COMMENTARY

Keep It Simple: What Endos Really Need to Know About PCOS

Andrea Dunaif, MD

Disclosures

March 29, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Hello. I'm Andrea Dunaif. We're here at ENDO 2019 in New Orleans, and I've just finished speaking about what every endocrinologist really needs to know about polycystic ovary syndrome (PCOS).

There has been a lot of confusion among endocrinologists about which are the appropriate diagnostic criteria. Patients need to see an average of four endocrinologists before the diagnosis is made,[1] and they're very unhappy with their experiences in being evaluated for PCOS.

I talked about the essential endocrine workup to diagnose patients with the endocrine features of PCOS (symptoms of androgen access) or the metabolic features of PCOS (eg, diabetes, prediabetes, metabolic syndrome) and the testing that they really need to do.

And I put it in the context of some very exciting recent genetic data[2] that show that when you compare the different forms of PCOS diagnosed by the different diagnostic criteria, there's no genetic difference. So we really don't need to sweat the diagnosis. We can use very broad criteria to make a diagnosis and manage these patients.

Which Tests Are Really Required?

The major take-home message for endocrinologists is that we don't need to assess the ovarian morphology. We need to check testosterone levels, both total and free. Or better yet, what's not bound to sex hormone binding globulin, which can be easily done by measuring the total testosterone using liquid chromatography and tandem mass spectrometry, and measuring the sex hormone binding globulin. There is a calculation that gives us the amount that's not bound. We can order this from the laboratory so it's documented in the chart.

That, combined with a history of irregular menstrual cycles, and excluding other uncommon disorders in the differential diagnosis such as hypothyroidism or high prolactin—that very limited workup will give us the diagnosis of PCOS.

If the patient is overweight, we also want to do a metabolic workup and exclude diabetes with a 2-hour glucose tolerance test with a fasting and 2-hour glucose. The A1c isn't sensitive enough in PCOS because these patients have mainly postprandial hyperglycemia. We want to check the lipid profile because metabolic syndrome is very common in women with PCOS, as are minor elevations in LDL levels.

Therapeutic Goals and Key Therapies

We are then left with patients who usually have two distinct therapeutic goals. They are either concerned about weight management and metabolic issues, or they're concerned about their symptoms of male hormone excess, such as hirsutism and hair loss.

For patients who are concerned about their metabolic symptoms, weight reduction is very effective. Metformin is also effective at restoring regular cycles. We usually give a 6-month trial to see if the patient will respond to metformin.

For women who are concerned about symptoms of hirsutism or hair loss, the key therapies are combined oral contraceptives with an antiandrogen. In the United States, the antiandrogen of choice is spironolactone. We usually give 200 mg daily—100 mg in two divided doses.

Keeping It Simple

With this straightforward workup and minimal metabolic testing if indicated in a woman with obesity or a strong family history of type 2 diabetes, we can precisely define PCOS and manage it. We don't need to be obtaining ovarian ultrasounds in everyone.

In fact, the most current international guidelines[3] on PCOS say that if the patient has filled the two main National Institutes of Health criteria for PCOS—hyperandrogenism and irregular menses—they don't need an ovarian ultrasound, and the Endocrine Society guidelines[4] for the management of hirsutism say that ovarian imaging is not necessary if you're just managing androgenic symptoms.

We can be very simple in our evaluation and much better serve our patients with an effective diagnosis and management plan.

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