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PCOS

Rana Malek, MD, Neda Frayha, MD, and Paul Simmons, MD
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Endocrinologist Dr. Rana Malek is back on Primary Care RAP, this time teaching Neda and Paul about the in’s and out’s of polycystic ovarian syndrome in her usual, chock-full-of-clinical-pearls way. 

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Lea Anna G. -

Does the timing of when the following labs are drawn matter/effect your interpretation? FSH, 17-hydroxyprogesterone, testosterone, and/or DHEAS levels

Neda F., MD -

Hi Lea Anna. From some of our research, at least some of these labs should be drawn in the morning. We've also asked Dr. Malek for her thoughts and will keep you posted.

UpToDate as well as a reference from the show notes both confirm morning testing:

"Serum 17-hydroxyprogesterone – We suggest measuring a morning serum 17-hydroxyprogesterone in the early follicular phase in all women with possible PCOS to rule out nonclassic congenital adrenal hyperplasia (NCCAH) due to 21-hydroxylase deficiency. For women who have some spontaneous menstrual cycles, this should be done in the early follicular phase, while for those without cycles, it can be drawn on a random day." UpToDate

"To screen for non-classical congenital adrenal hyperplasia due to CYP21 mutations, a fasting level of 17-hydroxyprogesterone should be obtained in the morning. A value less than 2 ng/mL is considered normal. If the sample is obtained in the morning and during the follicular phase, some investigators have proposed cutoffs as high as 4 ng/mL (118). Specificity decreases if the sample is obtained in the luteal phase due to increased progesterone production. High levels of 17-hydroxyprogesterone should prompt an adrenocorticotropic hormone (ACTH) stimulation test to confirm the diagnosis." (https://www.ncbi.nlm.nih.gov/books/NBK278959/)

Neda F., MD -

And here is Dr. Malek's response:

"labs should be done in the morning.
usually for PCOS, you are seeing women with oligomenorrhea so there is no follicular or luteal phase so you do it whenever. if however, you are doing the work up in a woman who is having menstrual cycles, you want to get it done in the early follicular phase."

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Hippo Primary Care January 2021 Written Summary 437 KB - PDF

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