Polycystic ovarian syndrome

The diagnosis of PCOS requires confirmation of ovarian dysfunction: irregular or anovulatory cycles, or polycystic morphology on scanning; and androgen excess: either clinical or biochemical.

General examination

To diagnose polycystic ovarian syndrome a detailed and full general examination is mandatory in the initial assessment of all endocrine patients.

Blood pressure

Elevated BP may not have been previously noted.

Body habitus, height, weight, waist hip ratio and BMI

Baseline recording of weight and BMI is useful for future comparison.

Body habitus may be indicative of Cushing's syndrome.  

Hirsutism

The symptom of hirsutism is highly subjective and depends on multiple social circumstances. 

It is therefore useful to document this as objectively as possible. 

The modified Ferriman Galloway score gives a score of 0-4 for each area where 0=no terminal hairs (terminal hairs are pigmented and >0.5cm long), 1=few, 2=modest, 3=severe, 4=equal to a hairy man. Nine distinct body areas are assessed: upper lip, chin/jaw, chest, abdomen, pubic area, upper arms, thighs, upper back, natal cleft, giving a maximum score of 36.

Hirsutism may be defined by scores above four, though some publications state 10 to indicate moderate hirsutism.

Capital hair distribution

Diffuse hair loss or temporal recession may be observed in hyperandrogenic states.

Acne

Document extent, severity and scarring of acne.

Acanthosis nigricans

Commonly seen in insulin resistance.

Skin

Also examine the skin for signs of Cushing’s syndrome: thinning of the skin, pigmented striae and excessive bruising. 

Gently pinch the skin on the back of the hand to seek the fine wrinkling of thinned atrophic skin. 

Striae are common and should fade soon after forming at times of rapid growth, for example puberty or pregnancy. In Cushing's, the striae remain livid - purple or red - and are often extensive.

External genitalia

Clitoromegaly is indicative of a hyperandrogenic state, for example virilising tumour or congenital adrenal hyperplasia.

Breasts

Galactorrhoea may indicate hyperprolactinaemia typically due to a prolactinoma which may also cause oligomenorrhoea and so mimic PCOS.

Thyroid status

Hypothyroidism may lead to weight gain and menstrual disturbance. This may mimic the symptoms of PCOS.

Myopathy

Proximal myopathy is almost always present in patients with Cushing's syndrome, but is not associated with PCOS.

One of the most sensitive tests is to ask the patient to squat on the floor with their heels flat on the ground. While demonstrating the same thing, ask the patient to then rise to a standing position without using their arms for support or swinging their bottom up and out first. More severe myopathy will be evident by asking the patient to rise from a chair without using their arms for support.

Virilisation

Examine the musculature for increased bulk in women. Examine for changes in secondary sexual characteristics, such as hirsuitism and clitoromegaly.