**3.2. Clinical manifestations**

Clinical manifestations are acne, hirsutism, and androgenic alopecia . Some patients appear with only one or two manifestations, while a few patients have all the three [2]. Sixty percent of patients with PCOS have hirsutism and 15–25% patients have acne [6].

## **3.3. Other diagnostic methods**

The BMI, blood pressure, waist circumference (WC), and hip circumference should be measured at the initial visit. Fasting lipid profile, sugar and glycohemoglobin, or a 2-hour oral glucose tolerance test (OGTT) should be performed if PCOS is suspected at the initial visit. Trans-vaginal ultrasound is indicated rather than trans-abdominal ultrasound if the patient has one of either irregular menstruation or HA. The Rotterdam PCOM criteria, considered to have sufficient specificity and sensitivity to define PCOM, requires the presence of ≥12 follicles measuring 2–9 mm in diameter and/or increased ovarian volume (>10 cm3 ) in a single ovary or both ovaries [32, 41–42]. In 2014, the AE-PCOS guidelines suggested using follicle number per ovary (FNPO) ≥25 for the definition of PCOM when using newer technology that allows maximal resolution of ovarian follicles (such as a transducer frequency of more than 8 MHz) [41, 43].

Serum hormone examination, such as serum androgens, should be performed on women with clinical appearance of PCOS. In addition, anti-Müllerian hormone (AMH) in women is generated by granulosa cells, and preantral and antral follicles, and its major function seems to be limited to inhibit the development of the initial stage of follicular maturation [44]. Serum AMH in women with PCOS is higher than in healthy women, which probably reflects the number of small follicles observed on the ultrasounds of polycystic ovaries [45]. Studies have reported that 97% of women with AMH >10 ng/mL had PCOS and this correlated positively with LH, total testosterone, and DHEA [45, 46]. Besides, serum AMH revealed high predictive ability for the presence of OA or amenorrhea [45, 46]. Recently, serum AMH is proving to be a better tool to understand ovarian function and follicular count; however, the clinical use of serum assays for AMH still poses some technical problems [33, 44].
