From the Guidelines
The workup for Polycystic Ovary Syndrome (PCOS) should include a comprehensive clinical evaluation, laboratory testing, and imaging studies, with a focus on assessing biochemical hyperandrogenism using total testosterone (TT), free testosterone (FT), and free androgen index (FAI) as first-line laboratory tests, as recommended by the 2023 International PCOS Guidelines 1. The diagnosis of PCOS requires a detailed medical history focusing on menstrual irregularities, hirsutism, acne, and fertility concerns, followed by a physical examination to assess for signs of hyperandrogenism.
- Essential laboratory tests include:
- Total and free testosterone
- DHEAS
- Androstenedione
- 17-hydroxyprogesterone
- TSH
- Prolactin
- FSH
- LH
- Fasting glucose
- Lipid profile
- A 2-hour oral glucose tolerance test with 75g glucose is recommended to assess insulin resistance, as insulin resistance plays a crucial role in the pathophysiology of PCOS 1.
- Transvaginal ultrasound should be performed to evaluate ovarian morphology, looking for the presence of 20 or more follicles measuring 2-9mm in diameter and/or increased ovarian volume (>10mL), as defined by the revised criteria for polycystic ovary morphology (PCOM) 1.
- Additional testing may include anti-Müllerian hormone levels, which are often elevated in PCOS, and can be used as a surrogate for elevated follicle number per ovary (FNPO) 1. It's essential to exclude other conditions that can mimic PCOS, such as thyroid disorders, hyperprolactinemia, congenital adrenal hyperplasia, Cushing's syndrome, and androgen-secreting tumors. The Rotterdam criteria are commonly used for diagnosis, requiring at least two of three features: oligo/anovulation, clinical/biochemical hyperandrogenism, and polycystic ovaries on ultrasound 1. This comprehensive approach ensures accurate diagnosis and appropriate management of PCOS, taking into account the latest evidence and guidelines 1.
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 three criteria: chronic anovulation, hyperandrogenism (clinical or biological), and polycystic ovaries 2, 3. 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 are essential in the evaluation of patients suspected of having PCOS 2.
Key Components of PCOS Workup
- Medical history and clinical evaluation to diagnose rare endocrine disorders 4
- Standardized blood samples to diagnose the condition 4
- Ovarian ultrasonography to evaluate ovarian morphology 2, 3, 5
- Hormonal testing to confirm hyperandrogenism and oligo-anovulation as needed 2, 3
- Assessment for the presence of hirsutism, acne, and alopecia 3
Imaging in PCOS Diagnosis
Ovarian imaging is crucial in the evaluation of patients with suspected PCOS, and the imaging report should include ovarian volumes and antral follicle counts 5. The diagnosis of PCOS in adolescents is particularly challenging, and ultrasound is not a first-line investigation in women <17 years of age 3.
Laboratory Evaluation
- Free testosterone (T) levels are more sensitive than the measurement of total T for establishing the existence of androgen excess 3
- Serum 17-hydroxyprogesterone and anti-Müllerian hormone are useful for determining a diagnosis of PCOS 3
- Measurement of levels of androgens other than T in patients with PCOS is relatively low 3
Treatment Approach
The management of women with PCOS should include reproductive function, as well as the care of hirsutism, alopecia, and acne 3. 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 2. Lifestyle modification, insulin sensitizers such as metformin, and inhibition of testosterone levels with oral contraceptives (OCPs) are common treatment modalities 4, 6.