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

Recommended Workup and Management for Polycystic Ovary Syndrome (PCOS)

The comprehensive workup and management of PCOS should include diagnostic evaluation based on Rotterdam criteria, lifestyle interventions as first-line treatment, and targeted medical therapies for specific symptoms. 1, 2

Diagnostic Criteria and Workup

Rotterdam Criteria (requires 2 of 3)

• Oligo/anovulation (menstrual cycles >35 days or <8 cycles per year)
• Clinical or biochemical hyperandrogenism
• Polycystic ovarian morphology on ultrasound (≥25 small follicles 2-9mm per ovary or ovarian volume ≥10mL)

Laboratory Assessment

1. Hormonal Testing:

   • Free testosterone (preferably by equilibrium dialysis) - more sensitive than total testosterone
   • Sex hormone-binding globulin (SHBG)
   • 17-hydroxyprogesterone (to rule out congenital adrenal hyperplasia)
   • Anti-Müllerian hormone (useful for diagnosis)
   • TSH and prolactin (to exclude other causes)

2. Metabolic Screening:

   • Fasting glucose and insulin
   • Oral glucose tolerance test (OGTT)
   • Lipid profile (LDL-C, HDL-C, triglycerides)
   • Blood pressure measurement

3. Imaging:

   • Transvaginal ultrasound (in women >17 years old)
   • Assess for ≥25 small follicles (2-9mm) per ovary
   • Measure ovarian volume (≥10mL is diagnostic)

Important: In adolescents (<17 years), diagnosis should be more stringent, requiring all three Rotterdam criteria, and ultrasound is not recommended as a first-line investigation due to common finding of multicystic ovaries in this age group 3

Management Approach

1. Lifestyle Interventions (First-Line)

• Weight Management:

  • Target 5-10% weight reduction for overweight/obese women
  • Daily caloric deficit of 500-750 kcal/day 2

• Physical Activity:

  • 150 minutes/week of moderate intensity or 75 minutes/week vigorous activity
  • Include both aerobic and resistance exercises
  • For adolescents: 60 minutes daily of moderate-to-vigorous activity 2

• Dietary Recommendations:

  • Low glycemic index diet
  • High fiber content
  • Rich in omega-3 fatty acids 2

2. Medical Management for Menstrual Dysfunction/Anovulation

• For Women Not Seeking Pregnancy:

  • Combined oral contraceptives (COCs) - first-line therapy
  • Oral micronized progesterone (200-300mg daily for 12-14 days monthly) to protect endometrium 2
  • Levonorgestrel intrauterine device (LNG-IUD) for women who fail first-line therapy 2

• For Women Seeking Pregnancy:

  • Clomiphene citrate - first-line (80% ovulation rate, 50% conception rate) 2
  • Letrozole - alternative first-line agent
  • Low-dose gonadotropin therapy if clomiphene fails 2
  • Metformin as adjunct therapy for women with insulin resistance 2

3. Management of Hyperandrogenism

• Hirsutism:

  • COCs (first-line) to increase SHBG and decrease free testosterone
  • Anti-androgens:
    • Spironolactone 100mg daily (visible improvement typically takes 6 months) 2
    • Finasteride (5α-reductase inhibitor)
  • Eflornithine hydrochloride cream (13.9%) as adjunctive therapy 2

• Acne:

  • COCs
  • Topical or systemic antibiotics
  • Isotretinoin for severe cases (with appropriate contraception)

• Androgenic Alopecia:

  • Anti-androgens (spironolactone, finasteride)
  • Minoxidil 5% solution

4. Metabolic Management

• Insulin Resistance:

  • Metformin for patients with:
    • Impaired glucose tolerance
    • Metabolic syndrome features
    • Menstrual irregularities
    • Anovulation in women attempting to conceive 2
  • Starting dose: 500mg daily, increasing to 1500-2000mg daily as tolerated
  • For lean adolescents: 850mg daily may be effective; overweight/obese adolescents may require 1.5-2.5g daily 3

• Dyslipidemia:

  • Lifestyle modifications as first-line
  • Statins if LDL-C goals not achieved
  • Target LDL-C <100 mg/dL for high-risk patients 2

Monitoring and Follow-up

• Regular follow-up every 6 months
• Blood pressure monitoring
• Periodic assessment of endometrial thickness by transvaginal ultrasound for women with irregular cycles
• Annual metabolic screening (glucose tolerance, lipid profile)
• Closer monitoring during pregnancy for complications (gestational diabetes, preeclampsia)

Red Flags Requiring Urgent Evaluation

• Rapid onset of symptoms
• Marked virilization or clitoromegaly
• Significant weight gain or worsening insulin resistance despite treatment
• Persistent abnormal uterine bleeding despite treatment 2

Note: PCOS management should be tailored based on the patient's phenotype and primary concerns (reproductive, metabolic, or dermatologic), with lifestyle interventions forming the foundation of all treatment approaches 1, 2

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