HDR Women’s Health

11th April 2012By Dr Mahya MirfattahiGP ST3

POLYCYSTIC OVARY SYNDROMEA SUMMARY OF RCOG GREEN-TOP GUIDELINE

Why is it important?•C

ommon disorder•C

hronic anovulatory infertility & hyperandrogenism• Oligomenorrhoea, hirsuitism & acne

•Obesity, impaired glucose tolerance, type 2 diabetes and sleep apnoea

•Adverse cardiovascular risk profile • Hypertension, dyslipidaemia, obesity, insulin resistance

Diagnosis•R

otterdam criteria•2

of 3• Polycystic ovaries (>12 peripheral follicles or increased

ovarian volume >10cm3)• Oligo- or anovulation• Clinical and/or biochemical signs of hyperandrogenism

Making the diagnosis•R

aised LH/FSH ratio is no longer a diagnostic criteria•R

ecommended baseline screening tests• TFTs• Serum prolactin• Free androgen index (total testosterone divided by SHBG x

100)• Note; if testosterone >5 nmol/l exlude androgen-secreting

tumours • Consider 17-hydroxyprogesterone• Test for Cushing syndrome if clinical suspicion

How should women be counselled?•L

ong-term risks to health•A

dvise regarding weight control & exercise

•Offer a glucose tolerance test if • Obese (BMI >30)• Strong family history of type 2 diabetes • >40 years

•Offer screening with annual fasting glucose

Cardiovascular risk•N

ote; conventional cardiovascular risk calculators have not been validated in women with PCOS

•BP and lipid profile• Treat BP as according to NICE guidelines• Lipid lowering treatment is not recommended routinely &

should be prescribed by a specialist• Mainly raised TG, total & LDL cholesterol

•Sleep apnoea• Ask about snoring & daytime fatigue/somnlonence

Pregnancy•H

igher risk of gestational diabetes• Screen before 20 weeks gestation• Greatest in those requiring ovulation induction & obese

women•M

etformin is currently not licensed for use in pregnancy

Cancer risk•O

ligo- or amenorrhoea in women with PCOS may predispose to endometrial hyperplasia & carcinoma• Good practice to recommend treatment with progestogens to

induce a withdrawal bleed at least every 3-4months•N

o association with breast or ovarian cancer

Treatment•L

ifestyle advice on diet & exercise• Loss of significant weight has been reported to result in

spontaneous resumption of ovulation, improvement in fertility, increased SHBG & normalisation of glucose metabolism

•Reduces likelihood of developing type 2 diabetes in later life

Drug therapy•I

nsulin-sensitising agents have not been licensed in UK for women who are not diabetic• Metformin & thiazolidinediones have been shown to have

short-term effects on insulin resistance & thereby reduce risk of developing type 2 diabetes• Metformin shown to modestly reduce androgen levels• No evidence of long-term benefits or support in prevention of

cardiovascular disease•W

eight-reduction drug may be helpful in reducing insulin-resistance through weight loss

Surgery•O

varian electrocautery should be reserved for selected anovulatory women with normal BMI• Persistence of ovulation & normalisation of serum androgens• May affect reproductive capacity of ovaries

Advice for hirsutism & acne•I

mpact on women’s self-image & psychological effects•I

nsufficient evidence in favour of either metformin or COCP•L

icensed treatments for hirsutism include COCP, cosmic measures (laser, electrolysis, bleaching, waxing, shaving) and topical facial eflornithine (Vaniqa)

•Non-licensed treatments• Spironolactone, antiandrogens (flutamide, finasteride, high

dose cyproterone acetate), metformin