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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 • • • • • • 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
