Getting a diagnosis of PCOS
The sooner you have a definite diagnosis of PCOS the better because early intervention and treatment is more effective in preventing progress to "full house" PCOS. Even if the "full house" of symptoms has set in, treatment can reverse or improve many of its manifestations. This requires a high level of suspicion on the part of your doctor. Your doctor can be alerted to the diagnosis by:
- A blood test showing that key hormones are abnormal: testosterone that is too high, high levels of LH while FSH levels are normal.
- An ultrasound examination showing "bulky" ovaries with cysts. In thin women, ultrasound through the abdominal wall will allow good views of uterus and ovaries but for those who are overweight, internal ultrasound examination is often necessary.
The ovaries are enlarged and contain 10 or more small cysts located at the periphery of the ovary. The size of these cysts is generally less than 8 mm and can usually be detected by ultrasound examination (see Figure below).
These cysts do not grow and usually remain small. They do not require surgical removal. Furthermore, these cysts do not represent cancer and are not associated with an increased risk of ovarian cancer.
Internal scan of a polycystic ovary. The patient was a 28-year-old with six months history of weight gain around the middle and irregular periods. The ovary is enlarged and contains many cysts located at the periphery of the ovary like "a string of pearls" which lead to the descriptive term, polycystic ovaries. The cysts are usually less than 8mm. (The scan was performed by Dr Sue Barton.)
It is important to stress that the symptoms, blood test results and ultrasound findings need to be interpreted by a medical practitioner with expertise in PCOS. Some women, particularly those with mild disease may not have the "classic" signs, or the "tell-tale" diagnostic blood test and ultrasound findings above.
Some doctors make a distinction between polycystic ovarian syndrome (PCOS) and polycystic ovarian disease (PCOD). You may have heard both terms used. Both PCOS and PCOD are underpinned by the same metabolic problem - insulin resistance. They have to be treated in much the same way. For simplicity we use the term PCOS to refer to both.
We do not insist, as do many specialists still, on the mandatory presence of features of polycystic ovarian disease on ultrasound to make the diagnosis. If serum testosterone, corrected for the sex hormone binding globulin, and serum LH is found to be elevated on more than one occasion then the diagnosis is clinched. Protein-free testosterone is the most helpful indication of androgen (male hormone) excess. The presence of the cysts and ovarian enlargement fluctuates depending on when the ultrasound scan is carried out. However, even though classical features of PCOS on ultrasound may not always be present, there are frequently some suspicious signs alerting an experience radiologist to the diagnosis. The support of the hormonal profile would then be essential.
It is important to recognize that PCOS may arise as a result of the use of some medication, e.g. steroids, or in diseases associated with excess glucocorticoid production, Cushing’s disease. Young women with insulin dependent diabetes requiring insulin injections are at a special risk of developing PCOS. Some inherited defects in the synthesis of adrenal hormones may be present for the first time later in life, with features indistinguishable from those of "classic" PCOS. These considerations need to be kept in mind and appropriate tests performed, as treatment may be different. The vast majority of women with good going PCOS secrete excess androgen produced by the adrenal glands.
"Full house" PCOS includes obesity, irregular or absent menstrual bleeding, shortening of the second half of the cycle, bleeds in between periods, hot flushes, emotional lability, increased hair growth in a male pattern, frontal baldness, acne/oily complexion, difficulty becoming pregnant or infertility, early fetal loss and mild to frank diabetes. Because of greater awareness many patients now present early and do not have the classic symptoms of PCOS (Table 1) although they would have the symptoms of insulin resistance such as unexplained fatigue, sugar craving, hypoglycemia, unexplained weight gain around the waistline and sleep disorders. Pursuing these symptoms allows early diagnosis and management of PCOS.
Thus, PCOS comprises several clinical features, each of which may be present to a greater or lesser degree. As a result, patients may seek medical advice to correct irregular menstruation, eradicate excessive hair growth, or achieve pregnancy.