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.

What is the patient's pubertal history? 

A detailed pubertal history is highly informative. A typical patient with PCOS may have been overweight as a child and have exhibited precocious puberty: for example early adrenarche with pubic hair development before eight years. Menarche may also be early. Conversely, some will have primary amenorrhoea with obesity which should prompt investigation for other causes.

What is the patient's menstrual and obstetric history? Are they trying to get pregnant now?

Determine the pattern of menses since menarche, including pill usage and depot contraceptions.

If the patient has regular periods, other causes of hyperandrogenism should be considered, and anovulation or polycystic morphology on ultrasound scanning will be required to confirm the diagnosis.

Oligomenorrhoea and secondary amenorrhoea are encountered more frequently. This is particularly common at times of weight gain. Oligomenorrhoea may not require any specific treatment if the patient has more than four periods a year, whereas amenorrhoea almost always requires some form of treatment.

Many patients with PCOS will have had healthy pregnancies. However, a typical patient might have taken a longer than expected time to fall pregnant, or be seeking fertility at presentation. Pregnancies may also have been associated with further weight gain and subsequent oligomenorrhoea or amenorrhoea.

Does the patient complain of acne? 

Acne is a common condition and frequently runs in families, presenting around puberty.

Acne occuring within the context of PCOS may be severe, more widespread, for example affecting the back, and between the breasts or more prolonged.

It also typically follows weight gain.

Has the patient developed unwanted hair or lost capital hair? 

Unwanted hair growth is common, but its perceived severity varies widely. Body hair distribution also follows distinct racial patterns, for example excess or dark hairs on the arms in some but not all races.

Androgenic hirsutism has a distinct distribution, however, and occurs after puberty and following weight gain (see Examination for description).

Document how this affects the patient’s quality of life and the methods, effectiveness and frequency of depilation used.

Androgenic alopecia may also occur in PCOS though raises the possibility of a virilising tumour.

Have there been any other skin changes? Has the patient or their family noticed increased redness of the skin, easy bruising or fragility? 

Plethora and easy bruising - as well as acne or hirsuitism - are more suggestive of a diagnosis of Cushing's.

Has the patient gained or lost weight? What is the pattern of the weight distribution, and what is the timing of the weight gain in relation to other symptoms? 

The symptoms of PCOS are typically exacerbated by weight gain, such that weight gain commonly predates other symptoms. A typical pattern would be of simple weight gain in childhood, particularly at the time of puberty, with gradual increase during the teenage years. 

Other symptoms frequently follow increased weight and will improve during times of weight loss, for example previously regular menses becoming irregular in early 20s following weight gain in late teenage years, improving again with weight control in adulthood.

Central weight gain and loss of growth velocity should alert you to the possibility of Cushing’s. 

Does the patient have other features of the metabolic syndrome: hypertension, impaired glucose tolerance or type 2 diabetes mellitus? 

PCOS is a risk factor for the metabolic syndrome and so associated risk factors should be sought and managed appropriately.

These conditions should also raise the clinical suspicion for Cushing's syndrome.

What is the family history? 

Maternal history of oligomenorrhoea or difficulty falling pregnant, is suggestive of a family history of PCOS.

Familial patterns of overweight, hirsuitism and acne are also important and should inform management. Patients with PCOS have an adverse metabolic profile, and so a family history of diabetes or of cardiovascular disease should be sought.

Does the patient have muscle weakness and wasting? Can they climb the stairs or rise from a chair easily? Can they brush or dry their hair easily? 

These questions are specifically seeking evidence of proximal myopathy seen with Cushing's syndrome.

Has the patient noticed change in their libido or in their sexual characteristics? 

Women with adrenal or ovarian tumours secreting testosterone may develop an increase in well being and in libido, as well as overt virilisation: acne, hirsuitism and clitoromegaly.

Has the patient noticed changes in their voice? 

New deepening of the voice is suggestive of an adrenal virilising tumour.

Has the patient noticed increased muscle bulk, for example broadening of the shoulders? 

This would be suggestive of a virilising tumour rather than PCOS.

Has the patient noticed a change in mood, for example depression or emotional lability? 

Depression is common in Cushing's.