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POLYCYSTIC OVARY
SYNDROME
A SUMMARY OF RCOG GREEN-TOP
GUIDELINE
HDR Women’s Health
11 th April 2012
By Dr Mahya Mirfattahi
GP ST3
Why is it important?
• Common disorder
• Chronic anovulatory infertility & hyperandrogenism
• Oligomenorrhoea, hirsuitism & acne
• Obesity, impaired glucose tolerance, type 2 diabetes and sleep
apnoea
• Adverse cardiovascular risk profile
• Hypertension, dyslipidaemia, obesity, insulin resistance
Diagnosis
• Rotterdam criteria
• 2 of 3
• Polycystic ovaries (>12 peripheral follicles or increased ovarian volume
>10cm3)
• Oligo- or anovulation
• Clinical and/or biochemical signs of hyperandrogenism
Making the diagnosis
• Raised LH/FSH ratio is no longer a diagnostic criteria
• Recommended baseline screening tests
•
•
•
•
•
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TFTs
Serum prolactin
Free androgen index (total testosterone divided by SHBG x 100)
Note; if testosterone >5 nmol/l exlude androgen-secreting tumours
Consider 17-hydroxyprogesterone
Test for Cushing syndrome if clinical suspicion
How should women be counselled?
• Long-term risks to health
• Advise regarding weight control & exercise
• Offer a glucose tolerance test if
• Obese (BMI >30)
• Strong family history of type 2 diabetes
• >40 years
• Offer screening with annual fasting glucose
Cardiovascular risk
• Note; conventional cardiovascular risk calculators have not been
validated in women with PCOS
• BP and lipid profile
• Treat BP as according to NICE guidelines
• Lipid lowering treatment is not recommended routinely & should be
prescribed by a specialist
• Mainly raised TG, total & LDL cholesterol
• Sleep apnoea
• Ask about snoring & daytime fatigue/somnlonence
Pregnancy
• Higher risk of gestational diabetes
• Screen before 20 weeks gestation
• Greatest in those requiring ovulation induction & obese women
• Metformin is currently not licensed for use in pregnancy
Cancer risk
• Oligo- or amenorrhoea in women with PCOS may predispose to
endometrial hyperplasia & carcinoma
• Good practice to recommend treatment with progestogens to induce a
withdrawal bleed at least every 3-4months
• No association with breast or ovarian cancer
Treatment
• Lifestyle advice on diet & exercise
• Loss of significant weight has been reported to result in spontaneous
resumption of ovulation, improvement in fertility, increased SHBG &
normalisation of glucose metabolism
• Reduces likelihood of developing type 2 diabetes in later life
Drug therapy
• Insulin-sensitising agents have not been licensed in UK for women
who are not diabetic
• Metformin & thiazolidinediones have been shown to have short-term
effects on insulin resistance & thereby reduce risk of developing type 2
diabetes
• Metformin shown to modestly reduce androgen levels
• No evidence of long-term benefits or support in prevention of
cardiovascular disease
• Weight-reduction drug may be helpful in reducing insulin-resistance
through weight loss
Surgery
• Ovarian electrocautery should be reserved for selected anovulatory
women with normal BMI
• Persistence of ovulation & normalisation of serum androgens
• May affect reproductive capacity of ovaries
Advice for hirsutism & acne
• Impact on women’s self-image & psychological effects
• Insufficient evidence in favour of either metformin or COCP
• Licensed treatments for hirsutism include COCP, cosmic measures
(laser, electrolysis, bleaching, waxing, shaving) and topical facial
eflornithine (Vaniqa)
• Non-licensed treatments
• Spironolactone, antiandrogens (flutamide, finasteride, high dose
cyproterone acetate), metformin