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For further information, see CMDT Part 18-18: Polycystic Ovary Syndrome

Key Features

Essentials of Diagnosis

  • Clinical or biochemical evidence of hyperandrogenism

  • Anovulation or oligoovulation

  • Polycystic ovaries on ultrasonography

General Considerations

  • Etiology is unknown

  • Presence of at least two of the following features outlined by the Rotterdam Criteria are diagnostic

    • Androgen production

    • Ovulatory dysfunction

    • Polycystic ovaries

  • Associated with hirsutism, obesity as well as an increased risk of diabetes mellitus, cardiovascular disease, and metabolic syndrome

  • Unrecognized or untreated PCOS is a risk factor for cardiovascular disease

Demographics

  • Affects 5–10% of women of reproductive age

Clinical Findings

Symptoms and Signs

  • Often presents as a menstrual disorder (from amenorrhea to menorrhagia) and infertility

  • Skin disorders due to peripheral androgen excess, including hirsutism or acne, are common

  • Patients may show signs of insulin resistance and hyperinsulinemia; these women are at increased risk for early-onset type 2 diabetes and metabolic syndrome

  • Patients who do become pregnant are at increased risk for perinatal complications, such as gestational diabetes and preeclampsia

  • In addition, they have an increased long-term risk of endometrial cancer secondary to unopposed estrogen secretion

Differential Diagnosis

  • Hypothalamic amenorrhea, eg, stress, weight change, exercise

  • Obesity

  • Hypothyroidism

  • Hyperprolactinemia

  • Premature ovarian failure

  • Cushing syndrome

  • Congenital adrenal hyperplasia

  • Androgen-secreting tumor (adrenal, ovarian)

  • Pregnancy

Diagnosis

Laboratory Tests

  • Check serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, thyroid-stimulating hormone (TSH), and dehydroepiandrosterone sulfate (DHEAS)

  • Fasting glucose test, hemoglobin A1C

  • Lipoprotein profile

Imaging Studies

  • Pelvic ultrasound may document polycystic ovaries (not necessary for diagnosis)

Treatment

Medications

  • If the patient wishes to become pregnant

    • Clomiphene or other drugs can be used for ovarian stimulation

    • Clomiphene is the first-line therapy for infertility

    • Metformin can improve menstruation but has little or no benefit in treating infertility; it is beneficial for metabolic or glucose abnormalities

  • If the patient does not desire pregnancy

    • Medroxyprogesterone acetate, 10 mg daily orally for the first 10 days of every 1–3 months

    • If contraception is desired, a combination contraceptive (pill, ring, or patch) can be used

  • The levonorgestrel-containing IUD

    • Another option to minimize uterine bleeding and protect against endometrial hyperplasia

    • However, the IUD does not help control hirsutism

  • Hirsutism

    • A low-dose combination oral contraceptive for at least 6–12 months

    • Spironolactone is also useful in doses of 25 mg three or four times daily orally

    • Flutamide, 125–250 mg once daily orally, and finasteride, 5 mg once daily orally, are also effective

    • Because spironolactone, flutamide, and finasteride are potentially teratogenic, they should only be used with secure contraception

    • Topical eflornithine cream applied to affected facial areas twice daily for 6 months may be helpful

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