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

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

The diagnosis of PCOS requires the presence of at least two of three criteria: chronic anovulation/irregular menstrual cycles, hyperandrogenism (clinical or biochemical), and polycystic ovary morphology on ultrasound, with exclusion of other causes of androgen excess. 1, 2

Diagnostic Criteria

Clinical History Assessment

• Evaluate onset and duration of signs of androgen excess 1
• Document menstrual history (cycle length >35 days suggests chronic anovulation) 1, 3
• Review medication use, including exogenous androgens 1
• Assess lifestyle factors (diet, exercise, alcohol use, smoking) 1
• Obtain family history of cardiovascular disease and diabetes 1

Physical Examination

• Look for signs of hyperandrogenism: acne, balding, hirsutism, clitoromegaly 1
• Assess body hair distribution patterns 1
• Check for signs of insulin resistance (obesity, acanthosis nigricans) 1
• Calculate BMI and waist-hip ratio 1
• Evaluate for ovarian enlargement on pelvic examination 1

Laboratory Testing

• Measure total testosterone or bioavailable/free testosterone levels (free testosterone is more sensitive for establishing androgen excess) 1, 3
• Perform thyroid-stimulating hormone test to exclude thyroid disease 1
• Check prolactin levels to rule out hyperprolactinemia 1
• Conduct two-hour oral glucose tolerance test to screen for diabetes and glucose intolerance 1
• Obtain fasting lipid profile (total cholesterol, LDL, HDL, triglycerides) 1
• Consider 17-hydroxyprogesterone measurement to exclude non-classic congenital adrenal hyperplasia 1, 4

Ultrasonographic Criteria

• Follicle number per ovary (FNPO) ≥20 follicles has higher sensitivity (87.64%) and specificity (93.74%) for PCOS diagnosis 1
• Ovarian volume (OV) >10 mL is considered the threshold between normal and increased ovary size 1, 3
• Transvaginal ultrasound with ≥8 MHz transducer frequency is recommended for optimal resolution in adults 1
• In adolescents (<17 years), ultrasound is not recommended as a first-line investigation due to poor specificity 1, 3

Differential Diagnosis

• Rule out Cushing's syndrome (buffalo hump, moon facies, hypertension, abdominal striae) 1
• Exclude androgen-secreting tumors of ovary or adrenal gland (rapid onset, severe hyperandrogenism) 1, 4
• Consider non-classic congenital adrenal hyperplasia 1, 4
• Evaluate for acromegaly, genetic defects in insulin action 1
• Check for primary hypothalamic amenorrhea, primary ovarian failure 1
• Rule out thyroid disease and prolactin disorders 1

Treatment Options

Lifestyle Modifications

• Implement regular exercise and weight control measures before drug therapy 1
• Weight loss of as little as 5% of initial weight can improve metabolic and reproductive abnormalities 1
• Target weight reduction when needed to improve ovulation and pregnancy rates 1, 2

Pharmacological Management for Menstrual Irregularities and Anovulation

• Use combination oral contraceptive pills as first-line therapy for long-term management 1
  • Benefits include suppression of ovarian androgen secretion and increased sex hormone binding globulin 1
  • Reduces risk of endometrial cancer 1
• Consider medroxyprogesterone acetate (depot or intermittent oral therapy) to suppress circulating androgen levels 1
• For women attempting to conceive, clomiphene citrate is recommended as first-line treatment (80% ovulate, 50% conceive) 1
• If clomiphene fails, use low-dose gonadotropin therapy to induce ovulation with lower risk of ovarian hyperstimulation 1

Management of Insulin Resistance and Metabolic Complications

• Screen all women with PCOS for type 2 diabetes and glucose intolerance 1
• Screen for dyslipidemia with fasting lipoprotein profile 1
• Consider metformin (insulin-sensitizing agent) to improve insulin sensitivity, glucose tolerance, and ovulation frequency 1, 2
  • In lean patients, doses as low as 850 mg daily may be effective 3
  • In overweight/obese patients, 1.5-2.5 g daily may be required 3

Treatment of Hirsutism and Other Androgenic Symptoms

• Oral contraceptives are first-line therapy for hirsutism 1, 2
• Anti-androgen therapy options include:
  • Spironolactone (competitive antagonism of androgen receptor) 3
  • Cyproterone acetate (competitive antagonism of androgen receptor) 3
  • Flutamide (competitive antagonism of androgen receptor) 3
  • Finasteride (inhibition of 5α-reductase) 3
• Consider combination of an anti-androgen and ovarian suppression agent for better efficacy 1
• Mechanical hair removal methods (plucking, shaving, waxing), electrolysis, and laser vaporization can be used for cosmetic management 1

Special Considerations for Adolescents

• Diagnosis requires both hyperandrogenism and irregular cycles; ovarian morphology is not included due to poor specificity 2
• Persistent oligomenorrhea 2-3 years post-menarche suggests underlying ovarian or adrenal dysfunction 3
• Metformin can be used as first-line monotherapy or in combination with OCPs 3
• Monitor bone mass with anti-androgen therapy in adolescents 3

Monitoring and Long-term Management

• Regular screening for cardiovascular risk factors 1
• Monitor for endometrial hyperplasia and cancer in women with chronic anovulation 3
• Implement early interventions to prevent associated comorbidities 5