What is the diagnosis and treatment approach for a patient suspected of having Polycystic Ovary Syndrome (PCOS)?

From the Guidelines

Polycystic Ovary Syndrome (PCOS) diagnosis and treatment should be approached with a comprehensive evaluation, including clinical, biochemical, and imaging findings, with treatment tailored to the patient's symptoms and reproductive goals, as recommended by the most recent guidelines 1.

Diagnosis

Diagnosis requires at least two of the following three criteria: oligo/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasound. Initial evaluation should include a thorough history, physical examination, and laboratory tests including:

• Total testosterone
• Free testosterone
• DHEAS
• Androstenedione
• Fasting glucose
• Insulin
• Lipid panel
• Thyroid function tests

Treatment

Treatment focuses on managing symptoms and preventing long-term complications. For patients not seeking pregnancy,

• Combined oral contraceptives (like ethinyl estradiol 20-35 mcg with drospirenone or norethindrone) regulate menstrual cycles and reduce androgen levels.
• Metformin (starting at 500 mg daily, increasing to 1500-2000 mg daily in divided doses) improves insulin sensitivity and may help with weight management.
• For hirsutism, spironolactone (50-200 mg daily) can be added. Lifestyle modifications, including weight loss of 5-10% through diet and exercise, are fundamental to treatment, as supported by recent studies 1.

Fertility Treatment

For patients desiring pregnancy,

• Ovulation induction with letrozole (2.5-7.5 mg daily for 5 days) is first-line, with clomiphene citrate as an alternative, as per recent guidelines 1. Regular monitoring for metabolic complications is essential, as PCOS increases risks for type 2 diabetes, cardiovascular disease, and endometrial cancer, highlighting the importance of a multifaceted approach that addresses both immediate symptoms and long-term health concerns associated with PCOS 1.

From the FDA Drug Label

The workup and treatment of candidates for clomiphene citrate therapy should be supervised by physicians experienced in management of gynecologic or endocrine disorders. Patients should be chosen for therapy with clomiphene citrate only after careful diagnostic evaluation The plan of therapy should be outlined in advance Impediments to achieving the goal of therapy must be excluded or adequately treated before beginning clomiphene citrate. Patients with polycystic ovary syndrome who are unusually sensitive to gonadotropin may have an exaggerated response to usual doses of clomiphene citrate.

The diagnosis and treatment approach for a patient suspected of having Polycystic Ovary Syndrome (PCOS) should be supervised by physicians experienced in management of gynecologic or endocrine disorders.

• A careful diagnostic evaluation should be performed to exclude impediments to achieving pregnancy.
• The treatment plan should be outlined in advance, and the patient should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy.
• Patients with PCOS should be monitored for signs of ovarian hyperstimulation syndrome (OHSS), and the dosage or duration of the next course should be reduced if ovarian enlargement occurs 2, 2, 2.

From the Research

Diagnosis of Polycystic Ovary Syndrome (PCOS)

• The diagnosis of PCOS is based on the presence of at least two of the following features: androgen excess, menstrual irregularity, and polycystic ovary appearance on ultrasound (PCO), after other causes of hyperandrogenism and dysovulation are excluded 3.
• The Rotterdam criteria are widely used for diagnosis, which require that patients have at least two of the following conditions: hyperandrogenism, ovulatory dysfunction, and polycystic ovaries 4.
• There are four recognized phenotypes of PCOS, each with different long-term health and metabolic implications 5.

Treatment Approach for PCOS

• The main interventions to minimize cardiovascular and metabolic risks in PCOS are lifestyle changes, pharmacological therapy, and bariatric surgery 3.
• Treatment with metformin has been shown to improve insulin sensitivity, lowering blood glucose and androgen levels 3.
• Weight loss through dietary modifications and exercise is recommended for patients with PCOS who are overweight 4.
• Oral contraceptives are the first-line treatment for regulating menstrual cycles and reducing manifestations of hyperandrogenism, such as acne and hirsutism 4.
• Clomiphene is the first-line drug for management of anovulatory infertility 4.
• Therapeutic decisions in PCOS depend on the patients' phenotype, concerns, and goals, and should focus on suppressing and counteracting androgen secretion and action, improving metabolic status, and improving fertility 5.

Management of Metabolic Abnormalities

• PCOS women present higher risk for type 2 diabetes and higher prevalence of cardiovascular risk factors 3.
• Insulin resistance is almost always present in women with PCOS, regardless of weight, and they often develop diabetes and metabolic syndrome 4.
• Metformin is recommended for metabolic abnormalities such as prediabetes 4.
• A statin should be prescribed for cardioprotection if the patient meets standard criteria for statin therapy 4.