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

Comprehensive Workup and Management for Polycystic Ovary Syndrome (PCOS)

The recommended workup for PCOS includes laboratory testing for thyroid function, prolactin levels, testosterone, glucose tolerance, and lipid profile, along with clinical evaluation of hyperandrogenism and menstrual irregularities, while management focuses on lifestyle modifications, oral contraceptives for non-fertility concerns, and specific fertility treatments when pregnancy is desired. 1

Diagnostic Workup

Clinical Evaluation

• Menstrual history: Document pattern of oligomenorrhea or amenorrhea
• Hyperandrogenism assessment:
  • Clinical signs: hirsutism, acne, male-pattern baldness
  • Exclude other causes of hyperandrogenism (Cushing's syndrome, congenital adrenal hyperplasia)

Laboratory Testing

• Hormone evaluation:

  • Thyroid-stimulating hormone (TSH) to rule out thyroid disease
  • Prolactin level to exclude hyperprolactinemia
  • Total testosterone or bioavailable/free testosterone levels to assess ovarian hyperandrogenism 1

• Metabolic assessment:

  • Two-hour oral glucose tolerance test with 75g glucose load (essential for all women with PCOS)
  • Fasting lipid profile (total cholesterol, LDL, HDL, triglycerides)
  • Calculate BMI and waist-hip ratio 1

Imaging

• Transvaginal ultrasound: To assess for polycystic ovarian morphology
  • Document ovarian volumes and antral follicle counts
  • Note presence/absence of dominant follicles or corpus luteum 2

Management Approach

1. Lifestyle Modifications (First-Line for All Patients)

• Exercise recommendations:

  • 150+ minutes/week of moderate activity or 75+ minutes/week of vigorous activity
  • Include resistance training 2-3 times weekly
  • For weight loss: increase to 300+ minutes/week 1

• Dietary interventions:

  • Focus on balanced diet with portion control
  • Reduce sugar-sweetened beverages
  • Target modest weight loss (5% of initial weight) which can significantly improve metabolic and reproductive abnormalities 1

2. Management for Women Not Seeking Pregnancy

• Hormonal management:

  • Combined oral contraceptive pills (first-line therapy)

    • Suppresses androgen secretion
    • Increases sex hormone binding globulin
    • Reduces risk of endometrial cancer
    • Regulates menstrual cycles 1, 3

  • Alternative: Medroxyprogesterone acetate (depot or intermittent oral therapy) 1

• Hirsutism management:

  • First-line: Oral contraceptives
  • Second-line: Add antiandrogens (spironolactone, flutamide, or finasteride) in combination with contraceptives
  • Topical options: Eflornithine hydrochloride cream (FDA-approved for hirsutism)
  • Mechanical hair removal: shaving, waxing, electrolysis, or laser treatments 1, 3

3. Metabolic Management

• Insulin-sensitizing agents:

  • Metformin: First-line for insulin resistance and metabolic complications

    • Tends to decrease weight
    • Improves glucose tolerance
    • May improve ovulation frequency 1, 3

  • Monitor for dyslipidemia and treat according to cardiovascular risk 1

4. Management for Women Seeking Pregnancy

• Ovulation induction protocol:
  1. Start with weight control and regular exercise program
  2. First-line medication: Letrozole for ovulation induction 3
  3. Alternative: Clomiphene citrate (approximately 80% ovulate, 50% conceive) 1
  4. For clomiphene failure: Low-dose gonadotropin therapy (safer than high-dose due to lower risk of ovarian hyperstimulation) 1
  5. Consider metformin to improve ovulation frequency 1, 4

Special Considerations

Mental Health Screening

• Screen for depression and anxiety, which are more common in women with PCOS 3

Long-term Monitoring

• Regular screening for:
  • Type 2 diabetes (higher risk in PCOS)
  • Cardiovascular disease risk factors
  • Endometrial hyperplasia/cancer (2x increased risk) 3
  • Obstructive sleep apnea 3

Common Pitfalls to Avoid

1. Incomplete workup: Failing to exclude other causes of hyperandrogenism and menstrual irregularity
2. Overlooking metabolic risks: All women with PCOS should be screened for diabetes and dyslipidemia regardless of weight
3. Focusing only on fertility: PCOS requires comprehensive management of metabolic, hormonal, and psychological aspects
4. Delaying intervention: Early management can prevent long-term complications including endometrial hyperplasia and cardiovascular disease

The management of PCOS requires addressing both immediate symptoms and long-term health risks, with treatment strategies tailored based on whether fertility is desired, and with lifestyle modifications forming the foundation of all treatment approaches.