require two of three key features of oligo- or anovulation, clinical and/or biochemical hyperandrogenism and polycystic ovaries on ultrasound.
Calculated bioavailable testosterone, calculated free testosterone or free androgen index should be first line investigation for hyperandrogenism in polycystic ovary syndrome. If androgen levels are markedly above laboratory reference ranges, secondary causes may be considered. Late-onset congenital adrenal hyperplasia, although rare, needs to be considered.
It is difficult to assess androgen status in women on the OCP as effects include oestrogen mediated increases in sex hormone-binding globulin and reduction in androgens. Where the OCP has already been commenced, it should be withdrawn for at least three months before testing.
In adolescent women (<18 years), after two years of irregular cycles (>35 or < 21 days) following the onset of menarche, polycystic ovary syndrome should be considered as well as other causes of irregular cycles (eg thyroid dysfunction or hyperprolactinemia)
Treatment Options Oligo menorrhoea/amenorrhoea
Lifestyle change (5%–10% weight loss + structured exercise)
Oral contraceptive pill (OCP) (low oestrogen doses [eg, 20μg] may have less impact on insulin resistance)
Cyclic progestins (eg, 10mg medroxyprogesterone acetate 10–14 days every 2–3 months)
Metformin (improves ovulation and regularity of periods)
OCP (monitor glucose tolerance in those at risk of diabetes)
Anti-androgen monotherapy (eg, spironolactone or cyproterone acetate) should not be used without adequate contraception
Trial therapies for 6 months before changing dose or medication
Combination therapy — if 6 months of OCP is ineffective, add anti-androgen to OCP (twice daily spironolactone > 50mg or cyproterone acetate 25mg/day, days 1–10 of OCP)
Self-administered and professional cosmetic therapy are also an option (laser recommended)
• Lifestyle intervention (to optimise preconception health and fertility and reduce pregnancy and long-term complications)
• Advise on folate, smoking cessation and optimal weight and exercise before conception
Pharmacological ovulation induction should not be recommended for first line therapy in women with polycystic ovary syndrome who are morbidly obese (body mass index _35 kg/m2) until appropriate weight loss has occurred either through diet, exercise, bariatric surgery, or other appropriate means. 18>