Polycystic ovary syndrome (PCOS) is a common disorder often complicated by chronic anovulatory infertility and hyperandrogenism, with the clinical manifestation of oligomenorrhoea, hirsutism and acne.
A diagnosis of PCOS can only be made when other aetiologies have been excluded (thyroid dysfunction, congenital adrenal hyperplasia, hyperprolactinaemia, androgen-secreting tumours and Cushing's syndrome).
The recommended baseline screening tests are TFTs, serum prolactin and androgen free index (total testosterone divided by SHBG multiplied by 100).
Two of the following criteria are diagnostic of the condition:
- Polycystic ovaries (12 or more peripheral follicles, or increased ovarian volume >10cm3)
- Oligoor anovulation
- Clinical or biochemical signs of hyperandrogenism
Women who are diagnosed with PCOS should be informed of the possible long-term risks to health that are associated with the condition. They should be advised regarding weight control and exercise.
Insulin resistance, diabetes
PCOS is an independent risk factor for type 2 diabetes in middle age.
A sensible approach to ensure early detection of diabetes might be to offer screening to women with PCOS, with annual measurement of fasting blood glucose. If the fasting blood glucose is 5.6mmol/L or greater, an oral glucose tolerance test should be arranged.
Women presenting with PCOS, particularly if they are obese (BMI >30), have a strong family history of type 2 diabetes, or are over the age of 40, are at increased risk of type 2 diabetes and should be offered a glucose tolerance test.
Snoring and drowsiness
Women diagnosed with PCOS (or their partners) should be asked about snoring and daytime fatigue/somnolence and informed of the possible risk of sleep apnoea. They should be offered investigation and treatment when necessary.
Women who have PCOS may have higher cardiovascular risk, putting them at increased risk of developing accelerated atherosclerosis, resulting in MI.
Patients who have persistent BP ≥140mmHg systolic and/or 90mmHg diastolic, and who do not respond to lifestyle measures, need to be considered for drug therapy.
Women with diabetes or other risk factors with BP >130mmHg systolic and/or 80mmHg diastolic may require drug therapy.
Lipid-lowering treatment is not routinely recommended. This should only be prescribed by a specialist.
PCOS and pregnancy
Women with PCOS have a significantly higher risk of pregnancy complications compared with controls.
Women diagnosed with PCOS before pregnancy should be screened for gestational diabetes before 20 weeks. They should be referred to a specialist obstetric diabetic service if abnormalities are detected.
Metformin is currently not licensed for use in pregnancy in the UK and is not recommended for use in pregnancy.
Oligomenorrhoea or amenorrhoea in women with PCOS may predispose to endometrial hyperplasia and later carcinoma.
It is good practice to recommend treatment with progestogens to induce a withdrawal bleed at least every three to four months. This could be in the form of progestogens for at least 12 days, oral contraceptive pills or an intrauterine system.
There does not appear to be an association with breast or ovarian cancer and no additional surveillance is required.
Strategies for risk reduction
Women with PCOS should be advised about weight loss through taking regular exercise and eating a healthy, balanced diet.
Significant weight loss has been reported to result in spontaneous resumption of ovulation, improvement in fertility, increased SHBG and reduced basal level of insulin, accompanied by normalisation in glucose metabolism.
Is there a cure?
There is no cure for PCOS. Medical treatments aim to manage and reduce the symptoms or consequences of the condition. Medication alone has not been shown to be any better than healthy lifestyle changes.
Many women with PCOS successfully manage their symptoms and long-term health risks without medical intervention.
- Dr Abdelrahman is an ST2 in obstetrics and gynaecology at Mater Hospital, Belfast