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

Diagnosis and Treatment of Polycystic Ovary Syndrome (PCOS)

PCOS should be diagnosed using the Rotterdam criteria (presence of two of the following: androgen excess, ovulatory dysfunction, or polycystic ovaries), and treatment should be tailored to address specific symptoms with combined oral contraceptives as first-line therapy for menstrual irregularities and hyperandrogenism, metformin for metabolic features, and clomiphene citrate for fertility concerns. 1

Diagnosis of PCOS

PCOS affects 5-10% of reproductive-age women and requires careful evaluation for accurate diagnosis 1, 2. The diagnostic approach includes:

• Rotterdam Criteria (requires 2 of 3):

  • Hyperandrogenism (clinical or biochemical)
  • Ovulatory dysfunction (oligomenorrhea or amenorrhea)
  • Polycystic ovaries on ultrasound

• Diagnostic Challenges:

  • Difficult to diagnose in adolescents and menopausal women
  • Hyperandrogenism is central to adolescent presentation
  • No consistent phenotype in postmenopausal women 3

• Exclusion of Other Conditions:

  • Rule out other causes of androgen excess
  • Evaluate for endometrial cancer risk factors
  • Screen for mood disorders, obstructive sleep apnea, diabetes, and cardiovascular disease 3

Treatment Approach Based on Symptoms

1. Menstrual Irregularities and Endometrial Protection

• First-line therapy: Combined oral contraceptives (COCs) 1, 4

  • Provides menstrual regulation
  • Reduces hyperandrogenism
  • Offers endometrial protection
  • Caution: Increases VTE risk three to fourfold (up to 4 per 10,000 woman-years)

• Alternative options:

  • Levonorgestrel-releasing intrauterine device (LNG-IUD)

    • Minimal systemic metabolic effects
    • Improves lipid profile (reduces LDL and total cholesterol)
    • Provides effective endometrial protection 1

  • Oral micronized progesterone (200-300 mg daily for 12-14 days monthly)

    • Better safety profile than synthetic progestins
    • Improves menstrual cycle regularity 1

2. Hyperandrogenism (Hirsutism, Acne, Male-pattern Hair Loss)

• First-line therapy: Combined oral contraceptives 1, 4

• Additional options:

  • Spironolactone 100 mg daily for hirsutism
    • Visible improvement typically takes 6 months 1
  • Topical agents for acne
  • Electrolysis or laser therapy for more permanent hair reduction 4

3. Metabolic Features and Weight Management

• Lifestyle modifications:

  • Calorie deficit of 500-750 kcal/day
  • At least 250 minutes of moderate-intensity physical activity weekly
  • Low-glycemic diet rich in fiber and omega-3 fatty acids
  • Strength training 2-3 times weekly 1

• Pharmacological therapy:

  • Metformin: First-line for PCOS with metabolic features

    • Starting dose: 500mg daily with meals
    • Increase gradually to 1000-1500mg daily in divided doses
    • Addresses insulin resistance and menstrual irregularities 1

  • GLP-1 receptor agonists: Consider for weight management

    • Liraglutide: 0.3-3.38 kg weight reduction
    • Semaglutide: 3.47-6.5 kg weight reduction
    • May be more effective than metformin for weight loss 1

4. Fertility Concerns

• First-line therapy: Clomiphene citrate 1, 5, 3

  • Start on day 5 of the cycle
  • 80% ovulation rate and 50% conception rate
  • Maximum 6 cycles (including 3 ovulatory cycles)
  • Caution: Monitor for ovarian hyperstimulation syndrome (OHSS)

• Additional considerations:

  • Weight loss if overweight (improves ovulation)
  • Metformin may be added to improve insulin sensitivity 1, 4

Monitoring and Follow-up

• Regular follow-up every 6 months to monitor:

  • Blood pressure
  • Weight and waist circumference
  • Lipid levels
  • Menstrual cyclicity
  • Metabolic parameters 1

• Red flags requiring prompt evaluation:

  • Persistent abnormal uterine bleeding despite treatment
  • Signs of significant virilization
  • Rapid development of symptoms
  • Significant weight gain or worsening insulin resistance despite treatment 1

Long-term Health Considerations

Women with PCOS have increased risk for:

• Glucose intolerance and type 2 diabetes
• Metabolic syndrome and hepatic steatosis
• Hypertension and dyslipidemia
• Endometrial hyperplasia or carcinoma
• Pregnancy complications (gestational diabetes, preeclampsia)
• Mood disorders 1, 2

Regular screening for these conditions is essential for comprehensive management of PCOS, with particular attention to cardiovascular risk factors and endometrial health 1, 2.