level of free IGF-I which stimulates ovarian androgen production, but recent data concludes this mechanism to be unlikely.[38]
PCOS has also been associated with a specific FMR1 sub-genotype. The research suggests that women who have heterozygous-normal/low FMR1 have polycystic-like symptoms of excessive follicle-activity and hyperactive ovarian function.[39]
Medical treatment of PCOS is tailored to the patient's goals. Broadly, these may be considered under four categories:
- Lowering of insulin resistance levels
- Restoration of fertility
- Treatment of hirsutism or acne
- Restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer
In each of these areas, there is considerable debate as to the optimal treatment. One of the major reasons for this is the lack of large scale clinical trials comparing different treatments. Smaller trials tend to be less reliable and hence may produce conflicting results.
General interventions that help to reduce weight or insulin resistance can be beneficial for all these aims, because they address what is believed to be the underlying cause.
As PCOS appears to cause significant emotional distress, appropriate support may be useful.[40]
Where PCOS is associated with overweight or obesity, successful weight loss is the most effective method of restoring normal ovulation/menstruation, but many women find it very difficult to achieve and sustain significant weight loss. A scientific review in 2013 found similar decreases in weight and body composition and improvements in pregnancy rate, menstrual regularity, ovulation, hyperandrogenism, insulin resistance, lipids and quality of life to occur with weight loss independent of diet composition.[41] Still, a low GI diet, in which a significant part of total carbohydrates are obtained from fruit, vegetables and whole grain sources, has resulted in increased menstrual regularity than a macronutrient-matched healthy diet.[41] Vitamin D deficiency may play some role in the development of the metabolic syndrome, so treatment of any such deficiency is indicated.[42]
Reducing insulin resistance by improving insulin sensitivity through medications such as metformin, and the newer thiazolidinedione (glitazones), have been an obvious approach and initial studies seemed to show effectiveness.[9][42][43] Although metformin is not licensed for use in PCOS, the United Kingdom's National Institute for Health and Clinical Excellence recommended in 2004 that women with PCOS and a body mass index above 25 be given metformin when other therapy has failed to produce results.[44] However subsequent reviews in 2008 and 2009 have noted that randomised control trials have in general not shown the promise suggested by the early observational studies.[45][46]
Not all women with PCOS have difficulty becoming pregnant. For those who do, anovulation or infrequent ovulation is a common cause. Other factors include changed levels of gonadotropins, hyperandrogenemia and hyperinsulinemia.[47] Like women without PCOS, women with PCOS who are ovulating may be infertile due to other causes, such as tubal blockages due to a history of sexually transmitted diseases.
For overweight, anovulatory women with PCOS, weight loss and diet adjustments, especially to reduce the intake of simple carbohydrates, are associated with resumption of natural ovulation.
For those who after weight loss still are anovulatory or for anovulatory lean women, then the ovulation-inducing medications clomiphene citrate[42] and FSH are the principal treatments used to promote ovulation.[9] Previously, the anti-diabetes medication metformin was recommended treatment for anovulation,[9] but it appears less effective than clomiphene.[48]
For patients who do not respond to clomiphene, diet and lifestyle modification, there are options available including assisted reproductive technology procedures such as controlled ovarian hyperstimulation with follicle-stimulating hormone (FSH) injections followed by in vitro fertilisation (IVF).
Though surgery is not commonly performed, the polycystic ovaries can be treated with a laparoscopic procedure called "ovarian drilling" (puncture of 4–10 small follicles with electrocautery, laser, or biopsy needles), which often results in either resumption of spontaneous ovulations[42] or ovulations after adjuvant treatment with clomiphene or FSH.[citation needed] (Ovarian wedge resection is no longer used as much due to complications such as adhesions and the presence of frequently effective medications.) There are, however, concerns about the long-term effects of ovarian drilling on ovarian function.[42]
Hirsutism and acne[edit]
When appropriate (e.g. in women of child-bearing age who require contraception), a standard contraceptive pill is frequently effective in reducing hirsutism.[9][42] A common choice of contraceptive pill is one that contains cyproterone acetate; in the UK the available brands are Dianette/Diane. Cyproterone acetate is a progestogen with anti-androgen effects that block the action of male hormones that are believed to contribute to acne and the growth of unwanted facial and body hair.[citation needed] On the other hand, progestogens such as norgestrel and levonorgestrel should be avoided due to their androgenic effects.[42]
Other drugs with anti-androgen effects include flutamide[49] and spironolactone,[9][42] which can give some improvement in hirsutism. Spironolactone is probably the most-commonly used drug in the US. Metformin can reduce hirsutism, perhaps by reducing insulin resistance, and is often used if there are other features such as insulin resistance, diabetes or obesity that should also benefit from metformin. Eflornithine (Vaniqa) is a drug which is applied to the skin in cream form, and acts directly on the hair follicles to inhibit hair growth. It is usually applied to the face.[42] Medications that reduce acne by indirect hormonal effects also include ergot dopamine agonists such as bromocriptine.[citation needed] 5-alpha reductase inhibitors (such as finasteride and dutasteride) may also be used;[50] they work by blocking the conversion of testosterone to dihydrotestosterone (the latter of which is responsible for most hair growth alterations and androgenic acne).
Although these agents have shown significant efficacy in clinical trials (for oral contraceptives, in 60–100% of individuals[42]), the reduction in hair growth may not be enough to eliminate the social embarrassment of hirsutism, or the inconvenience of plucking or shaving. Individuals vary in their response to different therapies. It is usually worth trying other drug treatments if one does not work, but drug treatments do not work well for all individuals. For removal of facial hairs, electrolysis or laser treatments are – at least for some – faster and more efficient alternatives than the above mentioned medical therapies.[citation needed]
Menstrual irregularity and endometrial hyperplasia[edit]
If fertility is not the primary aim, then menstruation can usually be regulated with a contraceptive pill.[9][42] The purpose of regulating menstruation is essentially for the woman's convenience, and perhaps her sense of well-being; there is no medical requirement for regular periods, so long as they occur sufficiently often.
If a regular menstrual cycle is not desired, then therapy for an irregular cycle is not necessarily required. Most experts say that if a menstrual bleed occurs at least every three months, then the endometrium (womb lining) is being shed sufficiently often to prevent an increased risk of endometrial abnormalities or cancer.[51] If menstruation occurs less often or not at all, some form of progestogen replacement is recommended.[50] An alternative is oral progestogen taken at intervals (e.g. every three months) to induce a predictable menstrual bleeding.[9]
Alternative medicine[edit]
There is insufficient evidence to conclude an effect from D-chiro-inositol.[52] Myo-inositol however appears to be effective based on a systematic review.[53]
Women with PCOS are at risk for the following:
- Endometrial hyperplasia and endometrial cancer (cancer of the uterine lining) are possible, due to overaccumulation of uterine lining, and also lack of progesterone resulting in prolonged stimulation of uterine cells by estrogen.[9][19] It is not clear if this risk is directly due to the syndrome or from the associated obesity, hyperinsulinemia, and hyperandrogenism.[54][55][56][57]
- Insulin resistance/Type II diabetes.[9] A review published in 2010 concluded that women with PCOS had an elevated prevalence of insulin resistance and type II diabetes, even when controlling for body mass index (BMI).[19][58] PCOS also makes a woman, particularly if obese, prone to gestational diabetes.[9]
- High blood pressure, particularly if obese and/or during pregnancy[9]
- Depression/Depression with Anxiety[7][59]
- Dyslipidemia[9] – disorders of lipid metabolism — cholesterol and triglycerides. PCOS patients show decreased removal of atherosclerosis-inducing remnants, seemingly independent of insulin resistance/Type II diabetes.[60]
- Cardiovascular disease,[9][19] with a meta-analysis estimating a 2-fold risk of arterial disease for women with PCOS relative to women without PCOS, independent of BMI.[61]
- Strokes[19]
- Weight gain[9]
- Miscarriage[4][5]
- Sleep apnea, particularly if obesity is present[9]
- Non-alcoholic fatty liver disease, again particularly if obesity is present[9]
- Acanthosis nigricans (patches of darkened skin under the arms, in the groin area, on the back of the neck)[19]
- Autoimmune thyroiditis[62]
Early diagnosis and treatment may reduce the risk of some of these, such as type 2 diabetes and heart disease.[9]
The prevalence of PCOS depends on the choice of diagnostic criteria. The World Health Organization estimates that it affects 116 million women worldwide as of 2010 (3.4% of the women).[63] One community-based prevalence study using the Rotterdam criteria found that about 18% of women had PCOS, and that 70% of them were previously undiagnosed.[7]
One study in the United Kingdom concluded that the risk of PCOS development was higher in lesbian women than in heterosexuals.[64] However, two subsequent studies of women with PCOS have not replicated this finding.[65][66] Ultrasonographic findings of polycystic ovary are found in 8-25% of normal women.[67][68][69][70] 14% women on oral contraceptives are found to have polycystic ovary.[68]
The condition was first described in 1935 by American gynecologists Irving F. Stein, Sr. and Michael L. Leventhal, from whom its original name of Stein-Leventhal syndrome is taken.[18][19]
The earliest published description of a patient with what is now recognized as PCOS was in 1721 in Italy.[71] Cyst-related changes to the ovaries were described in 1844.[71]
Other names for this syndrome include polycystic ovary disease, functional ovarian hyperandrogenism, ovarian hyperthecosis, sclerocystic ovary syndrome, and Stein-Leventhal syndrome. The eponymous last option is the original name; it is now used, if at all, only for the subset of patients with all the symptoms of amenorrhea with infertility, hirsutism, and enlarged polycystic ovaries.[18]
Most common names for this disease derive from a typical finding on medical images, called a polycystic ovary.[9] A polycystic ovary has an abnormally large number of developing eggs visible near its surface,[18] looking like many small cysts[72] or a string of pearls.
See also[edit]
- Androgen-dependent syndromes
- PCOS Challenge (reality television series)
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- ^ Kumar Cotran Robbins: Basic Pathology 6th ed. / Saunders 1996
- ^ Thozhukat Sathyapalan; Stephen L. Atkin (2010). "Mediators of Inflammation in Polycystic Ovary Syndrome in Relation to Adiposity". Mediators of Inflammation (Hindawi) 2010: 758656. doi:10.1155/2010/758656. PMC 2852606. PMID 20396393.
- ^ Fukuoka M, Yasuda K, Fujiwara H, Kanzaki H, Mori T (1992). "Interactions between interferon gamma, tumour necrosis factor alpha, and interleukin-1 in modulating progesterone and oestradiol production by human luteinized granulosa cells in culture". Hum Reprod 7 (10): 1361–4. PMID 1291559.
- ^ González F, Rote N, Minium J, Kirwan J (2006). "Reactive oxygen species-induced oxidative stress in the development of insulin resistance and hyperandrogenism in polycystic ovary syndrome". J Clin Endocrinol Metab 91 (1): 336–40. doi:10.1210/jc.2005-1696. PMID 16249279.
- ^ Murri, Mora; Luque-Ramírez, Manual et al. (2013). "Circulating markers of oxidative stress and polycystic ovary syndrome (PCOS): a systematic review and meta-analysis". Hum. Reprod. Update 19 (3): 268–288. doi:10.1093/humupd/dms059. PMID 23303572.
- ^ Kelly, C. J.; Stenton, S. R.; Lashen, H. (2010). "Insulin-like growth factor binding protein-1 in PCOS: a systematic review and meta-analysis". Human Reproduction Update 17 (1): 4–16. doi:10.1093/humupd/dmq027. PMID 20634211.
- ^ Gleicher N, Weghofer A, Lee IH, Barad DH (2010). "FMR1 Genotype with Autoimmunity-Associated Polycystic Ovary-Like Phenotype and Decreased Pregnancy Chance". In Mailund, Thomas. PLoS ONE 5 (12): e15303. doi:10.1371/journal.pone.0015303. PMC 3002956. PMID 21179569.
- ^ Veltman-Verhulst SM, Boivin J, Eijkemans MJ, Fauser BJ (2012). "Emotional distress is a common risk in women with polycystic ovary syndrome: a systematic review and meta-analysis of 28 studies". Hum. Reprod. Update 18 (6): 638–51. doi:10.1093/humupd/dms029. PMID 22824735.
- ^ a b Moran, L. J.; Ko, H.; Misso, M.; Marsh, K.; Noakes, M.; Talbot, M.; Frearson, M.; Thondan, M.; Stepto, N.; Teede, H. J. (2013). "Dietary composition in the treatment of polycystic ovary syndrome: A systematic review to inform evidence-based guidelines". Human Reproduction Update 19 (5): 432. doi:10.1093/humupd/dmt015. PMID 23727939.
- ^ a b c d e f g h i j k "Polycystic Ovarian Syndrome Treatment & Management". eMedicine. 25 October 2011. Retrieved 19 November 2011.
- ^ Lord JM, Flight IHK, Norman RJ (2003). "Metformin in polycystic ovary syndrome: systematic review and meta-analysis". BMJ 327 (7421): 951–3. doi:10.1136/bmj.327.7421.951. PMC 259161. PMID 14576245.
- ^ National Institute for Health and Clinical Excellence. 11 Clinical guideline 11 : Fertility: assessment and treatment for people with fertility problems . London, 2004.
- ^ Balen A (December 2008). "Metformin therapy for the management of infertility in women with polycystic ovary syndrome" (PDF). Scientific Advisory Committee Opinion Paper 13. Royal College of Obstetricians and Gynaecologists. Retrieved 2009-12-13.
- ^ Leeman L, Acharya U (August 2009). "The use of metformin in the management of polycystic ovary syndrome and associated anovulatory infertility: the current evidence". J Obstet Gynaecol 29 (6): 467–72. doi:10.1080/01443610902829414. PMID 19697191.
- ^ Qiao, J.; Feng, H. L. (2010). "Extra- and intra-ovarian factors in polycystic ovary syndrome: impact on oocyte maturation and embryo developmental competence". Human Reproduction Update 17 (1): 17. doi:10.1093/humupd/dmq032. PMC 3001338. PMID 20639519.
- ^ Legro RS, Barnhart HX, Schlaff WD (2007). "Clomiphene, Metformin, or Both for Infertility in the Polycystic Ovary Syndrome". N Engl J Med 356 (6): 551–66. doi:10.1056/NEJMoa063971. PMID 17287476.
- ^ "Polycystic ovary syndrome – Treatment". United Kingdom: National Health Service. 17 October 2011. Retrieved 19 November 2011.
- ^ a b Richard Scott Lucidi (25 October 2011). "Polycystic Ovarian Syndrome Medication". eMedicine. Retrieved 19 November 2011.
- ^ "What are the health risks of PCOS?". Verity – PCOS Charity. Verity. 2011. Retrieved 21 November 2011.
- ^ Galazis, N; Galazi, M; Atiomo, W (2011 Apr). "D-Chiro-inositol and its significance in polycystic ovary syndrome: a systematic review". Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology 27 (4): 256–62. doi:10.3109/09513590.2010.538099. PMID 21142777.
- ^ Unfer, V; Carlomagno, G; Dante, G; Facchinetti, F (2012 Jul). "Effects of myo-inositol in women with PCOS: a systematic review of randomized controlled trials". Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology 28 (7): 509–15. doi:10.3109/09513590.2011.650660. PMID 22296306.
- ^ New MI (May 1993). "Nonclassical congenital adrenal hyperplasia and the polycystic ovarian syndrome". Annals of the New York Academy of Sciences 687 (1 Intraovarian): 193–205. doi:10.1111/j.1749-6632.1993.tb43866.x. PMID 8323173.
- ^ Hardiman P, Pillay OC, Atiomo W (May 2003). "Polycystic ovary syndrome and endometrial carcinoma". Lancet 361 (9371): 1810–2. doi:10.1016/S0140-6736(03)13409-5. PMID 12781553.
- ^ Mather KJ, Kwan F, Corenblum B (January 2000). "Hyperinsulinemia in polycystic ovary syndrome correlates with increased cardiovascular risk independent of obesity". Fertility and Sterility 73 (1): 150–6. doi:10.1016/S0015-0282(99)00468-9. PMID 10632431.
- ^ Unfer V, Zacchè M, Serafini A, Redaelli A, Papaleo E (October 2008). "Treatment of hyperandrogenism and hyperinsulinemia in PCOS patients with essential amino acids. A pilot clinical study". Minerva ginecologica 60 (5): 363–8. PMID 18854802.
- ^ Moran LJ, Misso ML, Wild RA, Norman RJ (May 2010). "Impaired glucose tolerance, type 2 diabetes and metabolic syndrome in polycystic ovary syndrome: a systematic review and meta-analysis". Hum Reprod Update 16 (4): 347–63. doi:10.1093/humupd/dmq001. PMID 20159883.
- ^ Barry JA, Kuczmierzyck, AR, Hardiman, PJ (July 2011). "Anxiety and depression in polycystic ovary syndrome: a systematic review and meta-analysis". Hum. Reprod. 93 (6): 1948–56. doi:10.1093/humrep/der197. PMID 21725075.
- ^ Rocha MP, Maranhão RC, Seydell TM et al. (April 2010). "Metabolism of triglyceride-rich lipoproteins and lipid transfer to high-density lipoprotein in young obese and normal-weight patients with polycystic ovary syndrome". Fertil. Steril. 93 (6): 1948–56. doi:10.1016/j.fertnstert.2008.12.044. PMID 19765700.
- ^ De Groot, P. C. M.; Dekkers, O. M.; Romijn, J. A.; Dieben, S. W. M.; Helmerhorst, F. M. (2011). "PCOS, coronary heart disease, stroke and the influence of obesity: A systematic review and meta-analysis". Human Reproduction Update 17 (4): 495–500. doi:10.1093/humupd/dmr001. PMID 21335359.
- ^ Troischt MJ, Mehlman TR, and Nield LS (November 1, 2008). "Polycystic Ovary Syndrome: An Intriguing Diagnosis". Consultant for Pediatricians.
- ^ Vos, T; Flaxman, AD; Naghavi, M; Lozano, R; Michaud, C; Ezzati, M; Shibuya, K; Salomon, JA et al. (2012 Dec 15). "Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010". Lancet 380 (9859): 2163–96. doi:10.1016/S0140-6736(12)61729-2. PMID 23245607.
- ^ Agrawal R, Sharma S, Bekir J, Conway G, Bailey J, Balen AH, Prelevic G. (2004). "Prevalence of polycystic ovaries and polycystic ovary syndrome in lesbian women compared with heterosexual women". J Fertil Steril 82 (5): 1352–1357. doi:10.1016/j.fertnstert.2004.04.041. PMID 15533359.
- ^ De Sutter P, Dutré T, Vanden Meerschaut F, Stuyver I, Van Maele G, Dhont M (September 2008). "PCOS in lesbian and heterosexual women treated with artificial donor insemination". Reprod. Biomed. Online 17 (3): 398–402. doi:10.1016/S1472-6483(10)60224-6. PMID 18765011.
- ^ Smith HA, Markovic N, Matthews AK et al. (2011). "A comparison of polycystic ovary syndrome and related factors between lesbian and heterosexual women". Womens Health Issues 21 (3): 191–8. doi:10.1016/j.whi.2010.11.001. PMID 21310628.
- ^ Polson, DW; Adams, J; Wadsworth, J; Franks, S (1988 Apr 16). "Polycystic ovaries--a common finding in normal women". Lancet 1 (8590): 870–2. PMID 2895373.
- ^ a b Clayton, RN; Ogden, V; Hodgkinson, J; Worswick, L; Rodin, DA; Dyer, S; Meade, TW (1992 Aug). "How common are polycystic ovaries in normal women and what is their significance for the fertility of the population?". Clinical endocrinology 37 (2): 127–34. doi:10.1111/j.1365-2265.1992.tb02296.x. PMID 1395063.
- ^ Farquhar, CM; Birdsall, M; Manning, P; Mitchell, JM; France, JT (1994 Feb). "The prevalence of polycystic ovaries on ultrasound scanning in a population of randomly selected women". The Australian & New Zealand journal of obstetrics & gynaecology 34 (1): 67–72. doi:10.1111/j.1479-828X.1994.tb01041.x. PMID 8053879.
- ^ van Santbrink, EJ; Hop, WC; Fauser, BC (1997 Mar). "Classification of normogonadotropic infertility: polycystic ovaries diagnosed by ultrasound versus endocrine characteristics of polycystic ovary syndrome". Fertility and Sterility 67 (3): 452–8. doi:10.1016/S0015-0282(97)80068-4. PMID 9091329.
- ^ a b Kovacs, Gabor T.; Norman, Robert (2007-02-22). Polycystic Ovary Syndrome. Cambridge University Press. p. 4. ISBN 9781139462037. Retrieved 29 March 2013.
- ^ "What is Polycystic Ovary Syndrome (PCOS)?". Verity – PCOS Charity. Verity. 2011. Retrieved 21 November 2011.
External links[edit]


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SARATOGA, Calif., Sept. 12, 2013 /PRNewswire/ -- Acclaimed fast casual brand, Fuddruckers, is expanding its footprint in Southern California through a new franchise development partnership with Keilah LLC. Under the direction of principal, Oscar Bakhtiari, Keilah LLC is set to open ten new homes for the "World's Greatest Hamburgers" throughout Orange County over the next several years. The first is slated to debut by early 2015.
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About Luby's, Inc.
Luby's, Inc. operates restaurants under the brands Luby's Cafeteria, Fuddruckers and Cheeseburger in Paradise and provides food service management through its Luby's Culinary Services division. The company-operated restaurants include 92 Luby's cafeterias, 63 Fuddruckers restaurants, 23 Cheeseburger in Paradise full service restaurants and bars, two Koo Koo Roo Chicken Bistros, and one Bob Luby's Seafood Grill. Its 93 Luby's cafeterias are located throughout Texas and other states. Its Fuddruckers restaurants include 63 company-operated locations and 116 franchises across the United States (including Puerto Rico), Canada, and Mexico. Luby's Culinary Services provides food service management to 18 sites consisting of healthcare, higher education and corporate dining locations.
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My Very First Art Books
My very first art book
- A fantastic book filled with famous works of art accompanied by simple art activities using some of the same techniques as the artists.
- Activities include salt dough sculptures, printed flowers and fingerpaint fish, alongside art by Rembrandt, Rousseau, Kandinsky, Matisse and Picasso.
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Price: $15.95 | ISBN: 9781409522850Available


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A while ago I posted a short greasemonkey script to make saving a Stanford class video to disk a little easier. I've cleaned it up a little and posted in on userscripts.org as the Stanford Video MMS Commander. Same disclaimers as before apply, namely, this script is not to be used in any way to help violate Stanford's terms and conditions.
Stanford has a lot of their lectures online. To access them, you've got to have… access! That means you need to already have an SUNet ID with proper permissions. The standard way to get those permissions is to apply to Stanford, get accepted, and start paying Stanford lots of $$$.
Stanford doesn't want these lectures to get out on the open internet. So they do a few things to try to ensure that doesn't happen. First, part of Stanford's terms of use is that you will not redistribute their lectures. Note that the concepts and code I'm showing you here in this post could be used to help you illegally redistribute their lectures. I do not condone any such illegal use. By using the the concepts and code in this post in any way whatsoever (including just reading this post), you agree to follow Stanford's terms of use.. If you don't agree to these terms, please leave now.
In addition to their terms of use, Stanford places a more practical barrier in the way of illegal redistribution of their lectures – they only distribute their lectures as streaming WMV and Sliverlight. Now this sucks for me, the legal end-user, for a number of reasons. Most importantly, this means I need a high-bandwidth connection to watch my lectures. I can't watch them offline.
Enter MEncoder and Greasemonkey.
To save a lecture to disk for offline viewing, the basic command you want to run is:
mencoder mms://the-streaming-video.wmv -ovc copy -oac copy -O filename_out.avi
Now the 'path-to-streaming-video.wmv' you need to use will be unique for your authenticated SUNet session with Stanford's servers. You can manually find this unique path by navigating with your browser to the lecture you're interested in, viewing the source of the page, and manually scanning for the path. Or you can install the following small and simple Greasemonkey script.
// ==UserScript== // @name Stanford Video MMS Path Retriever // @copyright 2010, Mike Fogel, http://fogel.ca // @license This SW may not be used to violate Stanford's terms of use. // @namespace http://fogel.ca/greasemonkey // @description Adds a header containing mms path to Stanford player page. // @include https://myvideosu.stanford.edu/player/slplayer.aspx* // ==/UserScript== function get_mms_path() { var o = document.getElementById('WMPlayer'); return 'mms' + o.data.substring('http'.length); } function add_header(message) { var elem = document.createElement('div'); elem.id = 'GM_mms_path'; elem.style.color = 'green'; elem.innerHTML = '<h2>'+message+'</h2>'; document.body.insertBefore(elem, document.body.firstChild); return elem; } function set_selection(hdr) { var range = document.createRange(); range.selectNodeContents(hdr.firstChild); selection = window.getSelection(); selection.removeAllRanges(); selection.addRange(range); } function main() { var mms = get_mms_path(); var hdr = add_header(mms); set_selection(hdr); } main();
The Greasemonkey script scrapes the page, finds the 'path-to-streaming-video.wmv', adds it in large, bright green text to the top of the page, and selects it so you can just hit 'cntrl-c' to copy it to your clipboard. Then over in a terminal, you can paste that path into your MEncoder command. Running the command will take a long time – in fact, as long as the lecture is. This is because MEncoder simulates a regular streaming video player to the Stanford servers. MEncoder will convert and save the streaming video according the the suffix of the output filename you specify (eg. '.avi' in my above example).


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Throwback Thursday: Spiced Pork Tenderloin w/ Sauteed Apples
There is something peculiar about combining sweet and salty flavors. I used to find my self being skeptical about pairing strange flavors, but recently they have really begun to intrigue me. Pork and apples is an old favorite combination of … Continue reading
Posted in Main Course, Meat, Recipes
Tagged apple, dinner, pork, recipe, shallots, spiced, tenderloin, throwback thursday
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I'm in a debate with a christian, he can't seem to understand how easy it is to make vague predictions and apply them to anything. Are there any links that have a list of unfulfilled prophecies? Any…Continue
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I need some easy to comprehend books on evolution and the big bang. I haven't learned much about evolution or the big bang, so I need something that is meant to teach people who are just learning…Continue
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The message I got from this wasn't that people who abstain are retarded. The message I got from this was that people who abstain because the media tells them that they'll get cancer are…Continue
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Yu-Gi-Oh Card Camp
Week of August 27 - 31
For kids in grades 1- 9
Students provide lunch, beverage, and snacks.
Director: Eileen Bigham.
Enroll one camper in 4 or more full day camps in one transaction and receive 10% off each camp. For online registration, discount is applied at check out.Full day camps include Science Camps, Green Adventures, Pre-Teen Camps, TNT on the Go, Drama, Cartoon and Comics, Dance, Drama and Art Camp, Little Bands Camp and the following Literature and Enrichment Camps: Writing, Essays and Grammar Made Fun, Poetry, Science, Chess, New! The Hobbit, Circus, Star Wars, Japanese Anime, Harry Potter, Virtual Restaurant, Yu-Gi-Oh Card, Kidconomics, and Summer Math Explosion.


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1 Meetup Group matches "Hsing-I" near Wake Forest, NC
This is a group for practitioners of the internal martial arts. Pa Kua, Hsing I, Tai Chi, or one of the lesser known styles. Other martial artists and beginners with in interest in the internal styles are welcome to join as well. I am using this as my vehicle to promote my classes, but other competent martial artists are also welcome to promote their classes, events, and seminars through this. I'm hoping to see this become one more hub in the thriving martial arts community that is developing i …
Get an alert email when new Meetup Groups like this start near you.
You'll get advice, help finding members, and tools to make running a Meetup Group easier.


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Hostel Events Summer 2013
Take advantage of our weekly events to accentuate your Chicago experience…
*Monday Night Blues Bar Outing…follow us to the northside blues mecca, Kingston Mines, we will get you in for FREE and enjoy some excellent live performances. Good food, good drinks, and darn good blues. Slip on your dancing shoes and meet us in the lobby at 8:45pm, we'll go as a group.


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Sea View Bungalows are clean, new, and really lovely. It is a very relaxing place to stay, with ocean views, a close... More Info »
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Iran gains power in Latin America as Obama administration looks on; a brave leader speaks
Posted on Wednesday, September 19, 2012 at 06:44 PM
Recent Posts
- Dispelling liberal myths, the Tea Party is not racist and the right is not the realm of homophobes and misogynists
- Sean Hannity shows generosity, pays Obamacare worker fired for talking to him
- A country that does not control its borders….Is no longer a country
- Republicans can say 'we told you so' as Obamacare is inflicted on America
- The House Republicans are the adults in the room when it comes to debt talks
Bolivia's Evo Morales w/Irans Ahmadinejad |
With little notice in the main stream media, Iran has been cementing it's relationships with regimes in Venezuela & Bolivia, both countries under the control of strongmen friendly to communism. Iran is a main funder of terrorism throughout the world, For them to gain a foothold in Latin America, does not bode well for peace in our hemisphere.
Recently I spoke with Bolivian elected representative Senator Carmen Gonzales. She has had the courage to stand up and speak out about the repression besetting her country and it's ever closer alliances with Iran. She has been the object of continual harassment by the government for her vocal opposition; including being buried in lawsuits (18) designed to silence her.
Tell us about Iran's influence in Bolivia?
The influence of the Iranian theocracy in Bolivia is very wide and deep. Iran has inked many agreements with Bolivia, both known and unknown to the Bolivian people. I have demanded to know the extent of these agreements, but as of yet there has been no response from the leadership. Iran is interested in our mining industry, gas and uranium. Iran is interested in expanding its influence in Latin America, to provoke the United States. It is very advantageous to Iran to have the friendship of the Bolivian regime, with all of its natural resources, including uranium and being strategically placed in the center of the continent.
Sen. Gonzalez |
Recently Canada withdrew its embassy in Tehran in a clear sign that the civilized world will not tolerate the authoritarian practices of undemocratic and abusive Iran.
I am also worried as a Bolivian ,what may happen to the Jewish community here.
Recently, the Iranian defense minister was with our ruler, Evo Morales. That same minister is under orders for international prosecution, accused by an Argentine federal judge to be part of the deaths of hundreds of Jewish-Argentine AMIA (Asociación Mutual Israelita Argentina in 1994).
So, it is very dangerous for the Jewish community the fact that Bolivia has relations with Iran.
How do you see Iran's influence shaping up in Latin America?
Our ruler Evo Morales hates everything that has to do with democracy, modernity and definitely hates the United States and what it represents. He and his regime have been dubbed the Taliban of the Andes and he himself is referred to as the Fidel Castro of the Andes. In 2008 he expelled the U.S. ambassador, Mr Philippe Golberg, in a clear sign that the Bolivian regime hates the U.S.
Since Bolivian leadership has signed agreements with Iran as well as Venezuela, there is clear worry that these countries can serve as bases for terrorist activities against neighboring countries and become a springboard for jihadism. With Iran racing toward nuclear weapons capability, there is no doubt in many circles, that technology can filter to enemies of the US. The exporting of nuclear weapons technology to Latin America would cause huge political disruption to this region.
What can be done about this:
In Bolivia we do not like communism and citizens realized the mistake they made by giving the vote to Evo Morales in the last elections. Morales's agenda is the same agenda as Che Guevara: Establish a dictatorship the same style as Cuba. Che Guevara tried that here and we killed him for it. Morales came to power cheating the people of Bolivia, lying that he would "change the system."
I hope the Morales regime does not change the Constitution. In 2014 we are going to vote against him, and fire him from the Presidency. But only if he doesn't change the constitution, like his ally Hugo Chavez did in Venezuela. Legally speaking, he cannot run for the Presidency again. We hope the people of the US see what is happening here and lend us their support.
The US is coming face to face with a decision about what to do with Iran's race towards nuclear capability. A nuclear capable Iran not only means a threat to our allies in the mideast, it most surely means a threat to our friends and allies in Latin America.
The most unique gifts: Time capsules in American and world history: lifemagforsale. com
The most unique gifts: Time capsules in American and world history: lifemagforsale.
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For a refreshing change visit Tea Party Cheer7 comments
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WoundedKnee | Sep 24, 2012, 03:30 PM EDT
Hey, Farnan and Monsoonman: Check your bedrooms well tonite. You both have Reds under your beds.
Report abuse
Monsoonman | Sep 23, 2012, 04:09 PM EDT
I don't know who bolivian 92 is, must be someone close to the marxist regime of Bolivia, or maybe another communist thug/narco state. but I checked out Sen Gonzalez and she is real and everything else in this article is true. ANY intelligent freedom loving person would reject being associated with the terrorist leadership of iran.
Report abuse
bolivian92 | Sep 21, 2012, 05:35 PM EDT
ok first of all everything in this article is a lie.
That women is not a bolivian senator shes a legastive member, Evo is one of the most democratic presidents bolivia has ever had. Evo isnt a thug a thug is someone who is living in the united states right now and the u.s refuses to extradite him its Gonzales Sanchez DE lozada google him look what american democracy brought to bolivia.
the one whos dilusional is you my friend iran and bolivia work together on infrastracture and minerals please stop spreading lies about our small and poor but great country
Report abuse
Monsoonman | Sep 20, 2012, 05:46 PM EDT
Unbalanced, fascist diatribe? So you are calling the brave woman in this article a fascist for sounding the alarm about her country being hijacked by a thug dictator and inviting in the Iranians to harvest their uranium/spread their jihadist mischief in Latin America? YOU are delusional.
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merefalow | Sep 20, 2012, 05:07 PM EDT
provocative scaremongering,domino effect bomb the hell out of anyone who dances differently,i dont like muslim theocratic politics but i sometimes wonder listening to this sort of fascist diatribe,who is the MOST unbalanced and dangerous.
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WoundedKnee | Sep 20, 2012, 03:29 PM EDT
What a crazy nut Farnan is! Last week he was given space to print the ravings of some Israeli warmonger and psychopath, this week he is telling us that Iran is going to launch nuclear bombs against Paraguay and Chile. Estas mas loco que una cabra, Farnan. O un cabron.
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DaddyMac22 | Sep 20, 2012, 09:18 AM EDT
Can't wait to see your take on the Mitt hitting the fan this week!! Obama now 1/4 to win election, chuckle!
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The Eighth Commandment |
Mary Lou "Dunk" Bateson is charged with stealing a greek coin whose dispatch from owner to auction house she was overseeing. With the help of two men she determines to find the coin and absolve herself. This book takes you inside the world of the rich and depraved, seen through the eyes of a small town girl. ...
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A product of the imagination—and iron will—of Peter the Great, the city is a busy tableau of architectural whimsies (Neoclassical colonnades, palaces of yellow and mint green). Peter envisioned his imperial capital as a window into Europe, and it has long been a center of culture and sophistication, with some of the world's best art and ballet. The Soviet years were hard on St. Petersburg, and its ties with Europe were cause for official suspicion—and neglect. Ever since native son Vladimir Putin took office, however, the city has been getting a face-lift. Streets are newly landscaped, and a $2 billion refurbishment of the urban center—sparked by the 2003 tercentennial celebration—has created a flashy backdrop for the nouveau-riche residents.
Don't Miss
Dining on Russian cuisine—hearty borscht served with fluffy garlic rolls, anyone?—at Na Zdorovye!, an unassuming restaurant decorated with farming tools and wooden matryoshka dolls.
Hunting for Soviet-era propaganda posters with phrases such as "Keep quiet!", "Don't drinks!", and "Work harder!" at DVK, a local bookstore.
Climbing up the 250 steps to the colonnade of the dome at St. Isaac's Cathedral for 360-degree views of the canal-filled city.


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Results 11 to 13 of 13
Thread: engine temperature too low?
My truck started doing the same thing last week. It has been in the 20's here. I installed a new thermostat and all is well.
1995 Silverado 4x4
6" BDS Suspension Lift-3" Body Lift-Add A Leaf in rear -Trailmaster SSV Shocks-Duel Steering Stabilizer Kit -AirAid Cold air intake-
4.56 Gears with Detroit Auburn Locker-Pro-Comp Traction Bars with duel shocks-Aluminum Skid Plate Kit-38.5" x 16.5" Mickey Thompson Baja Claws-Constant Dropping fuel gauge
2005 Yukon XL Jet Power Programmer, Bilstein Shocks, Bilstein rear springs, Helwig Anti-sway bars, EGR Window Visors, EGR Hood Shield, Denali Headlights, Headlight harness upgrade, GE NightHawk Bulbs, White Night Rear lighting system http://www.gmtruckclub.com/forum/sho...5-GMC-Yukon-XL
2002 Silverado ext cab 2wd (Sold)
2003 Yukon XL (Totaled)
03-26-2013, 12:33 AM #122000 Chevrolet Silverado
4.3L V6, 4L60E, 2WD, Single Cab
Airaid CAI
Poweraid TB Spacer
Flowmaster 10-series exhaust (dumped)
Edge CS insight monitor
4.10 gears
Limited-slip differential
LS-1 Dual Electric fans
Corvette tranny servo swap
Head Unit: Alpine
Speakers: Alpine SPR-60C 6.5" component set, 4X6 Infinity Kappas
Subs: 2-12" Kicker CVT's
Amps: Alpine-M1000 (subs), Alpine MRX-F65 (Speakers)
305/70R16 NITTO Terra Grapplers
16" PROCOMP 7089'sSuspension:
2" leveling kit
3" Fabtech Spindle Lift Kit
Front/Rear-Bilstein 5100 shocks
35W HID Low Beams
RECON LED smoked roof cab lights
HELLA LED taillights and 3rd brakelight
HELLA FF-75 Aux. Reverse Lamps
RIGID dually D2, flush mount, wide beam
Hawk HPS Brake pads
Russell braided steel brake lines
Powerstop-red powdercoated brake calipers
Powerslot Cryo brake rotors
EGR in-channel window visors
03-26-2013, 12:36 AM #13186 is the factory spec for my yukon xl. So, I got a 186. It took me about 5 minuted to install.
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Welcome to Roy Arias Studios & Theaters! We are conveniently located in the heart of the Theater District of New York. We are home to numerous performance and multiple use spaces designed to fit the needs of the emerging artist and the seasoned professional. Here you will find the most unique performance and multiple use venues. Here at Roy Arias Studios & Theaters we acknowledge the difficulties in finding quality space. As we continue to expand, we are constantly creating and developing new spaces to provide the best in customer service. Non-profit rates are also available for daily and weekly rentals. Performances can be held in the Payan Theater (50 seats), Off-Off Broadway Playhouse (50 Flexible seats), Roy Arias Stage IV (74 Seats) and the Off Broadway Theater (99 to 130 seats).
If You Are Interested In Renting Any Of Our Stages, Please Contact Us Today For A Free Estimate At 212-957-8358!
Here at Roy Arias Studios & Theater our staff consists of industry professionals who share a special passion, and a love of the arts. Our theatres have housed many exciting professional productions including Off Off Broadway, Showcases, Backer's Auditions, Readings, Parties, Plays, and Fashion Shows. We are also home to several prominent acting teachers, dance companies, and corporate meetings. Most of our studios and theatres are located within a few short blocks of Port Authority, Penn Station, and most major subway lines…the accessibility is endless. All of our facilities are also handicap accessible.


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You're watching...
Online Lectures Help People Get Excited About Learning
Khan Academy founder Salman Khan on the success of his online educational lectures.
Feb 8, 2013
You're watching...
Khan Academy founder Salman Khan on the success of his online educational lectures.
Feb 8, 2013
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-- your kids have a good teacher.
How do you know.
And it teacher next door -- better maybe there's a better teacher and another state.
There's -- world's best teacher or several.
Wouldn't be greedy here kits could have -- teacher.
Well today yes UK.
Yeah I -- along.
I have yeah.
These kids are this excited about a man who went so.
The -- negative four minus war and we are.
Done talking outlawed it's five years ago hedge fund analyst sale concrete videos like these to tutor his -- -- worked out well also the third -- very her Brothers and more cousins and all the rest and I had to do the same lecture over and over again it's not a friend who who said -- -- lot of you put some of your lectures on YouTube I decided he could give it a shot.
Welcome to the presentation on basic addition soon.
Watched his lectures.
-- are getting letters from people and -- comments on YouTube and they are they're not like hey I think this kind of might have helped on my math exam -- like.
I got I failed calculus the first time I start watching videos now I'm -- the class.
The -- numbers kept rising and he got letters from the middle East Africa.
We'll talk com has done it's amazing.
Now -- and it's funded by Bill Gates and he offers web lectures on everything from history economics and computer science.
Is videos are viewed.
Millions of time.
Not only is it reaching millions of students right now but even if god forbid I got -- for by -- -- when I walked outside.
It'll still be able to reach millions of and maybe eventually billions of students you just happen to be good -- Oprah -- that is coupled with the -- It is a compliment he's a great teacher I hope that helps see in the next via.
Long it's exciting that he gets kids so excited about me ask.
In most parts of life things gotten much better cars computers cellphones.
Education worked so -- Right you know you we -- out of an eighty year nine year hundred years and you would have the local band of you know if you if you had a party that that ultimately could get that each village might have -- Hillary -- exactly clear exactly with a what you have mass media coming out -- -- -- that way while we take the best musician the best actor.
The best storyteller in whatever way and recorded and put it out on radio pointed out on on the records or you know whatever and I think.
That there that could've happened with -- education before but it hasn't even for basic math multiplication tables I thought they using video games.
There's a huge bureaucracy most of which wants to say -- to change the system blob yet solved if the blob and it is -- and I think what's.
-- from our point of view is that we are able to reach students.
Outside of the -- This California school district started using concert videos and fifth grade classroom.
The teachers were skeptical but now there -- impressed it -- it does for the kids.
They're happy to walk in the door every morning excited about -- it isn't.
In -- that they -- my god you know this yeah.
We assume that.
Most people on their own people wanna do don't want -- -- -- don't wanna get engaged in mathematics and but -- I think that is frustrated because there there is that most of them are in classrooms that are not catering to them.
At first teachers worried that the online instruction could replace them.
I think -- so Ron has my teachers would tell you they have -- more math than they've ever -- before now teachers can tutor kids one and loan.
And and his humor and send him to win.
Back from.
I -- -- because kids can go at their own pace but that's students who are still working on is not application.
And then -- -- -- has whom some kids enjoy cons listens so much.
They study at home some of them are doing two in three hours a night at home when I'm asking for fifteen minute banana.
-- -- -- Spot on.
So finally after all these years of kids being bored in school in that learning math that's over.
I've I think it might be hopes.
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Tyler White's unforgettable time with Carl Froch
Live this weekend: Aston Villa v Man Utd
Thierry Henry talked Arsenal, Ronaldo, Messi and more on our Champions League coverage.
How F1 history would have been different had double points always been awarded at the final GP.
Follow the latest from the written press with the best gossip and speculation from the papers.
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I'd be tempted to pick Boyd Rankin for what will be a high-intensity Test on a traditional WACA pitch.
Napoli boss Rafael Benitez has shown Arsenal's Premier League title rivals how to stretch the Gunners, says Jamie Redknapp.
Thierry Henry was our special guest on our Champions League coverage on Wednesday night and had plenty to say on all sorts of football topics. Take a look back at the Premier League legend's thoughts about former club Arsenal, Mesut Ozil, Lionel Messi and much more...


text: What's Hot 2013 Gift Ideas Fittest Celebs Watch Snob GALLERIES Robert Downey Jr. Pics 0 94 Back to Top ▲ Robert Downey Jr. Pics Robert Downey Jr. Pics AskMen Editors Ten years ago, the idea of Robert Downey Jr. playing a superhero in a major motion picture seemed ludicrous, unless his special powers revolved around obsessive cocaine abuse and an acute ability to get arrested while barefoot. Long considered one of the most gifted actors of his generation, Robert Downey Jr.'s career has always been saddled with the dichotomy of talent versus weakness; his... Continue reading Robert Downey Jr.'s profile. Next Page


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Good day Naturopathic Doctor!
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