Rule out

  • Other causes of hyperandrogenism such as:

           – Nonclassical congenital adrenal hyperplasia

           – Cushing syndrome


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           – Acromegaly

  • Other causes of anovulation including:

           – Pregnancy

           – Premature ovarian failure

           – Hypothyroidism

           – Hyperthyroidism

           – Hyperprolactinemia (pituitary adenoma)

           – Progestational agents

Testing

  • Tests to help diagnose PCOS:

           – Total testosterone levels ≥110 ng/dL suggests PCOS, and <60 ng/dL suggests absence of PCOS.

           – Elevated luteinizing hormone (LH) or elevated LH/follicle-stimulating hormone (FSH) ratio

           – Elevated dehydroepiandrosterone sulfate

           – Sex hormone-binding globulin to help determine the bioavailable amount of testosterone

           – Pelvic ultrasound; if single follicle >10 mm, repeat scan during ovarian quiescence

  • Tests to assess for insulin resistance or metabolic syndrome:

           – Fasting glucose level plus glucose level two hours after 75 g oral glucose load (two-hour oral glucose
           tolerance test)

           – Fasting insulin level

           – Fasting lipid profile

  • Additional tests to rule out other conditions include:

           – Urine human chorionic gonadotropin to rule out pregnancy

           – Thyroid-stimulating hormone

           – Prolactin level

           – 24-hour urinary free cortisol or low-dose dexameth­asone suppression test if suspecting Cushing
           syndrome

           – Insulin-like growth factor I or growth hormone levels if signs of acromegaly

Treatment

  • Initial treatment of PCOS is lifestyle modification using increased exercise plus dietary changes.

           – Lifestyle modification associated with reduced diabetes risk

           – Reduction in body weight associated with improved pregnancy rates, decreased hirsutism, and
           improvements in glucose levels

  • Metformin helps with multiple aspects of PCOS.

           – Improves glucose tolerance

           – Lowers circulating androgen levels and decreases hirsutism

           – May improve ovulation rate and pregnancy rate (but not live-birth rate)

  • For primary treatment of menstrual abnormalities, combination low-dose oral contraceptive pills (OCPs) are recommended.
  • For infertility

           – Clomiphene (Clomid, Serophene) is recommended as first-line choice for ovulation induction in women
           with PCOS.

           – If clomiphene citrate fails to result in pregnancy, recommended second-line therapy is exogenous
           gonadotropins or laparoscopic ovarian surgery.

           – Laparoscopic ovarian surgery appears no more effective than gonadotropins alone for increasing live-birth
           rate or reducing miscarriage rate in women with clomiphene-resistant PCOS, but ovarian drilling is
           associated with fewer multiple gestations.

           – Aromatase inhibitors (letrozole [Femara], anastrozole [Arimidex]) are also options to improve pregnancy 
           rates in infertile women with PCOS.

  • For hirsutism

           – There is no clear primary treatment for hirsutism in women with PCOS.

           – Spironolactone (Aldactone) 50-100 mg orally b.i.d. may be used to reduce hair growth and may be more
            effective than metformin.

           – There is insufficient evidence comparing such insulin-sensitizing drugs as metformin with OCPs.

           – Laser treatment may improve depression, anxiety, and quality of life in women with PCOS and facial
           hirsutism.

           – Addition of eflornithine (Vaniqa) to laser treatment increases effectiveness for treatment of hirsutism

  • Other treatments to consider

           – Bariatric surgery in morbidly obese women with PCOS might improve hirsutism, hyperandrogenism, insulin
           resistance, and menstrual cycles.

           – Addition of simvastatin (Zocor) to metformin is associated with improved testosterone levels and LH/FSH
           ratio in women with PCOS.

           – Daily spearmint tea consumption may improve self-assessed hirsutism at 30 days in patients with PCOS.

Prognosis

Women with PCOS appear to be at greater long-term risk of infertility, endometrial cancer, cerebrovascular disease, and diabetes.

Dr. Ehrlich is an assistant clinical professor in family medicine at the University of Massachusetts Medical School in Worcester. Dr. Yonder is a family physician at Central Michigan University in Mount Pleasant.