Dr Melissa Buttini m.b.b.s franzcog
The International Evidence Based Guideline for the Assessment and Management of PCOS
was released in July 2018. Read the whole guideline HERE.
Polycystic Ovary Syndrome (PCOS) is a common cause of heavy irregular periods, complete absence of periods, infertility, and signs of over production of androgens (male hormones). Women who have this condition often struggle to keep their weight under control, although a subset can be quite slim.
Women with PCOS are usually looking for a solution to their period problems, difficulty conceiving, or excess hair growth and acne, but they also need to be aware that they are at risk of other conditions such as impaired glucose tolerance/adult onset diabetes, elevated blood cholesterol/lipids, heart disease, and uterine precancer/cancer.
Women with PCOS may have heavy irregular periods, which are inconvenient because they are unpredictable, or cause iron deficiency and even anaemia. The cause of this problem is ovulatory dysfunction, and some women have no period at all. The problem is that women with PCOS have plenty of oestrogen production, the hormone that causes the lining of the uterus to grow, but if they are not ovulating regularly they have insufficient progesterone, which checks this growth. This can lead to overgrowth of the lining of the uterus and a condition called endometrial hyperplasia. In the worst cases, fortunately uncommon, the overgrowth can allow cancer of the endometrium to develop.
There are a number of ways to attack this problem. Firstly, it is well known that overweight or obese women with PCOS will tend to enjoy more normal cycles, as well as improved glucose tolerance and reduced insulin resistance (the precursor to diabetes) if they reduce their weight into the normal range, and I will usually suggest that they see a qualified dietician.
Some women are so obese they may even need to consider seeing a weight loss surgeon. This may seem radical, but if they are very overweight, they are at serious risk of diseases such as cancer, diabetes, and heart disease, and it may be the only practical solution to the problem in the long term.
In the meantime, my role will be to protect them from iron deficiency, anaemia and uterine cancer by ensuring they have endometrial protection with the oral contraceptive pill, Implanon implant, Nuva-ring or Mirena IUD.
If there has been evidence of very serious and irregular bleeding, they may require a hysteroscopy d&c to exclude endometrial hyperplasia/cancer, and this can be a good opportunity to insert a Mirena IUD (if they are not desirous of pregnancy), which has been shown in studies to prevent these outcomes, without some of the side effects of other treatments.
It's a bit hard to get pregnant if you are not ovulating. Again, if the woman is overweight or obese, it is essential to get this under control, because not only will she be more likely to recommence natural ovulatory cycles, but overweight and obesity is a serious risk factor in pregnancy for her and her baby. Getting your weight under control can help prevent many problems for you in pregnancy, as well as problems later in life for your child. As well, women who conceive naturally, are more likely to have a singleton pregnancy, which is less risky than a twin (or higher) pregnancy.
However, there are some women for whom ovulation doesn't resume, even when they are normal weight and these women can consider ovulation induction with Letrozole or Clomiphene. Some patients may not respond to this treatment and then need to consider seeking treatment at an IVF clinic with FSH injections. Both of these treatments have risks, including an increased rate of twinning, and the less common complication of ovarian hyperstimulation syndrome, so need to be carefully monitored by a suitably qualified specialist.
Some women with anovulation due to PCOS may have other problems such as period pain that require investigation and treatment with laparoscopy to rule out endometriosis; these women may be offered laparoscopic ovarian drilling, which has been shown to restore ovulation in about a half.
Metformin, a drug commonly used in non-insulin dependent diabetes, may also have a role in some patients.
Excess androgens (hair growth and acne).
This is a very distressing symptom for most women. The first task is to establish the severity of the clinical problem to the patient, and then carry out blood tests to establish hormonal levels and exclude causes other than PCOS such as:
Congenital adrenal hyperplasia
Drug induced hirsutism
Familial (genetic) hirsutism
Cancer induced hirsutism
Women with PCOS (the most common cause) often have only mildly elevated androgens, and these levels can be brought into the normal range by weight loss, an oestrogen containing oral contraceptive pill, and/or an anti androgen medication such as cyproterone or aldactone.
However, even when androgen levels are controlled, there may remain some stubborn hairs that need treatment with waxing or laser, and some ongoing acne issues that require review by a specialist dermatologist.
If you have read through this you will have noticed a common thread that is vital to your ongoing health:
It is true that too many of us nowadays are overweight or obese. One of the most important things that a woman with PCOS can do is get her weight in the normal range and keep it there, by calorie restriction and exercise, and with the expert help of a qualified dietician.Humans evolved as hunter/gatherers living on the edge of famine, and evolution has left us with genes that keep us alive even when we are starving. Maybe it's time we learned to live with the metabolism our ancestors gave us: eat less, make sure what we do eat is nutritious, and walk more.
Making long term changes in healthy eating habits and by increasing exercise works to reduce health risks of PCOS.
Many free "apps" exist to help us help ourselves.
One that patients might find useful is the Australian Easy Diet Diary. You can find it here.