Polycystic Ovarian Syndrome

Polycystic Ovarian Syndrome

Funmi Odusoga DFRSH MRCOG

Table of content

1. Definition

2. Differential Diagnosis

3. Investigations

4. Management

5. Essential Points for General Practitioners

6. References

Definition

PCOS is a common disorder often complicated by chronic anovulatory infertility and hyperandrogenism with clinical manifestations of oligomenorrhea, hirsutism and acne

It is associated with high incidence of

• Impaired glucose tolerance
• type 2 diabetes mellitus
• Sleep apnoea
• Visceral obesity
• Insulin resistance & Hyper-insulinaemia 65-80%

 Incidence/Diagnosis

Incidence: 2.2-26%

Diagnosis: Rotterdam Consensus Criteria

Two or more of the following is diagnostic of PCOS

1. Polycystic ovaries (Either 12 or more follicles or increased ovarian volume >10cc)
2. Oligo-ovulation or anovulation (irregular or absent cycle)
3. Clinical and/or biochemical signs of hyperandrogenism (Excess facial and body hair and midline hair growth)

Differential Diagnosis

Exclude other causes of irregular cycle before making diagnosis e.g.

• Thyroid dysfunction
• Acromegaly
• Hyperprolactinaemia

 Investigations

• Do Free Androgen Index= Total testosterone/sex hormone binding globulin x 100
• Exclude Androgen secreting tumours if there are signs of virilisation e.g. deep voice, reduced breast size, increased muscle bulk, clitoral hypertrophy, rapidly progressing hirsutism i.e. 1 year between hirsutism and consultation or if testosterone >5nmol/L.
• Rule out late onset non-classical congenital adrenal hyperplasia if signs of virilisation by doing 17 –hydroxyprogesterone in mid follicular phase.
• Keep a high index of suspicion congenital adrenal hyperplasia in Ashkenazi Jews or family history of CAH

N.B:Refer all patients with the above above to Endocriniologist

 Investigations

• Do transvaginal Ultrasonography to check polycystic ovaries and endometrial thickness
• Do Endometrial biopsy and or hysteroscopy if endometrial thickness is >7mm or presence of endometrial polyp.
• Do Oral Glucose Tolerance test if
• 40 years old and above
• BMI of 25 and more
• Personal History of gestational diabetes or family history of type 2 diabetes
• If impaired glucose tolerance is noted do Glucose tolerance test annually
• Offer investigations to rule out sleep apnea if patient has evidence of snoring or day time somnolence
• When pregnant, ensure you screen for gestational diabetes between 24-28weeks gestation

 Management

• Educate patient about long term risks to health
• There is no evidence that PCOS makes weight loss impossible
• No association with breast & ovarian cancer
• Refer to support group e.g. www.verity-pcos.org.uk
• Assess cardiovascular disease risk factors e.g. obesity, lack of physical activity, cigarette smoking, family history of type 2DM, dyslipidaemia, hypertension
• Screen for depression and anxiety as they have increased risk of psychological and behavioural disorders as well as reduced quality of life

 Management

• Life style changes: Diet, exercise and weight loss should precede and or accompany pharmacological treatment
• Lifestyle modification is superior in improving cardiometabolic risk factor and progress to type 2 Diabetes mellitus when compared to pharmacological treatment
• Prevent weight gain
• Consider bariatric Surgery if women fail to lose weight with lifestyle strategies and have a BMI of 40kg/m2 or more.
• Or BMI of 35 or more and hypertension or type 2 Diabetes Mellitus
• Bariatric surgery improves Diabetes Mellitus, Hypertension, dyslipidaemia, it reduces morbidity for cardiovascular disease and cancer when compared to lifestyle modification
• Metformin has short term benefit in patients with type 2 Diabetes
• No evidence that insulin sensitising agents confer any long term benefit
• Orlistat induces a small weight reduction and improves biochemical hyperandrogenism but has no effect on glucose-insulin homeostasis or lipidemia
• Ovarian electrocautery should be considered for anovulatory patients with normal BMI.
• In patients with oligo or amenorrhea induce a withdrawal bleed with progestogens (give for at least 12 days) every 3-4months . This prevents endometrial hyperplasia/cancer
• Consider combined oral contraceptives or long acting progesterone coil in women with Oligo or amenorrhea to prevent endometrial hyperplasia/cancer.
• Refer to Gynaecologists earlier for infertility management.

 Essential Points For General Practitioners

• Rule out differential diagnosis Thyroid dysfunction, Androgen secreting tumours, Congenital adrenal hyperplasia in high risk patients i.e. does with family history and Ashkenazi Jews (Refer to Endocrinologists)
• Education
• Encourage weight loss, Diet, life style modification
• Investigate sleep apnoea in patients with snoring and day time somnolence and fatigue
• Screen for depression and anxiety

 Essential Points For General Practitioners

• Induce a withdrawal bleed every 3 – 4months in patients with oligo-amenorrhea. This reduces the risk of endometrial hyperplasia/cancer
• There is increased risk of endometrial cancer in patients with amenorrhea
• No association with breast and ovarian cancer
• Consider bariatic surgery in appropriate women
• Refer patient with subfertility urgently

Reference