PCOS
Diagnosis, 2/3 of the following:
Diagnosis, 2/3 of the following:
- Oligo-ovulation/anovulation (LH:FSH >2)
- Oligomenorrhea (>35d) or amenorrhea
- Hyperandrogenism (clinical or biochemical)
- Acne, androgenic alopecia, hirsutism (terminal hairs >5mm)
- Elevated serum total/bioavailable/free testosterone or DHEAS
- Polycystic ovaries on ultrasound
Consider waiting 8 years post-menarche before diagnosing PCOS, given likelihood for physiological anovulation of adolescence
Investigations
Investigations
- b-hCG, Prolactin, TSH, FSH/LH
- Serum total/bioavailable/free testosterone
- If normal, unlikely PCOS (may consider repeat testing, preferably early morning)
- Pelvic ultrasound
- Optional if already met other criteria for PCOS
Consider endocrine work-up
- If rapidly progressive hirsutism, lowering of the voice, and clitoromegaly
- DHEAS >700mcg/dL, r/o virilizing tumour
- Morning 17OHP >170ng/dL, r/o CAH or virilizing tumour
- Abdo/Pelvic ultrasound, r/o adrenal/ovarian tumor
- If central obesity, striae, proximal myopathy, early osteoporosis/hypertension
- Mid-day/afternoon Cortisol, r/o Cushing's
- If elevated, consider 24-h urine collection for free cortisol and creatinine
- Mid-day/afternoon Cortisol, r/o Cushing's
- If acromegaly features,
- IGF-1, r/o acromegaly
Management
Management
- Monitor for diabetes, dyslipidemia, hypertension, weight (BMI)
- Weight loss (diet, exercise) first-line
- Combined OCP for hyperandrogenism, irregular menses , contraception
- For hirsutism, if OCP not effective after 6 months, consider adding Spirinolactone 50-100mg/day
- If desires pregnancy, target of BMI <35 and/or 5% to 10% weight loss
- Letrozole first-line medication for infertility
- Clomiphene citrate
- Consider adding Metformin to Clomiphene citrate
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