PCOS Diagnosis and Management

Diagnostic Criteria and Initial Evaluation

The American College of Obstetricians and Gynecologists recommends excluding other causes of androgen excess, including Cushing's syndrome, androgen-secreting tumors, nonclassic congenital adrenal hyperplasia, thyroid disease, hyperprolactinemia, and acromegaly, before diagnosing PCOS 1
Initial hormone panel must include TSH, prolactin, total testosterone or free/bioavailable testosterone, and DHEA-S to rule out thyroid disease, hyperprolactinemia, and adrenal androgen-secreting tumors 1, 2
Metabolic assessment, including fasting glucose, 2-hour glucose level after oral glucose load, fasting lipid panel, BMI, and waist-hip ratio calculation, is required for all PCOS patients due to increased cardiometabolic risk 2

The Endocrine Society recommends a multicomponent lifestyle intervention, including diet, exercise, and behavioral strategies, as the first-line treatment for all PCOS patients, regardless of body weight 1
A dietary approach with an energy deficit of 500-750 kcal/day and physical activity targets of 150 minutes/week of moderate-intensity activity or 75 minutes/week of vigorous-intensity activity, plus muscle-strengthening activities, is recommended 1
Weight loss goal of 5-10% improves reproductive and metabolic consequences 3
Combined oral contraceptive pills are the most common long-term management option and first-line pharmacotherapy for women with PCOS who are not attempting to conceive 1, 2
Insulin-sensitizing agents, such as metformin, may be used to improve insulin sensitivity, decrease circulating androgens, and improve glucose tolerance and metabolic outcomes 1, 2
Metformin is recommended as an adjunct to lifestyle management for treatment of weight, hormonal, and metabolic outcomes, with a focus on prevention of weight gain 4

Regular assessment of weight, waist circumference, blood pressure, HbA1c, and lipid status during weight loss and maintenance is recommended 1
Screening for psychological factors, including anxiety, depression, body image concerns, and disordered eating, is necessary 1
Addressing dyslipidemia with weight loss and lifestyle modification before drug therapy is recommended 2
Asian, Hispanic, and South Asian populations require lower BMI and waist circumference thresholds for intervention and greater consideration for lifestyle intervention due to high cardiometabolic risk 1