Polycystic ovary syndrome (PCOS) is common hormonal disorder among women of reproductive age, with a collection of metabolic, reproductive and psychological features. To be diagnosed women must have at least two of these features: irregular periods, hirsutism (excessive facial and body hair), high male hormone levels or polycystic ovaries on ultrasound. Psychological features may include poor self-esteem, anxiety and depression and eating disorders. Women won’t necessarily have all of these symptoms and they may vary according to a woman’s age
PCOS is an under-diagnosed and a major public health concern and economic burden. In addition to reproductive features it is associated with psychological and metabolic features and cardiovascular disease, and is in most cases underpinned by insulin resistance. Obesity exacerbates PCOS by increasing insulin resistance and hyperandrogenism. PCOS is a chronic disease, with manifestations across the lifespan, and is best managed using an interdisciplinary care model
Management should focus on support, education and addressing psychological factors and should have a strong emphasis on healthy lifestyle. Lifestyle management aiming for weight loss and/or prevention of weight gain should be first-line, with targeted medical therapy as required. Along with managing reproductive complications, monitoring for and managing longer-term metabolic complications (including glucose intolerance, diabetes, cardiovascular risk factors and hyperlipidaemia) is important. Consideration should also be given to screening family members for metabolic abnormalities.
Summary of key points
- PCOS is a chronic complex condition with psychological, reproductive and metabolic features.
Women with PCOS have a high risk of metabolic syndrome, prediabetes and diabetes.
- Screening for metabolic features, including a lipid profile and an OGTT, is needed regularly to detect prediabetes when progression to diabetes is still preventable (fasting glucose levels are not adequate).
- Treatment for most patients is lifestyle focused and, while medical therapy can support ifestyle change, an aggressive lifestyle-based multidisciplinary approach is optimal in most cases to manage the features of PCOS and prevent long-term complications.
- Small achievable goals of 5% loss of body weight or moderate exercise three times a week results in significant clinical improvement even if women remain clinically in the overweight or obese range (BMI >25kg/m2).
The physical and emotional impacts of PCOS are broad and are not confined to the adolescent and reproductive years; they can impact a woman’s health across a her lifespan. So while early diagnosis is important, so is the long-term management of this often misunderstood condition.
A new national guideline developed by Jean Hailes and the PCOS Australian Alliance has brought together the latest evidence, clinical expertise and the experiences of women with PCOS to create a comprehensive way forward in diagnosing, managing and supporting women who live with this condition.
Research shows women with PCOS have a four to seven-fold increased risk of developing type 2 diabetes and have increased cardiovascular or heart disease risk factors. Those risks increase if a woman is overweight as this increases the prevalence and severity of PCOS. Some women are also at greater risk of PCOS due to ethnicity e.g. Asian women and Native Americans. Women with a family history of type 2 diabetes or of PCOS are also at higher risk of the condition.
The causes of PCOS are related to genetics and lifestyle which lead to excess male-type hormones and excess insulin in the body. When the body’s insulin is not as effective as it should be, (such as in PCOS-related insulin resistance), the body compensates by making more insulin. Higher insulin levels trigger an increase in male hormones and disrupt the normal ovulation cycle, causing eggs in the ovary to stop mid-way through development. On an ultrasound screen, these look like small cysts within the ovary. The eggs do not ovulate, leading to some of the PCOS symptoms outlined earlier.
The sooner the better. We focus on diagnosing PCOS as early as possible to better manage a woman’s present and long-term health. Unfortunately at the moment the journey to diagnosis is long – a woman sees two to three health professionals and it can take up to two years before she’s diagnosed. She hopes the guideline will better inform women so they can raise possible symptoms with a health practitioner.
There is not enough awareness among adolescent girls when features of PCOS often emerge. Instead, girls may be popped on the Pill to regulate their cycle and they aren’t even aware they have PCOS until they come off it years later when they wish to start a family. Then they discover they have PCOS (symptoms of which were masked by the Pill) and may have difficulties getting pregnant or they may have already developed diabetes. If PCOS can be diagnosed in adolescence we can manage acne, excess hair growth and the psychological impacts at a vulnerable time in a woman’s life. Health professional should also proactively focus on lifestyle to prevent weight gain, because prevention of weight gain is paramount, as well as taking measures to optimise later fertility and prevent complications such as diabetes
As well as encouraging a swifter diagnosis of PCOS, the guideline focuses on equipping women with accurate information so they can be proactive in managing PCOS throughout their life. Balanced diet, regular exercise and weight management (including a strong emphasis on prevention of weight gain) is important in reducing PCOS impacts, such as insulin resistance, irregular menstrual cycles, infertility and diabetes prevention. “Prevention of weight gain and a focus on healthy lifestyle is life-long – I can’t emphasise that strongly enough. Not just weight loss once overweight, but prevention of weight gain is vital.
The information also draws attention to the emotional wellbeing aspects of PCOS, which has not been done before. Between 28-64% of women with PCOS experience depression compared to 7.1-8% of women without PCOS and 34-57% of women with PCOS report anxiety compared to 18% of women who don’t have the condition. Previously a woman with PCOS might have had impaired emotional wellbeing but not associated it as a feature of her PCOS and so may not have brought it up with her doctor. We hope that this will encourage women with PCOS to seek support and also prompt health practitioners to consider emotional wellbeing when managing their patients,” says Marie.