SAN FRANCISCO – Dermatologists are often on the frontline when it comes to diagnosing polycystic ovary syndrome (PCOS), which is one reason they should be up to date and aware of the changing diagnostic criteria for the condition, according to Kanade Shinkai, MD.
About one-quarter of patients who are diagnosed with PCOS are seen first by a dermatologist. That’s because skin conditions may be more concerning than reproductive issues in young women.
“Sometimes, people don’t see [irregular menstruation] as a problem,” explained Dr. Shinkai of the department of dermatology at the University of California, San Francisco. “Maybe they’re young, or they’re not trying to get pregnant. But if their hair is falling out, they see that as a problem, or if they have bad acne, or they’re becoming hirsute, they see that as a problem. So, they present to a dermatologist.”
Early recognition of PCOS is important, because many women with the condition go on to develop diabetes, impaired glucose intolerance, hyperlipidemia, hypertension, fertility problems, and obesity.
Dr. Kanade Shinkai
It used to be that physicians expected patients with PCOS to have menstrual irregularities, biochemical or clinical evidence of hyperandrogenism, and evidence of polycystic ovaries on ultrasound. But just two of the three are now considered enough to warrant a diagnosis.
“Our original view of the classic patient has gone away, and it’s really a heterogeneous phenotype,” Dr. Shinkai said. “Originally, it was all three [criteria], and the patient was obese, and they all had diabetes. Now, we know that’s not true. Every woman who has PCOS has her own version of PCOS.”
Dr. Shinkai’s team conducted a study of clinical markers associated with PCOS and found that some of the classic signs of PCOS may be unreliable.
“Alopecia turns out not to be a very reliable marker,” she explained. “That’s paradigm shifting, I think, because often if patients present with hair loss in a hormonal pattern, they get worked up for PCOS, and it turns out that workup is not always fruitful.” Acne can also be misleading, given its frequency in the general population.
More reliable signs include hirsutism and acanthosis nigricans; 70%-80% of women with hirsutism have PCOS, and 53% of patients with PCOS have hirsutism, most commonly on the trunk. Acanthosis nigricans occurs in 37% of PCOS patients.
“Those are the best specific signs for PCOS,” said Dr. Shinkai. “If we see those, we should probably work the patient up.”
In preparation, the patient should be off of birth control treatment for at least 4 weeks, because hormonal treatment can interfere with test results, Dr Shinkai noted.
She also recommended a transvaginal ultrasound and a free-testosterone test. Consensus statements recommend testing of 17-hydroxyprogesterone, but Dr. Shinkai said she isn’t so sure. “That’s only going to capture about 3% of your patients with cutaneous hyperandrogenism, so it’s pretty low yield,” she said.
For treatment of cutaneous symptoms of PCOS, it’s important for the patient to understand that treatment courses will last at least 6 months. “It’s not a quick fix,” said Dr. Shinkai. Oral contraceptives are a mainstay, and are often sufficient for mild hirsutism. But moderate or severe cases call for high doses of spironolactone (150-200 mg/day). She said she usually combines spironolactone with oral contraceptives, because the drug can lead to menstrual irregularities, which birth control pills can relieve.
Dr. Shinkai reported having no relevant financial disclosures.