Polycystic ovary syndrome (PCOS)
  • Complex condition affecting reproductive and metabolic health. May affect up to 20% of Aboriginal women
  • Condition and symptoms result from increased androgens (male-type hormones, eg testosterone) and insulin resistance
  • Features may include excessive body hair growth, scalp hair loss, acne, obesity, irregular periods, infertility
  • Increased risk of cardiovascular disease, type 2 diabetes, obstructive sleep apnoea and endometrial cancer
  • Affected women are vulnerable to poor mental and emotional health

Diagnosis

PCOS diagnosed if at least 2 of these present AND other causes excluded (eg thyroid abnormality, hyperprolactinaemia)

  • Irregular or absent periods
  • Evidence of elevated androgens, either
    • Clinical hyperandrogenism: excessive facial or body hair, scalp hair loss, acne
      OR biochemical hyperandrogenism: a blood test showing an increased free androgen index or calculated free testosterone or bioavailable free testosterone 
  • Presence of polycystic ovaries on ultrasound in a woman more than 8 years after menarche (periods starting)

Can be difficult to diagnose in adolescents or within 8 years of menarche starting — medical consult

Ask

  • If periods irregular or absent
  • Contraceptive history
  • Reproductive history
  • If facial or chest hair has been removed (eg by shaving or waxing)

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • U/A, pregnancy test
  • Head-to-toe exam — with attention to acne and abnormal body hair

Do

  • Cardiovascular risk assessment and manage accordingly
  • Adult Health Check
  • If not known to have diabetes — 75g OGTT or HbA1c
  • Blood for total testosterone, SHBG, free androgen index (FAI), free testosterone (can’t assess androgen while on hormonal contraception)
  • If periods irregular or absent — take blood for TFT and prolactin to exclude other problems
  • Mental health screen — higher risk of depression, anxiety
  • Medical consult — for management of type 2 diabetes, infertility, menstrual problems
  • If the person does not clearly meet criteria for PCOS doctor will organise other tests and investigations 

Management

Best outcomes in PCOS are achieved with holistic and team based approach — patients with PCOS are eligible for chronic disease management plan

  • Lifestyle intervention
    • Healthy lifestyle behaviours encouraged 
    • Lifestyle interventions for high-risk groups (eg overweight/obesity, diabetes) — diet, exercise, quit smoking and behavioural strategies
    • Medical consult — if lifestyle interventions insufficient to meet goals
  • Emotional wellbeing
    • Use a PCOS quality of life tool (eg PCOSQ, modified PCOSQ) to assess wellbeing of women with PCOS
    • Medical consult — if symptoms of depression, anxiety, psychosexual dysfunction, body dysmorphia or eating disorders
  • Contraception — women with PCOS can conceive naturally
    • If pregnancy not wanted OR optimisation of health preconception are important — organise contraception
  • Regulate periods
    • Menstrual regularity can be improved with 5–10% weight loss
    • Hormonal contraception (eg COC) can be used to achieve regular withdrawal bleeds
  • Protect against endometrial (uterine) cancer if having less than 4 periods a year — hormonal therapy
    • Combined oral contraceptive pill (COC)
    • OR cyclical progesterone (eg medroxyprogesterone — not a contraceptive)
    • OR injectable progesterone
    • OR long-acting reversible contraceptives — see Long-acting reversible contraception (LARC)
  • Infertility
    • Weight loss of 5–10% can help to restore regular ovulation and increase chances of spontaneous conception
    • Offer tubal patency testing if at risk of tubal factor infertility (eg history of STI)
    • Refer to specialist for further investigations — after 12 months of trying for pregnancy under age 35, 6 months for age 35 or more 
    • Other options — surgery, assisted reproductive technology
  • Excess body hair
    • Shaving and waxing can improve appearance of facial and other hair
    • Medicine, if directed by doctor, may include — oral contraceptive pill, spironolactone. Some medicines for excess hair growth are not safe in pregnancy
    • Other less accessible methods include electrolysis, laser or eflornithine cream (if small area affected)

Supporting resources

  • International polycystic ovary syndrome guidelines