Polycystic Ovary Syndrome: Assessment and Management Guidelines

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in reproductive-aged women, affecting up to 13% of this population. An international group of professional organizations has developed an evidence-based guideline for the assessment and management of PCOS.

To diagnose PCOS, two of the following criteria are required:

1. clinical or biochemical evidence of hyperandrogenism,
2. ovulatory dysfunction,
3. ultrasound images showing polycystic ovaries or elevated antimüllerian hormone levels.

Hyperandrogenism

At least 60% of women with PCOS have evidence of hyperandrogenism using clinical or biochemical markers. To diagnose clinical hyperandrogenism, the modified Ferriman-Gallwey score is recommended to assess facial and terminal hair growth, although presentations differ among ethnicities.

Testosterone testing may be the most useful in the absence of clinical features of hyperandrogenism. The guidelines strongly recommend evaluating for biochemical hyperandrogenism via total and free testosterone testing. Measuring androstenedione and dehydroepiandrosterone sulfate levels should be considered if total and free testosterone are normal.

Ovulatory dysfunction can be demonstrated by irregular menstrual cycles and is a cornerstone of a PCOS diagnosis. Anovulation can be confirmed by testing serum progesterone levels.

Diagnosing PCOS in adolescents can be challenging because irregular menstrual cycles are common. The guideline committee defines irregular cycles as the following:

• 1 year after menarche: more than 90 days for one cycle
• 1 to 3 years after menarche: less than 21 days or more than 45 days
• 3 years after menarche to perimenopause: less than 21 days or more than 35 days, or fewer than 8 cycles per year
• Primary amenorrhea more than 3 years after breast development or by 15 years of age.

Adolescents with clinical features of PCOS without meeting diagnostic criteria are considered at risk and should be reassessed for up to 8 years after menarche when ovaries have reached maturity. Menstrual regularity can vary with ethnicity, age of menarche, body habitus, and use of combined oral contraceptives. Although 95% of cycles range from 21 to 45 days, irregular cycles that continue 2 years after menarche likely represent ovulatory dysfunction.

Ultrasonography

Transvaginal ultrasonography is the most accurate means for diagnosing PCOS. There is no standard recommended technique for measuring follicles by ultrasound, although follicle number per ovary with a cutoff of at least 20 follicles in an ovary is the most accurate method for diagnosing PCOS in adults, followed by follicle number per cross-section and ovarian volume.

Standards for ultrasound findings in adolescents with PCOS are unclear, and ultrasonography is not recommended for diagnosing PCOS in adolescents.