PCOS – Polycystic Ovarian Syndrome

by | Dec 29, 2017

PCOS and failure to conceive were examined in KFP 2017.2 Case 5

Bill and Alana are 26 year old couple who have been trying to conceive for 7 months, with no success. They seek your help with helping them conceive. Alana has a history of irregular periods, long standing acne, hirsuitism, depression and sleep apnoea. Bill has no significant medical history.

What are the types of Ovulatory Dysfunction?

  • Group 1 = hypothalamic – ovarian axis failure  =low FSH/LH
  • Group 2 = hypothalamic – pituitary dysfunction = normal FSH eg PCOS
  • Group 3 = ovarian failure= high FSH (ovrian failure, no feedback)

What are the key features in history in PCOS?

  • Oligomennorhoea
  • Hirsuitism
  • Obesity
  • Infertility
  • Acne
  • Glucose intolerance
  • History of dyslipidaemia
  • Mental health disorders

What is in the Rotterdam Criteria for PCOS?

  • 2 out of 3 of
    • Oligo/Anovulation
    • Hyperandrogenism (clinical or chemical)
    • Polycystic Ovaries on USS

Investigations in PCOS?

  • Raised LH level with normal FSH levels (LH/FSH ratio >2)
  • Raised serum testosterone level
  • Transvaginal ultrasound (usually at least 12 follicles 2–9 mm in size in an enlarged ovary)
  • Possible endometrial biopsy

 

What broad-level screening activities should be undertaken in patients with PCOS?

  • Cardiovascular disease risk stratification
  • Emotional wellbeing screening
  • Obstructive Sleep Apnoea

What are the non-pharmacological management approaches to PCOS?

  • Lifestyle changes
    • weight control and ideally weight loss,
    • support for a balanced individual healthy eating plan,
    • increased physical activity

 

What are the management options for Oligomenorrhoea and amenorrhoea in PCOS?

Options include:

  • an oral contraceptive pill (OCP; low oestrogen doses [eg 20 μg] may have less impact on insulin resistance but also less impact on clinical hyperandrogenism)
  • cyclic progestins (eg 10 mg medroxyprogesterone acetate, 10–14 days every two to three months)
  • metformin (improves ovulation and menstrual cycles – though it is not PBS reimbursed for this option).228

What are the management options for Hirsutism in PCOS?

Choice of options depends on patient preference, impact on wellbeing, and access to and affordability of professional cosmetic laser therapy. Eflornithine cream can be added and may induce a more rapid response. Pharmacological therapy is as follows:

  • Primary therapy is the OCP.
  • Anti-androgen monotherapy (eg spironolactone or cyproterone acetate) should not be used without adequate contraception. Therapies should be trialled for ≥6 months before changing dose or medication.
  • Combination therapy – if ≥6 months of OCP is ineffective, add anti-androgen to OCP (twice daily spironolactone >50 mg or cyproterone acetate 25 mg/day, days one to 10 of OCP).229

What are the management options for Infertility in PCOS?

  • Patients and their partner may need advice and appropriate referral for fertility management.

 

References

  1. https://www.racgp.org.au/your-practice/guidelines/diabetes/13-diabetes-and-reproductive-health/131-polycystic-ovary-syndrome/
  2. https://www.racgp.org.au/afp/2012/october/polycystic-ovary-syndrome/
  3. https://www.mja.com.au/journal/2011/195/6/assessment-and-management-polycystic-ovary-syndrome-summary-evidence-based
  4. https://www.ncbi.nlm.nih.gov/pubmed/21929505