Subjective
Date of visit
Reason for visit (initial evaluation for suspected PCOS, follow-up for diagnosed PCOS)
History of present illness:
Menstrual irregularities (oligomenorrhea – infrequent periods, amenorrhea – absent periods)
Signs of hyperandrogenism (excess male hormones):
Acne
Hirsutism (excessive growth of coarse hair in a male pattern)
Male pattern baldness
Weight concerns (may or may not be present)
Infertility (difficulty getting pregnant)
Past medical history (relevant conditions, previous treatments for PCOS symptoms)
Family history (presence of PCOS in first-degree relatives)
Medications (current medications)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure) – usually normal
Physical exam:
General (assessing for body mass index – BMI)
Skin examination (looking for acne, hirsutism)
Pelvic exam (performed with patient’s consent) – may reveal enlarged ovaries with multiple small cysts
Blood pressure measurement (important due to increased cardiovascular risk with PCOS)
Assessment
Suspected PCOS based on Rotterdam criteria (presence of at least two of the following three findings: oligo/anovulation, clinical and/or biochemical hyperandrogenism, polycystic ovaries on ultrasound)
Consideration of alternative diagnoses (other causes of menstrual irregularities or hyperandrogenism)
Plan
Diagnostic workup (may include some of the following to confirm PCOS or assess complications):
Pelvic ultrasound (to visualize ovaries and cysts)
Blood tests:
Hormone levels (FSH, LH, testosterone, androgens)
Fasting blood sugar and lipid profile (assessing for insulin resistance and cardiovascular risk)
Treatment (tailored to individual needs and may include):
Lifestyle modifications:
Weight loss (if overweight or obese)
Exercise
Healthy diet
Hormonal therapy (to regulate menstrual cycles and ovulation):
Birth control pills
Anti-androgen medications (spironolactone)
Medications to address insulin resistance (metformin)
Fertility medications or ovulation induction (if desired)
Education
Explain PCOS, its causes, and the long-term health implications.
Discuss the importance of weight management, healthy lifestyle choices, and regular follow-up.
Review treatment options and potential side effects.
Provide resources for managing PCOS symptoms and emotional well-being.
Follow-up
Schedule for follow-up appointments:
Monitor response to treatment (menstrual regularity, symptoms)
Repeat blood tests periodically
Address any new or worsening symptoms
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of PCOS