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Polycystic Ovary Syndrome
Polycystic Ovary Syndrome

Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common problem amongst women (5-20%), emerging at puberty. It is a complex condition that causes ovarian dysfunction which leads to metabolic issues. It is the most common endocrine issue in women of reproductive age and leading cause of infertility and pregnancy complications.

Pathophysiology

Its aetiology is not known. Some theories believe that it’s an issue with the hypothalamic-pituitary axis causing increased amplitude and frequency of luteinising hormone (LH) while others believe it is an issue of insulin resistance leading to compensatory hyper-insulinaemia. While others believe it is an issue with the ovaries and adrenal glands. There may be an interaction between these systems:

  • Insulin resistance causes compensatory insulin hypersecretion.
  • Hyperinsulinaemia promotes androgen output from the ovaries and also promotes adrenal androgen output. It also suppress sex hormone-binding globulin production from the liver thus increasing free androgen circulation.
  • High levels of luteinising hormone promotes ovarian androgen output. The high levels of LH occur due to increased GnRH secretion from the hypothalamus.
  • This abnormal hormonal status impairs the folicle’s ability to develop → polycystic ovarian morphology.
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⚠️ Risk factors

  • Family history
  • Diabetes
  • Irregular menstruation

😷 Presentation

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  • Oligomenorrhoea or amenorrhoea
  • Subfertility or infertility
  • Obesity - 70% of patients with PCOS
  • Hyperandrogenism
    • Hirsutism - growth of course hair in places women typically have fine hair (above lip, chin, chest, abdomen, back)
    • Acne vulgaris
  • Hair loss in a male pattern
  • Acanthosis nigricans - due to insulin resistance.
  • Psychological disorders
    • Mood swings
    • Anxiety
    • Depression
💭
Differentials of hirsutism:
  1. Medications - phenytoin, ciclosporin, corticosteroids, testosterone, anabolic steroids.
  2. Ovarian or adrenal tumours - as these will secrete androgens.
  3. Cushing’s syndrome
  4. Congenital adrenal hyperplasia

💯 Criteria

The Rotterdam criteria are used for the diagnosis of PCOS in women, which requires at least 2 out 3 of the following features:

  1. Oligoovulation and/or anovulation - manifesting as irregular or absent menstrual periods.
  2. Hyperandrogenism - characterised by hirsutism and acne or elevated levels of total/free testosterone.
  3. Polycystic ovaries on ultrasound
    1. Presence of >12 follicles (that measure 2-9 mm in diameter) in one/both ovaries OR (string of pearls appearance).
    2. Increased ovarian volume >10cm³
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🔍 Investigations

NICE recommends the following:

  1. ⭐️ Total testosterone - normal to moderately elevated in PCOS.
  2. ⭐️ Sex hormone-binding globulin - normal to low in PCOS.
  3. Free androgen index - calculated by 100 x (total testosterone/SHBG). Normal or elevated in PCOS.
  4. ⭐️ Luteinising hormone and FSH - LH is more raised than FSH (which can be normal). They are also increased in women with premature ovarian failure and decrease in women with hypogonadotropic hypogonadism.
    1. LH:FSH ratio - increased >2. It is also useful in excluding menopause (ratio is normal in menopause).
  5. Prolactin - mildly elevated in PCOS
  6. TSH
  7. ⭐️ Ultrasound scan
    1. Presence of >12 follicles (that measure 2-9 mm in diameter) in one/both ovaries OR
    2. Increased ovarian volume >10cm³
  8. Fasting and oral glucose tolerance test - may show insulin resistance.

A formal diagnosis can only be made when investigations have also excluded other conditions.

🧰 Management

Patients should be offered screening for:

  1. T2DM - a 2-hour OGTT should be offered annually.
  2. CVD - QRISK2 assessment tool.

It is important to advise the patient on weight reduction and dietary modifications as well as educate them on the increased risks of CVD, diabetes and endometrial cancer.

Let’s take a look at how we can manage the clinical features of PCOS according to NICE guidelines:

🩸
Oligomenorrhoea or amenorrhoea:
  • Prolonged amenorrhoea (less than one period every 3 months)/abnormal vaginal bleeding/excess weight
    1. Cyclical progestogen (medroxyprogesterone) - to induce withdrawal bleed.
    2. After withdrawal bleeding has been induced → refer for transvaginal ultrasound to assess the endometrial thickness:
      1. If endometrial thickening present (>10mm) → refer for endometrial sampling to exclude endometrial hyperplasia or endometrial cancer.
      2. If endometrial thickness is normal - we can give medication depending on the women’s factors and wishes:
        • Combined oral contraceptive (COC)
        • Medroxyprogesterone
        • Levonorgestrel-releasing intrauterine system (LNG-IUS) - if she is unwilling to take cyclical hormone treatments such as COC or medroxyprogesterone.
🧴
Acne:
  1. COC - is first-line if there are no contraindications.
    1. Co-cyprindiol may be used as it has anti-androgen action as well.
  2. Topical retinoids - adapalene for example.
  3. Topical antibiotics - clindamycin for example
  4. Oral antibiotics - doxycycline for example.
🧔‍♀️
Hirsutism:
  1. COC - is first-line if there are no contraindications.
    1. Co-cyprindiol may be used as it has anti-androgen action as well.

      2. It is important to think about the increased risk of venous thromboembolism. Therefore it is stopped after 3 months.

Other options include:

  • Topical eflornithine - used to treat hirsutism.
  • Electrolysis
  • Laser hair removal
  • Spirinolactone - also has anti-androgen effects.
🤰
Infertility:

Encourage healthy lifestyle and advise on smoking cessation. Weight loss is the first step as it can regulate ovulation.

  • Refer to fertility clinic - they may use options such as:
    • Clomifene
    • Ovarian drilling
    • IVF