From the Guidelines
The evaluation of Polycystic Ovary Syndrome (PCOS) requires a comprehensive approach combining clinical assessment, laboratory testing, and imaging studies, with a focus on accurate diagnosis and management strategies tailored to the patient's specific symptoms and reproductive goals, as recommended by the most recent guidelines 1. The initial evaluation should include a detailed medical history focusing on menstrual irregularities, fertility concerns, hirsutism, acne, and weight changes.
- Physical examination should assess for signs of hyperandrogenism (excessive facial/body hair, acne, male-pattern baldness), obesity, and acanthosis nigricans.
- Laboratory testing is essential and should include measurements of total and free testosterone, DHEAS, androstenedione, 17-hydroxyprogesterone, TSH, prolactin, and fasting glucose and insulin levels.
- A lipid panel and hemoglobin A1c are also recommended to assess metabolic health. Transvaginal ultrasound should be performed to evaluate ovarian morphology, looking for the presence of multiple small follicles (≥12 follicles measuring 2-9mm in diameter) and/or increased ovarian volume (>10mL), as supported by recent studies 1. It's also important to exclude other conditions that can mimic PCOS, such as thyroid disorders, hyperprolactinemia, congenital adrenal hyperplasia, and Cushing's syndrome. Diagnosis typically follows the Rotterdam criteria, requiring at least two of three features: oligo/anovulation, clinical/biochemical hyperandrogenism, and polycystic ovaries on ultrasound, with recent guidelines emphasizing the importance of lifestyle management, including behavioral and cognitive behavioral intervention approaches, to improve adherence and impact of lifestyle interventions in PCOS 1. The most recent and highest quality study 1 prioritizes the use of liquid chromatography-tandem mass spectrometry (LC-MS/MS) for assessing steroids, including androgens, due to its technical complexity and accessibility, and recommends a comprehensive approach to evaluating PCOS, including clinical assessment, laboratory testing, and imaging studies.
From the Research
Approach to Evaluating Polycystic Ovary Syndrome (PCOS)
The evaluation of PCOS involves a combination of clinical, laboratory, and imaging assessments. The diagnosis of PCOS is established when a patient exhibits two of three Rotterdam criteria: oligoovulation or anovulation, excess androgen activity, and polycystic ovarian morphology 2.
- Clinical Assessment: A careful clinical assessment of women's history, physical examination, and laboratory evaluation is necessary, emphasizing the accuracy and validity of the methodology used for both biochemical measurements and ovarian imaging 2.
- Laboratory Evaluation: Free testosterone (T) levels are more sensitive than the measurement of total T for establishing the existence of androgen excess and should be ideally determined through equilibrium dialysis techniques 2. Serum 17-hydroxyprogesterone and anti-Müllerian hormone are useful for determining a diagnosis of PCOS 2.
- Imaging: New ultrasound machines allow diagnosis of PCOM in patients having at least 25 small follicles (2 to 9 mm) in the whole ovary. Ovarian size at 10 mL remains the threshold between normal and increased ovary size 2.
Diagnosis of PCOS in Adolescents
The diagnosis of PCOS in adolescents is particularly challenging given significant age and developmental issues in this group 2, 3.
- Clinical Presentation: Menstrual irregularities with anovulatory cycles and varied cycle length are common due to the immaturity of the hypothalamic-pituitary-ovarian axis in the 2- to 3-year time period post-menarche 2, 3.
- Laboratory Evaluation: Ovarian dysfunction in adolescents should be based on oligomenorrhea and/or biochemical evidence of oligo/anovulation, but there are major limitations to the sensitivity of T assays in ranges applicable to young girls 2, 3.
- Imaging: Large, multicystic ovaries are a common finding in adolescents, so ultrasound is not a first-line investigation in women <17 years of age 3.
Management of PCOS
The management of women with PCOS should include reproductive function, as well as the care of hirsutism, alopecia, and acne 2.
- Pharmacological Treatment: Oral contraceptives (OCPs) can effectively lower androgens and block the effect of androgens via suppression of ovarian androgen production and by increasing sex hormone-binding globulin 2. Anti-androgens can be used to block the effects of androgen in the pilosebaceous unit or in the hair follicle 2.
- Lifestyle Modification: Weight loss is the primary therapy in PCOS--reduction in weight of as little as 5% can restore regular menses and improve response to ovulation-inducing and fertility medications 4. Metformin in premenopausal PCOS women has been associated with a reduction in features of MetS 4.