Practical management and screening advice from the new PCOS guideline

Over 12% of Australian women suffer from Polycystic Ovary Syndrome, a lifelong multisystem disease that affects fertility, mental health, and metabolic health, and impact on quality of life is more profound than diabetes according to Professor Helena Teede of Monash University and the International PCOS Network.

“The associated psychological features are more severe than many other chronic diseases,” Professor Teede adds.

But timely diagnosis can significantly improve quality of life, protect fertility, and prevent complications such as cardiovascular disease and diabetes.

The 2023 International Evidence-based Guideline for the assessment and management of polycystic ovary syndrome provides updated diagnostic criteria and advice on management.

Management of PCOS

“Education and lifestyle is critical first,” Professor Teede says. She laments the widespread misinformation on the internet and social media, and recommends this new app released with the guideline (available free in 12 languages).

Lifestyle advice is first line therapy for all PCOS patients from the moment of diagnosis, Professor Teede says. A healthy, balanced diet may slow PCOS-associated weight gain, and dietary choices should be tailored to the individual’s needs.

“There is no perfect diet, but restriction diets are not recommended,” she says. “We need to be their support, rather than offering them futile options.”

“Exercise is about moving as much as they can, as often as they can, in about 10-minute bouts, and avoiding sedentary behaviours,” Professor Teede says.

“There are no on-label medications that have been approved for PCOS,” says Professor Teede, but that does not mean their use is not evidence-based. The combined oral contraceptive pill, metformin and anti-androgen agents have a place.

Treatment of Hirsutism

Following education and lifestyle changes, the combined oral contraceptive pill is the first line pharmaceutical choice. Professor Teede says it’s “relatively safe and very effective.”

The oral oestrogen component in the combined oral contraceptive pill increases sex hormone binding globulin in the liver, which in turn decreases free androgens.

“Progesterone-only contraceptives may provide endometrial protection in this condition, but they don’t do anything for the hirsutism,” Professor Teede says.

“For safety and side effect profile, use the lowest effective dose of oestrogen,” she says, adding that it’s important to consider the metabolic side effects when choosing a pill. She lets patients know that it will take 6 to 12 months to see if there’s an effect on hirsutism—if no effect by then, an anti-androgen may be added.

Professor Teede says cosmetic options are also important. The new guideline recommends for the first time that laser therapy can be effective. It does include caveats, noting that wavelength and delivery varies by skin and hair colour, and that laser is relatively ineffective on blond, grey or white hair.

Treatment of Irregular Cycles

A patient with less than four cycles a year needs endometrial protection. Endometrial cancer is increased by 10-fold in PCOS if the endometrium is not protected from the oligo/anovulation and lack of progesterone. “You don’t need to screen for this because even though the relative risk is high, the overall the absolute risk remains low,” Professor Teede says, “but you do need to ensure endometrial protection.”

Again, the first line pharmaceutical treatment is the COCP. Metformin is second line. Alternatively, Professor Teede says patients may be given a small dose of progesterone every few months to induce a withdrawal bleed.

“After diagnosis, women and their GP need to discuss their reproductive life plan,” Professor Teede says. “If they’re diagnosed early and have early family initiation, very few of these women need fertility treatment.” For those that do, the first line treatment is letrozole or another oral ovulation induction agent, via a fertility specialist. PCOS rarely requires IVF.

Associated Screening

PCOS is associated with rapid weight gain, higher weight, insulin resistance, earlier onset and highly prevalent diabetes, and premature and high rates of cardiovascular disease, so regularly screening for these conditions is important.

The guideline recommends oral glucose tolerance tests every three-years.

“Fasting glucose and HbA1c is inaccurate in this condition, especially in premenopausal women, because of the oestrogen effects on the liver,” Professor Teede says.

She says it is particularly important to diagnose comorbid diabetes before a pregnancy, as foetal abnormality rates are much higher if preconception diabetes is not well managed.

Blood pressure checks should be annual, and although lipids are usually elevated in PCOS, different frequency of screening is recommended depending on the person’s body mass index.

The guideline also recommends monitoring weight to tailor screening of associated risk factors to the individual patient.

“Because of the risk of weight bias and stigma, it’s important to seek permission to weigh, especially with the high prevalence of eating disorders in this condition. It’s actually really important to provide a rationale,” says Professor Teede.

Sleep apnoea is common in PCOS patients, but screening is only recommended if the patient is symptomatic. “We have a lack of evidence overall that obstructive sleep apnoea treatment improves metabolic outcomes,” Professor Teede explains.

The guideline recommends routine screening for depression and anxiety symptoms. “The prevalence is strikingly high,” Professor Teede says, with 70-80% of PCOS patients experiencing them.

PCOS is also associated with a higher rate of eating disorders and poor body image.

“Making a diagnosis and treating the clinical features of this condition improves the psychological features,” Professor Teede says.