Heterogeneous androgen excess syndrome characterized by some or all of the following:

  • Hirsutism
  • Secondary amenorrhea (due to anovulation)
  • Obesity
  • Hyperinsulinemia
  • Infertility
  • Bilaterally enlarged polycystic ovaries

ICD-9 codes

  • 256.4 polycystic ovaries

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  • 6%-7% prevalence among reproductive-aged women
  • Higher prevalence in overweight or obese women
  • Polycystic ovaries are common on ultrasound, but most are asymptomatic.


  • May be insulin resistance with resultant hyperinsulinemia stimulating excess ovarian androgen production


  • Chronic anovulation may lead to increased risk for:

           – Endometrial hyperplasia

           – Endometrial cancer

           – Infertility

  • Increased risk for ovarian hyperstimulation syndrome during ovulatory induction, resulting in multifetal pregnancy
  • Increased risk for complications of pregnancy including gestational diabetes and hypertensive disorders
  • Insulin resistance including type 2 diabetes mellitus
  • Cardiovascular disease
  • Metabolic syndrome


  • Presenting symptoms in polycystic ovary syndrome (PCOS):

           – 74% infertility

           – 70% menstrual dysfunction (amenorrhea or dysfunctional uterine bleeding)

           – 69% hyperandrogenism (hirsutism and/or acne)

           – 41% obesity

           – 20% no symptoms

  • Also ask about

           – Current medication use

           – Hair loss

           – Lipid disorders

           – Hypertension

           – Mood disturbance

           – Sleep apnea

           – Exogenous androgen use

Physical exam

  • Measure

           – BP

           – Height and weight to calculate BMI

           – Waist circumference (waist-hip ratio >0.85)

  • Obesity may occur in 70% of patients.
  • Perform pelvic examination to assess ovarian size
  • Clitoromegaly rarely associated with PCOS; if present, look for other causes
  • Look for stigmata of hyperandrogenism and insulin resistance such as:

           – Deep voice

           – Temporal balding and acne

           – Hirsutism (70% of women with PCOS)

           – Androgen alopecia (infrequent)

           – Acanthosis nigricans; features include: velvety, mossy, verrucous, hyperpigmented skin located on neck,   
             axillae, under breasts, or on vulva

Making the diagnosis

  • Diagnostic criteria may include

           – Hyperandrogenism (presence of hirsutism or biochemical hyperandrogenemia)

           – Oligomenorrhea or amenorrhea

           – Polycystic ovaries on ultrasound

  • Rotterdam Consensus Criteria 2003 guidelines require at least two of these three criteria.
  • National Institutes of Health Criteria 1990 require hyperandrogenism and oligomenorrhea or amenorrhea.
  • Updated Androgen Excess Polycystic Ovary Syndrome Society 2009 guidelines require hyperandrogenism plus at least one of oligomenorrhea/amenorrhea or polycystic ovaries.
  • All criteria recommend excluding other possible causes.