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INTERIM UPDATE: This Practice Bulletin is updated as highlighted to reflect recent evidence on the use of letrozole for
ovulation induction in women with polycystic ovary syndrome.
Hyperandrogenism║ R NR R
Oligoamenorhhea R NR NR
or amenorrhea
Polycystic ovaries NR NR
by ultrasound
diagnosis
Abbreviations: R, required for diagnosis; NR, possible diagnostic criteria but not required to be present.
*All criteria recommend excluding other possible etiologies of these signs and symptoms and more than one of the factors present
to make a diagnosis.
†
Dunaif A, Givens JR, Haseltine FP, Merriam GR, editors. Polycystic ovary syndrome. Boston (MA): Blackwell Scientific Publications;
1992.
‡
Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Rotterdam
ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Fertil Steril 2004;81:19–25.
§
Azziz R, Carmina E, Dewailly D, Diamantl-Kandarakis E, Escobar-Morreale HF, Futterwelt W, et al. Positions statement: criteria
for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an Androgen Excess Society guideline.
Androgen Excess Society. J Clin Endocrinol Metab 2006;91:4237–45.
║
Hyperandrogenism may be either the presence of hirsutism or biochemical hyperandrogenemia.
of women with PCOS are not obese. Obesity is more increased risk of insulin resistance and its associated con-
prevalent in the United States than in other countries ditions, such as the metabolic syndrome (see Box 2) (10),
and, therefore, the PCOS phenotype may be different. nonalcoholic fatty liver disease (11), and obesity-related
Compensatory hyperinsulinemia may result in decreased disorders such as sleep apnea (12). In turn, all of these
levels of sex hormone–binding globulin (SHBG) and, conditions are risk factors for long-term metabolic
thus, more bioavailable circulating androgen and serve as sequelae, such as type 2 diabetes and cardiovascular dis-
a trophic stimulus to androgen production in the adrenal ease. Women with PCOS also have multiple risk factors
gland and ovary. Insulin also may have direct hypotha- for endometrial cancer, including chronic anovulation,
lamic effects, such as abnormal appetite stimulation and centripetal obesity, and diabetes, although the strength
gonadotropin secretion. Hyperandrogenism, although of the association with PCOS per se is debated (13). In
central to the syndrome, may have multiple etiologies, recent years, there has been increased recognition of
some not related to insulin resistance. mood disturbances and depression among women with
PCOS (14).
Clinical Manifestations
Women with PCOS commonly present with menstrual Differential Diagnosis of PCOS
disorders (from amenorrhea to menorrhagia) and infer- The differential diagnosis of PCOS includes other causes
tility. For this reason, much attention has been focused on of androgen excess (see Box 3). The essential compo-
the risks of ovulation induction among women with nents of the history and physical examination necessary
PCOS because they are at increased risk of ovarian to diagnose the underlying cause of the disorder are
hyperstimulation syndrome and multifetal pregnancy. In described in Box 1. The history should focus on the onset
addition, women with PCOS appear to be at increased and duration of the various signs of androgen excess, the
risk of complications of pregnancy, including gestational menstrual history, and concomitant medications, includ-
diabetes and hypertensive disorders (8). The risk of com- ing the use of exogenous androgens. A family history of
plications is further exacerbated by iatrogenic multiple diabetes and cardiovascular disease (especially first-
pregnancy from infertility treatment. degree relatives with premature onset of cardiovascular
Skin disorders, especially those due to peripheral disease [male younger than 55 years and female younger
androgen excess such as hirsutism and acne, and to than 65 years]) is important.
a lesser degree androgenic alopecia, are common in The physical examination should include evalua-
women with PCOS (9). Women with PCOS are at tion of balding, acne, clitoromegaly, and body hair
Physical
c Blood pressure
abnormal, triglycerides greater than 150 mg/dL abnormal [low-density lipoproteins usually cal-
culated by Friedewald equation])
Ultrasound Examination
c Determination of polycystic ovaries: in one or both ovaries, either 12 or more follicles measuring
2–9 mm in diameter, or increased ovarian volume (greater than 10 cm3). If there is a follicle
greater than 10 mm in diameter, the scan should be repeated at a time of ovarian quiescence in
order to calculate volume and area. The presence of one polycystic ovary is sufficient to provide the
diagnosis.
c Identification of endometrial abnormalities
c Fasting insulin levels in younger women, those with severe stigmata of insulin resistance and
test in women with late onset of polycystic ovary syndrome symptoms or stigmata of Cushing
syndrome
distribution, as well as pelvic examination to look for pigmented skin. It has been noted on the back of the
ovarian enlargement. The presence and severity of neck, in the axillae, underneath the breasts, and even
acne should be noted. Signs of insulin resistance such on the vulva. The presence of acanthosis nigricans
as hypertension, obesity, centripetal fat distribution, appears to be more a sign of insulin resistance or
and the presence of acanthosis nigricans should be medication reaction than a distinct disease unto itself.
recorded. Acanthosis nigricans is a dermatologic con- Other pathologic conditions rarely associated with
dition marked by velvety, mossy, verrucous, hyper- acanthosis nigricans should be considered, such as
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care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the
treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such
course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or
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