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

Diagnostic and Treatment Approaches for Polycystic Ovary Syndrome (PCOS)

The most effective approach for PCOS management involves combined oral contraceptives as first-line treatment for women not attempting to conceive, and clomiphene citrate as first-line treatment for those seeking pregnancy, along with lifestyle modifications for all patients. 1, 2

Diagnostic Criteria

• PCOS diagnosis requires two of three Rotterdam criteria: oligo-anovulation, clinical/biochemical hyperandrogenism, and polycystic ovaries on ultrasound 3
• Laboratory evaluation should include:
  • Androgen levels (free and total testosterone, DHEA-S, androstenedione)
  • Gonadotropins (LH, FSH)
  • Screening for metabolic abnormalities (fasting glucose, lipid profile) 4, 5
• All women with PCOS should be screened for dyslipidemia with a fasting lipoprotein profile and for type 2 diabetes with fasting glucose and 2-hour glucose tolerance test 1
• Body mass index and waist-hip ratio should be calculated to assess metabolic risk 4

Treatment Approach Based on Reproductive Goals

For Women Not Attempting to Conceive

• Combined oral contraceptives (COCs) are the first-line medication for long-term management of PCOS 1, 2
  • COCs suppress ovarian androgen secretion, increase sex hormone binding globulin, and reduce endometrial cancer risk 4, 1
• Medroxyprogesterone acetate (depot or intermittent oral therapy) is an alternative that suppresses circulating androgen levels and pituitary gonadotropins 4, 1
• For hirsutism management:
  • Combination of an antiandrogen (spironolactone, flutamide, finasteride) with COCs is more effective than either treatment alone 1, 2, 5
  • Topical eflornithine hydrochloride cream can be used as an adjunct treatment 2
  • Laser hair removal may be beneficial but requires multiple treatments and concurrent medical management 5

For Women Attempting to Conceive

• Treatment should begin with lifestyle modifications (weight loss and regular exercise) 4, 2
• Clomiphene citrate is the first-line pharmacological treatment 4, 6
  • Approximately 80% of PCOS patients ovulate with clomiphene, and half of these conceive 4, 6
  • Start with 50mg daily for 5 days, beginning on day 5 of the cycle 6
  • If no ovulation occurs, increase to 100mg daily for 5 days in the next cycle 6
  • Treatment should not exceed 100mg/day for 5 days 6
  • Limit treatment to about six cycles (including three ovulatory cycles) 6
• If clomiphene treatment fails, low-dose gonadotropin therapy is recommended due to lower risk of ovarian hyperstimulation 4, 2
• Insulin-sensitizing agents (metformin) may improve ovulation frequency but are not FDA-approved for PCOS treatment 4, 2

Management of Metabolic Aspects

• Lifestyle modifications are the cornerstone of treatment 4, 1, 2
  • Weight loss of just 5% of initial body weight significantly improves metabolic and reproductive abnormalities 1, 2
  • Regular exercise program (minimum 150 minutes/week of moderate intensity) is beneficial even without weight loss 2
  • Energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day) is recommended for weight loss 2
• Metformin and thiazolidinediones may improve insulin sensitivity and have positive impacts on risk factors for diabetes and cardiovascular disease 4, 1
  • Metformin tends to decrease weight, while thiazolidinediones tend to increase weight 1
  • Glucose tolerance improves or remains steady over time with metformin use 4, 1

Long-term Monitoring and Complications

• Regular screening for metabolic abnormalities is essential due to increased risk of:
  • Type 2 diabetes mellitus 4, 1, 7
  • Cardiovascular disease (hypertension, dyslipidemia) 7, 8
  • Endometrial hyperplasia and cancer 4, 9
• Mental health assessment should be included as women with PCOS have higher rates of depression, anxiety, and eating disorders 7, 2
• Obese women require more frequent glucose tolerance testing due to potential rapid progression from normal to impaired glucose tolerance and diabetes 10

Common Pitfalls and Caveats

• Avoid exceeding recommended clomiphene dosage (100mg/day) or duration (six cycles total) due to risk of ovarian hyperstimulation syndrome, especially in PCOS patients 6
• Don't neglect metabolic screening even in normal-weight PCOS patients, as insulin resistance affects 50-70% of women with PCOS regardless of weight 7
• Remember that PCOS is a diagnosis of exclusion - other conditions causing similar symptoms (thyroid disorders, hyperprolactinemia, adrenal disorders) must be ruled out 6, 10
• Don't rely solely on pharmacological treatments without addressing lifestyle modifications, which are fundamental to long-term management 4, 2