HNY Policy and Pathway Repository - York

• PCOS is a common endocrine disorder, with a prevalence of 6-7% of population. It is characterized by ovulatory failure and hyperandrogenism; causing oligomenorrhoea, hirsuitism, acne and subfertility. (USS features of polycystic ovaries can be found in upto 20% of women, but the syndrome is only diagnosed with clinical features)
• Longer term sequelae include; Type 2 DM, cardio-metabolic syndrome, obesity and sleep apnoea.

• Endometrial Hyperplasia and carcinoma risk is elevated in this cohort, particularly when associated with < 4 periods a year (in the absence of hormonal therapy). Sudden changes in bleeding pattern over age 40 should be regarded as higher risk, consider early referral.
• Androgen-Secreting Tumours: a female with a total testosterone level >5nmol/L should be referred for further investigations.

Investigations

• History: establish clinical features, such as acne, hirsuitism, irregular periods, subfertility
• Examination: BMI, hirsuitism, presence of acne.
• Investigations:
  • baseline USS
  • Bloods: TFTs, Prolactin, FSH/LH (D1-5), Free Androgen Index
    • A raised free testosterone is more clinically significant than the traditional FSH/LH ratio for diagnostic purposes.

Management

• Subfertility: Please refer to the subfertility guideline, which supports early referral for patients with oligomenorrhoea, with a BMI under 35, for consideration of clomiphene therapy or ovarian driling.
• Oligomenorrhoea: general advice for any woman with PCOS is to ensure 4 withdrawal bleeds a year to prevent endometrial hyperplasia. This may be using any hormonal form of contraceptive.
• The Mirena offers excellent endometrial protection and contraception.
• If contraception is not required, then quarterly courses of progesterone e.g. Norethisterone 5mg tds for 10d to induce menses is recommended.
• The RCOG patient info sheet is a fantastic resource to guide patients.
• Symptoms of hyperandrogenism:
  • Weight loss- particularly if BMI >25 can improve sx
  • COCP- all will help reduce androgen levels, but Dianette, which contains cyproterone acetate, may yield quicker improvement, then consider conversion to a standard COCP after a year. Yasmin, is a second line COCP licensed for acne management.
  • Topical agents containing eflornithine; Vaniqa
  • Unlicensed therapies include: spironolactone and anti-androgens, but specialist advice should be sought to support the use of these agents.
• Longterm Risks: All patients should be given lifestyle advice on PCOS, about importance of healthy eating and exercise, but they should also be counselled about the 10-20% risk of T2DM and need for annual screening after age 40, with HbA1c levels.

Diagnosis

Two out of three of the following criteria should be met:

1. USS findings of polycystic ovaries (12+ peripheral “string of pearls” cycts)
    
2. Oligo – or Anovulation
    
3. Biochemical or clinical features of hyperandrogenism
    

Essential information for referral

• History should state if advice sought on diagnostic uncertainty, symptom management or subfertility input
• Hormone profile
• USS result
• Current contraception and parity
• Smear history
• Treatments options please indicate which tried, effective or contraindications exist
  • Mirena
  • COCP
• Relevant past medical/surgical history
• Current regular medication
• BMI – (Under 35 for surgery) and smoking status

Patient information leaflets/ PDAs

RCOG PILS
PatientUK
 

References

RCOG Long term Consequences of PCOS