Ambulatory Series: Polycystic Ovary Syndrome

Host/Editor: Dr. Alla Turshudzhyan, Chief Medical Resident at UCONN. PCOS is a complex condition and is quite common. It’s presenting symptoms are ovulatory and menstrual irregularity, subfertility or infertility, clinical hyperandrogenism, metabolic dysfunction, and/or polycystic ovaries. Since the condition was first described in 1935, a lot has changed in our understanding of the pathophysiology. Diagnosis of PCOS can be made by Rotterdam Criteria. More specifically, two out of three of the following criteria have to be met – 1) oligomenorrhea and/or anovulation, 2) clinical and/or biochemical signs of hyperandrogenism, 3) polycystic ovaries on TVUS. Important take away here is you don’t have to visualize polycystic ovaries to make the diagnosis. We no longer use LH:FSH ratio in working up PCOS. If patient has hyperandrogenic features, you can order a total testosterone. In cases where patient has virilization and severely elevated testosterone, other causes need to be investigated. If your patient also has oligomenorrhea, you should add an early morning 17-hydroxyprogesterone to rule out nonclassic congenital adrenal hyperplasia. Measurements of DHEA or free testosterone are not routinely recommended. You can consider adding hCG, TSH, FSH to your lab work. Treatment options will vary based on whether or not the patient is pursuing pregnancy. If pregnancy is not desired, COC should be prescribed for menstrual dysfunction, endometrial protection, and contraception. Metformin can be added if patient has glucose intolerance. Spironolactone or other antiandrogen medications can be added for androgen excess manifestations if COC are not enough. Weigh loss is another key component of PCOS treatment. Pay close attention to signs of depression or anxiety in your patients with PCOS. If your patients desire pregnancy, there are ovulation induction medications that can be tried first followed by laparoscopic surgery or exogenous gonadotropins. If all those steps fail, patients should be referred to IVF for further options. We hope you enjoy this episode! Thank you for listening.