polycystic%20ovarian%20syndrome
POLYCYSTIC OVARIAN SYNDROME
Treatment Guideline Chart
Polycystic ovarian syndrome (PCOS) is the accumulation of underdeveloped follicles in the ovaries due to anovulation. It is is characterized by menstrual abnormalities and clinical or biochemical features of hyperandrogenism.
It results mainly from abnormal steroidogenesis that may be caused by insulin resistance leading to hyperinsulinemia.
There is increased sensitivity to androgens and the majority of women have elevated androgen levels.

Polycystic%20ovarian%20syndrome Diagnosis

Diagnosis

  • Diagnosis is based on 2003 Rotterdam criteria:
    • 2 out of 3 of the following: Oligo-ovulation or anovulation (ovulatory dysfunction), clinical or biochemical signs of hyperandrogenism, polycystic ovaries
    • Exclusion of other causes (congenital adrenal hyperplasia, androgen-secreting tumors, Cushing’s syndrome, thyroid disease, prolactinoma)
  • Androgen Excess PCOS Society guidelines cite hyperandrogenism as an absolute requirement for diagnosis

History

  • Focus on the onset and duration of various signs of androgen excess, menstrual history, history of infertility and concomitant medications eg exogenous androgens
    • Menstrual history must screen for the status of ovulation in women with PCOS seeking fertility
    • Virilizing signs with rapid onset and progression are unusual for PCOS and may indicate an ovarian or adrenal neoplasm
  • Family history of DM or cardiovascular disease (CVD) (especially 1st-degree relatives with premature onset of CVD)

Physical Examination

  • Patients usually have features of hyperandrogenism and chronic anovulation; cutaneous symptoms of PCOS should be documented
    • Visual scales such as the modified Ferriman-Gallwey score (mFG) for hirsutism and the Ludwig visual score for alopecia may be used during evaluation
  • Body mass index (BMI) and waist-hip ratio are calculated
  • Blood pressure should be checked at each clinic visit 

Laboratory Tests

  • Women with PCOS present with a normal to mildly elevated prolactin level, a normal to moderately elevated testosterone level, a normal to mildly reduced FSH level and a generally moderately elevated LH level 
  • Urine pregnancy test should be obtained in every patient in the reproductive age group reporting for menstrual abnormalities
  • Midluteal serum progesterone may be done to document potential anovulation in PCOS patients with regular menses
  • Biochemical hyperandrogenism may be evaluated by measuring total or free testosterone or free androgen index using chromatography assays
    • If total or free testosterone levels are not increased, consider measuring androstenedione and dehydroepiandrosterone (DHEAS), though additional information from these is limited
  • Patient should undergo the following lab tests to exclude the corresponding conditions:  
    • Corticotropin-stimulated 17-α-hydroxyprogesterone: Congenital adrenal hyperplasia
    • Total testosterone and DHEAS: Androgen-secreting tumors of the ovary or adrenal gland
    • 24-hour urinary free cortisol, midnight salivary cortisol or 1-mg overnight Dexamethasone suppression test: Cushing syndrome
    • Thyroid-stimulating hormone (TSH): Thyroid disease
    • Prolactin: Hyperprolactinemia
  • Oral glucose tolerance test (OGTT) determines the degree of glucose tolerance and hyperinsulinemia 
  • Lipid profile to screen for dyslipidemia

Imaging

Ultrasonography

  • Used in the diagnosis of PCOS in patients who are 8 years past their menarche because a high incidence of multifollicular ovaries is seen in females with a gynecological age of <8 years 
  • Transvaginal ultrasound is the preferred approach if acceptable to the patient and if sexually active 
  • Determination of polycystic ovaries in one or both ovaries:
    • Endovaginal ultrasound findings of ≥20 follicles measuring 2-9 mm in diameter per ovary and/or increased ovarian volume (≥10 cm3) on either ovary; transabdominal ultrasound finding of an ovarian volume ≥10 cm3 due to difficulty of follicle counting
    • If there is a follicle >10 mm in diameter, the scan should be repeated at a time of ovarian quiescence in order to calculate volume and area
    • Presence of one polycystic ovary is sufficient to provide the diagnosis
  • Identification of endometrial abnormalities
    • Routine screening with ultrasound for endometrial thickness to rule out endometrial cancer in PCOS patients is not recommended

Differential Diagnosis

  • If the patient presents with clinical features of hyperandrogenism with chronic anovulation, then other identifiable causes need to be excluded  
  • Conditions that need to be considered and excluded include:  
    • Acromegaly
    • Androgen-secreting tumors of the ovary or adrenal gland
    • Congenital adrenal hyperplasia
    • Cushing syndrome
    • Functional hypothalamic amenorrhea
    • Hyperprolactinemia
    • Pregnancy
    • Primary ovarian insufficiency
    • Thyroid disease
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