What is the recommended hormone work-up and treatment plan for Polycystic Ovary Syndrome (PCOS)?

Hormone Work-Up for PCOS

The essential hormone work-up for PCOS includes TSH, prolactin, and total testosterone (or free/bioavailable testosterone), followed by a 2-hour oral glucose tolerance test with 75-gram glucose load and fasting lipid panel to assess metabolic complications. 1

Core Hormonal Testing to Establish Diagnosis

Androgen Assessment:

• Total testosterone or bioavailable/free testosterone is the single most important hormonal marker, with abnormal values in 70% of PCOS patients 2
• Androstenedione should be measured as it is elevated in 53% of PCOS cases 2
• DHEA-S (dehydroepiandrosterone sulfate) helps exclude adrenal androgen-secreting tumors 1
• The combination of testosterone, androstenedione, or LH identifies 86% of PCOS patients 2

Exclude Other Endocrine Disorders:

• TSH level to rule out thyroid disease 1
• Prolactin level to exclude hyperprolactinemia 1
• These tests are mandatory before confirming PCOS diagnosis 1

Gonadotropin Testing (Optional):

• LH and FSH measurements are less useful than previously thought 2
• LH/FSH ratio should NOT be used as a diagnostic criterion due to low sensitivity (abnormal in only 41-44% of cases) 2
• Mean LH is elevated in PCOS but only abnormal in 35% of patients 2

Metabolic Screening (Mandatory for All PCOS Patients)

Glucose Metabolism:

• Fasting glucose followed by 2-hour glucose level after 75-gram oral glucose load is required for all PCOS patients due to increased diabetes risk 1
• This recommendation is based on ACOG consensus that PCOS patients have demonstrated increased risk for type 2 diabetes 1

Lipid Assessment:

• Fasting lipid panel including total cholesterol, LDL, HDL, and triglycerides is mandatory 1
• PCOS patients frequently have dyslipidemia with elevated LDL, elevated triglycerides, and decreased HDL 1
• This screening is based on good and consistent scientific evidence per ACOG 1

Anthropometric Measurements:

• Calculate BMI and waist-hip ratio at initial evaluation 1

Additional Testing for Specific Clinical Scenarios

Signs of Cushing's Syndrome:

• Screen for Cushing's if patient has buffalo hump, moon facies, hypertension, abdominal striae, centripetal fat distribution, easy bruising, or proximal myopathies 1

Marked Virilization or Rapid Symptom Onset:

• Requires immediate evaluation for androgen-secreting tumors of ovary or adrenal gland 3
• Measure total testosterone and DHEA-S urgently 1

Prepubertal Children:

• Evaluate for early-onset body odor, axillary/pubic hair, accelerated growth, advanced bone age, and genital maturation 1
• Use growth charts and hand film for bone age as screening tools before specific hormonal testing 1

Postpubertal Females with Hyperandrogenism Features:

• Test when infrequent menses, hirsutism, androgenetic alopecia, infertility, clitoromegaly, or truncal obesity are present 1
• Typical hormone panel includes free and total testosterone, DHEA-S, androstenedione, LH, and FSH 1

Critical Pitfalls to Avoid

• Do not rely on LH/FSH ratio alone - it has poor sensitivity and should be abandoned as a diagnostic criterion 2
• Do not measure hormones while patient is on oral contraceptives - OCPs suppress FSH, LH, and estradiol by design, making interpretation impossible 4
• Do not use SHBG combined with testosterone to derive free testosterone - this does not improve diagnostic accuracy over total testosterone alone 2
• Ensure normal ranges are defined for your specific laboratory assay - absolute gonadotropin values differ significantly between assay methods 2
• Measure hormones in early follicular phase (if patient has cycles) for accurate interpretation 2

Treatment Considerations Based on Work-Up Results

For Non-Pregnant Patients:

• Combination oral contraceptive pills are first-line for menstrual regulation and androgen suppression 1
• Metformin is first-line for metabolic manifestations including hyperglycemia 3
• Weight loss and lifestyle modification should precede drug therapy for dyslipidemia 1

For Fertility Concerns:

• Insulin-sensitizing agents (metformin) improve ovulation frequency based on good and consistent scientific evidence 1
• Clomiphene and letrozole are first-line medications for infertility 3