Polycystic ovarian syndrome in the exam

Last revised by Joshua Yap on 27 Aug 2022

Getting a film with polycystic ovarian syndrome (PCOS) in a subfertile patient is one of the many exam set-pieces that can be prepared for. 

Description

Transabdominal and transvaginal pelvic ultrasound shows an anteverted uterus with a normal size. There is diffuse thickening of the endometrium to 17 mm. No myometrial or serosal abnormality seen.

Both ovaries are enlarged (>10 cc in volume) with multiple peripheral cysts arrayed around a prominent central echogenic stroma, with a string of pearls appearance. 

No dominant follicle (>10 mm) or corpus luteum is visualized (this makes the examiner aware that you are looking for evidence of recent ovulation; PCOS is associated with anovulation).

The follicular count per ovary (one or both) is >20 (or "I would inquire about the follicular count per ovary").

As per the diagnostic criteria of the 2018 international consensus guidelines (which now supersede/replace Rotterdam criteria), appearances are consistent with polycystic ovarian morphology (PCOM).

I would correlate this with the clinical picture of subfertility, amenorrhea, hirsutism, acne, male pattern alopecia and hormone levels, particularly raised LH and low FSH.

However, given the provided history of subfertility, the absence of ultrasound evidence of recent ovulation, and ultrasound appearances of polycystic ovarian morphology, findings are diagnostic of polycystic ovarian syndrome (PCOS)

If the patient is under 20 years old or within 8 years of menarche, ultrasound has no role in the diagnosis of polycystic ovarian morphology. 

Notes

  • 40% have diffuse endometrial thickening either secondary to prolonged proliferative phase or endometrial hyperplasia 
  • increased risk of endometrial carcinoma

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