QuestionSBA
QuestionChoice
Whilst PCOS is associated with impaired glucose tolerance and type 2 diabetes, a fasting serum blood glucose would not aid in diagnosing PCOS.
49785
d
Fasting serum blood glucose
QuestionChoice
This woman has features of polycystic ovary syndrome (PCOS). The Rotterdam criteria are used to diagnose PCOS and include (1) oligo- or anovulatory cycles; (2) clinical or biochemical hyperandrogenism and (3) a polycystic appearance of the ovaries on ultrasound. A diagnosis of PCOS can be made if two of the above three criteria are met and other causes of the person's symptoms have been excluded.

The long and irregular menstrual cycles are likely to be anovulatory cycles. The papulo-pustular rash on her face is likely due to shaving, an indication of troublesome hirsutism caused by hyperandrogenism.
49782
a
Transvaginal ultrasound scan
QuestionChoice
A 24-hour urinary cortisol would be indicated for the exclusion of Cushing's syndrome, but would not confirm the likely diagnosis of PCOS. Cushing's syndrome results in an excess of glucocorticoids (cortisol). It can present with similar signs such as obesity, acne and hirsutism but is much less common than PCOS.
49786
e
24-hour urinary cortisol
QuestionChoice
Serum follicle-stimulating hormone can be measured in conjunction with luteinising hormone (LH). In PCOS, the ratio of LH to FSH is increased (>2). Serum FSH can also help diagnose premature ovarian failure or menopause and is elevated in these conditions. FSH alone would not aid in the diagnosis of PCOS.
49783
b
Serum follicle-stimulating hormone (FSH)
QuestionChoice
Mid-luteal serum progesterone is used to confirm ovulation. Whilst this may be useful in the workup for primary infertility, the history of long cycles already suggests anovulatory cycles. A mid-luteal serum progesterone may confirm or refute ovulation, but does not aid in confirming the likely diagnosis of PCOS.
49784
c
Mid-luteal serum progesterone
Concept
Chapter
# Summary
  
 
Polycystic ovary syndrome (PCOS) is a disorder characterised by hyperandrogenism, ovulation disorders, and polycystic ovarian morphology. It is common among women of child-bearing age. Key signs and symptoms include oligomenorrhoea, hirsutism, acne, and subfertility among others. Investigations such as hormonal assays and imaging techniques are used in diagnosis. Management strategies encompass lifestyle modifications and a range of pharmacological treatments tailored to patient preferences, such as conception.
  
 
# Definition
  
 
Polycystic ovary syndrome (PCOS) is a disorder characterised by hyperandrogenism (manifesting as oligomenorrhoea, hirsutism, and acne), ovulation disorders, and polycystic ovarian morphology.
  
 
# Epidemiology
  
 
Polycystic ovary syndrome is a common endocrine condition, affecting up to a quarter of women during their reproductive years.
  
 
# Aetiology
  
 
The precise aetiology of PCOS remains undetermined. However, potential hormonal imbalances implicated in this syndrome include hyperandrogenism, insulin resistance, elevated levels of luteinizing hormone (LH) and raised oestrogen levels.
  
 
# Signs and Symptoms
  
 
The clinical presentation of PCOS is largely attributed to the hormonal imbalances, with symptoms including:
  
 
  - Oligomenorrhoea
  - Subfertility
  - Acne
  - Hirsuitism
  - Obesity
  - Mood changes including depression and anxiety
  - Male pattern baldness
  - Acanthosis nigricans (secondary to insulin resistance)
  
 
# Differential Diagnosis
  
 
For accurate diagnosis, other endocrine disorders presenting similar clinical features must be excluded. These include:
  
 
  - Menopause: Characterised by cessation of menstruation, hot flashes, vaginal dryness, mood changes, and sleep problems.
  - Congenital adrenal hyperplasia (CAH): Presenting with signs of androgen excess like hirsutism, acne, and irregular periods. Presents earlier on and can lead to ambiguous genitalia (for affected females). 
  - Hyperprolactinaemia: Symptoms include irregular periods, galactorrhoea, and infertility.
  - Androgen-secreting tumours: May cause virilisation, amenorrhoea, and hirsutism.
  - Cushing's syndrome: Characterised by weight gain, purple stretch marks, and easy bruising.
  
 
# Investigations
  
 
Biochemical assays and imaging techniques play a pivotal role in the diagnosis of PCOS:
  
**Bedside:**

- Clinical examination to identify features of hyperandrogenism (e.g. hirsutism) or features of insulin resistance (e.g. acanthosis nigricans, raised BMI)

**Bloods:**

- LH:FSH ratio: An increase (>2) aids in differentiating from menopause where the ratio is normal.
- Total testosterone: May be normal or slightly elevated.
- Fasting and oral glucose tolerance tests: Used to diagnose insulin resistance.
- Other tests may include TFTs (for thyroid dysfunction), 17-hydroxyprogesterone levels (for CAH), prolactin (for hyperprolactinaemia), DHEA-S and free androgen index (for androgen-secreting tumours), and 24-hour urinary cortisol (for Cushing's syndrome).

**Imaging:**

- Transabdominal and transvaginal ultrasound: Reveals increased ovarian volume and multiple cysts. May be important for fulfilling Rotterdam Diagnostic Criteria (See below) 


No **invasive tests** are required for diagnosis. 

 
 **Rotterdam Diagnostic Criteria:**
  
 
Upon exclusion of other causes, PCOS can be diagnosed if at least two of the following criteria are met:
  
 
  - Polycystic ovaries (defined as a follicle number per ovary of 20 or more in at least one ovary)
  - Oligo-/anovulation
  - Clinical or biochemical features of hyperandrogenism
  
 
# Management
  
 
The management of PCOS primarily focuses on symptom control and prevention of complications, with endometrial cancer risk reduction achieved through regular menstruation.
  
 
**Conservative:**
  
 
  - Encouragement of weight loss and exercise
  - Education on increased risks of cardiovascular disease, diabetes, and endometrial cancer
  
 
**Medical, for women not planning pregnancy:**
  
 
  - Co-cyprindrol: Reduces hirsutism and promotes regular menstruation.
  - Combined oral contraceptive pill (COCP): Decreases irregular bleeding and offers protection against endometrial cancer.
  - Metformin: Aids in regularising menstruation, reducing hirsutism, and acne.
  
 
**Medical, for women wishing to conceive:**
  
 
  - Clomiphene: Induces ovulation and enhances conception rates.
  - Metformin: Can be used alone or in combination with clomiphene to improve chances of pregnancy.
  - Gonadotrophins: Utilised to induce ovulation if clomiphene and metformin prove ineffective.

**Surgical, for women wishing to conceive:**

  - Ovarian drilling: A second-line laparoscopic surgical procedure that damages the hormone-producing cells of the ovary. 
  
# Complications


- Infertility: Caused by impaired or dysregulated ovulation.
- Metabolic syndrome and dyslipidaemia: PCOS leads to raised triglycerides and LDL and fall in HDL. 
- Type 2 diabetes: PCOS increases risk of T2DM by approximately two fold as a result of insulin resistance 
- Cardiovascular disease: This is likely a consequence of metabolic complications of PCOS and hormonal alterations. 
- Hypertension: Greater risk of hypertension seen in premenopausal as opposed to postmenopausal women. 
- Obstructive sleep apnoea: This occurs as a result of obesity (usually secondary insulin resistance and metabolic changes). 

# NICE Guidelines

[Click here for NICE guidelines on PCOS](https://cks.nice.org.uk/topics/polycystic-ovary-syndrome/)

# References 

[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/141)

[RCOG page](https://www.rcog.org.uk/for-the-public/browse-our-patient-information/polycystic-ovary-syndrome-pcos-what-it-means-for-your-long-term-health/)
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980
Polycystic ovary syndrome
Topic
26
Gynaecology
9993
A 31-year-old woman presents to the general practitioner as she has failed to become pregnant after 18 months of regular intercourse.

She has an irregular menstrual cycle, which varies between 35-60 days.

On examination, she is overweight and has a papulopustular folliculitis on her face, particularly on the chin.

Which single test would most likely to confirm the probable diagnosis?
a