In the case of PCOS, the costs of some diagnostic tests are relatively low. For example, based on estimates from Healthcare Bluebook,9 serum TSH and prolactin tests in San Francisco, California, are $44 and $51, respectively. However, the cumulative costs for even the most stringent routine workup for PCOS recommended in the AACE/AE-PCOS guideline consisting of a free testosterone measurement, 17-hydroxyprogesterone, and transvaginal ultrasound would still cost a total of $516. Additional TSH and prolactin tests recommended by ENDO would increase the cost of PCOS testing by approximately 18%. Routine testing for additional serum androgens—dehydroepiandrosterone sulfate (DHEA-S) and androstenedione—would further increase this amount by an additional $134 to a total cost of $745. The ENDO guideline only recommends DHEA-S testing to assist in the diagnosis of an androgen-secreting tumor when signs of virilization are present, while the AACE/AE-PCOS guideline discourages routine testing for DHEA-S and androstenedione based on the low frequency of cases in which these androgens are elevated in isolation.7,8
Although the selection of tests influences total cost, the setting of tests (ie, hospitals, physician offices, independent test settings) also can contribute to wide variations in cost. For example, Healthcare Bluebook’s estimates for transvaginal ultrasound in Chicago, Illinois, range from $236 to more than $740.9 When the separate physician visit fees are included, the total cost of a routine diagnostic evaluation of a patient with acne or hirsutism concerning for PCOS is not trivial.
Large national clinical registries and formal cost-effectiveness analyses are necessary to shed light on this issue, but it is clear that clinicians should rely on their clinical judgment when ordering laboratory tests in the evaluation for PCOS given the apparent low yield of routine screening for PCOS mimickers in the absence of clinical indications. For example, a TSH would not be warranted in a patient without evidence of thyroid dysfunction (ie, weight gain, fatigue, constipation, menstrual irregularities). Similarly, clinicians should routinely consider the principle of high-value care: whether the results of a test will change management of the patient. For example, a woman with amenorrhea and severe acne who already meets diagnostic criteria for PCOS would benefit from a combined oral contraceptive for both acne and endometrial protection. An ovarian ultrasound may not be needed to confirm the diagnosis unless there is suspicion for an ovarian condition other than PCOS causing the symptoms.
Finally, clinicians should discuss testing options and involve patients in decisions around testing. Although PCOS treatments generally target individual symptoms rather than the syndrome as a whole, confirmation of a PCOS diagnosis importantly informs women of their risk for cardiovascular and metabolic disease. The ENDO recommends screening for impaired glucose tolerance, type 2 diabetes mellitus, obesity, family history of early cardiovascular disease, tobacco use, hypertension, dyslipidemia, and obstructive sleep apnea in all women with PCOS, including nonobese patients.7 Ongoing efforts to gain and understand evidence to support high-value, cost-conscious care should be prioritized and kept in balance with shared decision-making in individual patients suspected of having PCOS.