Different Presentations of PCOS

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I recently received the following inquiry from a colleague regarding polycystic ovary syndrome (PCOS):

“I’ve had a number of PCOS patients that are NOT overweight and their insulin levels appear normal. What would you recommend in these cases? I have one such patient who has almost an underweight BMI, yet string of pearls was seen on her TVU. Not your typical PCOS patient.”

Here is a summary of my response:

PCOS represents a variety of clinical presentations. If you look at the diagnostic criteria typically used, hyperinsulinemia is not included.

The top accepted criteria for the diagnosis of PCOS include:

NIH consensus criteria 1990:

1. Menstrual irregularity due to oligo- or anovulation

2. Evidence of hyperandrogenism, whether clinical (hirsutism, acne, or male pattern balding) or biochemical (high serum androgen concentrations)

3. Exclusion of other causes of hyperandrogenism and menstrual irregularity, such as congenital adrenal hyperplasia, androgen-secreting tumors, and hyperprolactinemia

Rotterdam criteria 2003 includes two of the following three:

1. Oligo- and/or anovulation

2. Clinical and/or biochemical signs of hyperandrogenism

3. Polycystic ovaries (by ultrasound)

In addition, other etiologies (congenital adrenal hyperplasias, androgen-secreting tumors and Cushing’s syndrome) must be excluded.

In summary:

1. Remember: PCOS is a syndrome, not a disease. It represents multiple potential etiologies with variable clinical expressions.

2. No two women have exactly the same symptoms.

3. Not all patients with PCOS are overweight or obese.

4. There is no single test to identify PCOS.

5. There is a distinction between PCOS and polycystic ovaries. Studies have shown that 8 to 25 percent of normal ovulatory women will have ultrasound findings consistent with polycystic ovaries.  Not all women with PCOS have the typical polycystic ovaries at ultrasound.

6. Not all women with PCOS are insulin resistant.

7. Treatment will be dictated by clinical symptoms and the patient’s current goals- i.e. fertility, menstrual regulation, treatment of hirsutism, weight loss and nutrition and long-term health risks.

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