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Assess for Polycystic Ovary Syndrome (PCOS) using the Rotterdam diagnostic criteria. Evaluate menstrual patterns, hyperandrogenism signs, and ultrasound findings to determine PCOS phenotype and metabolic risk.
PCOS is diagnosed when 2 of 3 criteria are met (after excluding other conditions):
Normal: 21-35 days. Oligomenorrhea: > 35 days or < 9 cycles/year
Normal female: 15-50 ng/dL. Elevated > 50-60 suggests hyperandrogenism
Normal female: 35-430 mcg/dL. Elevated > 430 suggests hyperandrogenism
≥ 12 follicles (2-9mm diameter) in at least one ovary
Ovarian volume ≥ 10 cm³ (without dominant follicle or corpus luteum)
| Phenotype | Features | Metabolic Risk |
|---|---|---|
| A (Classic) | Oligo/anovulation + Hyperandrogenism + PCO | High |
| B | Oligo/anovulation + Hyperandrogenism | High |
| C (Ovulatory) | Hyperandrogenism + PCO | Moderate |
| D | Oligo/anovulation + PCO | Moderate-Low |
Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder in women of reproductive age, affecting 6-12% of women. It's a complex condition involving reproductive, metabolic, and psychological features with significant long-term health implications.
The Rotterdam criteria (2003) are the most widely accepted diagnostic criteria, requiring 2 of 3 features: (1) oligo/anovulation, (2) clinical or biochemical hyperandrogenism, and (3) polycystic ovaries on ultrasound. Other causes of these features must be excluded, including thyroid dysfunction, hyperprolactinemia, and congenital adrenal hyperplasia.
Reproductive: Irregular periods or amenorrhea, infertility due to anovulation, increased miscarriage risk, and pregnancy complications including gestational diabetes and preeclampsia.
Hyperandrogenism: Hirsutism (excess body hair in male-pattern distribution), acne, male-pattern baldness, and in severe cases, virilization. Biochemical hyperandrogenism may be present without clinical signs.
Metabolic: Insulin resistance (present in 50-70% of PCOS patients), impaired glucose tolerance, type 2 diabetes (2-4 times higher risk), dyslipidemia, obesity (especially central adiposity), metabolic syndrome, and increased cardiovascular disease risk.
Treatment is individualized based on symptoms and goals. Lifestyle modification (diet, exercise, weight loss) is first-line for all patients. Metformin improves insulin sensitivity and may restore ovulation. Combined oral contraceptives regulate cycles and reduce androgen levels. For fertility, ovulation induction with clomiphene or letrozole is used. Anti-androgens like spironolactone treat hirsutism. Regular metabolic screening and long-term cardiovascular risk management are essential.
The exact cause is unknown, but PCOS involves genetic and environmental factors. There's often familial clustering. Key features include insulin resistance (even in lean women), abnormal gonadotropin secretion (elevated LH/FSH ratio), and hyperandrogenism. Excess insulin stimulates ovarian androgen production. Androgens interfere with follicle development, causing accumulation of small follicles (polycystic appearance) and anovulation. It's a complex endocrine disorder affecting multiple systems.
No. Rotterdam criteria require only 2 of 3 features. Phenotype B (oligo/anovulation plus hyperandrogenism without polycystic ovaries) is a recognized PCOS phenotype with similar metabolic risk as classic PCOS. Conversely, polycystic ovaries alone (without menstrual irregularity or hyperandrogenism) are common in normal women and don't indicate PCOS. About 20-30% of women without PCOS have polycystic-appearing ovaries on ultrasound.
Comprehensive screening includes: (1) 2-hour oral glucose tolerance test or HbA1c for diabetes/prediabetes screening, repeated every 1-3 years; (2) fasting lipid panel (total cholesterol, LDL, HDL, triglycerides) at diagnosis and every 2 years; (3) blood pressure monitoring; (4) liver function tests (PCOS increases NAFLD risk); (5) screening for obstructive sleep apnea if overweight; (6) mental health assessment (depression/anxiety are common). Earlier and more frequent screening is needed if you're overweight, have family history of diabetes, or other risk factors.
Yes, most women with PCOS can achieve pregnancy with treatment. PCOS is the leading cause of anovulatory infertility but is highly treatable. Lifestyle modification and weight loss (even 5-10%) can restore ovulation in some women. Metformin may help, especially with insulin resistance. First-line fertility treatment is ovulation induction with clomiphene citrate or letrozole. If unsuccessful, gonadotropin injections or IVF may be considered. Success rates are good with appropriate treatment. PCOS pregnancies have higher risks of gestational diabetes and preeclampsia requiring closer monitoring.
Combined oral contraceptives serve multiple purposes in PCOS: (1) regulate menstrual cycles providing predictable bleeding, (2) reduce androgen levels improving hirsutism and acne, (3) provide endometrial protection - chronic anovulation causes unopposed estrogen exposure increasing endometrial cancer risk, (4) prevent pregnancy if not desired. However, OCPs may worsen insulin resistance and don't address metabolic issues, so they're not appropriate for everyone. Progestins alone can provide endometrial protection without estrogen if contraindicated.
Metformin isn't appropriate for all PCOS patients but can be very beneficial for some. It improves insulin sensitivity, may restore ovulation, aids weight loss, improves metabolic parameters, and may reduce diabetes risk. Consider metformin if you have: insulin resistance, prediabetes/diabetes, difficulty losing weight with lifestyle alone, desire for fertility, or metabolic syndrome. It's particularly beneficial in overweight/obese PCOS. However, it's not FDA-approved for PCOS (off-label use) and has GI side effects. Discuss risks/benefits with your doctor.
PCOS significantly increases type 2 diabetes risk. About 50-70% of women with PCOS have insulin resistance regardless of weight. Women with PCOS have 2-4 times higher risk of developing type 2 diabetes, often at younger ages. Prediabetes/impaired glucose tolerance affects 30-40% of PCOS patients. Risk is higher with obesity, family history of diabetes, certain ethnic backgrounds (Hispanic, African American, Asian), and increasing age. This is why glucose screening is essential at diagnosis and regularly thereafter. Weight loss and metformin can delay or prevent progression to diabetes.
PCOS symptoms change but don't completely resolve with menopause. Reproductive symptoms (irregular periods, infertility) become irrelevant. Hyperandrogenism often improves as ovarian androgen production decreases. However, metabolic features persist and may worsen. Women with PCOS have lifelong increased risk of diabetes, cardiovascular disease, and metabolic syndrome. Post-menopausal women with PCOS history need continued metabolic monitoring and cardiovascular risk factor management. Some evidence suggests PCOS may be associated with later menopause age.