Which usg for pcos?

While ultrasound alone isn't enough to confirm PCOS, results are an important part of the diagnostic puzzle. A healthcare provider will also take your medical history, a physical examination, and blood test findings into account.

This article discusses transvaginal ultrasound for PCOS. It explains how this type of imaging is performed and what your healthcare provider is looking for.

A transvaginal ultrasound can be performed in a healthcare provider's office. For the procedure, you may be asked to drink up to 42 ounces of fluid before your test to fill your bladder, making it easier to see your ovaries.

A lubricated ultrasound probe is placed inside the vagina, which transmits an image of the internal organs onto a screen. An ultrasound technician then measures and takes pictures of your ovaries and shares them with your healthcare provider.

PCOS is is essentially an imbalance of sex hormones. It is characterized by high levels of androgens, male hormones like testosterone.

Since these hormones are involved in the regulation of bodily processes ranging from reproduction to metabolism, the condition can lead to a wide variety of signs and symptoms of PCOS.

The first step when evaluating your symptoms, exam and laboratory findings is to exclude other disorders which might cause these findings.

These conditions (which may appear similar to PCOS but are different) include:

The Rotterdam Criteria, the current diagnostic criteria for PCOS, requires two of the following (with the exclusion of other causes):

It is possible to have cystic ovaries without symptoms of hyperandrogenism. It is also possible to be diagnosed with PCOS without having "classically cystic" ovaries.

A transvaginal ultrasound is used to examine internal structures in assessing for PCOS. The sonographer will examine your uterus, cervix, and uterus. The number of follicles on your ovary will be counted to yield what is known as an antral follicle count (AFC).

Antral follicles are resting follicles that are found in the ovary at the beginning of each menstrual cycle. They are approximately 2 to 9 mm in size, which is less than half an inch.

A high antral follicle count indicates a large number of eggs that remained in the ovary instead of being released. This may indicate PCOS.​

Both cysts and follicles are more common in people with PCOS than those without the condition. Many confuse cysts with follicles.

A name change for PCOS has been proposed to clear up confusion and properly educate health professionals and consumers.

People with PCOS tend to produce follicles, which are small collections of fluid in the ovary and are the result, not the cause of, the imbalance of sex hormones. Each month, the ovary produces follicles that mature and are released into the fallopian tube.

Because of the hormone imbalance in PCOS, these follicles don't mature and don't get released by the ovaries, which often leads to infertility.

PCOS can be diagnosed by a gynecologist, endocrinologist, or reproductive endocrinologist.—medical specialists with additional training in evaluating and treating hormonal disorders.

If you are uncertain about your diagnosis of PCOS (or lack of one), it can’t hurt to get a second opinion. Check out the American Society for Reproductive Medicine or the Androgen Excess and PCOS Society for a local recommendation.

The diagnosis of PCOS can be time-consuming and frustrating. Other conditions which can cause similar symptoms need to be ruled out first, and then symptoms such as menstrual abnormalities and evidence of androgen excess are evaluated.

Transvaginal ultrasound can provide important information about follicles (as opposed to cysts which has led to much confusion over the years.) The measurement of the anti-Mullerian hormone may provide a substitute for ultrasound in some circumstances.

Once a diagnosis is made, the treatment options for PCOS can be reviewed in order to help you cope with the many annoying (and sometimes serious) consequences of the condition.

The health consequences of PCOS are far-ranging and include infertility, hypertension, hyperlipidemia, type 2 diabetes, coronary artery disease and cerebral vascular disease. Up to 70 percent of all PCOS patients are clinically obese, and women with PCOS are more frequently glucose intolerant or diabetic than their non-PCOS counterparts, as reported by The Journal of Clinical Endocrinology & Metabolism. They are also at greater risk for endometrial hyperplasia and carcinoma as well as breast and ovarian cancers.

Though there are many extra‐ovarian characteristics of PCOS, ovarian dysfunction is a central component, which is why accurately diagnosing PCOS should include a pelvic ultrasound for ovarian assessment.

Ultrasound is used to identify and document the presence of polycystic ovaries. Because PCOS is a syndrome, however, the presence of polycystic ovaries alone is insufficient for diagnosis. Therefore, pelvic imaging cannot definitively diagnose PCOS, but it does provide invaluable information during the diagnostic process.

Polycystic ovaries are commonly seen during routine ultrasounds. The Lancet Journal reports that 23 percent of women of reproductive age are likely to have polycystic ovaries. Only 5-10 percent of these women, however, will have classic symptoms of PCOS, such as infertility, amenorrhea, signs of hirsutism or obesity. Those with polycystic ovaries should not be considered to have PCOS until an additional workup is performed.

The American College of Obstetricians and Gynecologists acknowledges two criteria on the basis of which a polycystic ovary may be identified: ovarian volume and number of follicles. These criteria are based on a review of literature in RadioGraphics comparing women with PCOS with healthy control subjects. According to their consensus definition, "polycystic ovaries are present when: (a) one or both ovaries demonstrate 12 or more follicles measuring 2-9 mm in diameter, or (b) the ovarian volume exceeds 10 cm³. Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries."

It's important to note, however, that women with PCOS are frequently ovulatory. The presence of a dominant follicle (a follicle with diameters greater than 10 mm) or corpus luteum may increase the ovarian volume to more than 10 cm³. In these cases, the physician should perform additional scans during the patient's next menstrual cycle.

When imaging to assess for polycystic ovaries, transvaginal ultrasound is considered the gold standard due to the optimal visualization it provides of the internal structure of the ovary, particularly in obese patients. Compared with transabdominal ultrasound, it is more effective for detecting the appearance of polycystic ovaries in women with PCOS.

If transabdominal ultrasound is required — because the patient has never been sexually active or declines transvaginal examination — care should be taken that the bladder is adequately filled but not overfilled. According to RadioGraphics, an overfilled bladder can compress the ovary, "potentially leading to a greater deviation from the model of an ellipsoid used to calculate ovarian volume." The authors advise recording cine clips through the ovaries for greater accuracy in counting follicles.

With the addition of 3D ultrasound to the transvaginal routine, it is even easier to assess and image the detail needed for accurate diagnosis of PCOS. Individual follicles can be counted with certainty and complete ovarian volumes can be calculated by the software, minimizing the likelihood of an error in the PCOS ultrasound image.

The technology makes it easy to compare ovarian sizes, and a high-resolution cine sweep makes it possible to record the ovary in real time.

An internal transvaginal ultrasound allows a doctor to look much more closely at your womb and ovaries and the most common method for diagnosing PCOS. “Transvaginal” means “through the vagina”.

There are many associated morbidities with PCOS, including infertility, metabolic syndrome, obesity, impaired glucose tolerance, type 2 diabetes mellitus, cardiovascular risk, depression, obstructive sleep apnea, endometrial cancer, and nonalcoholic fatty liver disease/ nonalcoholic steatohepatitis.

The American Association of Clinical Endocrinologists, American College of Endocrinology, and Androgen Excess and PCOS Society have published best practices for evaluating and treating PCOS. They state that the diagnosis of PCOS is based on the presence of at least 2 of the following 3 criteria: chronic anovulation, hyperandrogenism (clinical or biological), and polycystic ovaries. They note that ultrasonography now allows diagnosis of PCOM in patients with at least 25 small follicles (2-9 mm) in the whole ovary, and ovarian size of 10 ml is the threshold between normal and increased ovary size.

PCOS is usually diagnosed based on the Rotterdam criteria if 2 of 3 criteria are present: (1) oligo- and/or anovulation, (2) hyperandrogenism (HA) (clinical and/or biochemical), and (3) polycystic ovary morphology (PCOM) on ultrasonography (either 12 or more follicles measuring 2-9 mm in diameter and/or an increased ovarian volume >10 cm3). Irregular menstruation  is defined as less than 21 days or more than 35 days or fewer than 8 cycles per year. Clinical HA includes hirsutism, acne, or alopecia. Biochemical HA typically refers to an elevated serum testosterone level.

Although a multiplicity of clinical presentations exists for polycystic ovary disease, in 1935, Stein and Leventhal reported the classic symptomatology in a group of women who had amenorrhea, infertility, hirsutism, and enlarged polycystic ovaries. The authors found that, after ovarian biopsy, the women began to menstruate regularly. As was discovered over time, women may have polycystic ovaries, yet their cases may not conform to all of the original criteria for this condition. Therefore, Stein-Leventhal syndrome became a subgroup of a more encompassing disease called polycystic ovary disease.

Evidence suggests that the underlying disorder of polycystic ovary disease is insulin resistance, with the elevated insulin levels stimulating excess ovarian androgen production. In such cases, there is a predispositon for type 2 diabetes mellitus and cardiovascular disease in later life. Metformin may be used in specific cases of polycystic ovary disease.

In adolescent girls, large, multicystic ovaries are a common finding. For adolescents in whom diagnosis of PCOS remains uncertain after clinical and laboratory evaluation, MRI may be considered as a diagnostic imaging modality.  Many adults with PCOS present with pathognomonic symptoms as adolescents, making  early diagnosis valuable because of the associated long-term metabolic and reproductive health sequalae.

(See the images of polycystic ovary disease below.)

As more information regarding the nature of the condition has come to light, other terms have been applied, including polycystic ovarian/ovaries syndrome and polyfollicular ovarian disease. In actuality, polycystic ovaries are not the primary cause of amenorrhea or hirsutism in this condition. Rather, they are simply one sign of an underlying endocrinologic disorder that ultimately results in anovulation.

Shah et al proposed that premenarcheal girls presenting with ovarian torsion without obvious ovarian pathology be screened for ultrasound and biochemical evidence of polycystic ovary syndrome. In a retrospective observational case series, the authors studied PCOS in 6 premenarcheal adolescents and 6 adults with unexplained ovarian torsion. The authors suggested that, in those with evidence of PCOS, treatment with oral contraceptives be considered, taking into account age and pubertal development, to decrease ovarian volume.

According to the Rotterdam consensus and Androgen Excess & PCOS Society, ultrasound criteria consist of the presence of 12 or more follicles within the ovary, with a diameter of 2-9 mm and/or ovarian volume 10 cm3 or greater.

Polycystic ovaries are most often diagnosed by means of laboratory studies. The initial screening tests may include determinations of the blood serum levels of thyroid-stimulating hormone (TSH), FSH, LH, and prolactin (PL). The ratio of the FSH level to the LH level is useful in the diagnosis. TSH or PL levels may be useful in identifying an etiology, such as hyperthyroidism or a prolactinoma. In some patients, testosterone and dihydroepiandrosterone sulfate (DHEAS) levels or a progesterone challenge is useful.

Typically, a radiologic evaluation for polycystic ovaries is reserved for patients who have equivocal laboratory findings. However, radiologists make a significant number of incidental diagnoses. Should the radiologist's assistance be requested in the diagnosis of polycystic ovary syndrome, the imaging method of choice is transabdominal and/or transvaginal ultrasonography. Magnetic resonance imaging (MRI) is useful as an adjunct; however, although MRI is more sensitive than ultrasonography, its findings are less specific. The benefits of cross-sectional imaging and functional neuroimaging have been studied.

In a case-control study, by Fondin et a,l of 110 adolescent girls (age range, 13-17 yr) who underwent pelvic MR imaging, the most accurate diagnostic criteria on MRI for PCOS were ovarian volume, follicles per ovary  measuring 9 mm or less, and peripheral distribution of follicles.

Assessment of anti-Mullerian hormone levels may offer promise as a method of dertermining the presence of PCOS.

Polycystic ovary syndrome is not a primary disease process. When polycystic ovaries are discovered at radiologic examination, further diagnostic tests are needed to determine the etiology.

When the laboratory values are interpreted together with a thorough history as well as physical examination findings, they are useful in the diagnosis of polycystic ovaries. In some patients, such information may lead to a specific cause of the ovarian dysfunction (eg, hyperprolactinemia). When hormone levels do not provide adequate information, ultrasonography may prove useful; however, in the absence of correlative information, the significance of the radiologic findings is difficult to determine. The primary limitation of ultrasonography is that a radiologic diagnosis of polycystic ovaries does not reveal the underlying pathology, if it exists. Further studies are usually necessary to determine the cause of the radiologic finding.

Although polycystic ovaries are occasionally identified in patients without PCOS, this possibility does not relieve the radiologist of the responsibility to report the finding and recommend further clinical and biochemical evaluations.