[8 min read] Managing patients with polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a hyperandrogenic hormonal disorder affecting around 11 to 13 per cent of women of reproductive age in Australia. It is characterised by androgen excess, characteristically causing a polycystic appearance of the ovaries, but also manifesting as metabolic sequalae such as insulin resistance and menstrual disturbance due to anovulatory cycles, and phenotypic changes such as hirsutism.

The most common presenting complaints of PCOS are hirsutism, infertility, and menstrual disturbance, typically infrequent or irregular periods. However, PCOS can also manifest with acne, hair loss, weight gain, virilisation, hyperhidrosis, oily skin, acanthosis nigricans, mood changes and hypertension.

PCOS is more common in those with a family history, those who are obese, and those who experienced premature menarche.

The diagnosis of PCOS can be tricky, and it is often a diagnosis of exclusion, however international guidelines endorse the use of the Rotterdam PCOS diagnostic criteria, where two of the three following criteria must be met:

  1. biochemical hyperandrogenaemia or clinical hyperandrogenism;
  2. oligo or anovulation; and
  3. polycystic ovarian appearance on pelvic ultrasound.

Therefore, in patients with clinical features of hyperandrogenism (e.g. hirsutism) and menstrual irregularity, a pelvic ultrasound is not necessary for diagnosis. For those where the diagnosis is uncertain, serum androgens e.g. free testosterone, free androgen index or calculated bioavailable testosterone may be performed.

Additional investigations to exclude other pathology may include thyroid function tests to exclude hypo/hyperthyroidism, prolactin levels to exclude hyperprolactinaemia, and 17-hydroxyprogesterone to exclude adrenal hyperplasia. Fasting lipids and an oral glucose tolerance test should be performed in all patients in whom PCOS is suspected as there is a high concordance between insulin resistance, dyslipidaemia and PCOS.

Management of PCOS should be personalised to the goals and lifestyle choices of the patient, and broadly depends on whether the woman wishes fertility preservation or not. For those where fertility is desired, the first line and most effective measure to restore normal ovulation is weight loss; a loss of just five per cent of body weight can restore ovulation in up to 80 per cent of overweight patients with PCOS. In women where weight loss is unsuccessful, the addition of metformin can be considered, which may need to be continued for at least six to nine months for full effect. Other options include clomiphene or aromatase inhibitors.

For women with prolonged infertility, assisted conception strategies should be offered (e.g. IVF). For women who do not desire fertility, an oral combined contraceptive pill is the first line management strategy.

It is important to adequately support all manifestations and complications of PCOS. For women with insulin resistance or diabetes, it is important to adequately treat this to reduce associated cardiovascular risks. For women with troublesome hirsutism, discussion regarding hair removal techniques is warranted.

PCOS is also associated with an increased incidence of psychological phenomena such as depression and anxiety, so it is important to screen for these and offer the women appropriate support – psychological and/or pharmacological. PCOS can have a significant emotional impact on women, and the inclusion of education, support groups and self-empowerment strategies have been shown to improve well-being of the whole patient.

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References

  1. Department of Health, State Government of Victoria, Australia. Better Health Channel: Polycystic Ovarian Syndrome. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/polycystic-ovarian-syndrome-pcos
  2. Monash University (2018). International evidence-based guideline for the assessment and management of polycystic ovary syndrome. https://www.monash.edu/__data/assets/pdf_file/0004/1412644/PCOS_Evidence-Based-Guidelines_20181009.pdf
  3. Boyle, J & Teede, HJ (2012). Polycystic Ovary Syndrome: An Update. Australian Family Physician. 41 (10) 752–756. https://www.racgp.org.au/afp/2012/october/polycystic-ovary-syndrome/
  4. BMJ Best Practice (2020). Polycystic Ovary Syndrome. https://bestpractice.bmj.com/topics/en-gb/141

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