PCOS – Relevance to Health

and Fertility

Dr Sarah Wakeman

FRANZCOG, CREI

PCOS – what is it?

• Endocrine disorder affecting 8-10% women in

reproductive age group

• Diagnosis – Rotterdam criteria 2003

– 2 of 3

• Hyperandrogenism

• Irregular periods – oligo or anovulation

• Polycystic ovarian morphology on USS

• and exclusion of other related disorders such as Cushing ’ s

syndrome,congenital adrenal hyperplasia, hyperprolactinemia

and androgen-secreting tumors

PCOS – what is it?

• Diagnostic criteria

– Debated

– Androgen Excess,PCOS Society criteria

• Hyperandrogenism

• Oligo or an ovulation or PCO on USS

• Pathophysiologic defect unknown

• Insulin R exacerbates or causes

hyperandrogenism and vice versa

PCOS – Relevance to Health

PCOS presentation

• Reproductive age group

– Irregular periods

– Hirsutism

– Infertility

• Women with PCOS often have

– Impaired glucose tolerance

– Dyslipidaemia

– Increased risk Type 2 diabetes and metabolic

syndrome

PCOS presentation

• 60-80% have IR

• 95% who are obese have IR

• IGT predictor of later Type 2 diabetes and

GDM

• Obesity 30-70% - usually abdominal

PCOS in adolescents

• No definite agreed diagnostic criteria

• Hyperandrogenism and oligo or amenorrhoea

– Agreed by most that need both

– Oligomenorrhoea persisting for 2 years

– PCO on USS and irreg periods alone not enough

• Very common in young women

• Should have enlarged ovaries as well as PCO

– Important to rule out other conditions

• CAH, Cushings, inc prl, hypothyroidism, ovarian or

adrenal tumours

• Often family history of PCOS, diabetes etc

PCOS in adolescents

• Presentation

– Irregular periods

– Hirsutism,acne

– High proportion overweight or obese

• Obesity often predates anovulation and

hyperandrogenism

– HbA1C not a good screening test in adolescents

and should have OGT

• High rate of IGT, some will have Type 2 diabetes

PCOS in adolescents

• Lab tests

– Rule out other diagnoses

– Metabolic evaluation

• Testosterone, SHBG, FSH, LH, DHEAS, 17

hydroxyprogesterone, androstenedione,

TSH/T4, prl, lipids, HbA1C, OGTT, ALT and

AST

• ? Pelvic USS

PCOS after menopause

• Hyperandrogenism persists

• Insulin resistance so increased risk Type 2

diabetes

• Those with metabolic syndrome increased

risk CVS disease

– PCOS increased risk metabolic syndrome

• Unclear if PCOS associated with greater risk

CVS disease

PCOS after menopause

• No definite phenotype or diagnostic criteria

• Studies include women with history of PCOS

signs and symptoms

• Classic PCOS phenotype often improves

towards menopause

– AMH decreases, less ovarian follicles

PCOS in GP

• Diagnosis

– Excluding other conditions

• Managing current symptoms

– Menstrual problems, acne, hirsutism, infertility

• Assessing risk factors for long term problems

– Weight, BMI, waist circumference

– BP

– IGT/diabetes

– Lipids

– Endometrium – needs protection

PCOS in GP

• Endometrial protection

– Risk of endometrial hyperplasia and cancer

– If oligo or amenorrhoea

– Pelvic USS – endometrial thickness more than

7mm in early part of cycle or with low estrogen

and progesterone levels on blood test

• Need endometrial biopsy

PCOS treatment

• Weight loss, diet, exercise

– Mainstay

• Insulin sensitisers – Metformin

– For IGT,diabetes, dyslipidaemia

– Side effects – start low and increase slowly

– May assist weight loss

• COCP

– Irregular periods, endometrial protection, hirsutism

PCOS – Relevance to fertility

PCOS and fertility

• Difficulty conceiving

– Anovulation or infrequent ovulation

– Obesity

• Most common cause of ovulatory problems in

women

PCOS and fertility

• Treatment

–Lifestyle modification• Wt loss – diet and exercise

• Even small amounts of weight loss (5-

10kg) can cause big changes in

frequency of ovulation, pregnancy

PCOS and fertility

• Treatment

– 1st line ovulation induction

– Letrozole now rather than clomiphene citrate

• More single ovulations – less risk multiple pregnancy

• Higher pregnancy rates

• Off label use

– 2nd line

• Metformin

• FSH ovulation induction

• Laparoscopic ovarian drilling

• IVF

PCOS and fertility

• Overweight

– Lower chance of pregnancy

– Higher risk complications in pregnancy

• Hypertension, GDM, large baby, operative delivery, pre

term delivery

– Long term effects on child

PCOS – risks in pregnancy

• 3-4 x increased risk PIH and PET

• 3x increased risk gestation diabetes

• 2x increased risk premature delivery

• ?increased risk of miscarriage

– Debated

• Obesity – increased risk congenital

malformations in babies

PCOS – offspring health

• Probably increased risk endocrine and

cardiovascular dysfunction

– Genetic

– Environmental – pregnancy and early childhood

• If mother overweight inc risk child will be

Summary

• PCOS very relevant

– General Health

• Current

• Long term risks

– Fertility

• Current – becoming pregnant

• Pregnancy

• Future child