• Serum testosterone (T)
• Serum biologically free testosterone (the active fraction of testosterone)
• Serum luteinizing hormone and follicle stimulating hormone (Often there is an increased ratio of LH/FSH)
• Serum dehydroepiandrosterone sulfate (DHEAS) (An androgen that is a precursor to testosterone; this is useful in evaluation of the significance of the role of the adrenal cortex in the syndrome)
• Serum 17-hydroxyprogesterone as an initial screen for NCCAH; fasting plasma insulin and a blood glucose level
• Serum prolactin

It has been reported that about 10 to 20 percent of PCOS patients have high levels of prolactin. This should be recognized early, since management of women with high prolactin levels may differ from that of other women with the syndrome. Once PCOS is considered, lipid studies including total cholesterol and its sub-fractions (HDL, LDL), as well as serum triglycerides should be obtained. A number of authorities also recommend that patients take a two-hour glucose tolerance test to assess the extent of insulin dysregulation. An ultrasound of the pelvis is also useful to find changes relating to treatment as well as potential complications, such as uterine changes and the development of benign ovarian growths (usually dermoid cysts, with an incidence ranging from 5 to 15 percent).

Potential Complications of PCOS

Menstrual dysfunction and associated infertility, as well as skin and scalp manifestations are often what brings patients to their physicians. However, it's the potential of metabolic and cardiovascular complications that pose the greatest risk to those with PCOS. There's a wealth of data indicating that hyperinsulinism and the associated insulin resistance (often accompanied by an increase in the waist-to-hip ratio) not only allows for androgen excess, but also may lead to a higher incidence of type 2 diabetes mellitus and the possibility of cardiovascular events later in life. Additionally, a small but convincing series of reports suggest that hypertension and premature calcifications in the carotid arteries may already be present at a relatively early stage in life (30s and 40s).

Obesity and PCOS
There is no question that there is a significant incidence of abnormal glucose tolerance in 40 percent of obese patients with PCOS and 10 percent in normal-weight women with the syndrome. Some of these patients may already be diabetic (approximately 10 percent of the obese women with PCOS). With time, the incidence increases. The associated risk factors such as lipid abnormalities, high triglyceride levels, and increased clotting factors may predispose these patients to coronary heart disease. Studies assessing the long-term complications of these symptoms are currently in progress. Whether newer treatments for PCOS and lifestyle modifications may mitigate these risks remains to be seen.

There are data also indicating an increase in uterine hyperplasia (an increased number of normal uterine cells) and neoplasms (cancerous cells) in women with PCOS. Data for an increased breast cancer risk is as yet unproven. Another well recognized complication of PCOS is the relatively high miscarriage rate, possibly through an adverse effect of luteinizing hormone on maturation of the oocyte (egg). The long-term effect of ovulation induction treatments on the development of ovarian carcinoma will require years of more prolonged study.

Treatment of PCOS

Medical treatment of PCOS depends on a number of factors, mostly related to the patient's main complaint(s) of

• erratic menstrual cycles and/or infertility
• concern over the skin manifestations of the syndrome (acne, hirsutism, and alopecia)

Weight reduction employing a low-carbohydrate diet and changes in lifestyle, including exercise, are essential components of all treatments. Weight reduction alone (five to seven percent of the total body weight) is associated with reduced androgen levels, reduced hyperinsulinism, and frequently, improvement in menstrual cycles and skin appearance.

Many patients will require medical therapy to control symptoms. Often a low dose of combined oral contraceptive is effective. It is ideal to avoid an oral contraceptive pill containing androgenic progesterone, such as levonorgestrel, as this may exacerbate some symptoms. For this reason, new third-generation contraceptives, which have a lesser male hormone effect of the progestin in the formulation, are preferred. Other drugs used to manage the symptoms of PCOS include: anti-androgens such as spironolactone and cyproterone acetate (which is not FDA approved in the USA), glucocorticoids, and drugs that improve insulin sensitivity, such as metformin.

How Do You Treat the Skin Manifestations of this Syndrome?

In women who are plagued by cystic acne, the first line of treatment appears to be a combination of oral contraceptives and spironolactone. The use of contraceptives alone is often effective in mild to moderate acne cases, but combined treatment of these two agents is useful and effective in the vast majority of patients.