From the Guidelines
If 17-hydroxyprogesterone (17-OHP) is elevated in a workup for polycystic ovary syndrome (PCOS), the next step is to perform an ACTH stimulation test to rule out non-classical congenital adrenal hyperplasia (NCAH). This is based on the most recent and highest quality study available, which emphasizes the importance of distinguishing between PCOS and NCAH due to their different management strategies 1.
Rationale for ACTH Stimulation Test
The ACTH stimulation test is crucial for diagnosing NCAH, particularly 21-hydroxylase deficiency, which can present with symptoms similar to PCOS, including irregular periods, hirsutism, and infertility. The test involves measuring baseline 17-OHP levels, administering synthetic ACTH (cosyntropin 250 mcg IV), and then measuring 17-OHP levels 60 minutes later. If the stimulated 17-OHP level exceeds 10 ng/mL, this strongly suggests NCAH.
Importance of Distinguishing Between PCOS and NCAH
Distinguishing between PCOS and NCAH is vital because they require different management strategies. NCAH typically involves glucocorticoid therapy, such as dexamethasone 0.25-0.5 mg at bedtime or prednisone 2.5-5 mg daily, to suppress excess adrenal androgen production. In contrast, PCOS management often involves lifestyle modifications, including weight control and regular exercise, as well as medication such as clomiphene citrate for ovulation induction 1.
Lifestyle Management in PCOS
For patients with PCOS, lifestyle management is a critical component of treatment, as emphasized in recent guidelines 1. This includes weight loss, if applicable, and regular physical activity to improve insulin sensitivity and reduce hyperandrogenism. The goal is to improve metabolic and reproductive outcomes, as well as overall quality of life.
Conclusion Not Applicable - Direct Answer Only
The next step after finding elevated 17-OHP in a workup for PCOS is to perform an ACTH stimulation test, as this directly impacts the choice of treatment and patient outcomes, prioritizing morbidity, mortality, and quality of life 1.
From the Research
Next Steps for High OHP in PCOS
- For women with PCOS and high OHP, the management of PCOS is complex and includes lifestyle modification combined with dietary-induced weight loss, oral contraceptives, clomiphene citrate, gonadotropins, antiandrogens, and insulin-sensitizing agents 2.
- Hyperandrogenemia and hyperinsulinemia are central to the pathogenesis of PCOS and thus typically serve as the targets for treatment 3.
- When androgen excess is the main target for therapy, an antiandrogen and/or oral contraceptives is typically chosen 3.
- For clomiphene-resistant PCOS, letrozole has been shown to be more effective than combined clomiphene citrate and metformin for inducing ovulation, with higher clinical pregnancy rates and higher multiple pregnancy rates 4.
- Alternative treatments such as metformin-letrozole have been compared to metformin-clomiphene citrate in clomiphene-resistant PCOS patients undergoing IUI, with no significant difference in pregnancy rates between the two groups 5.
Treatment Options
- Clomiphene citrate combined with metformin 4, 6
- Letrozole 4, 6, 5
- Metformin and pioglitazone 6
- Oral contraceptives 2, 3
- Antiandrogens 3
- Insulin-sensitizing agents 2, 3