The first step is to find a physician that specializes in PCOS so that the appropriate work-up, diagnosis, and treatment plan can be implemented. Once the patient has established care with a physician, the physician will begin evaluation by obtaining a thorough history and physical examination. PCOS is a diagnosis of exclusion and other disorders that may present with the same signs and symptoms must be ruled out before a diagnosis of PCOS can be proven.
Other disorders that must be ruled out include: adrenal tumors, ovarian tumors, thyroid dysfunction, congenital adrenal hyperplasia, hyperprolactinemia, acromegaly, and Cushing syndrome. Each of these disorders listed above may result in the increased production of androgens and thus must be ruled out before moving forward with a diagnosis of PCOS. These can be ruled out using laboratory evaluation, imaging, and physical examination by the physician.
Laboratory testing to rule out the above disorders is imperative. In addition to those specialized laboratory tests, it is imperative to evaluate the androgen levels. In this panel of blood work, the following should be tested by your physician: free testosterone, DHEA-S, sex hormone0binding globulin (SHBG), androstenedione, FSH, LH, TSH, and free thyroxine. In addition the patients fasting glucose levels, insulin levels and lipids should also be evaluated.
In patients that are suspected to have PCOS, the results of their hormone levels may be as follows:
- Increased free testosterone
- DHEA-S slightly increased
- Low SHBG
- Increased androstenedione
- Normal to low FSH
- Increased LH
- LH:FSH ratio greater than 3. The key defining laboratory study that will help the physician lean toward a diagnosis of PCOS is the LH:FSH ratio greater than 3.
If PCOS is suspected then imaging studies may be required to evaluate the patient further. Ultrasound is the gold standard to evaluate the patient’s ovaries to determine if there are multiple follicles developing. While abdominal ultrasound may provide limited results, the trans-vaginal ultrasound is preferred for better visualization of the ovaries. The ultrasound is indicated if the pelvic examination is inconclusive. CT or MRI imaging studies may be required if the physician believes the patient may have an adnexal or adrenal tumor. A biopsy of the ovaries may also be indicated for confirmation of a PCOS diagnosis. Histological evaluation of an ovarian biopsy will indicate: enlarged, sclerotic tissue with multiple cystic follicles.
There are specific diagnostic criteria to help physicians definitely diagnose patients with PCOS. The diagnostic criteria has evolved since 1990 and continues to change when new information is obtained from research and clinical studies. The diagnostic criteria for PCOS includes:
- Anovulation or oligo-ovulation that presents with either amenorrhea or oligo-menorrhea respectively
- Excess secretion of androgens
- Exclusion of other disorders through laboratory and imaging evaluation
- Polycystic ovaries as identified through trans-vaginal ultrasonography.
The Society of Obstetricians and Gynecologists state that the definition of polycystic ovaries is when the ovary has greater than 12 small antral follicles. Not all of the criteria must be met to be diagnosed with PCOS, but it is recommended that at least two of the criteria are present prior to diagnosis.