Background
Polycystic ovary syndrome (PCOS) is the most common endocrine abnormality in reproductive-aged women having psychological, reproductive and metabolic manifestations. PCOS affects 5-10 per cent of reproductive-aged women or 400,000 women in Australia 1. In 2006 the estimated economic burden of PCOS in Australia was $40 million (menstrual dysfunction 31 per cent, infertility 12 per cent and PCOS-associated diabetes 40 per cent of total costs), representing a major health and economic burden 1.
Author
Professor Helena Teede
MBBS, PhD, FRACP
Research Director,
The Jean Hailes
Foundation for Women’s
Health, and
Chair, Women’s Health at Monash University. |
PCOS manifests as a variety of clinical features, none of which is pathognomonic. Clinical manifestations can include psychological features (anxiety, poor self esteem, reduced quality of life), reproductive features (hyperandrogenism, ovulatory and menstrual dysfunction, infertility, pregnancy complications including early pregnancy loss, gestational diabetes, pregnancy-induced hypertensive disorders and neo-natal complications) and metabolic features (insulin resistance, metabolic syndrome including lipid abnormalities, increased risk of impaired glucose tolerance [IGT], diabetes [DM2] and potentially cardiovascular disease [CVD]) 2, 3.
The diagnosis remains controversial, but is currently based on the presence of two of three reproductive criteria – ovulatory disturbance, hyperandrogenism and polycystic ovaries (PCO) on ultrasound in the absence of other causes. In the majority of both lean and overweight women with PCOS, insulin resistance (IR) is central to the pathogenesis of the syndrome with hyperinsulinaemia driving reproductive and metabolic features 4, 5, 6, 7. Insulin resistance is both genetic and lifestyle related. Obesity exacerbates psychological, reproductive and metabolic features of PCOS and as obesity increases in the community, the prevalence of the PCOS phenotype and associated glucose intolerance and diabetes are expected to rise significantly.
Clinical assessment and investigations
There is no single diagnostic test for PCOS. It is important to ensure the patient is not taking an oral contraceptive before hormone testing. Investigations include testosterone, SHBG free androgen index, prolactin and TSH level to exclude other causes. Other optional investigations include a pelvic ultrasound for ovarian morphology and endometrial thickness. An oral glucose tolerance test and lipid profiles should be performed in all women at diagnosis and regularly thereafter in those who are overweight or at increased risk of diabetes (1-2 yearly). Fasting glucose is inadequate in these women. There is no role in clinical practice for measuring insulin levels as the assays are inaccurate and highly variable. Insulin resistance is best reflected by features of metabolic syndrome and by glucose abnormalities on the OGTT.
Treatment of PCOS
Treatment needs to be individualised and underpinned by education on both short and long term sequalae of PCOS. Resources are readily available and include www.managingpcos.org.au or www.jeanhailes.org.au (both of which have community and health professional sections) as well as an Australian support group POSAA – www.posaa.asn.au Psychological features need to be acknowledged, discussed and counselling considered as women with PCOS are unlikely to successfully implement sustained lifestyle changes without first addressing psychosocial issues.
Figure 1
Targeted treatment options for the clinical features related to hyperandrogenism, menstrual disturbance (including infertility) and metabolic features.
The Royal Australian College of General Practitioners. check Program: Polycystic ovary syndrome, 2008. Reproduced with permission. |
Weight loss, exercise and lifestyle interventions
Lifestyle change is first-line therapy and is critical in all overweight women with PCOS and prevention of weight gain is important. 5-10 per cent weight loss has major clinical benefits, including improving psychological outcomes (self esteem, anxiety, mean depression scores and scores on general health questionnaire) 8, reproductive features (menstrual cyclicity, ovulation and fertility) 9, 10 and metabolic outcomes (IR, metabolic syndrome) and in non PCOS populations decreases DM2 and CVD) 9-13. It is critical to realise and to counsel patients that small achievable goals make a large impact, despite subjects remaining clinically overweight or obese 9, 14, 15. No specific dietary regimen has been proven superior in PCOS and although a low GI diet may offer theoretical advantages it is yet to be adequately researched in PCOS.
Structured moderate exercise (3 times per week for 40 minutes) is more effective than diet alone, inducing greater improvements in androgens, insulin resistance and ovulation, and a trend to increased pregnancy rate with exercise versus diet alone in PCOS, despite a greater weight loss with diet alone. Translation of current evidence into practice suggests a combination of exercise with overall sustainable reduction in caloric intake through long term behavioural change.
Targeted approach to therapy
Treatment options for the reproductive and metabolic implications of PCOS are varied and need to be tailored to the clinical presentation (figure 1). In addition to healthy lifestyle changes options include cyclic progestin to induce withdrawal bleeds (2-3 monthly), the oral contraceptive pill, metformin and targeted infertility therapies (figure 1, box 1).
Box 1 Targeted treatment options in PCOS:
Hirsutism / acne secondary to hyperandrogenism:
- Lifestyle changes and 5-10 per cent weight loss
- The OCP: combined OCPs increase SHBG and reduce androgens (lower dose 20 μg OCPs may be preferable as higher dose OCPs increase IR)
- Metformin* 1-2 g slow release given at night has equivalent efficacy to OCPs11
- Cosmetic therapy (e.g. electrolysis and laser)
- Topical antiandrogens (e.g. Vaniqa)
- Antiandrogens can be added to OCP (daily spironolactone 50 mg bd or cyproterone acetate 25 mg/day for day 1-10 of the active OCP tablets), take ~ 6 months, must be taken with the OCP to prevent abnormal menstrual bleeding and adverse effects in pregnancy
Irregular cycles:
- Lifestyle changes aiming for sustainable 5-10 per cent weight loss, including structured exercise 3 times per week
- Cyclic progestins (e.g. 10 mg provera, 14 days every 2-3 months), decreases risk of endometrial hyperplasia / carcinoma.
Infertility
- Obesity independently causes infertility and should be addressed with healthy lifestyle (lifestyle change is effective and critical, with small changes in weight having major benefits)
- Be wary of age-related infertility and, if possible, plan a family before age 35 years
- Other effective therapies are available if needed and include:
Clomiphene
Metformin*
Gonadotrophins
Metabolic syndrome, prediabetes, diabetes and CVD risk
- Obesity independently causes metabolic complications and should be addressed
- Lifestyle change with a 5 per cent weight loss reducing diabetes risk by 60 per cent in high risk groups
- Metformin* reduces the risk of diabetes by 60 per cent in high risk groups
* Note the use of metformin in PCOS is supported by Level I evidence including a Cochrane review and multiple randomised controlled trials, as well as by relevant professional bodies including the Endocrine Society of Australia. However no application has yet been lodged with the Therapeutics Goods Administration (TGA) and it therefore has not yet been approved for use in PCOS in Australia and prescriptions are off label. An application to the TGA is pending. |
Summary
PCOS is common and is a major health and economic burden. It is associated with psychological, reproductive and metabolic features and in the majority of cases is underpinned by insulin resistance. Management should focus on education, healthy lifestyle and targeted medical therapy as required. Monitoring for longer term metabolic complications including glucose intolerance and hyperlipidemia is also important.
 Talking Women - Treating PCOS (125.37 KB)
References
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Content Updated March 12, 2008 |
