Polycystic Ovary Syndrome (PCOS)

How do you manage the symptoms and risks associated with polycystic ovary syndrome (PCOS)?

Oligomenorrhoea / amenorrhoea/ prevention of endometrial cancer

To prevent endometrial cancer, a woman should have at least four to six periods in a year. This can be achieved through the following methods:

1. Lifestyle changes
   Management of lifestyle habits should be the first-line therapy for all women with PCOS and the target should be a weight loss (5-10 percent) in women with a body mass index (BMI) ≥ 25 kg/m2 and a prevention of weight gain in women with a BMI 18.5-24.9 kg/m2. The program should include both reduced dietary energy intake and regular exercise.

2. Oral contraceptive pill (OCP)
   It would preferably be a 30 μg Ethinyl Estradiol containing pill for its impact on insulin resistance. OCP is used when hyperandrogenism is associated and/or contraception is needed. 

3. Cyclic progestogens
   They should be used when contraception is not required and there are no signs of hyperandrogenism. Dydrogesterone or Medroxy Progesterone Acetate is usually used for 10-14 days every two to three months.

4. Metformin and Thiazolidinedione (glitazones) but they are not as efficient as initially shown.

Hirsutism

Choice of options depends on the patient’s preferences, impact on wellbeing, and access and affordability:

1. Self-administered and professional cosmetic therapy are first-line (laser recommended).

2. Eflornithine cream can be added and may induce a more rapid response.

3. Pharmacological therapy can be considered if cosmetic therapy is not adequate/affordable. The therapy chosen should be maintained for at least six months before changing dose or medication and a combination of therapies can be used.

The following options are available:

• OCP as a first-line in absence of contraindications.

• Anti-androgen (Spironolactone or Cyproterone acetate) in combination with an adequate contraception related to their teratogenic effect.

Infertility

Lifestyle intervention would be the first line of treatment to optimise preconception health and fertility and reduce pregnancy and longterm complications.

Patients should be advised for folates supplementation, smoking cessation before conception.

Infertility therapies may include:

• Clomiphene Citrate (CC) as the first-line. Standard practice is to titrate clomiphene citrate doses up to 150 mg/day. If ovulation is not achieved at this point, clomiphene citrate resistance is reached. If a pregnancy is not achieved after six ovulatory cycles with clomiphene citrate, this is termed a state of clomiphene citrate failure.
  
  Studies with clomiphene citrate show ovulation rates of 60–85 percent and pregnancy rates of 30-50 percent after six ovulatory cycles.

• Metformin should be combined with CC to improve fertility outcomes in women who are CC resistant, or immediately if BMI ≥ 30 kg/m2.
  
  
• As a second-line, the three following options should be discussed with the patient:
• Ovulation induction with Letrozole (Aromatase inhibitor which has shown its efficacy in ovulation induction but in an off-label fashion) or gonadotropins (daily subcutaneous injection),
• Laparoscopic ovarian drilling (procedure whereby a few holes, generally four are created at the surface of the ovary by a monopolar needle. Ovulation is achieved in 70-80 percent of cases) or
• Bariatric surgery for PCOS obese patients with a BMI ≥ 35 kg/m2, who are anovulatory, and who remain infertile despite undertaking a structured lifestyle management program for a minimum of six months.
• In-vitro fertilisation will be considered as the last resort.

Cardio-metabolic risk

1. Lifestyle changes: A weight loss of more than 5 percent, in overweight patients, reduces diabetes risk by approximately 50-60 percent in high-risk groups.

2. Optimise cardiovascular risk factors (Cholesterol and Glycemia)

3. Consider Metformin (reduces the risk of diabetes by approximately 50 percent in adherent high-risk groups)

4. Bariatric surgery for PCOS obese patients with a BMI ≥ 35 kg/m2, who have at least one metabolic or cardiovascular complication and who maintain their weight despite undertaking a structured lifestyle management program for a minimum of six months.