The diagnosis of polycystic ovary syndrome (PCOS) has been through many permutations in the last 30 years I have been in practice. The most widely used and accepted current definition of PCOS is from the consensus criteria from 2003, called the Rotterdam Criteria. The diagnostic criteria for the Rotterdam diagnosis of PCOS require the presence of two of the following:
1. oligomenorrhea/anovulation-as manifested by a cycle length of > 35 days
2. hyperandrogenism: indicated by hirsutism or male pattern baldness, or elevated serum androgen levels (testosterone, androstenedione or dehydroepiandrosterone) clinical
3. polycystic ovaries on ultrasound ( > 12 small follicles in an ovary)
Other etiologies must be excluded such as congenital adrenal hyperplasia, androgen secreting tumors, Cushing syndrome, thyroid dysfunction and hyperprolactinemia
The first step in the diagnosis is to determine if both hirsutism and oligomenorrhea are present based on a medical history and physical exam. If both these issues are present, then an ultrasound is not necessary and a diagnosis of PCOS is likely and treatment can begin, because approximately 95% of women with hirsutism and oligomenorrhea have multifollicular ovaries on a pelvic ultrasound.
If only one or the other, hirsutism or oligomenorrhea, is present, the additional tests need to be done. If hirsutism is the singular presenting symptom (without oligomenorrhea or amenorrhea), then a pelvic ultrasound should be ordered. If there are then 12 or more small follicles, i.e. multifollicular ovaries then a diagnosis of PCOS can be stated. If oligomenorrhea is the only symptom with no hirsutism, then it is recommended that serum androgens be ordered as well as a pelvic ultrasound. If there are elevated serum androgens and/or a multifollicular ovary are found, then a diagnosis of PCOS is concluded.
Women with amenorrhea should have other tests after a comprehensive medical history and physical exam, including serum prolactin, thyroid stimulating hormone, and after a comprehensive history and physical exam- a progesterone challenge test. Other tests may also include follicle stimulating hormone. Amenorrhea in women who have a history of at least one previous menses, has numerous causes and PCOS is just one of them. Others include hypothyroid, prolactin secreting tumors, stress, premature menopause, and something called hypothalamic amenorrhea (ex/ eating disorder). Women with PCOS who are overweight or obese, should have additional testing including those for prediabetes, type 2 diabetes, and hyperlipidemia.
PCOS is a complex endocrinological disorder and women should seek care from a clinician who is well versed in underlying causes, the multiple body systems it affects, and optimally uses an integrative medicine approach utilizing the benefits of nutrition, exercise, herbal and nutrient supplements and selected pharmaceutical prescriptions as needed.
Please see other blog postings for PCOS treatments utilizing natural therapies including green tea, N-acetyl cysteine and more.
1. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004;81:19–25
2. Legro R, et al. Diagnosis and treatment of polycystic ovary syndrome: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2013 Dec; 98:4565