Polycystic ovarian syndrome

Definition

• Syndrome characterized by oligomenorrhea, hyperandrogenism, and polycystic ovaries

Differential Diagnosis

• PCOS
• Non-classical congenital adrenal hyperplasia (CAH)
• Prolactinoma
• Cushing's disease

Epidemiology

• PCOS 5-10% of female population
• Asymptomatic polycystic ovaries in 20% of female population (up to 50% of south Asians)

Investigations

• Electrolytes, which may be abnormal in CAH or Cushing disease
• DHEAS, expected to be high
• LH/FSH on day 2-5 of cycle, expected to be low
• 17-OH progesterone during the follicular phase, will be elevated in CAH or if measured at the wrong time in PCOS (so make sure to include estradiol, which should be low)
• HbA1c and fasting glucose
  • 75g OGTT if above are normal but suspicion for PCOS is high

Diagnosis

• Otherwise unexplained combination of:
  • Abnormal uterine bleeding pattern
    • Abnormal for age or gynecologic age
    • Persistent symptoms for one to two years
  • Evidence of hyperandrogenism
    • Persistent testosterone elevation above adult norms in a reliable reference laboratory is the best evidence
    • Moderate-severe hirsutism is clinical evidence of hyperandrogenism
    • Moderate-severe inflammatory acne vulgaris is an indication to test for hyperandrogenemia

Management

• Screen for nonclassic congenital adrenal hyperplasia (NCCAH), Cushing's syndrome, prolactin excess, thyroid dysfunction, and acromegaly
• Once diagnosis is confirmed, management is based on the patient's symptoms and goals
• Hirsutism
  • Shaving/waxing
  • Spironolactone (at high doses)
  • Cyproterone
  • Eflornithine cream (Vaniqa)
• Acne
• Menstrual irregularities
• Low fertility