Diagnosis and investigation of PCOS (Polycystic ovarian syndrome)

CRITERIA FOR PCOS DIAGNOSIS:

At least 2 of following present:

1. Infrequent or absent ovulation
2. Clinical or biochemical evidence of hyperandrogenism
3. Polycystic ovaries on ultrasound examination

Exclude other causes of hyperandrogenism: ovarian/adrenal tumours, congenital adrenal hyperplasia, Cushing’s syndrome.

Suspect PCOS if presentation with:

• Signs of hyperandrogenism – hirsutism, acne, alopecia
• Oligo/amenorrhea
• Infertility

especially if accompanied by obesity, acanthosis nigricans or FH of PCOS.

EXAMINATION and INVESTIGATION:

To establish the diagnosis:

Pelvic ultrasound (transvaginal) – classic picture of PCOS:

• 12 or more follicles in at least 1 ovary, measuring 2-9 mm diameter

  OR ovarian volume >10mls

  (AMH > 40pmol/L in most cases)

LH, total testosterone, free androgen index not mandatory for diagnosis.

To exclude other causes of oligo- and amenorrhoea:

• Induce withdrawal bleed with progesterone.If no bleed:
• FSH – raised in premature ovarian failure, very low in hypogonadotrophic hypogonadism, normal or low normal in PCOS.
• Prolactin (may be only slightly raised in PCOS)

To exclude other causes of hyperandrogenism if suspected:

• If severe or rapid onset of symptoms/signs of virulisation:

Total testosterone, free androgen index (normal to moderately raised in PCOS but very high with tumours), DHEAS (very high with adrenal tumours). Ultrasound/MRI examination of ovaries and adrenals where indicated.

• 17-hydroxy-progesterone if family history of congenital adrenal hyperplasia.

If overweight or frankly obese:

• BMI, waist circumference, blood pressure
• Fasting glucose and insulin
• SHBG and fasting lipid profile
• Oral glucose challenge test

Anil Gudi , Amit Shah and Prof Homburg