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Practice Guidelines
The American College of Obstetricians and Gynecologists (ACOG) recently published a clinical management guideline on the diagnosis and management of polycystic ovary syndrome (PCOS). The guideline appeared in the December 2002 issue of Obstetrics and Gynecology.
Polycystic Ovary Syndrome
The ACOG noted that a universally accepted definition of PCOS is lacking. As proposed by the National Institutes of Health (NIH), the diagnostic criteria are chronic anovulation and hyperandrogenism (established by hormone measurements or clinical findings such as acne or hirsutism) in women in whom secondary causes (e.g., hyperprolactinemia, adult-onset congenital adrenal hyperplasia) have been excluded. Although insulin resistance is present in many women with hyperandrogenic chronic anovulation of unknown cause, the NIH did not include it as a diagnostic criterion. Polycystic-appearing ovaries on ultrasound examination are a nonspecific finding in PCOS.
Approximately 4 to 6 percent of women have hyperandrogenic chronic anovulation. Women with PCOS generally present with infertility or menstrual disorders. Ovulation induction in these women is a concern because of the increased risk of ovarian hyperstimulation syndrome, pregnancy loss in the first trimester, and multiple pregnancy. The risk of pregnancy complications, such as hypertension and gestational diabetes, also is increased.
The etiology of PCOS remains unknown, but selective insulin resistance may be a central factor. Conditions associated with insulin resistance, including centripetal distribution of fat, obesity, obesity-related sleep disorders, and acanthosis nigricans, are common in women with PCOS and are risk factors for cardiovascular disease and type 2 diabetes. (Acanthosis nigricans is a condition characterized by velvety, mossy, verrucous, hyperpigmented skin, often noted on the back of the neck, beneath the breasts, in the axillae, or on the vulva.) Furthermore, obesity, chronic anovulation, and hyperinsulinemia with decreased levels of sex hormone binding globulin are associated with endometrial cancer.
Important features of the history are as follows: the onset and duration of signs of androgen excess; the woman's menstrual history, medication use (including exogenous androgens), and lifestyle (e.g., diet, exercise, alcohol use, smoking); and family history of cardiovascular disease and diabetes. Important factors in the physical examination include the following: the presence of acne, balding, or ditoromegaly; the distribution of body hair; enlargement of the ovaries (based on a pelvic examination); and signs of insulin resistance (e.g., obesity, acanthosis...