Polycystic Ovarian Syndrome
Definition (2 out of following 3 criteria)
- Irregular or absent ovulation (menstruation)
- Clinical and/ or biochemical signs of raised androgens
- Polycystic ovaries on USS, defined as the presence of 12 or more follicles in one or both ovaries and/or increased ovarian volume
Ultrasound is not necessary to diagnose PCOS. The Ultrasonographers at RCHT do not accept referrals from GPs to look for cysts alone and polycystic ovaries do not have to be present to make the diagnosis of PCOS.
Other endocrine disorders may need to be excluded.
Assess cardiovascular risk factors such as hypertension, obesity, hypercholesterolaemia and T2 Diabetes.
Investigations prior to referral:
- Free androgen index (FAI = testosterone / SHBG x100 – one yellow top tube to biochemistry)
- Hormonal contraception should be stopped at least 3 months before investigations. This is due to effects on SHBG and altered gonadotrophin-dependent androgen production.
If testosterone greater than 5 consider androgen secreting tumour
- TSH if clinical suspicion
- LH/FSH and prolactin if anovulation/amenorrhoea
Treatment options*:
- Weight loss, exercise for all
- COCP/dianette (androgenic Sx and cycle control)
- Cyclical progestogens eg. Medroxyprogesteone 10mg daily for 14 days every 1-3 months (cycle control)
- Mirena (cycle control)
- Vaniqua (hirsuitism)
Referral:
Infertility - refer to Infertility service
Symptom control - if initial treatments (see above*) not effective:
- Hirsutism – Refer to Endocrinology
And\or
- Menstrual Disorders/Consideration of anti-androgens or metformin- Refer General Gynaecology
Surveillance of endometrium, or endometrium >10mm on USS
- If the woman has amenorrhoea >3 months prescribe a cyclical progestogen to induce a withdrawal bleed, then refer for a TV USS to assess endometrial thickness. If endometrial thickening present >10mm or has an unusual appearance, refer (either Routine or Urgent/2ww accordingly) for endometrial sampling.
- If the woman is unwilling/unable to use hormones, seek A&G or refer Gynaecology. Regular USS (every 6-12 months) is likely required to assess endometrial thickness and morphology.
Information to include in the referral letter to General Gynae Clinic:
- History of Raised Androgens, e.g. hirsutism, acne etc. including severity of Sx.
- Menstrual history
- Metabolic disturbance
- Obesity
- Treatments tried* and response to treatments
- TV USS report (attached)
References: cks.nice.org.uk/topics/polycystic-ovary-syndrome/
Date reviewed September 24
Next review due September 26
Author: Dr S Burns
Reviewed by: Dr M Schick
Contributors: Lisa Verity, Susan Bates Consultant Gynaecologists, RCHT
Version 1.2