How To Diagnose PCOS

by Dr. Pamela Frank, BSc(Hons), Naturopathic Doctor

I chose this as the first of a series of “how-to diagnose” posts, as it so often is done incorrectly.  There are 3 main criteria required to diagnose PCOS, only 2 of these 3 need to be present to diagnose PCOS according to the Rotterdam criteria:

1. Oligo-ovulation – this means lack of or irregular ovulation, most women would have no way of knowing if they ovulate regularly or not (regular periods do not indicate regular ovulation) and most doctors haven’t tested for it (repeated day 21 progesterone measurements).
2. Clinical signs or blood work demonstrating hyperandrogenism – this would be symptoms like acne, hair loss, excess facial or body hair, irregular periods and blood tests for testosterone, DHEAs, androstenedione, DHT (these tests have often never been done).
3. Cysts on the ovaries on ultrasound – this is a very misunderstood criteria.  Cysts can come and go, and only 2 of these 3 criteria are required, so a lack of cysts on the ovaries does NOT rule out PCOS.

What to Test for PCOS

To thoroughly assess a woman to determine whether or not to diagnose PCOS, the following tests should be done:

1. Blood work: DHEAs, total testosterone, androstenedione, DHT, day 3 LH, FSH and estradiol (if cycles are present), day 21 or 7 days post ovulation progesterone (more than once, to determine whether ovulation occurs regularly), HbA1c, fasting blood glucose/insulin and/or 2 hour pc glucose/insulin (to determine insulin resistance).  Testing free testosterone is not sufficient, as the total testosterone can be high while the body maintains free testosterone in the normal range.  Testing only testosterone and not also checking DHEAs, androstenedione and DHT is also not sufficient.
2. Pelvic and transvaginal ultrasound, more than once

5 Mistakes to Avoid When Diagnosing PCOS

The following are NOT adequate ways to diagnose PCOS:

1. Body weight.  Being overweight or obese, is not a criteria required to diagnose PCOS.  In fact, up to 40% of women with PCOS are thin.  Women with PCOS will often exercise frequently or adopt eating disorders to prevent weight gain.
2. Lack of cysts on the ovaries if the other two criteria are met.  Only 2 of the above 3 criteria need to be met to be diagnosed with PCOS.  The absence of cysts on the ovaries does not rule out PCOS.
3. Lack of facial hair or lack of excessive body hair.  Most women with PCOS find these symptoms highly embarrassing and will have excess facial or body hair removed by laser, electrolysis, plucking or shaving.
4. Clear skin.  Having acne is not a requirement to diagnose PCOS either.  Prior or current use of accutane and/or birth control pills may mask this symptom.
5. How a woman “looks”.  See acne, hair and weight above (I mention this because I have had several women tell me that their doctor told them they didn’t have PCOS because they didn’t “look” like it).  You cannot rule in or rule out PCOS by how someone looks.