What are the diagnosis and treatment options for Polycystic Ovary Syndrome (PCOS)?

Diagnosis and Treatment of Polycystic Ovary Syndrome (PCOS)

PCOS diagnosis requires two of three Rotterdam criteria: oligo-anovulation, hyperandrogenism, and polycystic ovaries on ultrasound, with treatment prioritizing lifestyle modifications as first-line therapy followed by targeted medications based on the patient's primary concerns. 1, 2

Diagnosis of PCOS

PCOS diagnosis requires meeting at least two of the following three Rotterdam criteria:

1. Oligo-anovulation (irregular or absent menstrual cycles)
2. Clinical or biochemical hyperandrogenism (hirsutism, acne, male-pattern hair loss)
3. Polycystic ovaries on ultrasound (≥1 ovary with volume >10mL and/or ≥12 follicles measuring 2-9mm in diameter) 2

Other conditions with similar presentations must be excluded before confirming PCOS diagnosis, including thyroid disorders, hyperprolactinemia, congenital adrenal hyperplasia, and androgen-secreting tumors.

Treatment Approach

First-Line Treatment: Lifestyle Modifications

• Weight management and exercise are foundational for all PCOS patients 1
  • Even modest weight loss (5%) significantly improves metabolic and reproductive abnormalities
  • Regular exercise programs benefit patients even without weight loss
  • These interventions should be the cornerstone of treatment regardless of other therapies

Menstrual Irregularities Management

1. Combined oral contraceptives (COCs) - first-line option providing:

   • Menstrual cycle regulation
   • Improvement of hyperandrogenism symptoms
   • Protection against endometrial cancer 1

2. Progestin therapy for those who cannot take COCs:

   • Medroxyprogesterone acetate (5-10mg daily for 12-14 days every 1-3 months)
   • Micronized progesterone (200mg daily for 12-14 days every 1-3 months) - preferred in patients with high cardiovascular risk 1

Hyperandrogenism Treatment

1. Hirsutism management:

   • Combination of antiandrogen medication and ovarian suppression agent
   • Spironolactone - improves hirsutism in 85% of patients with complete remission in 55%
   • Eflornithine hydrochloride cream (13.9%) - FDA-approved topical treatment for facial hirsutism
   • Cosmetic methods (electrolysis, laser therapy) for more permanent hair reduction 1, 3

2. Acne and male-pattern hair loss:

   • COCs with anti-androgenic properties
   • Topical agents as adjunctive therapy

Fertility Treatment

1. Clomiphene citrate - first-line medication with:

   • 80% ovulation rate and 50% conception rate 1
   • CAUTION: Monitor for visual disturbances (scotomata, blurred vision) and ovarian hyperstimulation syndrome (OHSS) 4
   • PCOS patients may be unusually sensitive to clomiphene; start with lowest recommended dose 4

2. Metformin - for patients with insulin resistance:

   • Improves insulin sensitivity
   • May aid in ovulation 1

3. Low-dose gonadotropin therapy - if clomiphene citrate fails 1

Metabolic Management

1. Metformin - recommended for:

   • Patients with insulin resistance
   • Impaired glucose tolerance
   • As adjunct to lifestyle modifications 1

2. Cardiovascular risk monitoring:

   • Regular screening for diabetes, dyslipidemia, hypertension
   • Assessment for nonalcoholic fatty liver disease
   • Screening for sleep apnea 1, 3

Common Pitfalls and Caveats

1. Ovarian Hyperstimulation Syndrome (OHSS) risk with clomiphene:

   • Monitor for abdominal pain, distention, nausea, vomiting, weight gain
   • Can progress rapidly (within 24 hours) to serious medical condition
   • Discontinue treatment if ovarian enlargement occurs 4

2. Visual side effects with clomiphene:

   • Discontinue treatment immediately if visual symptoms develop
   • Obtain prompt ophthalmological evaluation 4

3. Long-term metabolic risks:

   • PCOS is not just a reproductive disorder but a metabolic one
   • Patients require ongoing monitoring for type 2 diabetes and cardiovascular disease 5, 2

4. Mental health considerations:

   • Screen for depression and eating disorders
   • Provide psychological support as needed 3

5. Endometrial hyperplasia risk:

   • Assess endometrial thickness periodically by transvaginal ultrasound
   • Persistent abnormal bleeding requires endometrial sampling 1

PCOS management should follow a systematic approach addressing the patient's primary concerns while also monitoring for and preventing long-term health complications. Regular follow-up is essential to adjust treatment as needed and ensure comprehensive care.