PMOS Workup: The Tests You Should Ask For - AMH, Androgens, Insulin, Lipids, Thyroid

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Bharat Daftary Knowledge Centre · Diagnosis & Workup

Tests You Should
Ask for

- AMH, androgens, insulin, lipids, thyroid

The specific blood tests and imaging that make up a proper PMOS workup, what each one is looking for, and what to ask if your evaluation has been narrower than it should be.

By Dr Gautam V. DaftaryDirector, Aksigen IVF

Last reviewed June 20268-minute read1,850 words

A PMOS evaluation done properly involves a specific set of blood tests, an imaging study, and a screening conversation about mental health. The tests are not arbitrary. Each one answers a specific diagnostic question, and each one adds a specific piece of information to the pattern the clinician is trying to recognise.

In practice, workups vary. Some evaluations include only the hormones. Some skip the metabolic panel. Some rely on fasting glucose without doing the full oral glucose tolerance test the international guidelines now recommend¹. A narrower workup is not always wrong — but it can miss features of PMOS that matter for how the condition should be treated and monitored over the long term.

This article walks through the specific tests that make up a complete PMOS workup, explains what each one is looking for, and gives you the information you need to ask for the full evaluation if it has not already been offered.

The Androgens

Androgens — the hormones associated with masculine features — are produced in small amounts by every woman's ovaries and adrenal glands. In PMOS, they are often elevated, and this is one of the three core diagnostic features. The blood tests that establish or exclude hyperandrogenism include:

Total testosterone. The most direct measurement of the principal androgen. Normal ranges in women are much lower than in men; even modest elevations are clinically significant. Ideally measured in the morning, in the follicular phase (early in the cycle) when levels are most stable.

Sex hormone-binding globulin (SHBG). A protein that binds testosterone in the bloodstream. In PMOS, SHBG is often low, which increases the biologically active fraction of testosterone even when total testosterone is only mildly elevated. The ratio of testosterone to SHBG produces the free androgen index (FAI), which is often the most sensitive marker of hyperandrogenism.

DHEAS (dehydroepiandrosterone sulfate). The main androgen produced by the adrenal glands. Elevated DHEAS suggests adrenal contribution to hyperandrogenism, which is significant in a subset of women with PMOS. Very high DHEAS levels can also indicate an adrenal tumour and warrant further evaluation.

A normal total testosterone does not by itself rule out hyperandrogenism. The FAI and DHEAS may still be elevated, and clinical signs (hirsutism, persistent acne, hair thinning) count as hyperandrogenism even when blood levels are normal. This is why the diagnostic framework accepts either clinical or biochemical evidence.

Anti-Müllerian Hormone (AMH)

AMH is a blood marker of the number of small follicles in the ovaries. It reflects the same underlying biology as the polycystic ovarian morphology seen on ultrasound — more small follicles produce more AMH.

AMH is used in two ways in PMOS evaluation. First, as a surrogate for ultrasound morphology when imaging is not available or not diagnostic — an elevated AMH can substitute for the ultrasound criterion in the 2023 International Guideline framework. Second, as a general marker of ovarian reserve, useful for counselling about fertility timing and about response to ovarian stimulation if IVF is being considered.

AMH thresholds vary by age and by laboratory. An elevated AMH consistent with PMOS is typically well above the age-adjusted reference range. In adolescents, AMH is used cautiously because levels are naturally higher and normal thresholds are less established.

The Metabolic Panel

The metabolic panel is where PMOS evaluation has changed most in recent years. Under the old PCOS framework, metabolic assessment was often deferred to a later visit or done only if the woman was overweight. Under the current framework, the metabolic panel is done at diagnosis regardless of body weight, because the metabolic features of PMOS are present in lean women too and are the dimension that determines long-term health.

75-gram oral glucose tolerance test (OGTT). The single most important metabolic test in PMOS evaluation. A fasting blood glucose is measured, then 75 grams of glucose is given orally, and blood glucose is measured again at 2 hours. This test detects glucose intolerance that fasting tests alone miss. The 2023 International Guideline recommends OGTT for almost all women with PMOS at diagnosis, not only those with elevated BMI.

HbA1c. A measure of average blood glucose over the preceding 2 to 3 months. Useful alongside the OGTT to establish the metabolic baseline. HbA1c can miss early glucose intolerance that the OGTT catches, which is why the OGTT is the preferred test.

Fasting insulin. Elevated fasting insulin is a marker of insulin resistance — the central metabolic disturbance in PMOS. Fasting insulin is not a diagnostic criterion but is informative for tailoring metabolic treatment.

Fasting lipid profile. Total cholesterol, LDL, HDL, and triglycerides. Dyslipidaemia is common in PMOS and contributes to the elevated long-term cardiovascular risk associated with the condition. Baseline lipid profile at diagnosis allows monitoring over time.

The metabolic panel is not optional. It is where PMOS-related long-term health risk is quantified, and where the metabolic-first framework that defines modern PMOS care actually begins.

The Exclusion Tests

Several conditions can produce features that overlap with PMOS. Excluding them is what allows a PMOS diagnosis to be made with confidence, and it also ensures that a treatable alternative condition is not missed.

17-hydroxyprogesterone (17-OHP). Rules out non-classic congenital adrenal hyperplasia, a genetic condition that can present with hyperandrogenism and irregular cycles closely mimicking PMOS. An elevated 17-OHP triggers further evaluation.

Thyroid-stimulating hormone (TSH). Thyroid dysfunction, particularly hypothyroidism, can produce cycle irregularity and metabolic changes that overlap with PMOS. TSH is measured to rule this out.

Prolactin. Elevated prolactin can suppress ovulation and produce irregular cycles. Ruled out with a prolactin measurement, ideally done in the morning.

These three tests — 17-OHP, TSH, prolactin — should be part of every PMOS workup. If your evaluation did not include them, ask why. In rare cases, additional exclusion tests are needed — for suspected Cushing's syndrome or an androgen-secreting tumour — based on specific clinical features.

Imaging

A pelvic ultrasound assesses ovarian morphology (one of the three diagnostic features), measures ovarian volume, and rules out other pelvic conditions such as ovarian cysts, endometriomas, or uterine abnormalities that might contribute to symptoms.

Transvaginal ultrasound is the preferred approach in adult women because it provides better resolution of the ovaries. Transabdominal ultrasound is used in adolescents, in unmarried women where the transvaginal approach is not appropriate, or when the patient prefers it. The image quality is lower with transabdominal but is usually sufficient for diagnostic purposes.

The ultrasound criterion in the 2023 International Guideline is twenty or more follicles per ovary in at least one ovary, or an ovarian volume greater than 10 mL². This threshold is higher than earlier thresholds and reflects the improved resolution of modern ultrasound machines.

Not every woman with PMOS shows polycystic ovaries on ultrasound. This is not a diagnostic problem — the two-of-three framework allows for diagnosis based on the other two features. A normal ovarian appearance does not rule out PMOS.

Mental Health Screening

The 2023 International Guideline formally recommends screening for depression and anxiety at PMOS diagnosis. This is because both are substantially more common in women with PMOS than in the general population, and are often overlooked in a workup focused on hormones and metabolism.

Screening is typically done with brief validated questionnaires. If either screen is positive, appropriate referral or management follows. This is not incidental to PMOS care; it is part of it. Under the current framework, addressing the psychological dimension is understood as part of treating the condition, not as a separate concern.

What to Ask If Your Workup is Being Planned

If you are about to have a PMOS evaluation, or if the evaluation you had was narrower than the workup described above, a short list of specific questions is useful:

Which androgens are being measured? Total testosterone, SHBG (with free androgen index), and DHEAS are the standard set. A workup that measures only total testosterone is incomplete.

Is a 75-gram oral glucose tolerance test being done? Not just fasting glucose. Not just HbA1c. The full OGTT with 2-hour post-glucose measurement.

Are 17-OHP, TSH, and prolactin being included? These exclude congenital adrenal hyperplasia, thyroid dysfunction, and hyperprolactinaemia respectively. All three should be routine.

Is an ultrasound being done? Transvaginal preferred where appropriate. Transabdominal is fine where transvaginal is not indicated.

Is mental health being asked about? The 2023 International Guideline recommends formal screening. A brief conversation about mood and anxiety is now part of standard PMOS care.

None of these questions requires a confrontational conversation. They are the current international standard of care. A clinician working to that standard will have already planned the workup this way; a clinician who has not may welcome the reminder.

The Complete Picture is the Point

The purpose of a PMOS workup is not to check one hormone or find one ultrasound feature. It is to build a complete clinical picture — hormonal, metabolic, ovarian, psychological — that allows the diagnosis to be made accurately and the treatment plan to be built on the specific pattern of your PMOS rather than on the average pattern of the condition.

The tests described here are the current international standard. Doing all of them at diagnosis costs relatively little in time and money compared with the years of care that follow. The alternative — a partial workup, filled in later if problems emerge — misses the chance to establish the baseline and to plan management on the full picture from the start.

For the framework that these tests fit into, see the companion piece How PMOS is diagnosed today — the criteria explained. For the broader clinical picture of what PMOS is and what the diagnosis implies for treatment, see the pillar article Understanding PMOS.

About the Author

Dr Gautam V. Daftary is Director of Aksigen IVF and a senior consultant in reproductive medicine. He is a senior author on the 2026 review of PCOS / PMOS in the Indian context published in Insights in Reproductive Medicine.

This article is part of the Bharat Daftary Knowledge Centre, the patient-education programme of Aksigen IVF. It is intended for general information and does not replace consultation with a qualified clinician.

References

Teede HJ, Tay CT, Laven J, Dokras A, Moran LJ, Piltonen TT, et al., on behalf of the International PCOS Network. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Human Reproduction. 2023;38(9):1655–1679. DOI: 10.1093/humrep/dead156.
Dewailly D, Lujan ME, Carmina E, Cedars MI, Laven J, Norman RJ, Escobar-Morreale HF. Definition and significance of polycystic ovarian morphology: a task force report from the Androgen Excess and Polycystic Ovary Syndrome Society. Human Reproduction Update. 2014;20(3):334–352.

Aksigen IVF•Bharat Daftary Knowledge Centre•Tests you should ask for, v1.0•June 2026