Initial Workup for Polycystic Ovary Syndrome (PCOS)

Clinical History Assessment

The American Academy of Family Physicians recommends obtaining detailed information about menstrual history, including cycle length, regularity, and amenorrhea, as cycle length >35 days suggests chronic anovulation 1, 2
Documenting onset and duration of signs of androgen excess is crucial, as gradual onset suggests PCOS, while rapid onset suggests androgen-secreting tumor 1
Reviewing medication use, particularly exogenous androgens, is essential 1
Assessing lifestyle factors, including diet, exercise, alcohol use, and smoking, is important 1
Obtaining family history of cardiovascular disease and diabetes is recommended 1, 2

Evaluating for clinical signs of hyperandrogenism, such as hirsutism, acne, alopecia, and clitoromegaly, is necessary 1, 2
Assessing for signs of insulin resistance, including obesity, and calculating BMI and waist-hip ratio, is crucial 1, 2
Performing pelvic examination to evaluate for ovarian enlargement is recommended 1
Screening for signs of Cushing's syndrome, such as buffalo hump, moon facies, and abdominal striae, is essential 1, 2

Hormonal evaluation, including total testosterone or bioavailable/free testosterone, sex hormone-binding globulin (SHBG), thyroid-stimulating hormone (TSH), and prolactin level, is necessary 1, 2
Metabolic evaluation, including two-hour oral glucose tolerance test with 75g glucose load, and fasting lipid profile, is recommended 1, 2

Transvaginal ultrasound is the preferred approach for evaluating ovarian morphology, using 8MHz or higher transducer, and looking for ≥20 follicles (2-9mm) per ovary 3, 4
Measuring ovarian volume (≥10mL suggests PCOM) and documenting three dimensions of each ovary is essential 3, 4
Transabdominal ultrasound may be used as an alternative, focusing on ovarian volume with threshold of ≥10mL 4
MRI pelvis (without contrast) may be considered when ovaries cannot be adequately visualized by ultrasound 5, 6

Ruling out other causes of androgen excess, such as Cushing's syndrome, androgen-secreting tumors, non-classic congenital adrenal hyperplasia, acromegaly, primary ovarian failure, and hyperprolactinemia, is necessary 1, 2

Serum AMH levels should not yet be used as a single test for PCOS diagnosis despite emerging evidence 4
Ultrasound findings alone are insufficient for diagnosis as PCOM may be present in up to one-third of reproductive-aged women 8
Increased risk of endometrial cancer with chronic anovulation requires appropriate follow-up 1