Why Make the Diagnosis of PCOS?
By Samuel Thatcher, MD, Ph.D.
Q. I have not been diagnosed with PCOS and do not have some of the more definitive symptoms. However, I have struggled with acne (present on the paternal side of the family) and increased periareolar hair growth. The hair growth was alarming to me and happened over a three year period. I am not overweight for my height, and I have regular monthly menstrual periods. I have never used birth control pills. I asked my OB-GYN if I could have PCOS. She informed me that since I was having regular periods she doubted that I had PCOS. She further explained that in my case periareolar terminal hair growth was familial. She checked my testosterone and DHEA level (both results were WNL). I asked my mother if she had hair growth on her chest and she does not. Should I have a LH:FSH ratio done? Is a pelvic ultrasound indicated? If I am having regular menstrual periods, does this mean that I am ovulating monthly?
A. The strictest diagnosis of PCOS requires both hyperandrogenism, either by clinical signs or hormonal determination and anovulation, which usually translates into irregular cycles. The principle skin signs of hyperandrogenism are excessive hair growth (hirsutism) and acne. Adult acne is a reasonable reliable indicator of hyperandrogenism; hair around the nipples (periareolar) is not unless accompanied by hair in the middle of the chest and lower abdomen. It seems that in your case there may be mild "clinical" hyperandrogenism without laboratory confirmation. This occurs in at least 50% of cases. If so, it sounds like it came from your dad's side of the family. I would not be at all surprised that the ovaries were also at least mildly polycystic on ultrasound scan.
Oral contraceptives may help the acne by reducing luteinizing hormone and decreasing androgens. Even though your laboratory values are normal, there may be an increased sensitivity of the skin to androgens, and reduction may be of benefit.
It is possible that you may not be ovulating despite regular cycles. This is most important if fertility is an issue.
Whether you have PCOS is in some ways unimportant. The reason to make the diagnosis is most importantly a way to explain of a clustering of signs and symptoms and identify health risks. We direct therapy not at PCOS, but at its signs and symptoms. Of course the diagnosis of PCOS also may identify with a long-term outlook toward possible metabolic consequences.
The fact that you have regular cycles and do not have a weight problem probably removes many of the risks associated with PCOS. It may be of academic interest to determine the LH/FSH ratio, but it probably would not affect anything written. As a part of good health maintenance it may be prudent to have a lipid profile, fasting glucose and maybe insulin level. If there is a strong family history of type 2 diabetes even a glucose tolerance test with insulin levels. This may identify the risk of diabetes and possibly heart disease and promote life-style changes, even medical intervention that might allow a longer and healthier life.