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

PCOS Diagnostics

For adult women, diagnose PCOS using the Rotterdam criteria requiring at least 2 of 3 features: hyperandrogenism (clinical or biochemical), oligo-anovulation, and polycystic ovarian morphology on ultrasound, after excluding other causes of these findings. 1, 2

Diagnostic Criteria

Clinical Assessment

Document the following specific features:

• Menstrual history: Cycle length >35 days indicates chronic anovulation 1
• Hyperandrogenism signs: Acne, male-pattern balding, hirsutism, clitoromegaly 1
• Onset and duration: Rapid onset with severe hyperandrogenism suggests androgen-secreting tumor requiring immediate evaluation 1, 2
• Anthropometric measurements: Calculate BMI and waist-hip ratio 1
• Medication review: Document use of exogenous androgens 1
• Family history: Cardiovascular disease and diabetes 1
• Lifestyle factors: Diet, exercise, alcohol use, smoking 1

Ultrasound Criteria (Adults)

Follicle number per ovary (FNPO) is the gold standard ultrasonographic marker with the highest diagnostic accuracy (sensitivity 87.64%, specificity 93.74%) when FNPO ≥20 follicles. 3, 1

Technical specifications for optimal imaging:

• Use transvaginal ultrasound with ≥8 MHz transducer frequency 1
• Offline follicle counting improves accuracy compared to real-time methods 3

Alternative markers when accurate FNPO measurement is not possible:

• Ovarian volume (OV) >10 mL 3, 1
• Follicle number per single cross-section (FNPS) 3

Important caveat: OV and FNPS show poorer diagnostic performance compared to FNPO and should only be used as alternatives 3

Age-Specific Diagnostic Approach

Adolescents (<20 years, at least 1 year post-menarche):

• Delay evaluation until 2 years after menarche 2
• Require all three Rotterdam criteria be met before diagnosis 2
• Avoid ultrasound as first-line investigation due to poor specificity and high false-positive rate 1
• Rely more heavily on clinical and biochemical hyperandrogenism plus menstrual irregularity 1

Adults (18-50 years):

• Full Rotterdam criteria apply 1
• Transvaginal ultrasound is appropriate and recommended 1

Differential Diagnosis to Exclude

Rule out the following conditions before confirming PCOS:

• Cushing's syndrome: Buffalo hump, moon facies, hypertension, abdominal striae 1
• Androgen-secreting tumors: Rapid onset, severe hyperandrogenism, marked virilization 1, 2
• Non-classic congenital adrenal hyperplasia 1
• Thyroid disease and prolactin disorders 1
• Primary hypothalamic amenorrhea and primary ovarian failure 1
• Acromegaly and genetic defects in insulin action 1

Perform pelvic examination before each treatment course to exclude ovarian cysts 4

Treatment Options

First-Line: Lifestyle Modification

Implement regular exercise and weight control measures before initiating drug therapy. 1

• Weight loss of as little as 5% of initial weight improves metabolic and reproductive abnormalities 1
• This should be the initial approach for all overweight patients with PCOS 1

Treatment Based on Primary Concern

For Menstrual Irregularities and Anovulation (Not Seeking Pregnancy)

Use combination oral contraceptive pills as first-line therapy for long-term management. 1, 2

• Alternative: Medroxyprogesterone acetate (depot or intermittent oral) to suppress circulating androgen levels 1

For Infertility (Seeking Pregnancy)

Clomiphene citrate is first-line treatment with 80% ovulation rate and 50% conception rate. 1, 4

FDA-approved indications for clomiphene citrate:

• Treatment of ovulatory dysfunction in women desiring pregnancy 4
• Patients with PCOS are most likely to achieve success 4
• Start on or about day 5 of cycle 4
• Limit to approximately 6 total cycles (including 3 ovulatory cycles) 4

For clomiphene failures:

• Low-dose gonadotropin therapy induces ovulation with lower risk of ovarian hyperstimulation 1

Critical warning: Patients with PCOS are unusually sensitive to gonadotropins and may have exaggerated response to usual clomiphene doses; start with lowest recommended dose and shortest treatment duration 4

For Hirsutism and Dermatologic Manifestations

Oral contraceptives are first-line therapy for hirsutism. 1, 2

• Combination of anti-androgen plus ovarian suppression agent provides better efficacy 1
• Mechanical hair removal methods, electrolysis, and laser vaporization for cosmetic management 1

For Metabolic Complications

Screen all women with PCOS for type 2 diabetes and glucose intolerance. 1

• Screen for dyslipidemia with fasting lipoprotein profile 1
• Metformin (insulin-sensitizing agent) improves insulin sensitivity, glucose tolerance, and ovulation frequency 1
• Metformin is first-line medication for metabolic manifestations such as hyperglycemia 2

Monitoring Requirements

Regular screening for cardiovascular risk factors is essential in long-term management. 1

• PCOS patients have twice the rate of metabolic syndrome compared to general population 2
• Four times higher risk of developing type 2 diabetes mellitus 2

Common Pitfalls to Avoid

Ovarian Hyperstimulation Syndrome (OHSS):

• Can progress rapidly (within 24 hours to several days) to serious medical disorder 4
• Early warning signs: abdominal pain/distention, nausea, vomiting, diarrhea, weight gain 4
• Use lowest dose consistent with expected clinical results 4
• If ovarian enlargement occurs, do not give additional clomiphene until ovaries return to pretreatment size 4

Visual symptoms with clomiphene:

• Discontinue treatment immediately if visual symptoms occur 4
• Perform complete ophthalmological evaluation promptly 4

Adolescent diagnosis:

• Do not rush to diagnose; wait 2 years post-menarche 2
• Require all three Rotterdam criteria in this age group 2
• Avoid ultrasound as primary diagnostic tool 1