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.  

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.

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).

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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2. Wang JX, Davies MJ, Norman RJ. Polycystic ovarian syndrome and the risk of spontaneous abortion following assisted reproductive technology treatment. Hum Reprod. 2001;16(12):2606-9.

3. Boomsma CM, Eijkemans MJ, Hughes EG, Visser GH, Fauser BC, Macklon NS. A meta-analysis of pregnancy outcomes in women with polycystic ovary syndrome. Hum Reprod Update. 2006.

4. Diamanti-Kandarakis E. Insulin resistance in PCOS. Endocrine. 2006;30(1):13-7.

5. Diamanti-Kandarakis E, Papavassiliou AG. Molecular mechanisms of insulin resistance in polycystic ovary syndrome. Trends in Molecular Medicine. 2006;12(7):324-32.

6. Azziz R, Carmina E, Dewailly D, et al. Criteria for Defining Polycystic Ovary Syndrome as a Predominantly Hyperandrogenic Syndrome: An Androgen Excess Society Guideline. Journal of Clinical Endocrinology and Metabolism. 2006;91(11):4237-4245.

7. Teede H, Zoungas S, Hutchison S, Meyer C. Insulin resistance, metabolic syndrome, diabetes and cardiovascular disease in polycystic ovary syndrome. Endocrine. 2006;30  (1):45-53.

8. Galletly C, Clark A, Tomlinson L, Blaney F. A group program for obese, infertile women: weight loss and improved psychological health. J Psychosom Obstet Gynaecol. 1996;17(2):125-8.

9. Clark AM, Thornley B, Tomlinson L, Galletley C, Norman RJ. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod. 1998;13(6):1502-5.

10. Huber-Buchholz MM, Carey DG, Norman RJ. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone. J Clin Endocrinol Metab. 1999;84(4):1470-4.

11. Moran LJ, Noakes M, Clifton PM, Tomlinson L, Norman RJ. Dietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2003;88(2):812-9.

12. Andersen P, Seljeflot I, Abdelnoor M, et al. Increased insulin sensitivity and fibrinolytic capacity after dietary intervention in obese women with polycystic ovary syndrome. Metabolism. 1995;44(5):611-616.

13. Holte J, Bergh T, Berne C, Wilde L, Lithell H. Restored insulin sensitivity but persistently increased early insulin secretion after weight loss in obese women with polycystic ovary syndrome. J Clin Endocrinol Metab. 1995;80:2586-2593.

14. Hamilton-Fairley D, Kiddy D, Anyaoku V, Koistinen R, Seppala M, Franks S. Response of sex hormone binding globulin and insulin-like growth factor binding protein-1 to an oral glucose tolerance test in obese women with polycystic ovary syndrome before and after calorie restriction. Clin Endocrinol (Oxf). 1993;39(3):363-7.

15. Wahrenberg H, Ek I, Reynisdottir S, Carlstrom K, Bergqvist A, Arner P. Divergent effects of weight reduction and oral anticonception treatment on adrenergic lipolysis regulation in obese women with the polycystic ovary syndrome. J Clin Endocrinol Metab. 1999;84(6):2182-7.

Content Updated March 12, 2008