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PCOS is a diagnosis of inclusion and exclusion. There is not a specific test that can be used to diagnose PCOS and there is not widespread agreement on what the diagnostic criteria should be. A woman's doctor will do tests to rule out other causes of anovulation and infertility. He will usually order a variety of hormone tests to help determine whether the symptoms are due to hormone overproduction as seen in PCOS, an adrenal or ovarian tumor, or an overgrowth in adrenal tissue (adrenal hyperplasia). Ultrasounds are often used to look for cysts in the ovaries and to see if the internal structures appear normal.
A doctor will evaluate a combination of laboratory results and clinical findings that suggest PCOS. If a woman is diagnosed with PCOS, her doctor may order tests such as lipid profiles and glucose levels to evaluate and monitor the risk of developing future complications such as diabetes and cardiovascular disease.
- FSH (Follicle Stimulating Hormone) - will be normal or low with PCOS
- LH (Lutenizing Hormone) - will be elevated
- LH/FSH ratio - This ratio is normally about 1:1 in premenopausal women, but with PCOS a ratio of greater than 2:1 or 3:1 may be considered diagnostic.
- Prolactin - will be normal or low (elevated in hyperprolactinemia)
- Testosterone - total and/or free; usually elevated
- DHEAS - frequently mildly elevated with PCOS; may be done to rule out a virilizing adrenal tumor in women with rapidly advancing hirsutism
- Estrogens - may be normal or elevated
- Sex hormone binding globulin (SBGH) - may be reduced
- Androstenedione - may be elevated
- hCG (Human chorionic gonadotropin) - used to check for pregnancy; negative unless pregnant
- Lipid profile (low HDL, high LDL, and cholesterol, elevated triglycerides)
- Glucose - fasting and/or a glucose tolerance test; may be elevated
- Insulin - often elevated
- TSH (Thyroid stimulating hormone) - to check thyroid function
- Free Cortisol and Creatinine levels - rule out Cushing syndrome
- 17-hydroxyprogesterone - to rule out congenital adrenal hyperplasia
- IGF-1 - to rule out acromegaly
A pelvic ultrasound (transvaginal and/or pelvic/abdominal) is used to evaluate enlarged ovaries. With PCOS, the ovaries may be 1.5 to 3 times larger than normal and characteristically have more than 12 or more follicles per ovary measuring 2 - 9 mm in diameter. Often the cysts are lined up on the surface the ovaries, forming the appearance of a "pearl necklace." The follicles tend to be small and immature, thus never reaching full development. The ultrasound helps visualize these changes in more than 90% of women with PCOS, but they are also found in up to 25% of women without PCOS symptomology. (See Radiologyinfo.org: Pelvic ultrasound)
Laparoscopy may be used to evaluate ovaries, evaluate the endometrial lining of the uterus, and sometimes used as part of surgical treatment.
Treatment There is no cure for PCOS. Although there have been cases involving the spontaneous resumption of menstrual periods, most women will have progressive symptoms until after menopause. Treatment of PCOS is aimed at reducing its symptoms and prevention of further complications. The goals are to promote ovulation, prevent endometrial hyperplasia, counterbalance the effects of androgens, and reduce insulin resistance. Treatment options depend on the type and severity of the individual woman's symptoms and her desire to become pregnant. Low-dose oral contraceptives are often used to stabilize hormones and oppose estrogenic stimulation of the endometrium. Within several months, they can usually regulate menstrual periods, eliminate or minimize uterine bleeding, and reduce androgen levels - improving hirsutism and clearing up acne. Antiandrogens such as spironolactone, flutamide, and cyproterone are sometimes combined with oral contraceptives to help address more severe hirsutism and acne. Waxing, shaving, depilatory and electrolysis may be used to remove unwanted hair, and antibiotics or retinoic acids may be used to treat acne. Metformin is being used to reduce insulin resistance. It has also shown promising initial results in women with PCOS hirsutism and in helping to regulate menstrual cycles, but its effects on infertility and other symptoms are not yet known. If a woman with PCOS wants to become pregnant, she is usually given clomiphene citrate, a drug that helps induce ovulation. She may also be given human menstrual gonadotropin, although this drug increases the risk of multiple pregnancies. However, as with any drug regimen, certain side effects and risks may be present. Although sometimes performed, surgery is a rare PCOS treatment option. One surgical option, a "wedge resection." involves removing the part of the ovary that contains the cystic follicles to try to restore ovulation. Another option, ovarian drilling, involves using a needle with an electric current to make holes in the ovary. Both of these procedures may temporarily increase fertility but may also lead to scarring and adhesions; concerns in long-term ovarian function limit this practice. Lifestyle changes through better diet, weight loss, and exercise are recommended to help decrease insulin resistance and to minimize lipid abnormalities. Weight reduction can also decrease testosterone, insulin, and LH levels. Regular exercise and healthy foods, such as vegetables, fruits, nuts, and whole grains, will also lower blood pressure and cholesterol as well as improve sleep apnea problems. Smoke cessation also may lower androgen levels.
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