• Diagnosis is based on 2003 Rotterdam criteria:
  
  • 2 out of 3 of the following: Oligo-ovulation or anovulation, 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 and concomitant medications eg exogenous androgens
  
  • Menstrual history must screen for the status of ovulation in women with PCOS seeking fertility
• 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

• Urine pregnancy test should be obtained in every patient in the reproductive age group reporting for menstrual abnormalities
• If the patient presents with clinical features of hyperandrogenism with chronic anovulation, then other identifiable causes need to be excluded
• 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 lab tests to exclude:
  
  • Androgen-secreting tumors of the ovary or adrenal gland, late-onset congenital adrenal hyperplasia, and hyperprolactinemia
  • The above can be ruled out if prolactin, TSH, free testosterone, DHEAS and corticotropin-stimulated 17-α-hydroxyprogesterone levels are normal
• Oral glucose tolerance test (OGTT) determines the degree of glucose tolerance and hyperinsulinemia 
• Lipid profile
• Midluteal serum progesterone may be done to document potential anovulation in PCOS patients with regular menses

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