What are the diagnostic criteria and initial treatment for Polycystic Ovary Syndrome (PCOS)?

Diagnostic Criteria and Initial Treatment for Polycystic Ovary Syndrome (PCOS)

Diagnostic Criteria

The diagnosis of PCOS requires the presence of at least two of the following three Rotterdam criteria: hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology on ultrasound. 1, 2

Clinical and Biochemical Assessment

• Hyperandrogenism:

  • Clinical signs: hirsutism, acne, androgenic alopecia
  • Biochemical markers: elevated free and total testosterone, DHEA-S, androstenedione

• Ovulatory Dysfunction:

  • Oligomenorrhea (menstrual cycles >35 days)
  • Amenorrhea (absence of menstruation for ≥3 months)
  • Anovulation despite regular cycles

• Polycystic Ovarian Morphology (PCOM):

  • Transvaginal ultrasound showing ≥25 follicles (2-9mm) in at least one ovary 1
  • Ovarian volume >10 mL in at least one ovary
  • Higher frequency transducers (≥8 MHz) should be used for optimal follicle visualization 1

Diagnostic Testing

• Hormonal Testing:

  • Free and total testosterone
  • DHEA-S
  • Androstenedione
  • Luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
  • Consider thyroid function tests, prolactin, and 17-hydroxyprogesterone to exclude other disorders 1, 2

• Metabolic Assessment:

  • Fasting glucose and insulin
  • Lipid profile
  • Blood pressure measurement
  • BMI calculation

• Imaging:

  • Transvaginal ultrasound is the preferred method for adult women
  • Transabdominal ultrasound may be used for adolescents or women who decline transvaginal approach 1

Initial Treatment

Lifestyle Modifications

• Weight Management:

  • 5-10% weight loss can restore ovulation and improve fertility 2
  • Caloric deficit of 500-750 kcal/day
  • Diet low in glycemic index, rich in fiber and omega-3 fatty acids

• Physical Activity:

  • Minimum 150 minutes of moderate-intensity exercise weekly
  • Include strength training 2-3 times per week 2

Pharmacological Treatment

1. Menstrual Irregularity/Endometrial Protection:

   • First-line: Combined oral contraceptives (COCs) 2
   • Alternative: Cyclic progestins (oral micronized progesterone 200-300 mg daily for 12-14 days monthly) 2
   • For contraception needs: Levonorgestrel-releasing IUD provides endometrial protection with minimal metabolic impact 2

2. Hyperandrogenism (Hirsutism/Acne):

   • First-line: Combined oral contraceptives 2
   • Add-on therapy: Spironolactone 100 mg daily (visible improvement typically takes 6 months) 2
   • For acne: Topical treatments may be added as needed

3. Metabolic Abnormalities:

   • First-line: Metformin starting at 500 mg/day with meals, gradually increasing to 1000-1500 mg/day in divided doses 2
   • Benefits include improved insulin resistance, regularized menstrual cycles, and reduced cardiometabolic risks

4. Infertility Treatment:

   • First-line: Clomiphene citrate (starting on day 5 of cycle) 2
   • Alternative/Add-on: Metformin may improve ovulation rates when combined with clomiphene
   • Second-line: Letrozole or gonadotropins if clomiphene resistance occurs

Monitoring

• Regular follow-up every 6 months to monitor:
  • Blood pressure
  • Lipid profile
  • Menstrual cycles
  • Weight changes
  • Metabolic parameters 2

Special Considerations

• Adolescents: Diagnosis requires hyperandrogenism and persistent oligomenorrhea; ultrasound criteria are less reliable 1
• Obese Patients: May require more aggressive metabolic monitoring and intervention
• Fertility Desires: Treatment approach differs based on immediate vs. future fertility goals

Red Flags Requiring Prompt Evaluation

• Persistent abnormal uterine bleeding despite treatment
• Signs of significant virilization (clitoromegaly, voice deepening)
• Rapid development of symptoms
• Significant weight gain or worsening insulin resistance despite treatment 2

PCOS is a complex endocrine disorder with significant long-term health implications including increased risk of type 2 diabetes, cardiovascular disease, endometrial cancer, and mood disorders 2, 3. Early diagnosis and appropriate management are essential to improve quality of life and reduce long-term morbidity.