Diagnosis and Treatment of Polycystic Ovary Syndrome

 


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Am Fam Physician. 2016 Jul 15;94(2):106-113.

  Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/polycystic-ovary-syndrome.html.

Author disclosure: No relevant financial affiliations.

Polycystic ovary syndrome is the most common endocrinopathy among reproductive-aged women in the United States, affecting approximately 7% of female patients. Although the pathophysiology of the syndrome is complex and there is no single defect from which it is known to result, it is hypothesized that insulin resistance is a key factor. Metabolic syndrome is twice as common in patients with polycystic ovary syndrome compared with the general population, and patients with polycystic ovary syndrome are four times more likely than the general population to develop type 2 diabetes mellitus. Patient presentation is variable, ranging from asymptomatic to having multiple gynecologic, dermatologic, or metabolic manifestations. Guidelines from the Endocrine Society recommend using the Rotterdam criteria for diagnosis, which mandate the presence of two of the following three findings—hyperandrogenism, ovulatory dysfunction, and polycystic ovaries—plus the exclusion of other diagnoses that could result in hyperandrogenism or ovulatory dysfunction. It is reasonable to delay evaluation for polycystic ovary syndrome in adolescent patients until two years after menarche. For this age group, it is also recommended that all three Rotterdam criteria be met before the diagnosis is made. Patients who have marked virilization or rapid onset of symptoms require immediate evaluation for a potential androgen-secreting tumor. Treatment of polycystic ovary syndrome is individualized based on the patient's presentation and desire for pregnancy. For patients who are overweight, weight loss is recommended. Clomiphene and letrozole are first-line medications for infertility. Metformin is the first-line medication for metabolic manifestations, such as hyperglycemia. Hormonal contraceptives are first-line therapy for irregular menses and dermatologic manifestations.

Polycystic ovary syndrome (PCOS) is a complex condition that is most often diagnosed by the presence of two of the three following criteria: hyperandrogenism, ovulatory dysfunction, and polycystic ovaries. Because these findings may have multiple causes other than PCOS, a careful, targeted history and physical examination are required to ensure appropriate diagnosis and treatment. This article provides an algorithmic approach to the care of patients with suspected or known PCOS.

WHAT IS NEW ON THIS TOPIC: POLYCYSTIC OVARY SYNDROME

Recent studies suggest that letrozole (Femara) is associated with higher live-birth and ovulation rates compared with clomiphene in patients with polycystic ovary syndrome.

A 2012 Cochrane review concluded that metformin does not improve fertility in patients with polycystic ovary syndrome.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

All women diagnosed with PCOS should be screened for metabolic abnormalities (e.g., type 2 diabetes mellitus, dyslipidemia, hypertension), regardless of body mass index.

C

1921

All women with suspected PCOS should be screened for thyroid disease, hyperprolactinemia, and nonclassical congenital adrenal hyperplasia.

C

19

A calorie-restricted diet is recommended for all patients with PCOS who are overweight. Weight loss has been shown to have a positive effect on fertility and metabolic profile.

A

19, 37

Hormonal contraception (e.g., oral contraceptives) should be used as the initial treatment for menstrual cycle irregularity, hirsutism, and acne in patients with PCOS who are not actively trying to get pregnant.

A

19, 30


PCOS = polycystic ovary syndrome.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

All women diagnosed with PCOS should be screened for metabolic abnormalities (e.g., type 2 diabetes mellitus, dyslipidemia, hypertension), regardless of body mass index.

C

1921

All women with suspected PCOS should be screened for thyroid disease, hyperprolactinemia, and nonclassical congenital adrenal hyperplasia.

C

19

A calorie-restricted diet is recommended for all patients with PCOS who are overweight. Weight loss has been shown to have a positive effect on fertility and metabolic profile.

A

19, 37

Hormonal contraception (e.g., oral contraceptives) should be used as the initial treatment for menstrual cycle irregularity, hirsutism, and acne in patients with PCOS who are not actively trying to get pregnant.

A

19, 30


PCOS = polycystic ovary syndrome.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Epidemiology and P

The Authors

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TRACY WILLIAMS, MD, is the associate director of Via Christi Family Medicine Residency, Wichita, Kan., and an assistant professor in the Department of Family and Community Medicine at the University of Kansas School of Medicine–Wichita....

RAMI MORTADA, MD, is an assistant professor in the Department of Internal Medicine, Division of Endocrinology, at the University of Kansas School of Medicine–Wichita.

SAMUEL PORTER, MD, is a resident at Via Christi Family Medicine Residency.

Address correspondence to Tracy Williams, MD, Via Christi Family Medicine Residency, 707 N. Emporia, Wichita, KS 67214 (e-mail: tracy.williams@via-christi.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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