Polycystic ovary syndrome (PCOS) is a common endocrine disorder, characterised by excess androgen production and the presence of multiple immature follicles (“cysts”) within the ovary

The two most common hormonal abnormalities present in PCOS are:

Excess luteinising hormone (LH) – produced by the anterior pituitary gland in response to an increased GnRH pulse frequency.

This stimulates ovarian production of androgens.

Insulin resistance – resulting in high levels of insulin secretion.

Risk Factors

Individuals with diabetes, irregular menstruation and/or a family history of PCOS are at an increased risk of developing polycystic ovary syndrome.

Clinical Features

The most common symptoms reported by women include:

Immediate effects:

Irregular periods

Reduced menstrual flow

Excessive menstrual flow

Pimples / acne

Excessive facial & body hair ( Hirsutism )

Weight gain / Obesity

Mood swings, depression

Ovarian cysts

Hair loss

Acanthosis ( darkened skin )

Long term effects:

Infertility

Diabetes

Hypertension

Obesity

Endometrial / Uterine cancer

Management

The management of PCOS is tailored to the woman’s individual symptoms and needs. In general, first treat any underlying conditions such as diabetes or hypertension.

Oligomenorrhoea/Amenorrhoea

In anovulatory menstrual cycles, the effect of oestrogen is unopposed due to lower levels of progesterone. This can cause endometrial hyperplasia, which has a risk of becoming malignant. Therefore, in amenorrhoeic women, it is important to protect the endometrium from hyperplasia by inducing at least 3 bleeds per year. This can be done by using:

Combined oral contraceptive pill (low dose).

Dydrogesterone – a progesterone analogue. This is often used if the combined pill is contraindicated.

Obesity

Weight management in PCOS is vital – achieving a BMI of under 30 may be enough to trigger a regular menstrual cycle. Advise and encourage a heathy lifestyle, including healthy diet and exercise. This will increase insulin sensitivity.

Infertility

Clomifene +/- metformin helps induce ovulation and is therefore the first line of treatment for women wishing to conceive. However, there is an increased risk of multiple pregnancies, ovarian hyperstimulation syndrome and ovarian cancer (therefore it is limited to use in 6 cycles). Women with a normal BMI could also benefit from laparoscopic ovarian drilling.

Hirsutism

Hirsutism can be treated both cosmetically and/or with anti-androgen medication such as cyproterone, spironolactone or finasteride. However, these should be avoided during pregnancy as they are teratogenic. Eflornithine is a topical cream that can also be used to help reduce the growth rate of facial hair.

Summary

1. Polycystic ovary syndrome (PCOS) is a common endocrine disorder, characterised by excess androgen production and the presence of multiple immature follicles (“cysts”) within the ovaries.
2. The cause of PCOS is unknown but is thought to be due to a mix of genetic and environmental factors resulting in hormonal abnormalities (excess LH levels and insulin resistance).
3. Signs and symptoms include oligo-/amenorrhoea, infertility, hirsutism, obesity and acne.
4. Important investigations for a diagnosis are biochemistry and a pelvic ultrasound scan.
5. Management is catered to each woman’s needs:
   Low dose combined oral contraceptive pill or dydrogesterone for oligo-/amenorrhoea

   Exercise, orlistat for obesity

   Clomifene for infertility

   Cyproterone or spironolactone or finasteride and/or eflornithine for hirsutism.