A poorly diagnosed syndrome (PCOS) | Medical Observer


Medical ObserverJean Hailes is proud to provide a monthly column in the medical newspaper, Medical Observer. Designed to give GPs and health professionals a short informative summary of important women's health topics and conditions, these articles provide practical information to inform and enhance clinical practice. 

In this 'Talking Women' article for Medical Observer, Professor Helena Teede, Director at NHMRC Centre of Excellence in PCOS, writes about the latest evidence to assist GPs in caring for women with PCOS.

By Professor Helena Teede
MBBS PHD FRACP FAAHMS
Director, NHMRC Centre of Excellence in PCOS.

PCOS latest evidence assisting GPs

POLYCYSTIC ovary syndrome (PCOS) is a complex endocrine condition that can profoundly impact a woman's life.

The condition affects up to 13% of non-Indigenous women, and around 21% of Aboriginal and Torres Strait Islander women, of reproductive age.

PCOS is often characterised by excess body and facial hair, acne, and weight gain, but the symptoms are many and varied with diverse reproductive, metabolic and psychological features. Symptoms may differ due to ethnicity and may also change over a woman's life course.

Delays in diagnosis are common; in fact, 70% of women affected by PCOS remain undiagnosed.

Although there is currently no cure for this syndrome, accurate diagnosis and timely treatment of the symptoms can enable effective management and prevent longterm health problems.

Despite a perceived association with infertility, research shows that women with PCOS have, on average, the same number of children as women without the condition. However, they may need some medical assistance to achieve this.

The International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome 2018 represents the culmination of the advocacy of women with PCOS for improved resources to enhance timely and accurate diagnosis and care.

GPs are ideally placed to support women with PCOS, from diagnosis through to longterm management. Guideline resources for GPs have been developed with GPs, and include a health professional tool, algorithms, and a care plan template. These tools are designed to assist GPs to implement evidence-based practice, initiate multidisciplinary care, and engage patients in personalised management plans.

The guideline is the first international collaboration for PCOS assessment and management. Australia's Centre for Research Excellence in Polycystic Ovary Syndrome updated a 2011 NHMRC document, in partnership with the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine, and in collaboration with more than 70 international professional societies.

The guideline recommendations, endorsed by the NHMRC, have been published in the international journals Clinical Endocrinology, Human Reproduction and Fertility and Sterility.

Symptoms

Symptoms vary between women and across the life stages.

  • Reproductive features can include irregular menstrual cycles, hirsutism, sub-fertility and pregnancy complications.
  • Metabolic features can include insulin resistance, metabolic syndrome, prediabetes, type 2 diabetes and cardiovascular risk factors.
  • Psychological features can include distress, anxiety, depression, poor body image, sexual health challenges and disordered eating.

Diagnosis

The guideline endorses the Rotterdam diagnostic criteria (see below) in adults, and recommends tighter criteria requiring both hyperandrogenism and irregular cycles (See algorithm 1 in the guideline), with ultrasound not indicated in adolescents, because of the overlap with normal reproductive physiology.

Ultrasound is now not recommended in diagnosis in women within eight years of menarche. Where diagnosis is unclear, young women at risk can be identified and followed-up with reassessment.

The Rotterdam diagnostic criteria requires two of:

  1. Oligo- or anovulation
  2. Clinical and/or biochemical

Management 

Once diagnosed, assessment and management should address reproductive, metabolic and psychological features. Education, empowerment, multidisciplinary care, and lifestyle interventions for prevention or management of excess weight are important. Because PCOS is a heterogeneous chronic condition, helping the woman to engage in the development of a personalised management plan is essential.

Lifestyle is first-line treatment for all women with PCOS, addressing diet, physical activity and weight.

The combined oral contraceptive pill (COCP) is the first-line pharmacological management for menstrual irregularity and hyperandrogenism.

Hirsutism can also be managed through cosmetic options (for example, laser hair removal, depilatory creams and waxing).

Fertility interventions include recommending weight loss of 5-10% of total body weight if overweight, and encouraging women to consider conceiving before the age of 35 to allow time for fertility interventions, if needed.

Cardiovascular risk factors are increased for women with PCOS, so blood pressure and lipid profiles should be monitored, and lifestyle and pharmacological interventions identified.

Monitor emotional wellbeing and seek help for: distress, depression and/or anxiety; body image issues; disordered eating; or psychosexual dysfunction. Refer to a psychologist if necessary. Education, self-empowerment and reassurance also form a significant aspect of PCOS management.

Monitor clinically for sleep apnoea.

Referral 

Refer complex patients with PCOS to an endocrinologist or multidisciplinary team (for example, dietitian, psychologist, exercise physiologist) for initial workup, but for ongoing care by the GP.

Fertility specialist referral is appropriate after 12 months of intensive lifestyle intervention, if no other fertility factors are present and if the patient is under 35. If the patient is over 35, refer at six months.

Practice points

  • PCOS affects more than 1 in 10 non-Indigenous and more than 1 in 5 Indigenous women of reproductive age
  • Consider PCOS when irregular menstrual cycles are present
  • Lifestyle interventions are first-line
  • Pharmacological management and multidisciplinary care may be needed
  • Patient education and empowerment are crucial
  • Fertility should be considered before age 35

 

References on request

Resources

About the author

Professor Helena Teede is the Director of Monash Centre for Health Research and Implementation (MCHRI). Her areas of research are endocrinology, women's health, polycystic ovary syndrome (PCOS) and health services.

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