Clinical Tools of Relevance in Evaluating PCOS
BMI Calculator: Body mass index is a more reliable reflector of an individual’s health risks relating to body weight. We encourage all providers to assess patient’s body weight and height and convert these to body mass index (weight in kilograms / height in meters2). Available at http://www.nhlbisupport.com/bmi/
Hirsutism Scoring: Objective assessment of hair growth helps identify the severity of hair excess as well as helps evaluate response to treatment. Ferriman Galeway Hirsutism scoring pictoral chart is available at www.hirsutism.com/hirsutism-biology/ferriman-...
Depression screen: There are multiple questionnaire based tools that are available for screening patients for depression. Patient Health Questionnaire (PHQ) is a simple 9 item tool that has been shown to be user friendly and has been shown to reliably reflect depressive symptoms. Available online at www.aafp.org/afp/2008/0715/p244.html
Metabolic Syndrome: Refers to the presence of a collection of conditions each of which is a recognized risk for cardiovascular disease and their collective presence exacerbates this risk. According to the The National Cholesterol Education Program’s Adult Treatment Panel III report (ATP III) 6 components of the metabolic syndrome that relate to CVD are identified: Abdominal obesity, atherogenic dyslipidemia, raised blood pressure, insulin resistance ± glucose intolerance, proinflammatory and prothrombotic state.
The presence of any three of the following identifies a woman as meeting criteria for metabolic syndrome: http://circ.ahajournals.org/content/109/3/433.full
- Obesity – waist circumference >35 inches (or >30 inches if Asian)
- Dyslipidemia (Elevated total cholesterol or elevated triglycerides, or elevated LDL or HDL <50mg/dl.)
- Blood pressure > 130/85mmHg or known hypertensive on treatment
- Impaired fasting glucose (fasting blood sugar >100) or impaired glucose tolerance or known diabetic on medication.
Suggested Workup for PCOS:
PCOS is a diagnosis of exclusion. Common medical disorders can mimic PCOS and must be excluded before a diagnosis of PCOS can be made.
Rule out Common Disorders:
- Hypothyroidism by checking serum TSH
- Hyperprolactinemia by assessing fasting serum prolactin
- Late onset congenital adrenal hyperplasia by assessing serum 17 alpha hydroxy progesterone (preferably checked in the follicular phase of menstrual cycle)
- Cushing syndrome by assessing urinary free cortisol in 24 hour urine (consider this if patient demonstrates elevated blood sugar &/or blood pressure).
Recommended Tests for Evaluating PCOS:
- Androgen profile (total and free testosterone, SHBG, DHEAS)
- 17 Alpha OH Progesterone
- Chemistry (including liver function tests)
- Lipid profile
- 2 hour oral glucose tolerance test (0, 60 and 120 minute sampling) with glucose and insulin levels
- Additional considerations include assessment of CRP, homocysteine and serum 25OH vitamin D levels.
- Our UFC (if Cushing Syndrome is to be ruled out)
- 24 hour urine for micro-albuminuria (if known hypertension)
Transvaginal Pelvic Ultrasound
Endometrial Biopsy- Recommended if duration of oligomenorrhea >3months &/or
dysfunctional uterine bleeding
Saline Sonohysterogram- Recommended if focal endometrial pathology (e.g.
polyp) is suspected.
Pre-Conception Considerations in Women with PCOS
- Optimal weight and lifestyle management should be the first step in ensuring a healthy pregnancy for a healthy mother. A minimal of 5% weight reduction has been shown to decrease obesity related health risks.
- Higher dose folic acid supplementation is recommended for women with BMI>35
- Consider pre-conception consultation with high risk obstetricians for the morbidly obese, and women with metabolic syndrome given their increased risk for preeclampsia, gestational diabetes, and fetal macrosomia.
- Nutritional consultation is recommended for the obese and severely obese women to optimize weight loss strategies prior to embarking on fertility treatment.
- Psychological support must be offered to those manifesting depressive symptoms.