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Polycystic Ovary Syndrome (PCOS) — Management

Diagnosis (Rotterdam 2003 Criteria — NIH 2012 endorsed)

1. Oligo-ovulation or anovulation (oligomenorrhea/amenorrhea)
2. Hyperandrogenism — biochemical (elevated androgens) or clinical (hirsutism, acne, androgenic alopecia)
3. Polycystic ovaries on ultrasound (≥12 antral follicles per ovary or ovarian volume >10 mL)

Exclude: hypothyroidism, hyperprolactinemia, non-classical congenital adrenal hyperplasia, androgen-secreting tumors, pregnancy.

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Initial Workup

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Management by Clinical Goal

1. Lifestyle Modification (First-line for ALL patients)

• Weight loss of even 5% improves menstrual regularity, hyperandrogenism, and pregnancy rates in overweight/obese patients.
• Daily caloric reduction of ~500 kcal + regular physical exercise.
• Weight-loss interventions should precede fertility treatment in patients with excess weight.
• — Berek & Novak's Gynecology

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2. Menstrual Irregularity (No Fertility Desired)

• Combined oral contraceptive pills (OCPs) — first-line; provide cycle control, reduce LH, suppress ovarian androgen production, and protect the endometrium from unopposed estrogen.
• Cyclic progestins (e.g., medroxyprogesterone acetate 10 mg/day × 10 days) — to induce withdrawal bleeds at least every 3 months; prevents endometrial hyperplasia.
• Depot medroxyprogesterone acetate or levonorgestrel IUD — if contraception is also desired.

Key point: All women with chronic anovulation need progesterone exposure at least 4×/year to protect against endometrial hyperplasia and carcinoma (unopposed estrogen state). — Textbook of Family Medicine 9e

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3. Hyperandrogenism (Hirsutism, Acne)

• OCPs — suppress ovarian androgen production; first-line.
• Spironolactone — androgen receptor blocker; used as add-on or alternative when OCPs alone insufficient; requires contraception due to teratogenic risk.
• Flutamide, finasteride — additional anti-androgen options.
• Cosmetic measures (laser, electrolysis) as adjuncts.

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4. Insulin Resistance / Metabolic Syndrome

• Metformin — improves insulin sensitivity, may restore ovulation, reduces androgen levels; particularly useful in patients with glucose intolerance or frank T2DM.
• Screen all PCOS patients for diabetes (fasting glucose or OGTT) and dyslipidemia.
• Cardiovascular risk counseling is important — PCOS confers increased long-term risk for T2DM and CVD.

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5. Infertility / Ovulation Induction

60–85% of women with PCOS will ovulate with clomiphene or letrozole treatment. — Berek & Novak's Gynecology

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6. Endometrial Protection

• Chronic anovulation = unopposed estrogen = risk of endometrial hyperplasia → carcinoma.
• All anovulatory PCOS patients not on OCPs must receive progestin withdrawal bleeds ≥4×/year.
• Consider endometrial biopsy if prolonged amenorrhea or concerning symptoms.

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Summary Algorithm

PCOS confirmed
     │
     ├─ Overweight? → Lifestyle modification (weight loss) FIRST
     │
     ├─ Fertility NOT desired
     │       ├─ Menstrual irregularity → OCP or cyclic progestin
     │       ├─ Hirsutism/acne → OCP ± spironolactone
     │       └─ Metabolic concerns → Metformin + screening
     │
     └─ Fertility desired
             ├─ Optimize weight first
             ├─ Letrozole or clomiphene (first-line)
             ├─ Add metformin if insulin resistant
             └─ Gonadotropins / IVF if above fails

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Menorrhagia (Heavy Menstrual Bleeding / Abnormal Uterine Bleeding)

Terminology

• Cycle interval: 24–38 days
• Duration of flow: 4–8 days
• Bleeding <21-day cycles or >35-day cycles = abnormal

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PALM-COEIN Classification

PALM — Structural Causes (diagnosed by imaging/histology)

COEIN — Non-structural Causes

"Dysfunctional uterine bleeding" is obsolete and should not be used. — Rosen's Emergency Medicine

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Differential by Age

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Workup

All Patients

• Pregnancy test — always first
• CBC — assess for anaemia
• TSH — hypothyroidism causes AUB
• Prolactin — hyperprolactinemia causes anovulation
• Cervical cancer screening (if not up to date)
• STI screening if indicated

Selective Testing

• Coagulation screen (PT, aPTT, von Willebrand factor): if heavy bleeding since menarche, family history, or signs of systemic bleeding
• Testosterone, 17-OHP, DHEAS: if PCOS or androgen excess suspected
• Transvaginal ultrasound (TVUS): first-line imaging — detects fibroids, polyps, endometrial thickness
  • Endometrial stripe <4–5 mm in postmenopausal patient reliably excludes cancer

Endometrial Biopsy — Indicated If:

• Age ≥45 with AUB
• Any age with: obesity, unopposed estrogen exposure (anovulatory cycles), persistent or refractory AUB, elevated familial cancer risk

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Management

Acute / Emergency Bleeding

• IV fluids, blood products
• IV conjugated equine estrogen 25 mg IV every 4–6 hours (up to 24 h)
• Intrauterine tamponade (26-French Foley catheter with 30 mL saline)
• Urgent surgical options: D&C, uterine artery embolization, endometrial ablation, hysterectomy

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Long-term / Outpatient Medical Management

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Surgical Management

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Key Points to Remember

• Endometrial protection with progestin is mandatory in all women with chronic anovulation (at least 4 withdrawal bleeds/year) — unopposed estrogen drives hyperplasia → carcinoma.
• Von Willebrand disease is an underdiagnosed cause — screen all women with heavy bleeding since menarche.
• Tranexamic acid and OCP are the two most evidence-based outpatient medical options for heavy flow.
• Do not use tranexamic acid with combined OCPs (additive thrombotic risk).
• Postmenopausal bleeding is always abnormal — exclude malignancy first.

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