PCOS

• PCOS


  Polycystic ovary syndrome
• PCOS


  • Significant public health issue with reproductive, metabolic and psychological features
  • One of the most common conditions in reproductive aged women affecting 8-13% of reproductive-aged women with a higher prevalence in certain ethnicities
  • Up to 70% of affected women are undiagnosed
• Rotterdam Criteria


  Two of the following three criteria are required: Oligo/anovulation, Hyperandrogenism (clinical or biochemical), Polycystic ovaries on ultrasound
• Other aetiologies must be excluded such as congenital adrenal hyperplasia, androgen secreting tumours, Cushing syndrome, thyroid dysfunction and hyperprolactinaemia
• Presentation of PCOS


  • Hirsutism and male pattern balding consistent with hyperandrogenism, acne
  • Irregular or absent menstrual cycles
  • Subfertility or infertility
  • Psychological symptoms – anxiety, depression, psychosexual dysfunction, eating disorders
  • Metabolic features – obesity, dyslipidaemia, diabetes
• PCOS Phenotypes


  • Phenotype A: Androgen excess + ovulatory dysfunction + polycystic ovarian morphology
  • Phenotype B: Androgen excess + ovulatory dysfunction
  • Phenotype C: Androgen excess + polycystic ovarian morphology
  • Phenotype D: Ovulatory dysfunction + polycystic ovarian morphology
• Oligo/anovulation

  Irregular menstrual cycles defined as: normal in the first year post menarche, >1 to <3 years post menarche: <21 or >45 days, >3 years post menarche to perimenopause: <21 or >35 days or <8 cycles per year, >1 year post menarche >90 days for any one cycle, Primary amenorrhea by age 15 or >3 years post thelarche (breast development)
• Ovulatory dysfunction can still occur with regular cycles and if anovulation needs to be confirmed serum progesterone levels can be measured
• Hyperandrogenism

  • Hirsutism: difficult to assess as most women treat this
  • Acne
  • Male pattern alopecia
  • Biochemical hyperandrogenaemia
• If free testosterone is significantly raised or there is evidence of rapid virilisation, further investigations are required to exclude late onset congenital adrenal hyperplasia and virilising tumours
• Ovarian Morphology


  • Polycystic ovaries on ultrasound are diagnosed when 12 small antral follicles are seen in per ovary measuring 2 to 9 mm in diameter or an ovary that has a volume of greater than 10 mL. A single ovary meeting either or both of these definitions is sufficient for the diagnosis of polycystic ovaries.
  • A unilateral polycystic ovary is rare but still clinically significant.
  • Ultrasound is not reliable in the diagnosis of polycystic ovaries in adolescent and young women. Up to 70% of young women may have polycystic ovaries on ultrasound
  • Ultrasound should not be used to diagnose PCOS within 8 years of menarche.
• Management of PCOS

  • Lifestyle modification
  • Medical treatment
  • Surgical treatment
  • Ovulation induction/Assisted reproduction techniques
• Lifestyle Modification

  • Higher prevalence of PCOS in women who are overweight and obese
  • Women with PCOS have a higher rate of weight gain than those without PCOS – about 1–2 kg/year.
  • Even a small amount of weight loss (5%) can help restore menstrual cycle regularity and ovulation, assist mental wellbeing, halve the risk of diabetes in high risk groups and help prevent future cardiometabolic risk.
• Lifestyle Modification


  • Healthy diet with caloric restriction
  • Behaviour change support and exercise to aid in weight loss and prevention of future weight gain
• Medical Treatment for Irregular Menstrual Cycles


  • The combined oral contraceptive pill (COCP) is effective in achieving menstrual cycle regularity and also provides contraception if this is required.
  • The 35 microgram ethinyloestradiol plus cyproterone acetate preparations should not be considered first line in PCOS as per general population guidelines, due to adverse effects including venous thromboembolic risks.
  • In women with oligo/amenorrhoea, intermittent progestin every 3 months may be used to induce a withdrawal bleed and protect the endometrium from hyperplasia.
• Medical Treatment for Hirsutism

  • The choice of options depends on patient preference, impact on wellbeing and access and affordability.
  • The best treatment for localised hirsutism is cosmetic therapy (eg. laser and electrolysis) by an experienced operator, but expense and access may be barriers to this treatment for some women.
  • Treatment of local facial hair may be augmented in the short term by topical eflornithine, but this is also costly.
  • Generalised hirsutism may benefit from a combined medical and cosmetic approach. The COCP is first line medical therapy with no clear evidence to support the benefit of any particular COCP. Metformin may also provide some benefit.
• Surgical Treatment

  Laparoscopic ovarian drilling
• Subfertility


  Polycystic ovary syndrome is the most common cause of anovulatory infertility.
• Lifestyle Modification for Subfertility

  • In women aged less than 35 years with a BMI >25 kg/m2 and no other cause of infertility, an intensive lifestyle program addressing weight loss, without any pharmacological treatment for the first 6 months.
  • If lifestyle measures are unsuccessful, then consider referral to a fertility specialist.
  • Referral should be initiated early for women aged more than 35 years and in couples with additional factors contributing to infertility.
• Ovulation Induction in PCOS

  • 1st line: Letrozole superior to clomiphene citrate
  • 2nd line: gonadotrophins
  • If the above are unsuccessful or if there are other factors contributing to infertility such as endometriosis or male factors, in vitro fertilisation or intra-cytoplasmic sperm injection is recommended.
  • Laparoscopic ovarian drilling
• Cardiovascular Risk Modification


  • Assess cigarette smoking and discuss quitting
  • Weight monitoring and management
  • Lipid profile monitoring every 2 years if initially normal and every year if abnormal and/or overweight or obese.
  • Measure blood pressure annually if BMI <25 kg/m2, or every visit if BMI >25 kg/m2
  • Assess for prediabetes with oGTT
• Metformin

  • Proven to be beneficial in patients with impaired glucose tolerance/insulin resistance
  • Metformin in addition to lifestyle modification, could be recommended in adult women with PCOS, for the treatment of weight, hormonal and metabolic outcomes.
  • Can be used as an adjunct to COCP for cycle regulation
  • Can be used as an adjunct to oral or parenteral OI agents
  • Good safety profile
  • Side effects may be significant