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Polycystic Ovary Syndrome A s ummary of RCOG Green-top guideline

Polycystic Ovary Syndrome A s ummary of RCOG Green-top guideline. HDR Women’s Health 11 th April 2012 By Dr Mahya Mirfattahi GP ST3. Why is it important?. Common disorder Chronic anovulatory infertility & hyperandrogenism Oligomenorrhoea, hirsuitism & acne

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Polycystic Ovary Syndrome A s ummary of RCOG Green-top guideline

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  1. Polycystic Ovary SyndromeA summary of RCOG Green-top guideline HDR Women’s Health 11th April 2012 By Dr MahyaMirfattahi GP ST3

  2. 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

  3. Diagnosis • Rotterdam criteria • 2 of 3 • Polycystic ovaries (>12 peripheral follicles or increased ovarian volume >10cm3) • Oligo- or anovulation • Clinical and/or biochemical signs of hyperandrogenism

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. Drug therapy • Insulin-sensitising agents have not been licensed in UK for women who are not diabetic • Metformin & thiazolidinedioneshave 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

  11. 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

  12. 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

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