- Other causes of hyperandrogenism such as:
– Nonclassical congenital adrenal hyperplasia
– Cushing syndrome
- Other causes of anovulation including:
– Premature ovarian failure
– Hyperprolactinemia (pituitary adenoma)
– Progestational agents
- 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
– 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
– Insulin-like growth factor I or growth hormone levels if signs of acromegaly
- 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
– 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
– 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.
Women with PCOS appear to be at greater long-term risk of infertility, endometrial cancer, cerebrovascular disease, and diabetes.