What are the diagnosis and treatment options for Polycystic Ovary Disorder (PCOD)?

Diagnosis and Treatment of PCOD (Polycystic Ovary Disorder)

Diagnostic Approach

Diagnose PCOD using the Rotterdam criteria, which requires 2 of 3 findings: hyperandrogenism, ovulatory dysfunction, and polycystic ovaries on ultrasound, after excluding other causes of hyperandrogenism. 1, 2

Laboratory Evaluation

• Measure androgen levels (total and free testosterone) and gonadotropins (LH, FSH) to confirm hyperandrogenism and assess hormonal patterns 1
• Obtain fasting glucose followed by 2-hour glucose tolerance test to screen for diabetes 1, 3
• Check fasting lipid profile to assess cardiovascular risk 1, 3
• Calculate BMI and waist-hip ratio to evaluate metabolic risk 1

Imaging

• Perform pelvic ultrasound to identify polycystic ovarian morphology (multiple small follicles arranged peripherally) 1, 4

Critical Exclusions

• Rule out androgen-secreting tumors if marked virilization or rapid symptom onset is present 2
• Exclude thyroid disorders, hyperprolactinemia, and congenital adrenal hyperplasia 1, 2

Special Considerations for Adolescents

• Delay evaluation until 2 years after menarche, as irregular cycles are physiologic early in reproductive life 2
• Require all 3 Rotterdam criteria (not just 2) before diagnosing PCOD in adolescents 2

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Treatment Algorithm Based on Reproductive Goals

For Women NOT Attempting to Conceive

Combined oral contraceptives are first-line treatment, as they suppress ovarian androgen secretion, increase sex hormone-binding globulin, regulate menstrual cycles, and prevent endometrial hyperplasia. 1, 5

Hormonal Management

• Start combined oral contraceptives to address menstrual irregularity, hyperandrogenism (hirsutism, acne), and endometrial protection 1, 5
• Alternative: Progestin-only therapy (medroxyprogesterone acetate) if estrogen is contraindicated, which suppresses androgens and pituitary gonadotropins 5
• Add spironolactone (antiandrogen) for persistent hirsutism or acne after 6 months of hormonal contraception 1, 6
• Never use spironolactone in women attempting to conceive due to teratogenic risk 5

Metabolic Management

• Prescribe metformin 500-2000 mg daily when insulin resistance, glucose intolerance, or elevated cardiovascular risk factors are documented 1, 5
• Metformin improves insulin sensitivity, reduces ovarian androgen production, and maintains glucose tolerance over time 3, 2
• Consider GLP-1 agonists (semaglutide, liraglutide, exenatide) for weight reduction when lifestyle modifications plus metformin are insufficient 1

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For Women Attempting to Conceive

Clomiphene citrate is first-line pharmacological treatment for ovulation induction, with approximately 80% of patients ovulating and 50% of those conceiving. 1, 3

Preconception Steps

• Initiate lifestyle modifications targeting 5-10% weight loss before pharmacotherapy, as even 5% weight loss significantly improves ovulation and pregnancy rates 1, 3
• Screen for metabolic abnormalities before conception: fasting glucose, 2-hour glucose tolerance test, and lipid profile 3
• Provide preconception counseling about increased pregnancy risks (gestational diabetes, preeclampsia, preterm birth) 3

Ovulation Induction Protocol

• Start clomiphene citrate at the lowest effective dose (typically 50 mg daily for 5 days, starting cycle day 3-5) 1, 3
• Do not exceed recommended clomiphene dosage and duration due to risk of visual disturbances and ovarian hyperstimulation syndrome 5, 7
• Monitor for visual symptoms (blurring, scotomata, phosphenes) and discontinue immediately if they occur, with complete ophthalmologic evaluation 7
• If clomiphene fails after 3-6 cycles, advance to low-dose gonadotropin therapy due to lower risk of ovarian hyperstimulation compared to higher clomiphene doses 1

Adjunctive Metformin

• Add metformin to improve insulin sensitivity and ovulation frequency, particularly in women with documented insulin resistance 3
• Metformin appears safe during pregnancy and may reduce miscarriage risk 3, 5
• Avoid thiazolidinediones in pregnancy due to poorly documented effects on early pregnancy outcomes 5

Monitoring for Ovarian Hyperstimulation Syndrome (OHSS)

• Watch for early warning signs: abdominal pain and distention, nausea, vomiting, diarrhea, weight gain 7
• Severe OHSS can progress rapidly (within 24 hours) to gross ovarian enlargement, ascites, oliguria, pleural effusion, and thromboembolism 7
• Perform abdominal and pelvic examinations cautiously due to fragility of enlarged ovaries 7
• Women with PCOD are unusually sensitive to gonadotropins and may have exaggerated responses to usual clomiphene doses 7
• If ovarian enlargement occurs, withhold further clomiphene until ovaries return to pretreatment size, then reduce dosage or duration 7

Pregnancy Management

• Once pregnant, monitor closely throughout pregnancy with regular blood pressure checks, kidney function tests, and proteinuria screening 3
• Prescribe low-dose aspirin from week 12 to week 36 to reduce preeclampsia risk 3

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Foundational Lifestyle Modifications (For ALL Patients)

Lifestyle modification targeting 5-10% weight loss through diet and exercise is the cornerstone of PCOD treatment and must be implemented first, improving metabolic, reproductive, and psychological outcomes. 1, 3

Dietary Intervention

• Create an energy deficit of 500-750 kcal/day, with total intake of 1,200-1,500 kcal/day adjusted for individual requirements 1
• Any balanced dietary approach creating an energy deficit is acceptable; no specific diet type (low-carb, Mediterranean, etc.) is superior for PCOD 1
• Follow general healthy eating principles tailored to food preferences, avoiding overly restrictive or nutritionally unbalanced diets 1

Exercise Prescription

• For weight maintenance: Perform at least 150 minutes/week of moderate-intensity activity or 75 minutes/week of vigorous activity, plus muscle-strengthening on 2 non-consecutive days/week 1
• For weight loss: Perform at least 250 minutes/week of moderate-intensity activity or 150 minutes/week of vigorous activity, plus muscle-strengthening on 2 non-consecutive days/week 1
• Exercise shows positive effects on PCOD symptoms even without weight loss 3, 5

Behavioral Strategies

• Incorporate goal-setting, self-monitoring, stimulus control, problem-solving, slower eating, and relapse prevention to optimize weight management 1
• Address mental health issues (depression, anxiety, eating disorders) which occur at higher rates in PCOD patients 1, 6

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Long-Term Monitoring and Complication Prevention

Metabolic Surveillance (Required for ALL Patients, Regardless of Weight)

• Screen for type 2 diabetes with fasting glucose and 2-hour glucose tolerance test annually or biannually 1, 5
• Monitor fasting lipid profile regularly to assess cardiovascular risk 1, 3
• Calculate BMI and waist-hip ratio at each visit 1
• Do not assume normal weight excludes metabolic dysfunction in PCOD 5

Additional Screening

• Assess for nonalcoholic fatty liver disease with liver function tests and imaging as indicated 6
• Screen for sleep apnea, which occurs more commonly in women with PCOD 6
• Monitor blood pressure for hypertension development 3, 4
• Perform mental health assessment for depression, anxiety, and eating disorders 1, 6

Endometrial Protection

• Ensure regular menstrual cycles (at least every 3 months) to prevent endometrial hyperplasia and potential endometrial carcinoma 1, 6
• Achieve this through hormonal contraception, cyclic progesterone therapy, or weight loss 1, 6

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Common Pitfalls to Avoid

• Do not delay lifestyle intervention—it must be the foundation, not an afterthought 5
• Do not neglect metabolic screening in normal-weight PCOD patients, as metabolic dysfunction can occur at any BMI 1, 5
• Do not exceed recommended clomiphene dosage and duration due to visual complications and OHSS risk 5, 7
• Do not use spironolactone in women attempting to conceive due to teratogenic effects 5
• Do not use thiazolidinediones in pregnancy; metformin is the safer insulin-sensitizing option 5
• Do not ignore ethnic-specific BMI and waist circumference categories when assessing cardiometabolic risk 1