Table 4.

Diagnoses to Consider Excluding in Select Women, Depending on Presentation

Other Diagnosesa	Suggestive Features in the Presentation	Tests to Assist in the Diagnosis	Reference for Further Evaluation and Treatment of Abnormal Findings; First Author, Year (Ref.)
Pregnancy	Amenorrhea (as opposed to oligomenorrhea), other signs and symptoms of pregnancy including breast fullness, uterine cramping, etc	Serum or urine hCG (positive)	Morse, 2011 (17)
HA including functional HA	Amenorrhea, clinical history of low body weight/BMI, excessive exercise, and a physical exam in which signs of androgen excess are lacking; multifollicular ovaries are sometimes present	Serum LH and FSH (both low to low normal), serum estradiol (low)	Wang, 2008 (18)
Primary ovarian insufficiency	Amenorrhea combined with symptoms of estrogen deficiency including hot flashes and urogenital symptoms	Serum FSH (elevated), serum estradiol (low)	Nelson, 2009 (296)
Androgen-secreting tumor	Virilization including change in voice, male pattern androgenic alopecia, and clitoromegaly; rapid onset of symptoms	Serum T and DHEAS levels (markedly elevated), ultrasound imaging of ovaries, MRI of adrenal glands (mass or tumor present)	Carmina, 2006 (16)
Cushing's syndrome	Many of the signs and symptoms of PCOS can overlap with Cushing's (ie, striae, obesity, dorsocervical fat (ie, buffalo hump, glucose intolerance); however, Cushing's is more likely to be present when a large number of signs and symptoms, especially those with high discriminatory index (eg, myopathy, plethora, violaceous striae, easy bruising) are present, and this presentation should lead to screening	24-h urinary collection for urinary free cortisol (elevated), late night salivary cortisol (elevated), overnight dexamethasone suppression test (failure to suppress morning serum cortisol level)	Nieman, 2008 (19)
Acromegaly	Oligomenorrhea and skin changes (thickening, tags, hirsutism, hyperhidrosis) may overlap with PCOS. However, headaches, peripheral vision loss, enlarged jaw (macrognathia), frontal bossing, macroglossia, increased shoe and glove size, etc, are indications for screening	Serum free IGF-1 level (elevated), MRI of pituitary (mass or tumor present)	Melmed, 2009 (20)

Abbreviations: DHEAS, dehydroepiandrosterone sulfate; HA, hypothalamic amenorrhea; hCG, human chorionic gonadotropin; MRI, magnetic resonance imaging.

^aAdditionally there are very rare causes of hyperandrogenic chronic anovulation that are not included in this table because they are so rare, but they must be considered in patients with an appropriate history. These include other forms of congenital adrenal hyperplasia (eg, 11β-hydroxylase deficiency, 3β-hydroxysteroid dehydrogenase), related congenital disorders of adrenal steroid metabolism or action (eg, apparent/cortisone reductase deficiency, apparent DHEA sulfotransferase deficiency, glucocorticoid resistance), virilizing congenital adrenal hyperplasia (adrenal rests, poor control, fetal programming), syndromes of extreme IR, drugs, portohepatic shunting, and disorders of sex development.