Polycystic Ovarian Syndrome (PCOS)

20 y/o F with h/o obesity, NAFL, HLD presents with irregular menses lasting longer than 6 months. Started menarche more than 2 years ago, denies currently being pregnant, and is currently attempting to conceive. Obesity, terminal hair, alopecia, acne, acanthosis nigricans, and skin tags noted on exam.

  • Risk factor screening

    • PHQ-9 positive for depression

    • STOP-BANG score suggesting sleep apnea

  • Diagnostic testing

    • Beta-HCG negative; TSH (N = 0.5-5 mIU/L) and prolactin (N = 2-29 ng/mL) WNL

    • Total serum testosterone at upper limit of normal (N = 15-70 ng/dL)

    • Obtain HbA1c, lipid panel

    • Pelvic U/S shows polycystic ovaries with >12 follicles measuring 2-9 mm

  • Treatment

    • Discuss referral to endocrine and starting clomiphene to increase chance of conception success

    • Start hormonal birth control once pt is no longer attempting to become pregnant

    • Recommend hair electrolysis vs. laser-based therapy for hair removal

    • Recommend treating acne with a combination of topical benzoyl peroxide, topical retinoids, and/or topical antibiotics; may consider spironolactone when no longer attempting to conceive

  • Counseling

    • Pt counseled about importance of weight loss; calories restricted diet recommended

    • Pt counseled that her risk for DM type 2 is 4x greater than the general population

Notes

  • Epidemiology/Etiology

    • Affects approximately 7% of U.S. age females

    • Insulin resistance may play a role in the pathophysiology of the condition

  • Diagnosis

    • Do not start workup within 2 years of menarche as periods are often irregular

    • Rotterdam criteria for diagnosis: Must meet 2 of 3 findings

      • Ovulatory dysfunction

      • Hyperandrogenism (physical exam + serum testosterone)

      • Polycystic ovaries on U/S

    • LH:FSH ratio >2 is NOT diagnostic

    • Consider obtaining TSH, prolactin level, and 17-hydroxyprogesterone level to rule out hypothyroidism, prolactinoma, and/or non-classical congenital adrenal hyperplasia, respectively

    • If patient meets criteria of ovulatory dysfunction and hyperandrogenism, U/S is not needed to confirm diagnosis

  • Physical exam

    • Hirsutism includes terminal hair, alopecia, and acne

    • Acanthosis nigricans and skin tags are findings indicative of DM

  • Common comorbidities include obesity, sleep apnea, non-alcoholic fatty liver disease, hyperlipidemia, and depression