Management of PCOS in primary care

Dr Yvonne Jeanes, Susan Bury and Dr Sue Reeves surveyed GPs to assess how polycystic ovary syndrome is managed in south-west London.

PCOS symptoms include infertility, acne, hirsutism, alopecia and obesity (SPL)
PCOS symptoms include infertility, acne, hirsutism, alopecia and obesity (SPL)

Polycystic ovary syndrome (PCOS) affects one in 10 women and is the most common endocrine disorder in women.1

Symptoms of PCOS include menstrual irregularity and infertility, acne, hirsutism, male pattern alopecia and obesity.2

Many of these symptoms have been shown to lead to a reduction in health-related quality of life and consequently, depression and anxiety are also often reported.3

PCOS is also an independent risk factor for type 2 diabetes and cardiovascular disease - many women with PCOS have impaired glucose tolerance and insulin resistance.

Diagnostic criteria

The most commonly used diagnostic criteria for PCOS are the Rotterdam criteria.4 In the absence of other endocrine disorders, two of the features listed in the box below should be present to establish a diagnosis of PCOS.

Management

Lifestyle management is the primary therapy in overweight and obese women with PCOS.5,6

A modest weight loss of 5-10%, without medical intervention, has been shown to improve many of the symptoms associated with PCOS.

Benefits of this level of weight loss include lower fasting insulin levels, reduced free testosterone, increased SHBG and improved reproductive function.7

The PCOS survey

We designed our survey to investigate the feasibility of following the Royal College of Obstetricians and Gynaecologists (RCOG) and NICE Clinical Knowledge Summaries (CKS) guidelines for managing women with PCOS, and to assess GPs' needs.

The research was undertaken in collaboration with St George's, University of London. GP practices in south-west London were invited to participate in a short online survey in March-June 2014.

The survey included short questions and case studies. A total of 221 practices were contacted by letter, fax or email. Emails were also sent to six CCGs and the south-west London area commissioning support unit, for dissemination to GPs.

The response rate was 10% and most GPs who responded had an interest in women's health.

What the survey found

The results of the survey are presented below, in conjunction with the relevant RCOG and NICE CKS guidelines.

RCOG guideline BP measurement and fasting blood glucose should be taken

The NICE CKS guidance states: 'Consider screening women aged over 35 years regularly for cardiovascular risk factors including BP, waist circumference, BMI and lipids.'

From our survey, 23% of GPs reported measuring fasting blood glucose and 36% took a BP measurement in all women with PCOS.

NICE CKS guideline Offer an initial oral glucose tolerance test (OGTT) to all women presenting with PCOS

None of the GPs reported offering an OGTT to all women with PCOS, although HbA1c was measured by 9% of GPs.

The NICE CKS guidance states: 'In women who have impaired glucose tolerance, offer an annual OGTT.'

Most (86%) of the GPs surveyed said that they did not offer annual monitoring of glucose tolerance for women with PCOS.

RCOG guideline Women who have a BMI >30 or a strong family history of type 2 diabetes should have an OGTT, particularly if fertility is an issue

A total of 9% of GPs responded that they would carry out an OGTT if the patient had a BMI >30; 55% would carry out a fasting glucose test and 32% would measure HbA1c.

None of the GPs reported conducting an OGTT in women with PCOS with a strong family history of diabetes, although 50% would carry out a fasting glucose test and 18% would measure HbA1c.

RCOG guideline All overweight women with PCOS should be provided with dietary and lifestyle advice

Most (91%) GPs offered weight loss advice to obese women with PCOS.

Factors influencing their decisions about the content of the advice included patient choice and local services available. The NICE CKS guidance recommends that primary care practitioners should encourage a healthy lifestyle, to reduce possible long-term risks to health (type 2 diabetes and cardiovascular disease).

RCOG guideline Amenorrhoeic or severely oligomenorrhoeic women with PCOS should have induced withdrawal bleeds at regular intervals to reduce the risk of endometrial hyperplasia

Only 9% of the GPs surveyed mentioned inducing withdrawal bleeds, in response to how they would manage a theoretical case study. The remaining 91% of GPs said they would refer the patient to a specialist.

The NICE CKS guidance states: 'Induce a withdrawal bleed, then refer for ultrasonography to assess endometrial thickness.'

The GPs surveyed consistently reported that there was a need for local guidance, with referral criteria and local specialist clinic advice. Patient leaflets were also highlighted as a useful additional resource.

  •  Dr Yvonne Jeanes is senior lecturer clinical nutrition, Dr Sue Reeves is programme convenor health sciences, and Susan Bury is a research assistant at the Health Science Research Centre, University of Roehampton.

The survey was funded by South-West London Academic, Health and Social Care System

References

1. March WA, Moore VM, Willson KJ et al. The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Hum Reprod 2010; 25: 544-51.

2. Teede H, Deeks A, Moran L.

Polycystic ovary syndrome: a complex condition with psychological, reproductive and metabolic manifestations that impacts on health across the lifespan. BMC Medicine 2010; 8: 41.

3. Dokras A, Clifton S, Futterweit W et al. Increased risk for abnormal depression scores in women with polycystic ovary syndrome: a systematic review and meta-analysis. Obstet Gynecol 2011; 117(1): 1-2.

4. Rotterdam ESHRE/ASRM- Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004; 81: 19-25.

5. Royal College of Obstetricians and Gynaecologists. Green-top Guideline No 33. Long-term consequences of polycystic ovary syndrome. https://www.rcog.org.uk/en/ guidelines-research-services/guidelines/gtg33/

6. NICE CKS. PCOS. February 2013. http://cks.nice.org.uk/ polycystic-ovary-syndrome#!diagnosis

7. Moran LJ, Hutchison SK, Norman RJ et al. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev 2011; 16: 2: CD007506

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