Monday, October 31, 2011

Happy Pumpkin Day Again

Happy Halloween, y'all.  Just a brief post to wish you joy of the day if you celebrate it.  We love this holiday at our house.

What are your children dressing up as for Halloween?

Now that my kids are getting older, traditions are changing a bit at our house.  Two of my kids are teens (my "bigs"), and two are younger (my "littles", or more precisely, one "little" and one "tween").  And having two teens in the house is changing things.

When my bigs were young, our Halloween costumes followed the usual themes....kitty cat, pumpkin, astronaut, pirate, teddy bear, princess, baseball player, fairy, firefighter, knight, lion, witch, etc. Oh, and at one point, my oldest son went as "Everyone's Worst IRS Agent."

Although we encouraged non-commercial, non-media costumes for the most part, we did give in sometimes and had Madeline, Harry Potter, Tigger, Thomas the Tank Engine, various superheros, and Star Trek visit our home a few times.   (Yes, we keep a list so we can remember who wore what which year! This is really fun to look back at.)

We also had a couple of cool themed years.  A couple of times everyone (including littles) went as someone from Peter Pan (Peter, Wendy, Captain Hook, Tinkerbell, the Crocodile).  That was precious, especially the Crocodile.  That cute little reptile is now a hulking teen with a deep bass voice and a bottomless appetite, but I'll always remember him as the Croc with a Clock.

My personal favorite was the year they all dressed as a Star Wars character, along with some good friends (we had Princess Leia, the Emperor, Darth Vader, Luke Skywalker, and a Clone Trooper.  I tried to get the toddler to be an Ewok but she wasn't having it).  That's a picture I treasure now.

They were so adorable.  Oh, how I miss those days!

This year, one teen, the "tween" and I are going to participate behind the scenes in a Haunted House.  The other teen is going trick-or-treating for the local food bank with a club from his school, and DH and the youngest will tag along to help supervise. After that, we'll take them all for a brief round of trick-or-treating in our old neighborhood, just enough for the littles to show off their costumes and get a little candy.

Sadly, Halloween costumes have changed now that my bigs are teenagers.  I find that their teen "hipness" vibe has changed the costume choices of my littles, even though the bigs are no longer dressing up.  Know what my littles are going to be for Halloween?

The "tween" is going to be a Barrel of Toxic Waste.  Yes, toxic waste.  Sigh.

The "littlest" is going with a non-princess theme for the first time since she was a baby.  For years it was All Princesses All The Time, although the last two years the princesses had combined with other themes and became a Cowboy Princess and then a Ninja Fairy Princess.  But not this year.

Nope, this year she's going to be.......get this.......a Zombie Bride.

Yes, both of those were completely THEIR ideas.  No teens tried to "hip up" their ideas or anything.  Yet just having 2 worldly, hip teens in the house changed their expectations and visions.

Sigh.  Although these are pretty funny and precious in their own way, I have to say I miss the old days!  I may never see a sweet, "unhip," plain-vanilla costume again till I have grandkids.  Wah!

Although it's wonderful to see my kids growing up and becoming such fine big people, every so often I get all misty and nostalgic for those "little one" innocent-joy moments.  The bittersweet nature of being a parent, I guess.  Sniff.

Well, Happy Pumpkin Day to you all.  If you still have littles, enjoy the sweetness and innocence of these days.  It will pass all too soon into zombies and toxic waste.

Friday, October 28, 2011

Restricting Prenatal Weight Gain in Women of Size: Adverse Side Effects

Here's another study questioning whether rigid weight-gain restrictions in "obese" women are wise.  

We've talked about this extensively before.  But given how often care providers tout this as a way to improve outcomes in women of size, it bears frequent repetition.

In this study, the lower Cedergren weight gain criteria for obese women (less than 13 lbs.) resulted in slightly lower cesarean rates and definitely less macrosomia than the IOM guidelines.

However, it also resulted in an increase in preterm births, low birth weight babies, and NICU admissions.

Many providers mean well when they advise women of size to gain less weight in pregnancy. The question is, are we harming more than we are helping?

When restrictions are too draconian, I think the balance definitely falls to harm.

Discuss good nutrition and reasonable intake? Absolutely.  Have rigid weight gain goals that require significant restriction?  Not a good idea.

How about we emphasize excellent nutrition and trust the woman's body to gain what it needs?

Am J Perinatol. 2010 May;27(5):415-20. Obstetric outcomes in normal weight and obese women in relation to gestational weight gain: comparison between Institute of Medicine guidelines and Cedergren criteria. Potti S, Sliwinski CS, Jain NJ, Dandolu V.  PMID: 20013574 
We compared obstetric outcomes based on gestational weight gain in normal-weight and obese women using traditional Institute of Medicine (IOM) guidelines and newly recommended Cedergren criteria. Using the New Jersey Pregnancy Risk Assessment Monitoring System (PRAMS) database and electronic birth records, perinatal outcomes were analyzed to estimate the independent effects of prepregnancy body mass index (BMI) and gestational weight gain by IOM versus Cedergren criteria. Of 9125 subjects in PRAMS database from 2002 to 2006, 53.7% had normal BMI, 12.3% were overweight, 18.2% were obese, and the rest were underweight. 
Among normal-weight mothers, when compared with the IOM guidelines, macrosomia (6.45% versus 4.27%) and cesarean delivery rates (30.42% versus 29.83%) were lower using Cedergren criteria but the rates of preterm delivery (5.06% versus 9.44%), low birth weight (0.38% versus 2.42%), and neonatal intensive care unit (NICU) admissions (7.02% versus 10.86%) were higher with the Cedergren criteria.  
Similarly, among obese patients, when compared with IOM guidelines, macrosomia (10.79% versus 5.47%) and cesarean delivery rates (43.95% versus 40.71%) were lower using Cedergren criteria but the rates of preterm delivery (6.83% versus 8.32%), low birth weight (0.87% versus 1.88%), and NICU admissions (8.92% versus 13.78%) were higher with the Cedergren criteria.  
Based on our results, ideal gestational weight gain is presumably somewhere between the IOM and Cedergren's guidelines.

Saturday, October 22, 2011

BMI and Blood Pressure Measurement in Pregnancy

BP Cuff Size Chart
(exact cutoffs may vary by brand)
We've written before about the importance of using a large cuff for blood pressure measurement in women of size.

Yet sometimes using a large BP cuff for women of size is not done routinely, especially in obstetrics.  

Here's yet another study documenting the importance of the correct cuff size in "obese" women in pregnancy.  

Note that Class One obesity is usually BMI 30-35, Class Two is usually BMI 35-40, and Class Three is BMI over 40.

In this study, nearly half of Class One obese women needed a large cuff, and with Class Two and above, 100% needed a large cuff.  

My BMI is about 48 and has been for all four of my pregnancies, which occurred in the mid-90s through the mid 2000s.  Research on the importance of blood pressure cuff size in "obese" people had been around for years before that, yet getting the correct cuff size was a problem in three of my four pregnancies.

And I still hear stories about use of the wrong cuff size from other high-BMI women, inside and outside of pregnancy, even today.

In theory, care providers know about the importance of the correct cuff size, but in practice, many don't follow the guidelines, don't think cuff size really makes that much difference, don't really check what size cuff was used (even when encountering a high BP in a large person), and don't emphasize the importance of cuff size adequately to the nurses and techs who do the actual BP measurements most of the time.

Yes, BP taken at the wrist with a regular cuff can be done for a ballpark figure in high-BMI people, but is not accurate enough for decision-making purposes. It tends to overestimate blood pressure in many cases.

A large or thigh cuff  (depending on arm circumference) used on the arm is the only really accurate method of BP measurement in "obese" people.

You need accurate data on which to base care decisions. Ensuring the correct cuff size is a very simple but extremely important way that care providers can improve care for women of size.

Hypertens Pregnancy. 2011;30(4):396-400. Body Mass Index and Blood Pressure Measurement during Pregnancy. Hogan JL, et al.  PMID: 20726743

Objective. The accurate measurement of blood pressure requires the use of a large cuff in subjects with a high mid-arm circumference (MAC). This prospective study examined the need for a large cuff during pregnancy and its correlation with maternal obesity.

Methods. Maternal body mass index (BMI), fat mass, and MAC were measured.

Results. Of 179 women studied, 15.6% were obese. With a BMI of level 1 obesity, 44% needed a large cuff and with a BMI of level 2 obesity 100% needed a large cuff. 

Conclusion. All women booking for antenatal care should have their MAC measured to avoid the overdiagnosis of pregnancy hypertension.

Tuesday, October 11, 2011

PCOS: Possible Causes

We've been talking about PCOS (Polycystic Ovarian Syndrome), its definition and symptoms, how it presents, and its testing and diagnosis.

Today let's talk about the controversy over possible causes of PCOS.

Determining the causes of things like PCOS can be incredibly complex.  Furthermore, as research develops, a better understanding of cause develops over time.  Therefore, insert many caveats to this information and remember that our understanding may change as further research is done.
What Causes PCOS?

Unfortunately, no one really understands why PCOS happens or what causes it.

Because of this, PCOS is a controversial diagnosis. Some doctors don't really believe it exists, some think it's merely a marker for Syndrome X ("metabolic syndrome") in females, some think it's all about hormones only, some think it's all about insulin resistance, some think it's caused by obesity, some think it causes obesity. 

Part of the problem is that PCOS is a syndrome and not a formal disease. One website clarifies the difference:
A syndrome refers to a group of symptoms, while a disease refers to an established condition.  A disease a condition that is marked by 3 basic factors. 
    1. An established biological cause behind the condition
    2. A defined group of symptoms
    3. Consistent change in anatomy due to the condition 
A syndrome does not have any of these features. Even the symptoms that are present are usually not consistent, and definitely not traceable to a single cause.

The reason behind most syndromes has still not been identified. For this reason, they are a type of medical mystery. In contrast, the reason or cause behind a disease can be identified very easily.
In other words, no one really knows why it happens or what causes it, and it presents with a wide variety of symptoms that make it difficult to classify.

Here's what we do know: In PCOS, an excess of androgens (male hormones) and  insulin resistance seem to be key parts of the syndrome. However, what causes this, which comes first, and which is more important is not clear.

Some researchers consider PCOS to be primarily a hormone imbalance disorder, and view insulin resistance as a side effect of the hormonal issues.

Other researchers consider insulin resistance (problems processing insulin) to be the real root of the issue, which then causes hormonal disturbances.

At this point, it's a bit of a chicken-or-the-egg question and no one has any definitive answers as to what causes PCOS.  All we have are educated guesses.

Hormones and Obesity and Insulin, Oh My

The most common suspects for a root cause of PCOS are hormones, obesity, and insulin resistance.  Each has arguments for and against it.

Hormonal Imbalance 

The prevailing view of PCOS suggests that it is primarily a hormonal disorder, and that an imbalance of hormones is the root cause of problems. Here is one common explanation, as given by one website:
A main underlying problem with PCOS is a hormonal imbalance. In women with PCOS, the ovaries make more androgens than normal. Androgens are male hormones that females also make. High levels of these hormones affect the development and release of eggs during ovulation...

The ovaries, where a woman’s eggs are produced, have tiny fluid-filled sacs called follicles or cysts. As the egg grows, the follicle builds up fluid. When the egg matures, the follicle breaks open, the egg is released, and the egg travels through the fallopian tube to the uterus (womb) for fertilization. This is called ovulation.

In women with PCOS, the ovary doesn't make all of the hormones it needs for an egg to fully mature. The follicles may start to grow and build up fluid but ovulation does not occur. Instead, some follicles may remain as cysts. For these reasons, ovulation does not occur and the hormone progesterone is not made. Without progesterone, a woman's menstrual cycle is irregular or absent. Plus, the ovaries make male hormones, which also prevent ovulation.
In this model, the immature follicles form cysts on the ovaries, and these cysts give off androgens ("male" hormones), and do not produce the progesterone that would normally be created if ovulation had occurred. The woman skips periods because she has not ovulated, and the endometrial lining builds up because it has not been shed and has been exposed to unopposed estrogen.

So the focus in this theory is on the ovaries, and the hormonal imbalances that cause ovarian cysts. However, the problem with this theory is that not all women with PCOS have cystic ovaries, yet clearly have symptoms of androgen excess. And some have cystic ovaries but no real signs of androgen excess.

Another model proposes that the basic problem is that the body does not produce or process androgens normally.
Women with polycystic ovarian syndrome (PCOS) have abnormalities in the metabolism of androgens and estrogen and in the control of androgen production...

...some evidence suggests that patients have a functional abnormality of cytochrome P450c17, the 17-hydroxylase, which is the rate-limiting enzyme in androgen biosynthesis.

Cytochrome P450c17 is active in the adrenals and ovaries, and excess activity of this enzyme could explain the increased androgen production from both sources in PCOS. 
Whatever the reason, the end result is that women with PCOS have too many androgens floating around, and that creates side effects in the body.

Women with PCOS also tend to be estrogen-dominant, meaning too much estrogen and not enough progesterone. This can make it difficult to sustain a pregnancy, even when one is achieved. For some women with PCOS, the key to maintaining a pregnancy seems to be treatment with supplemental progesterone before and during in the first trimester, although this treatment remains controversial to some.

The question is where the hormonal imbalance originates.  Some researchers theorize that PCOS originates with problems in the HPO (hypothalamic-pituitary-ovarian) axis.  This in turn affects many other glands (like the thyroid or the gonadotropic glands) and sets up a cascade of imbalances and negative effects.

If this is true, it means that many of the treatments we have today are simply "band-aid" approaches, addressing only the symptoms and not the real cause of issues.  But if a way to identify and treat HPO axis issues were to be found, perhaps PCOS could be prevented altogether.


Some doctors will tell you that "obesity" may cause PCOS, because fat stores produce extra estrogen and this in turn can alter other hormones.

However, it is more logical that perhaps the metabolic changes of PCOS cause the obesity instead.

In my opinion, this seems a much more likely explanation, especially since many women with PCOS report bouts of sudden, severe, unexplainable weight gains at various points in life, despite no changes in habits or intake.  And several studies report that the overall caloric intake of women with PCOS is similar to those without PCOS.  So there may be more to the story than the usual "eating too much" theory.

Because our society is so biased about "obesity" and weight issues, and because PCOS and obesity go hand in hand so often, it's very difficult to get researchers (and consumers) to view it objectively.  Many cannot disentangle their biases that obesity = gluttony long enough to consider the question of root causes of PCOS more objectively.

I certainly have heard from PCOS advocates who staunchly believe that their obesity is to blame for their PCOS status, and I've read materials from doctors theorizing that PCOS starts mostly in overweight teens because of their obesity which then triggers hyperandrogenism (in other words, there was a genetic predisposition there but it was the teens' overweight status that caused those genes to express, not the other way around).

However, this ignores the fact that average-sized women get PCOS too, and can have just as much androgen excess and insulin resistance as "obese" women with PCOS.  And not every fat woman has PCOS.

This view of obesity "causing" PCOS seems to be falling out of favor now, and most resources acknowledge that obesity does not cause PCOS, although it can exacerbate the symptoms.

The question is, does significant obesity amplify and worsen PCOS, or is significant obesity simply a symptom of a more severe manifestation of the syndrome?  Or do the two work synergistically in a negative feedback loop?

Insulin Resistance

It is clear that many women with PCOS have very strong insulin resistance (IR) issues, so it's been theorized that insulin resistance (and resulting hyperinsulinemia) causes both the tendency towards obesity, the hyperandrogenism, and the resulting PCOS symptoms. In other words, a problem with the insulin may be the root cause of everything else.

Polycystic ovary syndrome is in sore need of a new name, Dr. Barbara S. Apgar said at the annual meeting of the American Academy of Family Physicians.

Put aside the traditional notion that the primary defect in polycystic ovary syndrome (PCOS) involves the ovaries. Focus instead on hyperinsulinemia, which lies at the core of this common endocrinopathy, advised Dr. Apgar, a family physician at the University of Michigan, Ann Arbor.

Indeed, the finding of enlarged ovaries on palpation or polycystic ovaries on ultrasound in merely a sign of PCOS. Insulin abnormalities precede the elevated androgen levels that characterize PCOS. And switching off the ovaries via a GnRH agonist doesn't affect the hyperinsulinemia and insulin resistance, she noted...

In PCOS, hyperinsulinemia leads to hyperandrogenism, resulting in chronically elevated LH levels. The hair follicles are genetically sensitive to androgen stimulation, so acne and hirsutism are commonly part of the PCOS picture. Glucose intolerance, type 2 diabetes, and lipid abnormalities also are common. And 40%-60% of patients with PCOS are obese.

Treatment is not directed at the ovary. It's directed at the hair follicle level and also at the pancreatic level, where we see the insulin resistance, she explained.
Some doctors have hypothesized that perhaps women with PCOS have defective insulin receptors, so the body must overproduce insulin in order to get them to work properly.   Another theory is that, while insulin receptors are normal, there is a "post-binding defect in insulin signaling," as suggested here:
Insulin resistance in PCOS can be secondary to a postbinding defect in insulin receptor signaling pathways, and elevated insulin levels may have gonadotropin-augmenting effects on ovarian function.
Another theory put forth in the past was that perhaps women with PCOS produce insulin that is slightly defective in some way, so again the body would need to work harder and overproduce in order to help the insulin "unlock" the doors to the cells and get blood sugar into them.

Whatever the reason, it is thought that women with PCOS overproduce insulin, and all that excess insulin floating around the body then causes hormonal disturbances and imbalances, including the production of excess androgens. These excess androgens then interfere with ovulation, reproduction, and can cause hirsutism, acne, and other issues.

One argument against insulin resistance as a root cause in PCOS is that not all women with PCOS are documented as having IR.  Sources generally estimate that about 50-70% of women with PCOS have IR.  However, perhaps PCOS women without overt IR may simply have a more subtle presentation of it, one that is on the IR spectrum but does not quite reach "official" diagnostic levels.

Other Possible Causes

Some have suggested that PCOS may be an autoimmune condition.  However, it may simply be that autoimmune issues (like Hashimoto's hypothyroidism) are a side effect or coincidental co-morbidity of PCOS.  This is an area that deserves further research.

Research suggests that whatever the base cause, genetics plays a strong role in PCOS.
Because the symptoms of PCOS tend to run in families, the syndrome is probably caused, at least in part, by a change (or mutation) in one or more genes. However, because of the complex pattern of how PCOS symptoms change from one generation to the next, gene mutations are probably not the only cause of PCOS.

It is likely that PCOS results from a combination of factors, including genes and environmental features. Recent research conducted in animal models also suggests that, in some cases, the origins of PCOS may occur in the womb.
This idea that both genetic and environmental influences are needed for full expression of the syndrome is growing in acceptance, despite not knowing exactly which genes are involved:
Familial clustering of PCOS has been consistently reported suggesting that genetic factors play a role in the development of the syndrome although PCOS cases do not exhibit a clear pattern of Mendelian inheritance. It is now well established that PCOS represents a complex trait similar to type-2 diabetes and obesity, and that both inherited and environmental factors contribute to the PCOS pathogenesis.
Some researchers combine all the theories together, proposing that both genetics and environment play a role, and that the most severe cases of PCOS have both an insulin resistance source and an androgen production or metabolism problem.  From
PCOS is, in some cases, a familial disorder, but the genetic basis of the syndrome remains unclear. Studies of family members with PCOS indicate that an autosomal dominant mode of inheritance, with premature male pattern baldness as the male phenotype, may occur. Full expression of the syndrome may require an insulin abnormality and a defect in androgen biosynthesis, but no gene (or genes) has been identified.

What causes PCOS is a chicken-and-egg question at this point.  No one is sure what the underlying first cause is, and untangling that is a long and difficult process.

The two most likely candidates are a disturbance in androgen production/metabolism, or insulin resistance due to problems with insulin production, receptors, or signaling.

Another interesting possibility is an underlying disturbance in the HPO axis, which then creates the other disturbances commonly found with PCOS.

Familial clustering suggests a strong genetic component to PCOS, but some researchers believe that both genetic and environmental influences must combine for the full syndrome to express.  Other possibilities include autoimmune issues.

At this point, most of our treatments for PCOS are aimed at lessening the symptoms and hopefully mitigating future risk for complications.  In other words, they are "band-aid" approaches.

What we really need is to understand is the root cause of PCOS; only then can we begin to develop truly effective treatments.


*As always, trigger warning for many of these links and references.  Most contain lots of weight loss promotion or assumptions about the habits of people of size.

General Information on PCOS and Possible Causes

Articles on Insulin Resistance and PCOS

Am J Physiol Endocrinol Metab. 2001 Aug;281(2):E392-9. Defects in insulin receptor signaling in vivo in the polycystic ovary syndrome (PCOS). Dunaif A, Wu X, Lee A, Diamanti-Kandarakis E.  PMID: 11440917
Women with polycystic ovary syndrome (PCOS) are insulin resistant secondary to a postbinding defect in insulin signaling. Sequential euglycemic glucose clamp studies at 40 and 400 mU. m(-2). min(-1) insulin doses with serial skeletal muscle biopsies were performed in PCOS and age-, weight-, and ethnicity-matched control women...We conclude that there is a physiologically relevant defect in insulin receptor signaling in PCOS that is independent of obesity and type 2 diabetes mellitus.
Am J Physiol Endocrinol Metab. 2005 May;288(5):E1047-54.  Insulin resistance in the skeletal muscle of women with PCOS involves intrinsic and acquired defects in insulin signaling. Corbould A, Kim YB, Youngren JF, Pender C, Kahn BB, Lee A, Dunaif A.  PMID: 15613682
Insulin resistance in polycystic ovary syndrome (PCOS) is due to a postbinding defect in signaling that persists in cultured skin fibroblasts and is associated with constitutive serine phosphorylation of the insulin receptor (IR). Cultured skeletal muscle from obese women with PCOS and age- and body mass index-matched control women (n = 10/group) was studied to determine whether signaling defects observed in this tissue in vivo were intrinsic or acquired...In summary, decreased insulin-stimulated glucose uptake in PCOS skeletal muscle in vivo is an acquired defect. Nevertheless, there are intrinsic abnormalities in glucose transport and insulin signaling in myotubes from affected women, including increased phosphorylation of IRS-1 Ser312, that may confer increased susceptibility to insulin resistance-inducing factors in the in vivo environment. These abnormalities differ from those reported in other insulin resistant states consistent with the hypothesis that PCOS is a genetically unique disorder conferring an increased risk for type 2 diabetes.
Diabet Med. 2011 Sep 26. doi: 10.1111/j.1464-5491.2011.03460.x. Current perspectives of insulin resistance and polycystic ovary syndrome. Pauli JM, Raja-Khan N, Wu X, Legro RS.  PMID: 21950959
"Insulin resistance likely plays a central pathogenic role in polycystic ovary syndrome and may explain the pleiotropic presentation and involvement of multiple organ systems. Insulin resistance in the skeletal muscle of women with polycystic ovary syndrome involves both intrinsic and acquired defects in insulin signalling. The cellular insulin resistance in polycystic ovary syndrome has been further shown to involve a novel post-binding defect in insulin signal transduction...Insulin resistance is linked to polycystic ovary syndrome. Further study of lifestyle and pharmacologic interventions that reduce insulin resistance, such as metformin, are needed to demonstrate that they are effective in reducing the risk of diabetes, endometrial abnormalities and cardiovascular disease events in women with polycystic ovary syndrome."

Tuesday, October 4, 2011

PCOS: Testing and Diagnosis

We have begun a new series on the blog about PCOS, or Polycystic Ovarian Syndrome.  This is an abnormal hormonal and metabolic condition that is common in women of size.

Today let's talk about the testing and diagnosis of it.

Previously we discussed the definition and symptoms of PCOS, and how it often presents in women.

In the future, we'll discuss its treatment,  how it affects fertility, pregnancy, and breastfeeding, and its effects on menopause and aging.

But for now, let's talk about how to find out whether or not you have it, including what type of care providers to see, what type of tests are usually ordered and why, what they mean, and diagnostic debates.

Diagnostic Criteria for PCOS

PCOS is a somewhat controversial diagnosis. Unfortunately, this means that not everyone agrees on the best way to diagnose it.  For example, 3 different organizations have come up with 3 slightly different criteria for diagnosis over the past 20+ years.

In 1990, the NIH came up with the following criteria to diagnose PCOS:
  1. Clinical and/or biochemical hyperandrogenism
  2. Chronic anovulation
  3. Exclusion of related disorders
In 2003, the Rotterdam criteria were developed.  To be diagnosed via the Rotterdam criteria, a woman must have two of the following three manifestations:
  1. Irregular or absent ovulation
  2. Elevated levels of androgenic hormones
  3. Enlarged ovaries containing at least 12 follicles each.
To make things even more confusing, the Androgen Excess Society recently came up with its own criteria too:
  1. presence of hyperandrogenism (clinical and/or biochemical)
  2. ovarian dysfunction (oligo-anovulation and/or polycystic ovaries)
  3. exclusion of related disorders
Fortunately, all of these different criteria have some similarities.  They are all basically looking for:
  • evidence of disturbed menstrual cycles/ovulation, and 
  • evidence of elevated androgens (male hormones)
These seem to be the key items in deciding whether someone has PCOS or not.  However, since these all occur on a wide spectrum of severity, the milder presentations of these symptoms can still make the diagnosis ambiguous at times.

Variations in Interpreting the Criteria

Some doctors are more strict in their interpretation of these criteria than others.  For example, some doctors consider women to have PCOS only if they have few, if any, menstrual periods.  Others consider any menstrual cycle longer than about 35-40 days to be abnormal and indicative of PCOS.  Still others require 8 or fewer menstrual cycles per year (which translates to cycles of about 45+ days each).

Some doctors require that you demonstrate impaired fertility, and believe that any woman who has had children without fertility treatment could not have PCOS.  Others believe that some women can have spontaneous pregnancies yet still demonstrate other symptoms strongly enough that PCOS is likely. 

Some doctors require lab work confirming that a woman has elevated androgen levels, while others will take physical symptoms of androgen excess (facial hair, thinning scalp hair, cystic acne) as enough proof of elevated androgens.

Ovarian follicles/cysts are now considered a particularly "soft" diagnostic requirement, since some women have cystic ovaries but no other symptoms of PCOS, while others clearly are symptomatic of PCOS yet do not have cystic ovaries.  However, polycystic ovaries are a possible marker, so many providers still look for them, just not as "the" defining symptom of the syndrome.

The Rotterdam criteria is controversial because only 2 of the 3 criteria are needed for diagnosis, and "irregular" as well as "chronic" anovulation is considered.  This opens up official diagnostic recognition to more borderline cases, such as:
...women with hyperandrogenism and polycystic ovaries but normal ovulatory function, and women with ovulatory dysfunction and polycystic ovaries but no clinical or biochemical evidence of hyperandrogenism  (Azziz 2004, see references below).
In other words, it significantly widens the scope of who could be considered to have PCOS, while other criteria defines it more narrowly.

At this point, authorities are still debating the "best" criteria and who should and should not be considered to have PCOS.  Diagnostic criteria are still evolving.

Testing for PCOS: An Overview

There is no simple test to measure conclusively whether or not someone has PCOS. Therefore, in order to try and diagnose PCOS, care providers usually:
  • do a medical history to elicit menstual and fertility history
  • do a physical exam to check for clinical evidence of symptoms
  • do blood work to check various hormone levels
  • do an ultrasound of the ovaries (not always done by every care provider)
PCOS tends to be a diagnosis of exclusion, meaning that other conditions that might cause similar symptoms must be ruled out before one can conclude that PCOS is present. Among others, these conditions might include:
Blood work in particular is helpful in ruling out these other conditions, since many present with similar symptoms to PCOS (hirsutism, mentrual irregularities, weight gain, etc.).

Getting Diagnosed: What Type of Care Provider?

A difficult question for many women is what type of provider to see when trying to decide whether or not they have PCOS. Unfortunately, there is no definitive answer to this question.

Women with PCOS have been diagnosed and treated by Family Doctors, GPs (General Practitioners), Internists, Midwives, OBs, Endocrinologists, and Reproductive Endocrinologists. Occasionally PCOS is caught by a Dermatologist or other specialist, but the patient is usually referred back to another specialty for further testing and treatment of non-skin symptoms.

Many women see their family doctor or GP (General Practitioner) for testing. The advantage of this is that the family doctor or GP tends to be less fat-phobic on average than specialists, and tend to listen better at appointments.  However, not every family doctor or GP has very deep or thorough knowledge about PCOS and its proper testing and treatment.

Midwives and OBs are often the main source of diagnosis because PCOS problems usually reach critical levels around menstrual, fertility, gynecologic, or obstetric issues.  Therefore, many midwives and OBs catch previously undiagnosed cases of PCOS when women come in for birth control advice, infertility care, maternity care, or with questions about skipped periods.

The advantage of midwives is that they are generally more size-friendly than doctors, have training in gynecological issues, listen better, and take more time with you in appointments.  However, not all are well-versed in such a specialized condition as PCOS.

Because of fertility issues, many women get their diagnosis of PCOS from OBs. And while many OBs are reasonably knowledgeable about PCOS, there's still a lot of misinformation about it even in the obstetric community.  Furthermore, there's a lot of fat-phobia in medical training and in obstetrics in particular; this means that some OBs have a hard time treating a woman of size with compassion and objectivity.

Because PCOS is a hormonal and metabolic issue at heart, endocrinologists should be the go-to specialty for diagnosis of PCOS. They tend to be more well-versed in PCOS than the average care provider (especially the Reproductive Endocrinologist sub-specialty), and they have an intimate knowledge of the pros and cons of various tests and treatments for PCOS. Unfortunately, endocrinologists have an extremely well-deserved reputation for fat-phobia, and that can make it hard for fat people to get good care from them.

So what do you do?

Making a Decision

When deciding which type of care provider to see about testing for PCOS, there are a couple of important questions to ask.  First, how important is it to you to avoid even the merest whiff of size bias; second, are you in a rush to have a child; and third, what do you know about the size-friendliness of various providers in your area?

If you can stand the possibility of size bias, an endocrinologist really is best place to start your diagnostic journey.  They are the ones with the specialized knowledge about PCOS, the ones who know which tests to order to rule out other possibilities, and they are more inclined to treat PCOS with insulin-sensitizing agents instead of just birth control pills, which may be important for long-term health.

On the other hand, if you already have a good relationship with an OB, that can be a decent place to start.  Just keep good track of the tests ordered so you can make sure the right tests are being used and the right follow-ups are being done.

If size-friendliness is really important to you and you don't know the weight-neutrality status of any local providers, the midwife or the family practice doctor may be a good place to start instead.  Of course, title alone does not guarantee size-friendliness, but generally speaking you'll probably encounter less fat-phobia on average in these two groups.

If fertility is an issue for you or you are wanting to get started on having a child ASAP, go straight to a Reproductive Endocrinologist. They are the specialists in PCOS and tend to get you into treatment (and hopefully, fertile enough for pregnancy) a lot sooner than the other specialties.

Of course, the best option is finding a size-friendly/weight-neutral provider, whatever their title.  Although it's certainly not comprehensive for all locations, remember the Fat-Friendly Health Professionals List, which has peer-to-peer recommendations for size-friendly providers in the USA, and this similar list for Australia.

Preparing for an Diagnostic Appointment

A little prep work can go a long way towards making your diagnostic appointment faster and easier.

First, write down a list of your symptoms so you don't forget to mention anything.  Include both obvious PCOS symptoms and those that may not have anything to do with PCOS, since things like headaches and vision problems can sometimes be associated with conditions that can mimic PCOS (like a benign pituitary tumor). Have your list on a separate sheet of paper so you can just give it to the care provider, which will speed up the appointment considerably.

Also document your cycles for as long as you can ─ their length, regularity, and severity ─ and any concerns you have about them (length, heaviness, spotting, severe cramps, etc.)  Make an extra copy of this for the care provider.

If you have been doing fertility charting, bring those charts along to document whether/when you ovulate, how long you bleed, etc.  Some providers will take these seriously, some will not, but they are definitely worth doing because they are a very powerful tool for figuring out what's going on.  Be sure to keep copies for yourself for future reference. (See the website or the book, Taking Charge of Your Fertility, for more information on how to do fertility charting.)

A list of your current medications (if any) and dosages would also be important, since medications can sometimes affect lab results or have side effects that mimic PCOS symptoms.

It's a good idea to have a list of questions you want to ask.  You may not always have time to ask everything at the first appointment because care providers are usually on very strict schedules, but it can help you prioritize your questions so the most important ones get asked first, and help you remember your other questions for follow-up appointments.

Before your appointment, be sure to gather all your pertinent medical records together.  If you have records of previous labs or other tests, have these sent ahead of time to the new provider, or bring copies of them yourself. This can save a lot of time and duplication.  Some tests will need to be repeated, regardless, but it's useful to have a record of your results over time.  Many people create a simple spread sheet, documenting  pertinent tests over time, which can be useful in tracking any fluctuations in your condition.

The timing of your appointment may be important. If you want the care provider to order hormonal tests, the best time for such tests is shortly after your period. Avoid the time around mid-cycle or ovulation, as this can affect hormone levels.

Make your appointment for first thing in the morning, while you are in a fasting state. Certain tests need to have a 12-hour fast before doing the test.  If you arrive fasting, you can do all these tests on the same day and won't have to come back to do them another day.

If you are concerned about finding a size-friendly provider, call or write a letter ahead of time that asks if the provider can provide size-friendly care, and whether they are able to respect your decision to avoid focusing on weight loss.  Or bring an advocate with you, someone who can take notes and help you speak up for yourself if the provider starts focusing only on weight.  (Obviously, this person should be someone you would be comfortable with hearing a discussion of intimate topics like menstrual periods, birth control, etc., and someone who shares your beliefs about size acceptance.)

Really thinking through your appointment ahead of time and even rehearsing what you are going to say can be very helpful if you have are nervous about the appointment or have had bad experiences with care providers in the past.  Don't forget that YOU are the employer and the care provider is your employee; you always have the right to decline tests or treatment you do not want, or to terminate the relationship if needed.

The Diagnostic Appointment 

At your diagnostic appointment, your care provider should take a medical history, do a physical exam, and start the blood work needed for diagnosis.

More than one appointment may be needed to do do follow-up lab work. Afterwards, there should be an appointment to discuss the results of testing and to develop a treatment plan, if needed.

Medical History

The first thing a care provider should do when trying to diagnose PCOS is to take a medical history  This exam should look something like this:
A health care professional...will ask questions about your menstrual history, including how old you were when you started your period, how long your cycles are, how much time passes between cycles, and how much you bleed in a cycle. Your health care provider will also ask about your reproductive history, including any pregnancies, miscarriages, or abortions you have had, and birth control methods you are using or have used in the past. He or she will also ask about menstrual irregularities in other members of your family.
In addition, the woman should be asked about the presence of other symptoms, like hirsutism, acne, scalp hair loss, sebaceous cysts, or nipple discharge.  Although sometimes neglected, a weight history should be taken as well, looking for episodes of unexplained weight gain, difficulty losing weight, etc.

Family medical history should also be asked about.  There is a strong genetic predisposition in some families towards PCOS, with frequent history of irregular menstrual cycles, hirsutism, diabetes, hypertension, or infertility among females, and premature balding and the metabolic syndrome among males.  A history of any of these in your family would increase the suspicion index for PCOS.

Finally, the care provider should review any medications you have been on.  Although rare, some medications can cause PCOS-like symptoms to occur (for example, chronic use of corticosteroids, or anti-seizure medications like Depakote).  In addition, certain medications (like birth control pills) can alter lab results on certain tests (like SHBG levels).

Physical Exam

Next, a physical exam should be done.  The care provider will look for hirsutism (excess facial or body hair, especially along the midline of your body), acanthosis nigricans (dark, velvety patches of skin on the thighs, armpits, or back of the neck), skin tags, central obesity, etc. Be sure to tell your care provider about any symptoms you have, including thinning hair etc., so they are sure to take it into account.

Height, weight, and blood pressure will be checked. This is one occasion when it is appropriate for a woman to be weighed, if only to document "obesity" as a possible symptom ─ but preferably in a weight-neutral and non-judgmental manner.  Blood pressure should be checked using an appropriately-sized cuff (a too-small cuff will falsely elevate blood pressure).

A pelvic exam is also common, with care providers checking to see if your ovaries seem enlarged or swollen. They will also check to see if your genitalia look normal (an unusual appearance can indicate adrenal hyperplasia) and whether there are any pelvic masses.

Some doctors order an ultrasound to check for the presence of ovarian cysts. Because of hormonal imbalances, women with PCOS often have difficulty finishing ovulation. This half-finished ovulation causes many small cysts all over the ovaries, giving it a characteristic "string of pearls" appearance, as in the picture at the top of this post.  One diagnostic criteria for polycystic ovaries is 12 or more cysts of 2-9 mm size (but some practices have different guidelines).

Remember, even if the ovaries do appear normal, the absence of ovarian cysts does not mean that you don’t have PCOS. Not everyone with PCOS has ovarian cysts.


Multiple blood tests are usually run.  Lab work may include some or all of the following:
  • Follicle Stimulating Hormone (FSH)
  • Luteinizing Hormone (LH)
  • Total or Free testosterone
  • Other androgenic hormones like Androstenedione
  • DHEA-S (dehydroepiandrosterone sulfate)
  • Sex Hormone Binding Globulin (SHBG)
  • Cortisol (and/or other adrenal hormones)
  • Prolactin
  • TSH (Thyroid Stimulating Hormone)
  • Free T3 and free T4 levels
  • Thyroid antibody tests
  • Anti-Mullerian Hormone (AMH)
  • 17-hydroxyprogesterone (17OH-progesterone)
In addition, most doctors will order labs for standard measures of health, like cholesterol, triglycerides, blood sugar, etc. Some will do these in conjunction with PCOS bloodwork; some will wait and only do these after PCOS has been confirmed.

Some providers add liver function tests to be sure you are not experiencing Non-Alcoholic Fatty Liver Disease (NAFLD).  Others may also check levels of certain nutrients, like Vitamin D or iron, because these are often abnormal in women with PCOS.

Be aware that certain tests (like LH and FSH) need to be taken on certain days of your cycle in order to be interpreted correctly.  Unfortunately, not all doctors are aware of this, and may test on inappropriate days.  If you have been told you do not have PCOS but were tested without regard to day of your cycle, these tests should be repeated before ruling out PCOS.

Interpreting Results

Results on these tests can be confusing and it's very important that you get help interpreting them.  Remember to ask for exact results, not just whether your levels are "normal" or "abnormal," because borderline results may be meaningful in some contexts.

It's best to ask for a copy of all lab results; this is your information and you have every right to it.  That way you can take those results to another provider if needed, and you can also track your results over time.

The following are a few test results that seem common in women with PCOS, according to various resources online.  However, tests results are always subject to interpretation and our understanding of these things changes over time, so be sure to discuss your results with a healthcare professional.
  • A high testosterone level is common with PCOS but is not an absolute requirement for it. Very high levels may indicate an adrenal tumor instead
  • The DHEA-S level is often mildly elevated in PCOS, but this could also indicate an adrenal issue instead of PCOS (or in addition to it)
  • Androstenedione is often somewhat elevated
  • Sex Hormone Binding Globulin (SHBG) is usually low in PCOS, and seems to be associated with insulin resistance and/or hypothyroidism
  • A high prolactin level probably indicates hyperprolactinemia; some women with PCOS have mildly elevated prolactin levels, but very high levels are usually due to hyperprolactinemia
  • FSH levels are usually low to normal, but LH levels are often high.  A level of 2:1 or more in the LH:FSH ratio is usually considered diagnostic for PCOS
  • Lipid profiles are often abnormal; a common pattern is borderline to high LDL, low HDL, and high triglycerides
  • TSH is often borderline high but not quite high enough for diagnosis under the criteria some doctors use. However, some sources believe that any TSH over 2 or so should be treated

Blood Sugar and Insulin Testing 

Blood sugar tests are a standard part of testing because of the high rate of diabetes associated with PCOS. However, there are several ways to test this.

Some providers use fasting glucose only, but some resources feel strongly that this misses some cases of diabetes. They think PCOS women should be tested using a 2-hour Oral Glucose Tolerance Test (OGTT) instead. However, many women with PCOS have a tendency towards reactive hypoglycemia (unstable blood sugar due to strong insulin surges) and find the OGTT makes them feel quite ill. Therefore which test should be used is a judgment call.

Checking insulin levels is controversial.  Just about everyone agrees that insulin resistance is a major issue in PCOS, but how best to measure it is debated.  The gold standard test is hyperinsulinemic/euglycemic clamp testing, but this is usually too cumbersome and expensive for anything but research studies.

Some doctors test fasting insulin levels, because this is an easy lab draw.  Anything over 20 μU/mL is considered abnormal, but critics point out that the "normal" range for this is quite wide, and contend that levels much lower than 20 show insulin issues.  Some prefer to use a fasting glucose/insulin ratio instead, looking for a ratio of less than 4.5, but critics point out that this ratio has not been validated using clamp techniques.

One technique that has been validated by clamp techniques is Homeostatic Model Assessment (HOMA) testing, which takes fasting glucose and fasting insulin and divides them by a constant. However, this (like all of the fasting tests) is criticized as missing many cases of insulin resistance, because many PCOS women have relatively normal levels while fasting but abnormal insulin and glucose levels in response to food intake. Therefore, many doctors prefer to order a 2-hour post-prandial insulin test or OGTT, where your insulin response is tested after eating food or the standardized glucose liquid.

Here is what one provider wrote about testing insulin levels.  Other providers may find these criteria too liberal:
Fasting insulin is often elevated in PCOS. Some doctors don't order this test because the normal range (0-20) is so wide. However, we find that results greater than 9 indicate insulin resistance...Some doctors may also order a 2-hour post-prandial insulin test, along with a 2-hour post-prandial glucose test. For the post-prandial insulin, results over 25 or 30 may indicate insulin resistance.
On the other hand, some doctors don't test insulin levels at all, either because they believe that insulin levels are not as relevant as hormonal levels, or because they don't believe that insulin testing is that meaningful.  They may go by clinical signs of insulin resistance instead (acanthosis nigricans, skin tags, abdominal obesity, etc.).

Other Tests

As previously noted, doctors used to do a vaginal ultrasound to see if the ovaries had a "string of pearls" look, studded with cysts. Now however, many providers do not consider cystic ovaries to be a very good measure of PCOS.  Some will test for it, some will not.

Providers are becoming more aware that sleep apnea is fairly common among women with PCOS, so some have added sleep testing to the list of additional tests ordered after someone is diagnosed with PCOS.  Some research suggests that testing for sleep apnea is underutilized in women with PCOS and should be expanded, especially for those with more severe insulin resistance/glucose intolerance.

If your preliminary labs or symptoms suggest that you may have non-classical congenital adrenal hyperplasia instead of PCOS, your doctor may want to order additional labs, including an ACTH (adrenocorticotropic hormone) stimulation test.

If your providers suspect Cushing's syndrome, they may order a 24-hour urine test for free cortisol, or suggest an overnight dexamethasone suppression test.

If you are someone who has no or very few menstrual cycles (less than 6 per year), care providers may also recommend an endometrial biopsy.  Because of a hormonal imbalance, many women with PCOS do not completely slough off the endometrial lining that has built up during a cycle. Over time, this endometrial lining can build up ("endometrial hyperplasia") and cause problems.

The risk for endometrial cancer is signficantly higher in women who do not have at least six periods per year, so if you have missed a lot of periods, it's very important that you get checked periodically for this.

Changes in Diagnosis Protocols Over The Years

The protocol for diagnosing PCOS has changed over the years and remains controversial.

As noted, some doctors insist on an ultrasound of the ovaries, while others consider that outdated or unnecessary. Some demand biochemical evidence of abnormal hormone levels (i.e., abnormalities on lab tests), while others are content to rely on physical manifestations alone.  Some run elaborate blood tests to rule out a wide variety of other possible conditions, while others are willing to move to a trial of meds and/or lifestyle more quickly based on symptoms alone.  Much depends on the care provider you see.

Doctors used to look for a specific imbalance of hormones ─ specifically a ratio of luteinizing hormone (LH) to follicle-stimulating hormone (FSH) of more than 3:1. Some doctors still look for elevated LH levels (although not necessarily a 3:1 ratio anymore), while others do not test these levels at all.

Some doctors believe that insulin resistance (either through an insulin receptor defect or through post-receptor signaling) is the base cause of PCOS, while others believe that while common, not every woman with PCOS actually demonstrates insulin resistance. So while some doctors place a strong emphasis on insulin levels in PCOS, others don't.

A recent addition to testing protocols seems to be "anti-mullerian" hormone levels:
Anti Mullerian Hormone (AMH) or Mullerian Inhibiting Substance is a special protein released by cells that are involved with the growth of an egg follicle each month. AMH levels correlate with the number of antral follicles found on the ovary each month; the higher the antral follicle count, the higher the AMH levels. Because women with PCOS typically have high numbers of antral follicles, high AMH levels are often seen as well.
Apparently some doctors are considering AMH a classic marker for the disease now and want this tested; others do not routinely use it.

Obviously, diagnosing PCOS is an evolving science.  Tests that were routine 10-15 years ago are not always considered necessary now, and new tests have emerged that didn't exist previously.  This is why it's important to keep up on the latest testing protocols and the pros and cons of each test.


It should be apparent that diagnosing PCOS is not an easy task.  Different protocols for testing and diagnosis exist, standards change over time, and the highly variable nature of PCOS makes diagnosis less than clear at times. A great deal is left up to the individual judgment of the care provider.

Therefore, it is not uncommon for women to hear different results from different doctors, with one saying she doesn't have PCOS, and another saying she does. Some women with PCOS go for years before they are diagnosed, even with obvious symptoms.  Subtle cases may take even longer.

Persistence is very important in trying to figure out whether or not you have PCOS.  Don't give up easily, and be prepared to see more than one care provider when trying to find answers.  Most women go through multiple care providers and tests before they are able to definitively determine that they do or don't have PCOS.

Sometimes a person's results may be "borderline normal" and that can still be significant, especially if there is a cluster of similarly "borderline" results on other tests.  As Dr. Samuel Thatcher says in PolyCystic Ovarian Syndrome: The Hidden Epidemic:
Virtually all patients with PCOS will have at least some subtle laboratory abnormalities.  The reported results may be on the upper limits of the normal range, showing only a tendency rather than a discrete abnormality.  Often a pattern will emerge only after considering a group of tests together, rather than as a result of a single test value.  
Furthermore, don't accept a care provider's pronouncement about your PCOS status without looking at your own lab results, comparing them to what is considered "normal," and researching the results online.  Because knowledge about PCOS is evolving, not all providers are "up" on the best ways to test it or changes in diagnostic protocols.  Furthermore, anti-fat bias can lead some to dismiss or explain away results that clearly merit a second look.  It's important to double-check their work.

Remember that diagnosis can be a judgment call at times, so you should plan to be actively involved in the process.  Don't be a passive recipient of care; get copies of all of your lab results, create a spread sheet to track them over time, research PCOS online from a variety of sources, ask lots of questions, and don't be afraid to switch care providers if you don't feel your questions and concerns are being addressed adequately.

Don't forget that there is a spectrum of PCOS severity. Even if you do not officially "qualify" as having PCOS, it may still be something you should learn about because some cases are too "mild" for official diagnosis but may still benefit from treatment or careful monitoring of health indices.

Finally, if you don't have PCOS, don't be afraid to push for further testing to explain your symptoms.  PCOS is not the only thing that can be wrong in people of size, and treatment for rarer conditions like Cushing's Syndrome or adrenal tumors can make a tremendous difference in your health. Explore all the possibilities.

Diagnosing PCOS is not an exact science, but finding answers can be critical for your long-term health status.


Finding Size-Friendly Care Providers
General Resources for PCOS Support
General Information about PCOS
Book Resources
  • PolyCystic Ovarian Syndrome: The Hidden Epidemic - Samuel S. Thatcher MD, PhD
  • Androgen Disorders in Women: The Most Neglected Hormone Problem - Theresa Cheung
  • Taking Charge of Your Fertility - Toni Weschler; 
Information about PCOS Testing and Diagnosis
Interpreting Lab Results - What is Normal?
Specific PCOS Diagnosis Studies

Reprod Biomed Online. 2004 Jun;8(6):644-8. PCOS: a diagnostic challenge. Azziz R. PMID: 15169578
"Useful research and diagnostic criteria for PCOS arose from a conference in 1990, whereby PCOS could be defined by: (i) clinical and/or biochemical hyperandrogenism, (ii) chronic anovulation, and (iii) exclusion of related disorders. The presence of "polycystic ovaries" was not included in this definition, which created significant concern since many women with PCOS have polycystic ovaries on ultrasound, and conversely women with this ovarian morphology have a higher prevalence of androgen excess and insulin resistance. More recently, at an expert meeting in 2003 in Rotterdam, it was recommended that PCOS be defined when at least two of the following three features were present, after exclusion of other aetiologies: (i) oligo- or anovulation, (ii) clinical and/or biochemical hyperandrogenism, or (iii) polycystic ovaries. These newer criteria effectively create additional phenotypes of PCOS (e.g. women with hyperandrogenism and polycystic ovaries but normal ovulatory function, and women with ovulatory dysfunction and polycystic ovaries but no clinical or biochemical evidence of hyperandrogenism). It remains to be demonstrated whether these phenotypes actually represent patients with PCOS. Nonetheless, the trend towards the use of uniform diagnostic criteria in studies of PCOS will increase the comparability and potentially the value of published research."
Fertil Steril. 2009 Feb;91(2):456-88. Epub 2008 Oct 23. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, Janssen OE, Legro RS, Norman RJ, Taylor AE, Witchel SF; Task Force on the Phenotype of the Polycystic Ovary Syndrome of The Androgen Excess and PCOS Society.   PMID: 18950759
"Based on the available data, it is the view of the AE-PCOS Society Task Force that PCOS should be defined by the presence of hyperandrogenism (clinical and/or biochemical), ovarian dysfunction (oligo-anovulation and/or polycystic ovaries), and the exclusion of related disorders. However, a minority considered the possibility that there may be forms of PCOS without overt evidence of hyperandrogenism, but recognized that more data are required before validating this supposition. Finally, the Task Force recognized and fully expects that the definition of this syndrome will evolve over time to incorporate new research findings."
Can Fam Physician. 2007 Jun;53(6):1042-7, 1041. Polycystic ovary syndrome: validated questionnaire for use in diagnosis. Pedersen SD, Brar S, Faris P, Corenblum B.  PMID: 17872783  Free full text at:
"Development of a questionnaire to help diagnose PCOS. "A history of infrequent menses, hirsutism, obesity, and acne were strongly predictive of a diagnosis of PCOS, whereas a history of failed pregnancy attempts was not useful. A history of nipple discharge outside of pregnancy strongly predicted no diagnosis of PCOS. We constructed a 4-item questionnaire for use in diagnosis of PCOS; the questionnaire yielded a sensitivity of 85% and a specificity of 85% on multivariate logistic regression and a sensitivity of 77% and a specificity of 94% using the 4-item questionnaire."
Hum Reprod.  2004 Jan;19(1):41-7. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group.  PMID: 14688154
"Since the 1990 NIH-sponsored conference on polycystic ovary syndrome (PCOS), it has become appreciated that the syndrome encompasses a broader spectrum of signs and symptoms of ovarian dysfunction than those defined by the original diagnostic criteria. The 2003 Rotterdam consensus workshop concluded that PCOS is a syndrome of ovarian dysfunction along with the cardinal features hyperandrogenism and polycystic ovary (PCO) morphology. PCOS remains a syndrome and, as such, no single diagnostic criterion (such as hyperandrogenism or PCO) is sufficient for clinical diagnosis. Its clinical manifestations may include: menstrual irregularities, signs of androgen excess, and obesity. Insulin resistance and elevated serum LH levels are also common features in PCOS. PCOS is associated with an increased risk of type 2 diabetes and cardiovascular events."
Clin Endocrinol (Oxf). 2005 Mar;62(3):289-95. Polycystic ovarian syndrome: marked differences between endocrinologists and gynaecologistsin diagnosis and management. Cussons AJ et al.  PMID: 15730409
"...A mailed questionnaire containing a hypothetical patient's case history with varying presentations--oligomenorrhoea, hirsutism, infertility and obesity--was sent to Australian clinical endocrinologists and gynaecologists in teaching hospitals and private practice...Endocrinologists regarded androgenization (81%) and menstrual irregularity (70%) as essential diagnostic criteria, whereas gynaecologists required polycystic ovaries (61%), androgenization (59%), menstrual irregularity (47%) and an elevated LH/FSH ratio (47%) (all P-values less than 0.001). In investigation, gynaecologists were more likely to request ovarian ultrasound (91%vs. 44%, P less than 0.001) and endocrinologists more likely to measure adrenal androgens (80% vs. 58%, P  less than 0.001) and lipids (67%vs. 34%, P less than 0.001). Gynaecologists were less likely to assess glucose homeostasis but more likely to use a glucose tolerance test to do so. Diet and exercise were chosen by most respondents as first-line treatment for all presentations. However, endocrinologists were more likely to use insulin sensitizers, particularly metformin, for these indications. In particular, for infertility, endocrinologists favoured metformin treatment whereas gynaecologists recommended clomiphene. CONCLUSIONS: There is a lack of consensus between endocrinologists and gynaecologists in the definition, diagnosis and treatment of PCOS. As a consequence, women may receive a different diagnosis or treatment depending on the type of specialist consulted.
Clin Endocrinol (Oxf). 2008 Jul;69(1):52-60. The evaluation of metabolic parameters and insulin sensitivity for a more robust diagnosis of thepolycystic ovary syndrome. Amato MC, et al.  PMID: 18034780
PCOS diagnostic criteria [National Institute of Health (NIH), Rotterdam Consensus (ROT), Androgen Excess Society (AES)] are unanimous recognized. We aimed to assess in women with suspected PCOS whether the application of the three diagnostic criteria differently characterizes the metabolic profile and insulin sensitivity. Two hundred and four women with suspected PCOS in comparison to a group of normal, age-matched Sicilian women (N = 34) without signs of metabolic syndrome...The prevalence of PCOS was 51% according to NIH, 83% to ROT and 70.6% to AES, and only 100 patients were qualified simultaneously under these three criteria.