RCOG's new guideline looks at the long term health problems with polycystic ovarian syndrome PCOS. There isn't very much that's new, but I think that generally we aren't very good at following these women up, so I'm doing a general summary. The biggest risk is with diabetes, both gestational and type 2 if you don't want to read on...
- Type 2 Diabetes (T2DM). This risk is independent of obesity, but is exacerbated by obesity.
- Gestational diabetes. There is double the risk.
- Sleep apnoea if they are also obese. Interestingly sleep apnoea further worsens insulin resistance and CPAP improves it.
- Cardiovascular risk.
- Endometrial cancer - if oligomenorrheic or amenorrhoeic.
Managing these risks.
When a woman presents with PCOS, if she has any other risk factors (as below), she needs screening with an OGTT. Fasting glucose and HbA1c aren't accurate enough (but you can use an HbA1c of over 6.5 if you can't get an OGTT). The other risk factors are:
- Age > 40
- BMI > 25
- A history of gestational diabetes
- A family history of T2DM
Conventional risk calculators haven't been validated in PCOS, so assess their risk clinically. Do BMI and waist circumference at presentation.
If they are oligomenorrheic or amenorrhoeic, induce a bleed every 3 to 4m. You can use progesterones or the COC. Alternatively a mirena can be used to give endometrial protection.
If they aren't having bleeds, do a TVUSS to assess endometrial thickness. If it is less than 7mm, hyperplasia is unlikely. They don't advise how often the TVUSS should be repeated.
What advice should we give?
Lose weight if needed. There is no evidence that PCOS makes weight loss difficult or impossible (my experience is that it's very hard to persuade patients of this fact).
Help groups e.g. Verity
Are drugs helpful?
Metformin. There is some evidence of short term benefit to CVD risk markers, but no studies looking at long term effects. They advise considering it where a woman has IGT and where lifestyle changes have not bought about improvements in the glucose levels.
This can be considered when a woman has a BMI > 40 (or >35 with an obesity related condition) if other weight loss strategies have been unsuccessful.