What is the typical workup and management for Polycystic Ovary Syndrome (PCOS)?

From the Guidelines

The workup and management for Polycystic Ovary Syndrome (PCOS) should prioritize lifestyle modifications, including a weight loss of 5-10% for overweight patients, as this has been shown to improve many symptoms of PCOS, including menstrual irregularity, hyperandrogenism, and insulin resistance 1.

Key Components of Workup and Management

• Diagnosis requires at least two of three Rotterdam criteria: oligo/anovulation, clinical/biochemical hyperandrogenism, and polycystic ovaries on ultrasound.
• Initial laboratory tests should include total testosterone, free testosterone, DHEAS, androstenedione, TSH, prolactin, 17-hydroxyprogesterone, and fasting glucose/insulin or hemoglobin A1c to rule out other conditions.
• Transvaginal ultrasound may reveal multiple small follicles in the ovaries.
• Management focuses on addressing specific patient concerns and includes:
  • Lifestyle modifications with weight loss of 5-10% for overweight patients.
  • For menstrual irregularity, combined oral contraceptives (e.g., ethinyl estradiol 20-35 mcg with progestin) are first-line therapy.
  • Alternatively, cyclic progestins like medroxyprogesterone acetate 10 mg daily for 10-14 days monthly can be used.
  • For hyperandrogenism symptoms, spironolactone 50-200 mg daily is effective for hirsutism and acne, with results typically seen after 6 months.
  • Metformin 500-2000 mg daily improves insulin sensitivity and may help with weight management and ovulation.
  • For fertility concerns, letrozole 2.5-7.5 mg daily on cycle days 3-7 is preferred over clomiphene citrate.

Additional Considerations

• Regular screening for metabolic complications is essential, including lipid profiles, glucose tolerance tests, and blood pressure monitoring, as PCOS increases risks for type 2 diabetes, cardiovascular disease, endometrial hyperplasia, and psychological disorders.
• Bariatric surgery may be considered as an adjunct therapy for PCOS in patients with excess weight, as it has been shown to improve anthropometric, metabolic, and reproductive outcomes in women with PCOS 1.
• Anti-obesity pharmacological agents, such as glucagon-like peptide 1 receptor agonists, may also be considered as adjunctive treatments to promote weight loss in PCOS, although their efficacy and safety in this population are still being studied 1.

From the FDA Drug Label

Some patients with polycystic ovary syndrome who are unusually sensitive to gonadotropin may have an exaggerated response to usual doses of clomiphene citrate. Therefore, patients with polycystic ovary syndrome should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy

The typical workup and management for Polycystic Ovary Syndrome (PCOS) is not directly addressed in the provided drug label. However, it is mentioned that patients with PCOS should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy when using clomiphene citrate.

• Key considerations for managing PCOS patients include:
  • Starting with the lowest dose of clomiphene citrate
  • Using the shortest treatment duration for the first course of therapy
  • Monitoring for ovarian enlargement and adjusting treatment accordingly 2

From the Research

Workup for PCOS

• The evaluation of patients suspected of having PCOS includes a thorough history and physical examination, assessment for the presence of hirsutism, ovarian ultrasonography, and hormonal testing to confirm hyperandrogenism and oligo-anovulation as needed and to exclude similar or mimicking disorders 3.
• The diagnosis of PCOS is based on a combination of signs and symptoms of androgen excess and ovarian dysfunction in the absence of other specific diagnoses 4.
• Testing the blood values of 17-hydroxyprogesterone (17-OHP) in fertile aged women with suspicious hyperandrogenism can help differentiate between PCOS and non-classical adrenal hyperplasia (NCAH) 5.

Management of PCOS

• 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 3.
• Treatment options for PCOS include drugs such as combined oral contraceptive pills, metformin, pioglitazone, and low-dose spironolactone, which can help improve pregnancy rates by decreasing androgen levels in vivo 6.
• Management of PCOS should also address the associated metabolic disorders, such as insulin resistance, obesity, and cardiovascular risk factors 4.
• Hyperandrogenism is an important clinic feature in patients with PCOS, and understanding its role and related signals can provide important clues to clinic strategies in patients with PCOS 7.

Key Considerations

• PCOS is a heterogeneous disorder, and hyperandrogenism is not the only pathogenic factor 6.
• Obesity and insulin resistance can aggravate the symptoms of hyperandrogenism, forming a vicious cycle that promotes PCOS development 6.
• A thorough understanding of the pathophysiology and diagnosis of PCOS is essential for proper management and treatment of the disorder 3, 4.