Polycystic ovary (ovarian) syndrome (PCOS) is common (affects 5–10% of Caucasian
women of reproductive age) and is the commonest hormonal cause of hirsutism, which
may be the presenting complaint.
PCOS is caused by a combination of genetic and non-hereditable factors, but the
pathogenesis is incompletely understood.
Many patients also have the metabolic syndrome (central obesity, glucose or insulin
abnormalities, dyslipidaemias, elevated blood pressure) and are at risk of cardiovascular
disease (stroke, coronary artery disease, congestive heart failure). Lipodystrophy is a rare
association.
What should I ask?
• Menstrual history/history of infertility?
• Family or personal history of diabetes, hyperlipidaemia, acne, or hirsutism?
What should I look for?
• Cutaneous manifestations of excess androgens:
Hirsutism: which may be mild (or altered by treatment).
Female pattern of hair loss: frontal hairline is preserved in women (unlike men),
but hair on the vertex of the scalp thins diffusely.
Acne.
Seborrhoea: oily skin on central face (nose and forehead).
• Acanthosis nigricans usually secondary to obesity with insulin resistance.
• HAIR-AN syndrome: hyperandrogenism (acne), insulin resistance, and acanthosis
nigricans. May also have hirsutism.
• Central obesity (record the waist–hip ratio or waist circumference).
• Evidence of the metabolic syndrome, including hypertension. Record the height and
weight, and calculate the body mass index (BMI).
• Rarely lipodystrophy.
What should I do?
• Pregnancy test, in patients with amenorrhea.
• Measure plasma testosterone, ideally in early morning (normal or increased).
• Transvaginal ultrasound to detect polycystic ovaries.
• Luteinizing hormone (LH)/follicle-stimulating hormone (FSH) ratio >2 suggests PCOS,
but, as the ratio is raised in <50% of cases, it is not a useful test for confirming PCOS.
• Fasting glucose and lipids (the metabolic syndrome is common).
• PCOS is the commonest cause of hirsutism, but consider excluding other causes of
hirsutism, if clinically relevant.