What is PCOS?

Polycystic ovarian syndrome is a complex hormonal condition involving many different aspects of our physical and mental health. This is why your specialist GP is the best person to diagnose and manage this disorder.

Women with PCOS can present with a range of symptoms and signs including:

• Acne
• Increased facial and body hair
• Scalp hair loss
• Irregular menstrual periods
• Difficulty getting pregnant/Infertility
• Pregnancy complications
• Insulin resistance, prediabetes
• High blood pressure
• Type 2 diabetes
• Heart attack and stroke (cardiovascular disease)
• Depression
• Anxiety

Women with PCOS commonly have high levels of insulin, or male hormones known as ‘androgens’, or both. The cause of this is unclear, but insulin resistance is thought to be the key problem driving this syndrome, and this is why a diet low in carbohydrate is the cornerstone of managing PCOS.

In some women, PCOS runs in the family, whereas for others, the condition only occurs when they are overweight.

Diagnosis

Diagnostic criteria for Rotterdam diagnosis of polycystic ovary syndrome
Two of the following three criteria are required:

1. Irregular Menstrual Cycles (Oligo/Anovulation)
2. High levels of androgen (male) hormones (Hyperandrogenism) Clinical (hirsutism, acne or less commonly male pattern alopecia) or Biochemical (raised FAI or free testosterone)
3. Polycystic ovaries on ultrasound

Other causes must be excluded such as congenital adrenal hyperplasia, androgen secreting tumours, Cushing syndrome, thyroid dysfunction and hyperprolactinaemia

There are a number of different definitions of PCOS, however the Rotterdam consensus is the most widely accepted in Australia, Europe and Asia and was the definition used for the Evidence-based guideline for the assessment and management of polycystic ovary syndrome developed by the PCOS Australian Alliance in 2011 (and updated in 2015). The information presented here is taken directly from the guideline.

1. Irregular menstrual cycles (Oligo/Anovulation)

In adolescents, at what time point after onset of menarche do irregular cycles indicate ongoing menstrual dysfunction?

Recommendations

CLINICAL CONSENSUS RECOMMENDATION
In adolescent women (<18 years), after two years of irregular cycles (>35 or <21 days) following the onset of menarche, polycystic ovary syndrome should be considered and appropriate assessment should be undertaken. As polycystic ovary syndrome is a diagnosis of exclusion, other causes of irregular cycles (such as thyroid dysfunction or hyperprolactinemia) need to be considered and excluded prior to the diagnosis of polycystic ovary syndrome.

CLINICAL PRACTICE POINT

If oral contraceptive pill therapy is being considered or has commenced in adolescents (<18 years), the following are recommended:

• After twelve months of irregular cycles (>35 or <21 days) after onset of menarche, polycystic ovary syndrome should be considered before commencement of the oral contraceptive pill.
• Where the oral contraceptive pill has already been commenced, when girls are not sexually active, if biochemical hyperandrogenism is needed for the diagnosis of polycystic ovary syndrome, the oral contraceptive pill could be withdrawn for three months to facilitate appropriate hormonal assessments. Withdrawal of the oral contraceptive pill may facilitate assessment and early diagnosis of polycystic ovary syndrome as diagnosis can have important implications including optimisation of healthy lifestyle, regular metabolic screening and proactive fertility planning, with consideration of planning for conception at an earlier age. However, the risk of unplanned pregnancy needs to considered and weighed up against potential benefits of early diagnosis. Contraception may still need to be otherwise managed during this time.

Clinical impact of the recommendations: Very large
Irregular cycles (>35 or <21 days) that continue for more than two years after the onset of menarche are likely to reflect oligo-anovulation. Consideration should be given to age of menarche. Current practice is unclear. It is likely that current practice involves prescription of the oral contraceptive pill without diagnosis of PCOS in adolescents. This recommendation may increase referral for diagnostic testing and specialist care, however the benefits of early diagnosis and prevention of associated complications and infertility are likely to result in significant savings. Focus on lifestyle management, rather than medical management, may be increased.

2. Hyperandrogenism

In women with suspected PCOS, what is the most effective measure to diagnose PCOS related hyperandrogenism?

Recommendations

CLINICAL CONSENSUS RECOMMENDATION
Late-onset congenital adrenal hyperplasia, although rare, needs to be considered, before the diagnosis of polycystic ovary syndrome is confirmed. In more severe clinical cases of hyperandrogenism, 21-hydroxylase deficiency, the most common form of congenital adrenal hyperplasia can be excluded by measuring serum 17-hydroxyprogesterone in the follicular phase to explore this diagnosis.
EVIDENCE-BASED RECOMMENDATION
Calculated bioavailable testosterone, calculated free testosterone or free androgen index should be first line investigation for biochemical determination of hyperandrogenism in polycystic ovary syndrome.
The addition of androstenedione and dehydroepiandrosterone sulfate could be second line investigation for biochemical determination of hyperandrogenism in polycystic ovary syndrome.
CLINICAL PRACTICE POINT
It is difficult to assess androgen status in women on the oral contraceptive pill as effects include oestrogen mediated increases in sex hormone-binding globulin and reduction in androgens.
Where the oral contraceptive pill has already been commenced, it should be withdrawn for at least three months before appropriate hormonal assessments for diagnosis of polycystic ovary syndrome are undertaken. Contraception should be otherwise managed during this time.
CLINICAL PRACTICE POINT
If androgen levels are markedly above laboratory reference ranges, secondary causes may be considered. Mild elevations of androstenedione may be seen in polycystic ovary syndrome, whereas marked elevations are more indicative of non-classical adrenal hyperplasia.
Reference ranges for different methods and different laboratories vary widely and clinical decisions should be guided by the reference ranges of the laboratory used.

3. Polycystic ovaries

In adolescents, what are the most effective criteria to diagnose polycystic ovaries on ultrasound?

“Between the ages of two and nine years, the size and morphology of the ovaries are relatively stable with the volume of each ovary being less than 2 cm; however from around nine years of age onward, the ovaries undergo progressive increases in size. The number of large antral follicles and ovarian size reaches its maximum around the time of menarche and many girls with regular menstrual patterns may have polycystic ovaries. Recently up to 68% of 19-21 year old Danish women were shown to have polycystic ovaries according to Rotterdam criteria on community based screening. As follicle counts are high at a younger age, this needs to be considered to avoid over diagnosis of PCOS. It seems unlikely that the adult criteria (presence of 12 or more follicles in each ovary measuring 2-9mm in diameter, and/or increased ovarian volume (>10ml)) for diagnosing PCOS according to polycystic ovaries are directly applicable to adolescents. There is continuing discussion as to the quantitative characteristics of a polycystic ovary given increasing resolution of ultrasound.”

Recommendations

CLINICAL CONSENSUS RECOMMENDATION
Given the apparent lack of specificity of polycystic ovaries on ultrasound in adolescents, generally, ultrasound should not be recommended first line in this age group for diagnosis of polycystic ovary syndrome pending further research. If pelvic ultrasounds are to be ordered in adolescents, the results should be interpreted with caution.
CLINICAL PRACTICE POINT
Vaginal ultrasound is not appropriate in adolescents who have not been sexually active.

Treatment of PCOS

It is important that all the symptoms of PCOS are addressed and managed long term, to avoid associated health problems. PCOS is a long-term condition and long-term management is needed.

Lifestyle modifications

Lifestyle changes – such as eating a healthy diet low in carbohydrate and introducing regular physical activity into your weekly routine – can have a positive effect on your health in so many ways. For women who have PCOS, a healthy lifestyle can lead to an improvement in symptoms, particularly if your new lifestyle helps you to lose weight.

Weight reduction

You don’t even have to lose much weight to feel the benefit. Studies suggest that just 5 to 10 per cent weight loss can: restore normal hormone production – which can help regulate periods and improve fertility improve mood reduce symptoms such as:

• facial and body hair growth
• scalp hair loss
• acne

It can also reduce your risk of developing type 2 diabetes and cardiovascular disease.

Medical treatments for PCOS

Medical treatments for PCOS treatments include:

1. Combined oral contraceptive pill (COCP)
   If you are suffering from irregular, heavy periods, the oral contraceptive pill is often prescribed for contraception, to regulate the cycle, reduce excess hair growth and acne, and prevent the lining of the womb from thickening excessively
2. Anti-androgen medication (blocks hormones such as testosterone)
   E.g. spironolactone – these may be used to reduce excess hair growth or scalp hair loss and treat acne
3. Anti-acne medications
   See our acne section
4. Fertility medications
   If fertility is a problem, clomiphene citrate (sold as Clomid) or metformin may be taken orally to bring about ovulation (egg release) and increase the chance of falling pregnant
5. Psychological counselling
   Your doctor and specialists can advise you about what treatment best suits you.
6. Medication to reduce the risk of heart attack and stroke
   E.g. cholesterol and blood pressure lowering medication
7. Medication for prediabetes and type 2 diabetes
   E.g. metformin

Ref:
1. Polycystic ovary syndrome: an update. AFP. Volume 41, No.10, October 2012 Pages 752-756
2. Evidence-based guidelines for the assessment and management of polycystic ovary syndrome. Jean Hailes for Women’s Health on behalf of the PCOS Australian Alliance; Melbourne, 2015.