From the Guidelines
The workup for Polycystic Ovary Syndrome (PCOS) should include a comprehensive clinical evaluation, laboratory testing, and imaging studies, prioritizing the most recent and highest quality evidence to minimize morbidity, mortality, and improve quality of life. Begin with a detailed medical history focusing on menstrual irregularities, hirsutism, acne, and fertility concerns, followed by a physical examination to assess for signs of hyperandrogenism.
Key Components of the Workup
- Laboratory testing should include total and free testosterone, DHEAS, androstenedione, 17-hydroxyprogesterone, TSH, prolactin, and fasting glucose and insulin levels, as these are crucial for diagnosing biochemical hyperandrogenism and assessing metabolic risks 1.
- An oral glucose tolerance test is recommended to evaluate for insulin resistance, a common feature in PCOS patients that significantly impacts morbidity and mortality 1.
- Transvaginal ultrasound should be performed to assess ovarian morphology, looking for the presence of multiple follicles (≥25 follicles measuring 2-9mm in diameter) and/or increased ovarian volume (>10mL), as per the revised criteria for diagnosing PCOM 1.
Additional Considerations
- Additional testing may include lipid profile and inflammatory markers due to the increased cardiovascular risk in PCOS patients, emphasizing the need for a comprehensive approach to manage long-term health risks 1.
- The Rotterdam criteria are commonly used for diagnosis, requiring at least two of the following: oligo/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasound, but it's essential to consider the challenges and controversies surrounding the diagnostic criteria, including the role of AMH and ultrasound in PCOS diagnosis 1.
- It's crucial to exclude other conditions that can mimic PCOS, such as thyroid disorders, hyperprolactinemia, congenital adrenal hyperplasia, Cushing's syndrome, and androgen-secreting tumors, before confirming the diagnosis, to ensure appropriate management and minimize potential harms.
Prioritizing Recent and High-Quality Evidence
The most recent and highest quality study, 1, published in 2025, provides critical insights into the diagnostic accuracy of androgen measurement in PCOS, informing evidence-based guidelines and highlighting the importance of accurate biochemical hyperandrogenism assessment in the workup for PCOS.
From the Research
Workup for PCOS
The workup for Polycystic Ovarian Syndrome (PCOS) involves a combination of clinical, hormonal, and metabolic evaluations. The key components of the workup include:
- Clinical presentation: Irregular menstruation, acne, and excessive amounts of androgenic hormones are common symptoms of PCOS 2, 3, 4
- Hormonal evaluation: Measurement of luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, and thyroid-stimulating hormone (TSH) levels 2, 5, 6
- Metabolic evaluation: Assessment of body mass index (BMI), waist-to-hip ratio, and presence of metabolic disorders such as obesity, dyslipidemia, hypertension, and type 2 diabetes mellitus 2, 3, 4
- Ultrasound findings: Abnormal ovarian size and morphology may be present in women with PCOS 4
Diagnostic Criteria
The diagnosis of PCOS is based on the presence of at least two of the following criteria:
- Clinical or laboratory evidence of hyperandrogenism
- Ovarian dysfunction (oligomenorrhea or amenorrhea)
- Polycystic ovaries on ultrasound
- Exclusion of other disorders that may cause similar symptoms 2, 3, 4
Laboratory Tests
The following laboratory tests may be ordered as part of the workup for PCOS:
- LH and FSH levels to assess the LH/FSH ratio 2, 5, 6
- Prolactin and TSH levels to rule out other endocrine disorders 2, 5, 6
- Fasting glucose and insulin levels to assess for insulin resistance and type 2 diabetes mellitus 2, 3, 4
- Lipid profile to assess for dyslipidemia 2, 3, 4
Special Considerations
Obesity is a common finding in women with PCOS, but it is not part of the diagnostic criteria 2, 3, 4. The LH/FSH ratio may be elevated in women with PCOS, but it is not a diagnostic criterion 2, 5, 6. The workup for PCOS should be individualized based on the patient's clinical presentation and medical history 3, 4.