Diagnosis (International guideline 2023, modified Rotterdam)
- Two of three: oligo- or anovulation (cycles over 35 days or fewer than 8 a year), clinical or biochemical hyperandrogenism (hirsutism, acne, raised free testosterone or free androgen index), and polycystic ovarian morphology (or a raised AMH in adults as an alternative).
- Exclude other causes: thyroid disease, hyperprolactinaemia, non-classical congenital adrenal hyperplasia (17-hydroxyprogesterone), Cushing's, an androgen-secreting tumour (rapid virilisation, very high testosterone).
- In adolescents, ultrasound and AMH are not used; both irregular cycles (allowing for the years after menarche) and hyperandrogenism are required, otherwise the label is 'at risk' and reassessed.
Polycystic ovarian morphology
Transvaginal. An enlarged ovary.
Open in the Ultrasound LabPolycystic ovarian morphology
Transvaginal. Multiple small peripheral follicles.
Open in the Ultrasound LabWhat it means over a lifetime
- Metabolic: insulin resistance, impaired glucose tolerance and type 2 diabetes, dyslipidaemia, obstructive sleep apnoea; screen with an OGTT or HbA1c and lipids, repeated every 1 to 3 years.
- Endometrial: unopposed oestrogen from anovulation; induce a withdrawal bleed at least every 3 to 4 months or use a progestin-containing method to protect the endometrium.
- Reproductive: anovulatory subfertility (letrozole is first line for ovulation induction), higher risks in pregnancy of gestational diabetes and hypertensive disorders.
- Psychological: depression, anxiety, disordered eating and body image concerns are common and screened for.
Management
| Goal | Options |
|---|---|
| Cycle regulation and endometrial protection | Combined hormonal contraception (first line); cyclical progestin; levonorgestrel IUD |
| Hirsutism and acne | Combined hormonal contraception; spironolactone added after 6 months if needed (with contraception); mechanical hair removal; topical eflornithine |
| Metabolic health | Lifestyle (any sustainable approach); metformin for metabolic features and in adolescents; GLP-1 agonists in selected cases |
| Fertility | Letrozole first, then clomiphene, gonadotrophins or laparoscopic ovarian drilling; IVF |
On the modelOvariesEndometrium