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PCOS/PCOD
Polycystic Ovary Syndrome
Understanding the Ultrasound Appearance of a PCOS.
PCOD
Polycystic Ovary Syndrome / Polycystic Ovarian Disease (PCOS / PCOD) is a common endocrine disorder in reproductive-age females. It is associated with chronic anovulation, menstrual irregularity, hyperandrogenism, infertility, obesity, insulin resistance, and characteristic polycystic ovarian morphology on ultrasound. Imaging helps assess ovarian morphology, ovarian volume, follicle number, stromal echogenicity, endometrial thickness, and exclude other adnexal pathology.
Ultrasound Features of PCOS / PCOD:
Typical Ultrasound Criteria:
1. Ovarian volume greater than 10 mL in one or both ovaries.
2. Multiple small follicles, usually 2–9 mm in size.
3. Peripheral follicular distribution may produce “string of pearls” appearance.
4. Increased central stromal echogenicity and stromal volume may be present.
Color Doppler: May show mildly increased stromal vascularity in some cases.
Endometrium: Endometrial thickness varies with menstrual cycle; prolonged anovulation may cause endometrial thickening.
Adnexa: No adnexal mass should be seen in uncomplicated PCOS / PCOD.
Free Fluid: Usually absent.
Finding: Both ovaries are mildly enlarged with multiple small peripheral follicles measuring approximately 2–9 mm. Increased central stromal echogenicity is noted. No adnexal mass or free fluid is seen.
Impression: Bilateral polycystic ovarian morphology suggestive of PCOS / PCOD. Clinical and hormonal correlation is advised.
Recommendation: Correlation with menstrual history, clinical evidence of hyperandrogenism, serum LH/FSH, testosterone, prolactin, TSH, fasting insulin/glucose profile, and gynecological consultation is advised.
Limitation: Ultrasound findings alone do not establish the diagnosis of PCOS. Clinical and laboratory correlation is essential.
Ovarian Volume:
FINDINGS: One or both ovaries may be enlarged. Ovarian volume greater than 10 mL supports polycystic ovarian morphology. The ovary may appear bulky with increased central stromal component.
CONCLUSION: Enlarged ovarian volume supports PCOS / PCOD morphology.
RECOMMENDATION: Correlation with clinical history, menstrual pattern, and hormonal profile is advised.
FINDINGS: One or both ovaries may be enlarged. Ovarian volume greater than 10 mL supports polycystic ovarian morphology. The ovary may appear bulky with increased central stromal component.
CONCLUSION: Enlarged ovarian volume supports PCOS / PCOD morphology.
RECOMMENDATION: Correlation with clinical history, menstrual pattern, and hormonal profile is advised.
Multiple Small Follicles:
FINDINGS: Multiple small follicles are seen in the ovary, commonly measuring 2–9 mm. Follicles may be arranged peripherally or scattered throughout the ovarian parenchyma.
CONCLUSION: Multiple small ovarian follicles are suggestive of polycystic ovarian morphology.
RECOMMENDATION: Clinical and biochemical correlation is recommended before labeling PCOS.
FINDINGS: Multiple small follicles are seen in the ovary, commonly measuring 2–9 mm. Follicles may be arranged peripherally or scattered throughout the ovarian parenchyma.
CONCLUSION: Multiple small ovarian follicles are suggestive of polycystic ovarian morphology.
RECOMMENDATION: Clinical and biochemical correlation is recommended before labeling PCOS.
String of Pearls Appearance:
FINDINGS: Multiple small follicles are arranged along the ovarian periphery, producing a characteristic “string of pearls” appearance. Central ovarian stroma may appear prominent and echogenic.
CONCLUSION: Ultrasound appearance is consistent with polycystic ovarian morphology.
RECOMMENDATION: Correlate with menstrual irregularity, hyperandrogenism, and endocrine profile.
FINDINGS: Multiple small follicles are arranged along the ovarian periphery, producing a characteristic “string of pearls” appearance. Central ovarian stroma may appear prominent and echogenic.
CONCLUSION: Ultrasound appearance is consistent with polycystic ovarian morphology.
RECOMMENDATION: Correlate with menstrual irregularity, hyperandrogenism, and endocrine profile.
Ovarian Stroma:
FINDINGS: Increased central stromal echogenicity and stromal volume may be seen. The stromal component may appear relatively more prominent than follicles.
CONCLUSION: Prominent echogenic ovarian stroma supports PCOS / PCOD morphology.
RECOMMENDATION: Endocrine evaluation is advised.
FINDINGS: Increased central stromal echogenicity and stromal volume may be seen. The stromal component may appear relatively more prominent than follicles.
CONCLUSION: Prominent echogenic ovarian stroma supports PCOS / PCOD morphology.
RECOMMENDATION: Endocrine evaluation is advised.
Typical Ultrasound Criteria:
1. Ovarian volume greater than 10 mL in one or both ovaries.
2. Multiple small follicles, usually 2–9 mm in size.
3. Peripheral follicular distribution may produce “string of pearls” appearance.
4. Increased central stromal echogenicity and stromal volume may be present.
Color Doppler: May show mildly increased stromal vascularity in some cases.
Endometrium: Endometrial thickness varies with menstrual cycle; prolonged anovulation may cause endometrial thickening.
Adnexa: No adnexal mass should be seen in uncomplicated PCOS / PCOD.
Free Fluid: Usually absent.
Finding: Both ovaries are mildly enlarged with multiple small peripheral follicles measuring approximately 2–9 mm. Increased central stromal echogenicity is noted. No adnexal mass or free fluid is seen.
Impression: Bilateral polycystic ovarian morphology suggestive of PCOS / PCOD. Clinical and hormonal correlation is advised.
Recommendation: Correlation with menstrual history, clinical evidence of hyperandrogenism, serum LH/FSH, testosterone, prolactin, TSH, fasting insulin/glucose profile, and gynecological consultation is advised.
Limitation: Ultrasound findings alone do not establish the diagnosis of PCOS. Clinical and laboratory correlation is essential.
Differential Diagnosis / Mimics:
Key Point: PCOS diagnosis requires clinical, biochemical, and ultrasound correlation. Polycystic ovarian morphology alone is not equal to PCOS.
Multifollicular Ovaries:
FINDINGS: Multiple follicles are present, usually without marked stromal hypertrophy or classic peripheral distribution.
CONCLUSION: May mimic PCOS but commonly occurs in puberty, recovery from hypothalamic amenorrhea, or temporary hormonal imbalance.
RECOMMENDATION: Clinical and hormonal correlation is advised.
FINDINGS: Multiple follicles are present, usually without marked stromal hypertrophy or classic peripheral distribution.
CONCLUSION: May mimic PCOS but commonly occurs in puberty, recovery from hypothalamic amenorrhea, or temporary hormonal imbalance.
RECOMMENDATION: Clinical and hormonal correlation is advised.
Ovarian Hyperstimulation:
FINDINGS: Bilateral enlarged ovaries with multiple cystic follicles may be seen, usually following ovulation induction treatment.
CONCLUSION: Findings may mimic PCOS but clinical history of fertility treatment is the key clue.
RECOMMENDATION: Gynecological follow-up is advised.
FINDINGS: Bilateral enlarged ovaries with multiple cystic follicles may be seen, usually following ovulation induction treatment.
CONCLUSION: Findings may mimic PCOS but clinical history of fertility treatment is the key clue.
RECOMMENDATION: Gynecological follow-up is advised.
Theca Lutein Cysts:
FINDINGS: Bilateral multiloculated ovarian cystic enlargement may be associated with high beta-hCG states.
CONCLUSION: Consider in pregnancy, molar pregnancy, or trophoblastic disease.
RECOMMENDATION: Beta-hCG correlation is advised.
FINDINGS: Bilateral multiloculated ovarian cystic enlargement may be associated with high beta-hCG states.
CONCLUSION: Consider in pregnancy, molar pregnancy, or trophoblastic disease.
RECOMMENDATION: Beta-hCG correlation is advised.
Androgen-Secreting Ovarian Tumor:
FINDINGS: A solid ovarian mass or focal ovarian lesion may be seen with marked clinical hyperandrogenism.
CONCLUSION: Should be considered when symptoms are severe, rapidly progressive, or imaging shows a focal mass.
RECOMMENDATION: Further evaluation with MRI and hormonal workup is advised.
FINDINGS: A solid ovarian mass or focal ovarian lesion may be seen with marked clinical hyperandrogenism.
CONCLUSION: Should be considered when symptoms are severe, rapidly progressive, or imaging shows a focal mass.
RECOMMENDATION: Further evaluation with MRI and hormonal workup is advised.
MRI Features of PCOS / PCOD:
Ovarian Size: Bilateral ovarian enlargement may be present.
Follicles: Multiple small peripheral follicles are seen in the ovarian cortex.
Stroma: Increased central stromal volume with low to intermediate signal intensity may be seen.
T2-Weighted Imaging: Multiple small hyperintense follicles with relatively hypointense central stroma.
T1-Weighted Imaging: Usually no hemorrhagic component unless associated pathology is present.
Post-Contrast Imaging: Ovarian stroma may enhance; no suspicious solid mass should be present.
Associated Findings: Endometrial thickening may be seen in prolonged anovulation.
Key Diagnostic Clue: Bilateral enlarged ovaries with multiple small follicles and increased central stromal volume.
Finding: MRI pelvis shows bilateral mildly enlarged ovaries with multiple small peripheral follicles and prominent central ovarian stroma. No suspicious adnexal mass is identified.
Impression: MRI features are suggestive of bilateral polycystic ovarian morphology.
Recommendation: Clinical and biochemical correlation is advised for diagnosis of PCOS.
Limitation: MRI is not routinely required for typical PCOS and is mainly useful when ultrasound is inconclusive or a mass is suspected.
Ovarian Size: Bilateral ovarian enlargement may be present.
Follicles: Multiple small peripheral follicles are seen in the ovarian cortex.
Stroma: Increased central stromal volume with low to intermediate signal intensity may be seen.
T2-Weighted Imaging: Multiple small hyperintense follicles with relatively hypointense central stroma.
T1-Weighted Imaging: Usually no hemorrhagic component unless associated pathology is present.
Post-Contrast Imaging: Ovarian stroma may enhance; no suspicious solid mass should be present.
Associated Findings: Endometrial thickening may be seen in prolonged anovulation.
Key Diagnostic Clue: Bilateral enlarged ovaries with multiple small follicles and increased central stromal volume.
Finding: MRI pelvis shows bilateral mildly enlarged ovaries with multiple small peripheral follicles and prominent central ovarian stroma. No suspicious adnexal mass is identified.
Impression: MRI features are suggestive of bilateral polycystic ovarian morphology.
Recommendation: Clinical and biochemical correlation is advised for diagnosis of PCOS.
Limitation: MRI is not routinely required for typical PCOS and is mainly useful when ultrasound is inconclusive or a mass is suspected.
CECT Features of PCOS / PCOD:
Role of CT: CT is not the preferred imaging modality for PCOS / PCOD.
Ovarian Size: Ovaries may appear mildly enlarged bilaterally.
Follicles: Multiple small follicles may be difficult to characterize accurately on CT compared with ultrasound or MRI.
Stroma: Stromal assessment is limited on CT.
Associated Findings: CT may incidentally show bulky ovaries or exclude other pelvic pathology.
Key Diagnostic Clue: CT is usually not diagnostic; ultrasound is preferred.
Finding: CT pelvis may show mildly bulky bilateral ovaries; however, follicular morphology and stromal details are better assessed on pelvic ultrasound.
Impression: CT is not the imaging modality of choice for PCOS / PCOD. Ultrasound correlation is recommended.
Recommendation: Pelvic ultrasound and hormonal correlation are advised.
Limitation: CT has limited sensitivity for follicle count and ovarian stromal assessment.
Role of CT: CT is not the preferred imaging modality for PCOS / PCOD.
Ovarian Size: Ovaries may appear mildly enlarged bilaterally.
Follicles: Multiple small follicles may be difficult to characterize accurately on CT compared with ultrasound or MRI.
Stroma: Stromal assessment is limited on CT.
Associated Findings: CT may incidentally show bulky ovaries or exclude other pelvic pathology.
Key Diagnostic Clue: CT is usually not diagnostic; ultrasound is preferred.
Finding: CT pelvis may show mildly bulky bilateral ovaries; however, follicular morphology and stromal details are better assessed on pelvic ultrasound.
Impression: CT is not the imaging modality of choice for PCOS / PCOD. Ultrasound correlation is recommended.
Recommendation: Pelvic ultrasound and hormonal correlation are advised.
Limitation: CT has limited sensitivity for follicle count and ovarian stromal assessment.
Pathology / Pathophysiology Features of PCOS / PCOD:
Nature: Endocrine-metabolic disorder affecting ovarian function.
Ovulation: Chronic anovulation or oligo-ovulation is common.
Hormonal Pattern: Hyperandrogenism may be present clinically or biochemically.
Follicles: Multiple arrested follicles may be seen in the ovary.
Stroma: Ovarian stromal hypertrophy and increased stromal activity may occur.
Metabolic Association: Insulin resistance, obesity, dyslipidemia, and increased diabetes risk may be associated.
Endometrium: Long-standing anovulation may increase risk of endometrial hyperplasia.
Key Diagnostic Clue: Combination of menstrual irregularity, hyperandrogenism, and polycystic ovarian morphology.
Finding: PCOS represents an endocrine-metabolic ovarian disorder characterized by chronic ovulatory dysfunction, hyperandrogenism, and polycystic ovarian morphology.
Impression: Clinical diagnosis supported by imaging and laboratory findings.
Recommendation: Gynecological and endocrine evaluation is advised.
Limitation: Histopathology is not required for routine diagnosis of PCOS.
Nature: Endocrine-metabolic disorder affecting ovarian function.
Ovulation: Chronic anovulation or oligo-ovulation is common.
Hormonal Pattern: Hyperandrogenism may be present clinically or biochemically.
Follicles: Multiple arrested follicles may be seen in the ovary.
Stroma: Ovarian stromal hypertrophy and increased stromal activity may occur.
Metabolic Association: Insulin resistance, obesity, dyslipidemia, and increased diabetes risk may be associated.
Endometrium: Long-standing anovulation may increase risk of endometrial hyperplasia.
Key Diagnostic Clue: Combination of menstrual irregularity, hyperandrogenism, and polycystic ovarian morphology.
Finding: PCOS represents an endocrine-metabolic ovarian disorder characterized by chronic ovulatory dysfunction, hyperandrogenism, and polycystic ovarian morphology.
Impression: Clinical diagnosis supported by imaging and laboratory findings.
Recommendation: Gynecological and endocrine evaluation is advised.
Limitation: Histopathology is not required for routine diagnosis of PCOS.
Important Reporting Points:
1. Mention uterus size, shape, and myometrial echotexture.
2. Measure endometrial thickness and correlate with menstrual cycle day.
3. Mention right ovarian size and volume.
4. Mention left ovarian size and volume.
5. Describe follicle number and size range.
6. Mention peripheral follicular arrangement if present.
7. Describe ovarian stromal echogenicity and stromal prominence.
8. Comment on adnexal mass if present or absent.
9. Mention presence or absence of free fluid in pouch of Douglas.
10. Add that ultrasound findings need clinical and hormonal correlation.
Short Report Template:
FINDINGS:
Uterus is normal in size and echotexture. Endometrial thickness measures ____ mm. Both ovaries are mildly enlarged. Right ovary measures ____ × ____ × ____ cm with volume of ____ mL. Left ovary measures ____ × ____ × ____ cm with volume of ____ mL. Multiple small peripheral follicles measuring 2–9 mm are seen in both ovaries with increased central stromal echogenicity. No adnexal mass or free fluid is seen.
IMPRESSION:
Bilateral polycystic ovarian morphology suggestive of PCOS / PCOD. Clinical and hormonal correlation is recommended.
1. Mention uterus size, shape, and myometrial echotexture.
2. Measure endometrial thickness and correlate with menstrual cycle day.
3. Mention right ovarian size and volume.
4. Mention left ovarian size and volume.
5. Describe follicle number and size range.
6. Mention peripheral follicular arrangement if present.
7. Describe ovarian stromal echogenicity and stromal prominence.
8. Comment on adnexal mass if present or absent.
9. Mention presence or absence of free fluid in pouch of Douglas.
10. Add that ultrasound findings need clinical and hormonal correlation.
Short Report Template:
FINDINGS:
Uterus is normal in size and echotexture. Endometrial thickness measures ____ mm. Both ovaries are mildly enlarged. Right ovary measures ____ × ____ × ____ cm with volume of ____ mL. Left ovary measures ____ × ____ × ____ cm with volume of ____ mL. Multiple small peripheral follicles measuring 2–9 mm are seen in both ovaries with increased central stromal echogenicity. No adnexal mass or free fluid is seen.
IMPRESSION:
Bilateral polycystic ovarian morphology suggestive of PCOS / PCOD. Clinical and hormonal correlation is recommended.
Case Study
Patient: 24-year-old female with irregular menstrual cycles, acne, and weight gain.
Ultrasound Findings: Uterus is normal in size. Endometrial thickness measures 8 mm. Both ovaries are mildly enlarged with multiple small peripheral follicles measuring 2–9 mm. Increased central stromal echogenicity is noted bilaterally. No adnexal mass or free fluid is seen.
MRI Findings: Bilateral enlarged ovaries with multiple peripheral follicles and prominent central stroma. No suspicious adnexal mass.
Diagnosis: Bilateral polycystic ovarian morphology suggestive of PCOS / PCOD.
Teaching Point: Ultrasound supports the diagnosis but PCOS should be diagnosed only after clinical and biochemical correlation.
Patient: 24-year-old female with irregular menstrual cycles, acne, and weight gain.
Ultrasound Findings: Uterus is normal in size. Endometrial thickness measures 8 mm. Both ovaries are mildly enlarged with multiple small peripheral follicles measuring 2–9 mm. Increased central stromal echogenicity is noted bilaterally. No adnexal mass or free fluid is seen.
MRI Findings: Bilateral enlarged ovaries with multiple peripheral follicles and prominent central stroma. No suspicious adnexal mass.
Diagnosis: Bilateral polycystic ovarian morphology suggestive of PCOS / PCOD.
Teaching Point: Ultrasound supports the diagnosis but PCOS should be diagnosed only after clinical and biochemical correlation.
Video Explanation
SonoAcademy Digital MCQ Examination
Topic: PCOS / PCOD — Polycystic Ovary Syndrome
Total Questions: 10 | Total Marks: 10 | Time: 30 Minutes
Instruction: Enter your details, start the exam, answer all questions, and download your PDF marksheet after submission.
Exam Result
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Topic: PCOS / PCOD — Polycystic Ovary Syndrome
Total Marks: 10
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