Polycystic ovarian syndrome (PCOS), recently referred also as hyperandrogenic anovulation, is a chronic anovulation syndrome associated with androgen excess.
The diagnosis of PCOS generally requires any two of the following three criteria for the diagnosis, as well as the exclusion of other etiologies (e.g. congenital adrenal hyperplasia, Cushing syndrome and/or an androgen-secreting tumor) 4,18:
- ovulatory dysfunction (oligo- or anovulation)
- clinical and/or biochemical hyperandrogenism
- polycystic ovarian morphology on ultrasound
Hence, ultrasound is not necessary for the diagnosis if features of both ovulatory dysfunction and hyperandrogenism are present, but will identify the complete PCOS phenotype.
Hyperandrogenic anovulation has been proposed as a more accurate and potentially less confusing term, as the ovarian feature is of multiple follicles and not cysts 13. At this stage however, PCOS remains the term that is widely known and used.
The estimated prevalence is 8-13% of women of reproductive age but this varies (up to 20%) depending on the diagnostic criteria used 11.
The classic triad of PCOS is:
In addition to this, patients may have infertility, acne, alopecia or biochemically show increased androgen levels.
Biochemical hyperandrogenism is based on measurement of free testosterone, free androgen index or calculated bioavailable testosterone.
Anti-Müllerian hormone (AMH) levels are generally increased, and there is emerging evidence for the utility of AMH in the diagnosis of PCOS. At the time of writing, there is insufficient assay standardization and validation, and AMH should not be used in the diagnosis of PCOS at this stage 18.
- subfertility and recurrent pregnancy loss
- long-term increased risk of
- high prevalence of anxiety and depression
- women with polycystic ovarian morphology are at increased risk of OHSS when undergoing IVF, regardless of whether they have PCOS 15
Ovaries may be normal in PCOS, and conversely, polycystic ovarian morphology (PCOM) may be seen in women without the syndrome. However, it is well accepted that women with PCOS tend to have larger ovaries with an increased number of follicles.
The specific diagnostic cut-offs, however, have been the subject of debate and revision in recent years. The updated diagnostic criteria at the time of review are based on a 2018 international consensus guideline 18.
In patients >8 years post menarche, and using a high-frequency endovaginal probe:
- follicle number per ovary (FNPO) ≥ 20, and/or
- ovarian volume ≥10 mL, ensuring no corpora lutea, cysts or dominant follicles are present
If using transabdominal scanning, or older technology where ovarian morphology is not well visualized, consider using the ovarian volume threshold of ≥10 mL on either ovary.
The diagnostic criteria are adjusted in adolescent females (defined as within 8 years of menarche, or age <20 years) 18, in whom ultrasound should not be used for the diagnosis of PCOS due to the high incidence of multi-follicular ovaries in this life stage.
This supersedes the initial Rotterdam criteria of ≥12 follicles and interim recommendations of 24 or 25 follicles per ovary. The presence of a single multifollicular ovary is sufficient to provide the sonographic criterion for PCOS 2.
Other morphological features have been described, but do not contribute to formal diagnostic criteria:
- hyperechoic central stroma
- peripheral location of follicles (string of pearls sign)
- follicles of similar size measuring 2-9 mm
MRI is not warranted routinely in the investigation of PCOS, nonetheless pelvic MRI may show most or all of the above sonographic features. Signal characteristics include:
- T1: small uniform follicles are low in signal while the central stroma is of intermediate signal (vs normal myometrium)
- T2: follicles have high T2 signal while the central stroma is of comparatively low T2 signal 8
History and etymology
The syndrome was first described by I F Stein and M L Leventhal in 1935 7.
- with a lack of consensus sometimes it is easier to report the number of follicles in each ovary rather than attempt to label the ovaries as "polycystic" or "multifollicular"
- ultrasound should not be used for the diagnosis of PCOS in patients <8 years after menarche due to the high incidence of multi-follicular ovaries in this life stage
- as the individual age of menarche may not be known, an age cut-off of 20 years is suggested for the utility of ultrasound in this diagnosis (based on the median age at menarche being approximately 12 years)
- post menopause, a new or continuing diagnosis of PCOS could be considered based on past history and clinical evidence of persistent hyperandrogenism
- postmenopausal women presenting with new-onset, severe or worsening hyperandrogenism including hirsutism, require further investigation to rule out androgen-secreting tumors and ovarian hyperthecosis.
- 1. Weissleder R, Wittenberg J, Harisinghani MM et-al. Primer of Diagnostic Imaging, Expert Consult- Online and Print. Mosby. (2011) ISBN:0323065384. Read it at Google Books - Find it at Amazon
- 2. Balen AH, Laven JS, Tan SL et-al. Ultrasound assessment of the polycystic ovary: international consensus definitions. Hum. Reprod. Update. 9 (6): 505-14. doi:10.1093/humupd/dmg044 - Pubmed citation
- 3. Atiomo WU, Pearson S, Shaw S et-al. Ultrasound criteria in the diagnosis of polycystic ovary syndrome (PCOS). Ultrasound Med Biol. 2000;26 (6): 977-80. Ultrasound Med Biol (link) - Pubmed citation
- 4. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil. Steril. 2004;81 (1): 19-25. Fertil. Steril. (link) - Pubmed citation
- 5. Franks S. Controversy in clinical endocrinology: diagnosis of polycystic ovarian syndrome: in defense of the Rotterdam criteria. J. Clin. Endocrinol. Metab. 2006;91 (3): 786-9. doi:10.1210/jc.2005-2501 - Pubmed citation
- 6. Balen A. Polycystic ovary syndrome and cancer. Hum. Reprod. Update. 7 (6): 522-5. doi:10.1093/humupd/7.6.522 - Pubmed citation
- 7. Stein IF, Leventhal ML. Amenorrhoea associated with bilateral polycystic ovaries. Am J Obstet Gynecol 1935;29:181–91
- 8. Giudice LC. Endometrium in PCOS: Implantation and predisposition to endocrine CA. Best Pract. Res. Clin. Endocrinol. Metab. 2006;20 (2): 235-44. doi:10.1016/j.beem.2006.03.005 - Pubmed citation
- 9. Azziz R, Carmina E, Dewailly D et-al. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil. Steril. 2009;91 (2): 456-88. doi:10.1016/j.fertnstert.2008.06.035 - Pubmed citation
- 10. McCartney CR, Eagleson CA, Marshall JC. Regulation of gonadotropin secretion: implications for polycystic ovary syndrome. Semin. Reprod. Med. 2002;20 (4): 317-26. doi:10.1055/s-2002-36706 - Pubmed citation
- 11. Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2014;6: 1-13. doi:10.2147/CLEP.S37559 - Free text at pubmed - Pubmed citation
- 12. Lujan ME, Jarrett BY, Brooks ED et-al. Updated ultrasound criteria for polycystic ovary syndrome: reliable thresholds for elevated follicle population and ovarian volume. Hum. Reprod. 2013;28 (5): 1361-8. doi:10.1093/humrep/det062 - Pubmed citation
- 13. Martins WP, Kollmann M, Raine-Fenning N. Counting ovarian follicles: updated threshold for diagnosis of hyperandrogenic anovulation. Ultrasound Obstet Gynecol. 2014;44 (2): 131-4. doi:10.1002/uog.13402 - Pubmed citation
- 14. Dewailly D, Gronier H, Poncelet E et-al. Diagnosis of polycystic ovary syndrome (PCOS): revisiting the threshold values of follicle count on ultrasound and of the serum AMH level for the definition of polycystic ovaries. Hum. Reprod. 2011;26 (11): 3123-9. doi:10.1093/humrep/der297 - Pubmed citation
- 15. Dewailly D, Lujan ME, Carmina E et-al. Definition and significance of polycystic ovarian morphology: a task force report from the Androgen Excess and Polycystic Ovary Syndrome Society. Hum. Reprod. Update. 2014;20 (3): 334-52. doi:10.1093/humupd/dmt061 - Pubmed citation
- 16. Mitchell DG, Gefter WB, Spritzer CE, Blasco L, Nulson J, Livolsi V, Axel L, Arger PH, Kressel HY. Polycystic ovaries: MR imaging. Radiology. 160 (2): 425-9. doi:10.1148/radiology.160.2.3726121 - Pubmed
- 17. Lee TT, Rausch ME. Polycystic ovarian syndrome: role of imaging in diagnosis. Radiographics : a review publication of the Radiological Society of North America, Inc. 32 (6): 1643-57. doi:10.1148/rg.326125503 - Pubmed
- 18. Monash Centre for Health Research and Implementation (MCHRI). International evidence-based guideline for the assessment and management of polycystic ovary syndrome. 2018. monash.edu/
- 19. Teede HJ, Misso ML, Costello MF, Dokras A, Laven J, Moran L, Piltonen T, Norman RJ. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. (2018) Human reproduction (Oxford, England). 33 (9): 1602-1618. doi:10.1093/humrep/dey256 - Pubmed