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Polycystic ovary syndrome (PCOS) is a hormonal disorder characterised by hyperandrogenism, causing a range of manifestations such as skin changes, menstrual disturbance, weight gain and infertility. PCOS can be diagnosed clinically and initial management typically takes place in primary care.

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Management of PCOS typically involves both lifestyle changes and pharmacological treatment, and is dependent on the clinical manifestations and fertility desires, with an overall management plan being tailored to the individual patient.

All women with PCOS with a BMI ≥30kg/m2 should be supported to lose weight through personalised dietary modification and exercise. If weight loss is unsuccessful through lifestyle modifications, metformin may be added as an adjunct. Metformin is suitable for women desiring fertility and has been shown to increase pregnancy rates. Bariatric surgery may be considered in women with a BMI ≥35kg/m2 where lifestyle and pharmacotherapy have been unsuccessful.

For women with troublesome menstrual irregularities, who are not looking to become pregnant, the use of a combined oral contraceptive pill (COCP) containing 20 or 30mcg ethinylestradiol can regulate menstrual bleeding. The progestogen component of COCPs is important to consider, with levonorgestrel being considered the most androgenic progestogen, and newer progestogens desogestrel, norgestimate and drospirenone being considered less androgenic.

For women with troublesome hirsutism, mechanical hair removal is often the first-line management, due to its accessibility and low rate of complications. Eflornithine cream may be used to slow the growth of hair, particularly on the face, however requires continuous treatment to maintain efficacy. Endocrine therapy with anti-androgens such as spironolactone, cyproterone and finasteride can slow hair growth and lead to thinner, less obvious hair growth, however, these drugs are contraindicated in pregnancy, so effective contraception is essential alongside. Anti-androgen therapy should be continued for at least 6 months, and maximal effect on hirsutism may not be reached for 9–12 months.

For women who are planning pregnancy, ovulation induction agents may be considered. Letrozole is an aromatase inhibitor and is considered the first-line pharmacological agent for restoration of ovulation. Clomifene is a non-steroidal anti-oestrogen agent which increases follicle-stimulating hormone (FSH) which may facilitate follicular maturation and ovulation in anovulatory women desiring fertility. Ovulation induction agents are typically used in conjunction with lifestyle modifications and metformin therapy. For women with prolonged infertility, referral to secondary care for consideration of specialist gonadotrophin therapy or assisted conception strategies (e.g. in-vitro fertilisation) is recommended.

PCOS is associated with various psychological phenomena such as anxiety and depression, so holistic management may involve psychological and/or pharmacological management of these conditions. Women with PCOS have a significantly higher cardiometabolic risk than those without PCOS, therefore appropriate screening for cardiovascular risk factors and initiating risk reduction strategies is paramount. This may include weight loss, smoking cessation, management of insulin resistance or type 2 diabetes, cholesterol-lowering therapy, and anti-hypertensive therapy.

In conclusion, most cases of PCOS can be effectively managed in primary care, however, in patients where first-line therapies have failed to manage the condition, referral to a gynaecologist, endocrinologist or fertility specialist should be considered.

Dr Samantha Miller, MBChB

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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
5. Lua, A., How, C. H., & King, T. (2018). Managing polycystic ovary syndrome in primary care. Singapore medical journal, 59(11), 567–571. https://doi.org/10.11622/smedj.2018135