Ep 115 – Polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in women of reproductive age, as well as being a major cause of infertility and pregnancy complications. It includes symptoms of hyperandrogenism, the presence of hyperandrogenaemia, oligo-ovulation or anovulation and polycystic ovarian morphology on ultrasound. It is strongly associated with complications that may arise from it, including insulin resistance, metabolic syndrome, fatty liver disease and an increased risk of developing type 2 diabetes. The main aims of treatment are directed at reducing hyperandrogenism or inducing fertility. In this episode, Dr Roger Henderson looks at these in more detail as well as what to remember when dealing with patients with PCOS in primary care.

Key references

1. Norman RJ, et al. Lancet. 2007;25;370(9588):685-97. doi: 10.1016/S0140-6736(07)61345-2.
2. Royal College of Obstetricians & Gynaecologists. https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/long-term-consequences-of-polycystic-ovary-syndrome-green-top-guideline-no-33/.
3. NICE. Clinical guideline [CG156]. https://www.nice.org.uk/guidance/cg156.
4. Morley LC, et al. Cochrane Database Syst Rev. 2017;11(11):CD003053. doi: 10.1002/14651858.CD003053.pub6.
5. Teede H, et al. BMC Med. 2010:8:41. doi: 10.1186/1741-7015-8-41.

Key take-home points

• PCOS is the most common endocrinopathy in women of reproductive age and a well-known cause of infertility and complications in pregnancy.
• In the UK, up to one in three women have more than 10 follicles per ovary detected on ultrasound (polycystic ovaries), but only one in three of these have PCOS.
• It is commonly defined as the presence of polycystic ovaries combined with one or more characteristic features, such as acne, male-pattern baldness, hirsutism, amenorrhoea or oligomenorrhoea, or raised serum concentrations of testosterone or luteinising hormone (LH).
• The cause remains unclear, but it is multifactorial and appears to be inherited as a common complex disorder.
• Insulin resistance is present in around 65–80% of women with PCOS independent of obesity; it is further worsened by excess weight triggered by the condition.
• LH levels are increased in almost four in 10 women with PCOS due to increased production from the anterior pituitary gland.
• Women with PCOS may also have increased serum oestrogen levels.
• The Rotterdam PCOS diagnostic criteria (2003) allow a diagnosis to be made if other causes have been excluded and if two of the following criteria are present: polycystic ovaries, oligo-ovulation or anovulation, and biochemical or clinical signs of hyperandrogenism.
• The diagnosis is largely one of exclusion.
• Common features of PCOS include hirsutism, acne, scalp hair loss or male-pattern baldness, irregular and infrequent periods, weight gain or difficulty losing weight, and infertility.
• PCOS investigations consist of endocrine tests and ovarian imaging.
• Women with PCOS typically show a serum concentration of testosterone above 2.5 nmol/L and a serum LH above 10 IU/L.
• Ultrasound scanning is used to assess for the presence of polycystic ovarian morphology unless the diagnosis of PCOS is obvious on clinical and biochemical grounds.
• Polycystic ovaries do not have to be present to make a diagnosis of PCOS, and the finding of polycystic ovaries does not alone establish the diagnosis.
• There is no single treatment which reverses PCOS hormonal changes or treats every clinical feature, so medical management is aimed at the symptoms present in each individual.
• Metformin (alone or in combination with combined oral contraceptive) may offer greater benefit in high metabolic risk groups, including those with diabetes risk factors, those with impaired glucose tolerance or people with high-risk ethnicity.
• If metformin is initiated in primary care it should be explained what an off-label use is and that adverse effects, such as gastrointestinal symptoms and reduced vitamin B12 levels, may occur.