HDR Women’s Health 11 th April 2012 By Dr Mahya Mirfattahi GP ST3 POLYCYSTIC OVARY SYNDROME A SUMMARY OF RCOG GREEN-TOP GUIDELINE

Why is it important? Common disorder Chronic 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 Rotterdam criteria 2 of 3 Polycystic ovaries (>12 peripheral follicles or increased ovarian volume >10cm 3 ) Oligo- or anovulation Clinical and/or biochemical signs of hyperandrogenism

Making the diagnosis Raised LH/FSH ratio is no longer a diagnostic criteria Recommended 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? Long-term risks to health Advise 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 Note; 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 Higher risk of gestational diabetes Screen before 20 weeks gestation Greatest in those requiring ovulation induction & obese women Metformin is currently not licensed for use in pregnancy

Cancer risk Oligo- 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 No association with breast or ovarian cancer

Treatment Lifestyle 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 Insulin-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 Weight-reduction drug may be helpful in reducing insulin-resistance through weight loss

Surgery Ovarian 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 Impact on women’s self-image & psychological effects Insufficient evidence in favour of either metformin or COCP Licensed 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