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

Recommended Workup for Polycystic Ovary Syndrome (PCOS)

The recommended workup for PCOS should follow the Rotterdam criteria, which requires the presence of at least two of the following: androgen excess, ovulatory dysfunction, or polycystic ovaries, after excluding other disorders that can cause similar symptoms. 1

Diagnostic Criteria

• Use the Rotterdam criteria for diagnosing PCOS, which requires the presence of at least two of the following three features 1:

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

• Clinical hyperandrogenism includes hirsutism, acne, and male-pattern alopecia 1

• Biochemical hyperandrogenism involves elevated serum androgen levels (total/free testosterone, DHEAS) 1

• Ovulatory dysfunction manifests as oligomenorrhea (menstrual cycles >35 days) or amenorrhea 1

• Polycystic ovaries on ultrasound are defined as ≥12 follicles measuring 2-9mm in diameter per ovary and/or increased ovarian volume (>10mL) 2

Initial Laboratory Assessment

• Serum total testosterone and free testosterone to evaluate hyperandrogenism 1

• Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to assess for elevated LH:FSH ratio 1

• Thyroid-stimulating hormone (TSH) to rule out thyroid dysfunction 1

• Prolactin to exclude hyperprolactinemia 1

• 17-hydroxyprogesterone to rule out congenital adrenal hyperplasia 1

• Fasting glucose and insulin levels to assess insulin resistance 1

• Lipid profile to evaluate cardiovascular risk 1

• Hemoglobin A1c or oral glucose tolerance test to screen for diabetes 1

Imaging Studies

• Transvaginal ultrasound (preferred) or transabdominal ultrasound (for virginal patients) to evaluate ovarian morphology 2

• Ultrasound report should specifically include 2:

  • Ovarian volumes
  • Antral follicle counts
  • Presence of dominant follicle or corpus luteum
  • Other pertinent findings

Additional Assessments

• Body mass index (BMI) calculation and waist circumference measurement to assess for central obesity 3

• Blood pressure measurement to evaluate cardiovascular risk 1

• Screening for mood disorders (depression, anxiety) given higher prevalence in PCOS 1

• Assessment for obstructive sleep apnea risk factors 1

Special Considerations

• For adolescents: Diagnosis is challenging and should focus on hyperandrogenism and persistent menstrual irregularities; ultrasound findings are less reliable 4

• For ethnic groups with high cardiometabolic risk: Consider ethnic-specific BMI and waist circumference categories 5

• For women with obesity: Comprehensive metabolic evaluation is particularly important 3

Exclusion of Other Conditions

• Rule out other causes of androgen excess and menstrual irregularity 1:
  • Thyroid dysfunction
  • Hyperprolactinemia
  • Nonclassical congenital adrenal hyperplasia
  • Cushing's syndrome
  • Androgen-secreting tumors
  • Medication-induced hyperandrogenism

Management Considerations Based on Phenotype

• Identify the predominant phenotype to guide treatment approach 6:
  • Metabolic phenotype: Focus on lifestyle modifications and insulin sensitizers
  • Hyperandrogenic phenotype: Consider combined oral contraceptives with or without antiandrogens
  • Reproductive phenotype: Address fertility concerns with appropriate interventions

Lifestyle Management

• Recommend healthy lifestyle behaviors including healthy eating and regular physical activity for all patients with PCOS 5

• For patients with excess weight, recommend multicomponent lifestyle intervention including diet, exercise, and behavioral strategies 5

• Set achievable weight loss goals of 5-10% in those with excess weight, which can yield significant clinical improvements 5

• Consider psychological factors such as anxiety, depression, body image concerns, and disordered eating when developing lifestyle interventions 5

Common Pitfalls to Avoid

• Relying solely on ultrasound findings for diagnosis, as polycystic ovaries can be an incidental finding in women without PCOS 2

• Failing to exclude other causes of hyperandrogenism and menstrual irregularity 1

• Not addressing the increased risk for metabolic complications, including diabetes and cardiovascular disease 1

• Overlooking the psychological impact of PCOS, including increased risk of depression and anxiety 1

• Not providing appropriate transition of care for adolescents with PCOS as they move to adult healthcare 4