Polycystic Ovary Syndrome: An Overview

Mac Pannill, MPAS, PA-C

Disclosures

Topics in Advanced Practice Nursing eJournal. 2002;2(3) 

In This Article

Assessment of the PCOS Patient

History

In addition to obtaining a thorough medical and surgical history, elicit a completed menstrual history, including menarche and family history of PCOS. A history of hirsutism, acne, alopecia, menstrual irregularities, or infertility, especially in the patient's mother, is very important. A diagnosis of PCOS may often be made with a complete history. Pay particular attention to the onset of menstrual irregularities, as this will usually date back to menarche. Inquire about recent pregnancy status and other reproductive history such as miscarriages.

Medical history. A history of headaches or blurred vision (indicating pituitary tumor), any signs or symptoms of thyroid dysfunction (as a differential diagnosis of amenorrhea), or clinical signs of diabetes (indicating adrenal tumor) need to be elicited. Inquire about a history of acne, hirsutism, deepening of the voice, and increase in muscle mass (without exercise). If these symptoms have occurred, what has been tried to control them? It is imperative to know if the symptoms are recent or have occurred rapidly, either of which could indicate a virilizing syndrome or neoplasia. A rapid onset of these symptoms is rare in a PCOS patient, but if present, they suggest a need for an urgent work-up, as an ovarian tumor or adrenal tumor needs to be ruled out. Also, masculinization is uncommon with PCOS patients and is more suggestive of congenital adrenal hyperplasia.

Family history. PCOS tends to run in families; it is important to ask about family history. Some believe that if a mother has PCOS and her daughter is showing signs of it, she should be evaluated by her pediatrician or by an endocrinologist.[14]

Social/cultural history. Ethnic factors must be considered in the evaluation of women who are hirsute. Northern European white women and women from Asia usually have small amounts of hair on their face, torso, and extremities. However, Mediterranean white women will frequently have hair on their upper lip, chin, and have dark hair on their arms and legs. Also, certain conditions like pregnancy and menopause can cause transient hirsutism. An important caveat to remember is the patient may not appear hirsute at the time of the examination as she may be using cosmetic procedures like waxing, shaving, or electrolysis to control it.

Medications. In addition to asking about the patient's current medications it is important to remember that there are certain medications and classes of medications that can cause transient hirsutism. Examples of these are phenytoin (Dilantin), diazoxide, glucocorticoids, and the phenothiazines.[1,9,15,16]

Clinical Features

Evaluate the skin for evidence of hirsutism, acne, alopecia, fat distribution, and pigment changes in the skin, specifically acanthosis nigricans. Hirsutism can be defined as hair in locations in women where it is usually not found. Examples of these locations are upper lip, chin, midline of the body, and in the intermammary region. Hirsutism can be graded using the Ferriman-Gallowey scoring system (Figure 2). This scoring system evaluates 9 key anatomic sites. These sites can be graded from 0 (no terminal hair growth) to 4 (maximal growth). The maximum score is 36. A score of 8 or greater suggests an androgen excess.[1,9,15]

Ferriman-Gallowey scoring system for hirsutism. Reproduced with permission of publisher from Barbieri RL: V Polycystic Ovary Syndrome. 16 Women's Health. WebMD Scientific American® Medicine Online. Dale DC, Federman DD, Eds. WebMD Corporation, New York, 2002. http://www.samed.com

Even when a PCOS patient has increased levels of androgens, hirsutism may not be present unless there is an increase in peripheral androgen metabolism. This is why some women with PCOS are hirsute and others are not. Temporal balding is usually seen after prolonged exposure to androgens. Frontal balding is associated with a virilizing ovarian or adrenal tumor.

Central obesity with a hip ratio of > 0.85 is associated with cardiovascular disease and is a marker for PCOS. A "buffalo hump" on the back or purple striae on the abdomen might suggest Cushing's syndrome.

During the pelvic examination, assess for clitoromegaly and pelvic masses. Bilateral pelvic masses would be more consistent with PCOS whereas a unilateral pelvic mass may be more consistent with a neoplasia. Remember, too, that the pelvic exam may not reveal any masses in a patient with PCOS.

Laboratory Studies

The results of the history, in concert with the physical examination, will guide the laboratory work up ( Table 1 ). This testing is designed to exclude life-threatening tumors and promote long-term health.

Endocrine screening. Prolactin and thyroid-stimulating hormone (TSH) levels are tested to rule out pituitary or thyroid disease as an etiology of anovulation. LH and follicle-stimulating hormone (FSH) may be analyzed, and they are usually seen in a ratio of > 2.5 to 3. However, a normal LH/FSH ratio does not exclude the diagnosis of PCOS. An FSH level will also help rule out premature ovarian failure in a woman with amenorrhea.[1,6,9,15]

Total testosterone and dehydroepiandrosterone sulfate (DHEAS) are evaluated to rule out an androgen-producing neoplasm. Total testosterone levels of 200 ng/dL are not generally seen in PCOS and suggest a virilizing tumor. DHEAS is a weak androgen that primarily comes from the adrenal glands. A level greater than 800 mcg/dL suggests a virilizing adrenal tumor.

17-hydroxyprogesterone (17OH-progesterone) is a useful screen for late-onset congenital adrenal hyperplasia (LOCAD). 17OH-progesterone levels less than 2 ng/mL are normal. A level > 5 ng/mL is diagnostic for LOCAD. A value between 2 ng/mL and 5 ng/mL should prompt an investigation with an adrenocorticotropic hormone stimulation test. If there is a suspicion for Cushing's syndrome, you may get a 24-hour urine for free cortisol or do a 1-mg dexamethasone suppression test overnight.

Cardiac risk profile. Because PCOS patients have hyperandrogenism, they are at an increased risk of cardiovascular disease. It is imperative, then, that the patients are screened for an abnormal HDL, cholesterol, and triglycerides at 35 years of age. Normal results should be repeated in 3-5 years. If these results are abnormal, these entities can be treated early, thus reducing the risk of cardiovascular disease.

Glucose testing. Glucose tolerance testing is important. As many as 35% to 45% of PCOS patients will have impaired glucose testing and about 7% to 10% will have type 2 diabetes mellitus. A fasting glucose to fasting insulin ratio less than 4.5 is predictive of insulin resistance. Values on the 2HR glucose tolerance test are as follows: 2H < 140 mg/dL (normal); 140-199 mg/dl (impaired glucose); and > 200 mg/dL (type 2 diabetes).[13,17]

Endometrial Aspiration

Many PCOS patients have unopposed estrogen stimulation for prolonged periods of time and are thus at risk for endometrial hyperplasia or endometrial carcinoma. Any PCOS patient with prolonged oligomenorrhea or amenorrhea or a patient with PCOS who is older than aged 35 years and has irregular bleeding should have endometrial aspiration to rule out endometrial carcinoma. An important point to remember is that advancing age is not a factor in deciding to obtain endometrial aspiration in patients with PCOS as it is in non-PCOS patients.

Radiologic Studies

An enlarged uterus or enlarged ovaries palpated on pelvic examination suggests a need for a pelvic ultrasound to distinguish uterine fibroids from an adnexal mass. If a patient has elevated DHEAS, adrenal imaging is indicated. An important caveat to remember is that polycystic ovaries can been seen in a number of healthy women who do not have PCOS, and women with PCOS do not always have radiographically demonstrated polycystic ovaries. Remember, by ultrasound, 25% of "normal" ovulating women would have polycystic-appearing ovaries.[5,6,9,18]

A transvaginal ultrasound should be done, as 90% of virilizing tumors can be identified with this method. Polycystic ovaries are also better evaluated transvaginally than transabdominally. Ovaries will have a typical appearance of enlarged subcapsular small follicles (> 10 mm) -- follicles are normally 2 mm to 10 mm in diameter. The ovarian volume in women with PCOS is > 10 cm3 and the normal range is 4.7-5.2 cm3.

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