What is the initial workup and management for a patient with Polycystic Ovary Syndrome (PCOS)?

From the Guidelines

The initial workup and management for a patient with Polycystic Ovary Syndrome (PCOS) should prioritize a comprehensive history, physical examination, and lifestyle modifications, including healthy eating and regular physical activity, to achieve and/or maintain a healthy weight and optimize hormonal outcomes, general health, and quality of life (QoL) across the life course 1.

Key Components of Initial Workup

• Comprehensive history to identify primary concerns such as irregular menses, hirsutism, acne, or fertility issues
• Physical examination to assess for signs of hyperandrogenism and metabolic complications
• Laboratory tests, including serum testosterone, free testosterone, DHEAS, 17-hydroxyprogesterone, prolactin, TSH, and fasting glucose and insulin levels
• Transvaginal ultrasound to evaluate ovarian morphology, if necessary

Lifestyle Modifications

• Healthy lifestyle behaviors, encompassing healthy eating and regular physical activity, should be recommended to all patients with PCOS to achieve and/or maintain a healthy weight and optimize hormonal outcomes, general health, and QoL 1
• Lifestyle intervention, preferably multicomponent, including diet, exercise, and behavioral strategies, should be recommended for patients with excess weight to reduce weight, central obesity, and insulin resistance 1
• Achievable goals, such as 5-10% weight loss in those with excess weight, can yield significant clinical improvements and are considered successful weight reduction within 6 months 1

Management of Specific Symptoms

• For menstrual irregularity, combined oral contraceptives (COCs) are first-line therapy
• For hirsutism and acne, COCs are effective, with spironolactone added if needed after 6 months of COC therapy
• Metformin is recommended for patients with impaired glucose tolerance or those with fertility concerns, as it can improve ovulation rates
• For fertility, clomiphene citrate is typically the first-line ovulation induction agent

Regular Screening and Monitoring

• Regular screening for metabolic complications, including annual lipid profiles and glucose tolerance tests, is essential, as PCOS patients have increased risk for type 2 diabetes, cardiovascular disease, and endometrial hyperplasia
• Ongoing assessment and monitoring are important during weight loss and maintenance in all women with PCOS 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 initial workup and management for a patient with Polycystic Ovary Syndrome (PCOS) should consider the potential for an exaggerated response to gonadotropin. Key points to consider are:

• Lowest recommended dose: Start with the lowest recommended dose of clomiphene citrate.
• Shortest treatment duration: Use the shortest treatment duration for the first course of therapy.
• Monitor for ovarian enlargement: Be cautious of ovarian enlargement and adjust the dosage or duration of the next course if necessary.
• Conservative management: Manage ovarian cysts conservatively, unless a surgical indication exists 2.

From the Research

Initial Workup for PCOS

The initial workup for Polycystic Ovary Syndrome (PCOS) involves a comprehensive evaluation of the patient's medical history, clinical presentation, and laboratory tests. The following are some key components of the initial workup:

• Medical history: A thorough medical history should be taken to identify symptoms of PCOS, such as irregular menstrual cycles, hirsutism, and acne 3.
• Physical examination: A physical examination should be performed to assess for signs of hyperandrogenism, such as hirsutism and acne, and to evaluate the patient's body mass index (BMI) 3.
• Laboratory tests: Laboratory tests, such as hormone levels (e.g., testosterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH)), glucose tolerance, and lipid profiles, should be performed to confirm the diagnosis and evaluate for associated metabolic complications 3, 4.

Management of PCOS

The management of PCOS involves a multidisciplinary approach that includes lifestyle modifications, medical therapy, and surgical options. The following are some key components of PCOS management:

• Lifestyle modifications: Lifestyle modifications, such as weight loss, dietary changes, and increased physical activity, are recommended as first-line therapy for PCOS 5, 6, 7.
• Medical therapy: Medical therapy, such as hormonal contraceptives, anti-androgens, and metformin, may be prescribed to regulate menstrual cycles, improve hyperandrogenism, and reduce the risk of metabolic complications 3, 4.
• Surgical options: Surgical options, such as ovarian drilling or wedge resection, may be considered for women with PCOS who have not responded to medical therapy and desire fertility 3.

Dietary and Lifestyle Modifications

Dietary and lifestyle modifications play a crucial role in the management of PCOS. The following are some key recommendations:

• Balanced diet: A balanced diet that includes foods with low glycemic index scores, high-fiber, omega-three fatty acid-rich diets, and antioxidant-rich foods is recommended 5, 6.
• Physical activity: Regular physical activity, such as aerobic and resistance exercise, is recommended to improve insulin sensitivity, reduce weight, and improve metabolic and reproductive outcomes 5, 7.
• Weight loss: Weight loss is recommended for overweight and obese women with PCOS, as it can improve reproductive, metabolic, and psychological symptoms 7.