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

PCOS Workup and Management

The workup for PCOS requires exclusion of other causes of androgen excess, followed by comprehensive metabolic and cardiovascular risk screening, with first-line management centered on multicomponent lifestyle intervention regardless of body weight. 1

Initial Diagnostic Workup

Exclude Other Causes of Androgen Excess

Before diagnosing PCOS, you must rule out the following conditions 1:

• Cushing's syndrome - Screen if patient has buffalo hump, moon facies, hypertension, abdominal striae, centripetal fat distribution, easy bruising, or proximal myopathies 1
• Androgen-secreting tumors of ovary or adrenal gland 1
• Nonclassic (late-onset) congenital adrenal hyperplasia 1
• Thyroid disease 1
• Hyperprolactinemia 1
• Acromegaly 1

Essential Laboratory Tests

Order the following baseline labs 1:

• TSH - to exclude thyroid disease 1
• Prolactin - to exclude hyperprolactinemia 1
• Total testosterone OR free/bioavailable testosterone - free testosterone is more sensitive for detecting androgen excess 1, 2
• Fasting glucose followed by 2-hour glucose after 75-gram oral glucose load - all women with PCOS must be screened for type 2 diabetes and glucose intolerance 1
• Fasting lipid panel including total cholesterol, LDL, HDL, and triglycerides 1

Anthropometric Measurements

Calculate and document 1, 3:

• BMI - using ethnic-specific cutoffs for high-risk populations (Asian, Hispanic, South Asian require lower thresholds) 3
• Waist circumference - using ethnic-specific cutoffs 3
• Waist-hip ratio 1

Imaging Considerations

• Pelvic ultrasound is useful but not required in all cases 4
• In adolescents <17 years, ultrasound is NOT first-line since large multicystic ovaries are common normal findings 2
• When performed, report should include ovarian volumes and antral follicle counts (≥25 follicles of 2-9mm indicates polycystic ovarian morphology with newer ultrasound machines) 4

First-Line Management: Lifestyle Intervention

Multicomponent lifestyle intervention including diet, exercise, and behavioral strategies is the first-line treatment for ALL patients with PCOS, regardless of body weight, because insulin resistance affects both lean and overweight women. 1, 5, 3

Critical Pitfall to Avoid

Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight 3

Dietary Intervention

Implement the following dietary approach 1, 5, 3:

• Energy deficit of 500-750 kcal/day (total 1,200-1,500 kcal/day) for those with excess weight, adjusted for individual energy requirements 1, 5
• No specific diet type is superior - tailor to patient's food preferences and cultural needs while maintaining nutritional balance 1, 3
• Avoid restrictive or nutritionally unbalanced diets 3
• Consider low glycemic index foods, high-fiber diets, omega-3 fatty acids, Mediterranean diet, or anti-inflammatory diets 6

Physical Activity Prescription

Prescribe specific exercise targets 1, 5, 3:

For weight maintenance and health:

• 150 minutes/week of moderate-intensity activity (brisk walking, cycling 8-15 km/h, low-impact aerobics, yoga) OR 1, 5
• 75 minutes/week of vigorous-intensity activity (jogging/running, high-impact aerobics, competitive sports) 1, 5

For weight loss and greater metabolic benefit:

• 250 minutes/week of moderate-intensity activity OR 1, 3
• 150 minutes/week of vigorous-intensity activity 1, 3

Additional requirements:

• Muscle-strengthening activities on 2 non-consecutive days/week 3
• Activity in at least 10-minute bouts, aiming for 30 minutes daily on most days 3
• Both aerobic and resistance exercise improve insulin sensitivity 5, 3

Behavioral Strategies

Implement SMART goal-setting and include 1, 5, 3:

• Goal-setting and self-monitoring 1, 5
• Stimulus control 1, 5
• Problem-solving and assertiveness training 1, 5
• Slower eating 1, 5
• Relapse prevention strategies 1, 5
• Consider comprehensive cognitive behavioral interventions to increase engagement and adherence 1, 3

Realistic Weight Loss Goals

Set achievable targets 1, 5:

• 5-10% weight loss within 6 months yields significant clinical improvements in those with excess weight 1, 5
• Lifestyle intervention improves total testosterone, hirsutism scores, weight, waist circumference, waist-hip ratio, and fasting insulin 1
• Healthy lifestyle may benefit health and quality of life even without weight loss 1, 3

Medical Management for Specific Indications

For Women NOT Attempting to Conceive

Combination oral contraceptive pills are the most common long-term management option 1:

• Suppress ovarian androgen secretion 1
• Increase sex hormone binding globulin 1
• Reduce endometrial cancer risk (though extent in PCOS is unknown) 1
• May increase triglycerides and HDL, but no evidence of increased cardiovascular events in PCOS compared to general population 1

Medroxyprogesterone acetate (depot or intermittent oral) 1:

• Suppresses circulating androgen and pituitary gonadotropin levels 1
• Optimal progestin type, duration, and frequency for endometrial cancer prevention is unknown 1

Insulin-Sensitizing Agents

Metformin and thiazolidinediones improve insulin sensitivity 1:

• Metformin tends to decrease weight; thiazolidinediones tend to increase weight 1
• Improve insulin sensitivity, decrease circulating androgens, improve glucose tolerance and metabolic outcomes 1
• Improve ovulation frequency 1
• FDA has not labeled any insulin-sensitizing agent for PCOS treatment 1
• Role in cardiovascular disease prevention remains unknown 1

Ongoing Monitoring

Perform regular assessment 1, 5:

• Weight and waist circumference monitoring during weight loss and maintenance 1, 5
• Screen for metabolic syndrome elements including blood pressure, HbA1c, and lipid status 7
• Address psychological factors including anxiety, depression, body image concerns, and disordered eating 1

Special Populations

Adolescents

Diagnosis is particularly challenging 2:

• Menstrual irregularities are common 2-3 years post-menarche due to immature hypothalamic-pituitary-ovarian axis 2
• Persistent oligomenorrhea >2-3 years beyond menarche predicts ongoing irregularities and greater likelihood of ovarian/adrenal dysfunction 2
• Base diagnosis on oligomenorrhea and/or biochemical evidence of oligo/anovulation, NOT ultrasound in those <17 years 2
• Metformin 850mg daily may be effective in lean adolescents; 1.5-2.5g daily likely required in overweight/obese adolescents 2

High-Risk Ethnic Groups

Asian, Hispanic, and South Asian populations require 3:

• Lower BMI and waist circumference thresholds for intervention 3
• Greater consideration for lifestyle intervention due to high cardiometabolic risk 1, 3

Key Clinical Considerations

Avoid weight-related stigma - health professional interactions must be respectful, patient-centered, and considerate of individual sensitivities and cultural differences 1, 3

PCOS is a lifelong condition affecting multiple organ systems with increased risk for type 2 diabetes, cardiovascular disease, endometrial cancer, and mood disorders 8, 7

Clearly document the patient's phenotype when making the diagnosis, as the four recognized phenotypes have different long-term health and metabolic implications 8