Polycystic%20ovarian%20syndrome 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

• 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)

• 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 

• 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

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

• 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