Polycystic Ovary Syndrome isn’t always managed optimally

GPs by the very nature of the job are rarely specialists in any one area. To “help” them, endless and often conflicting guidelines are produced by various groups who see themselves as knowing something about how a particular condition should be managed. This time is was NICE and the Royal College of Obstetricians and Gynaecologists who have produced guidelines on how polycystic ovarian syndrome should be managed in primary care.

Dr Yvonne Jeanes, Dr Sue Reeves and Susan Bury surveyed GPs in London about their management of Polycystic Ovarian Syndrome and compared the results with recent guidelines in an article that was published in GP Magazine 24 November 2014. The survey was sent to 221 practices but only 10% of them responded. Most responding GPs had an interest in women’s health and probably knew more about the condition than the non- responders.

As many of our readers will know, polycystic ovarian syndrome sufferers usually have marked insulin resistance and impaired glucose tolerance and are at risk of developing type two diabetes. Their health can often be greatly improved by a low carbohydrate diet and weight/resistance training as described in our book.

One in 10 to 20 women are thought to have the condition.  Symptoms include menstrual irregularity, particularly scanty or absent periods, infertility, acne, hirsutism, male pattern loss of hair and obesity.  The condition worsens quality of life and depression and anxiety are common.

Both NICE and the Royal College of Obstetricians and Gynaecologists state that “lifestyle management” is the primary therapy in overweight women with PCOS because many symptoms are improved if weight can be lowered by 5-10% due to the effect on hormonal function.

Guideline recommendations:

Blood pressure and fasting blood glucose should be taken as well as waist circumference, BMI and lipids.  Result: 23-36% did these checks regularly in the affected women.

Initial oral glucose tolerance tests should be done in affected women and thereafter annual tests should be done if the woman has impaired glucose tolerance. Result: No GPs offered such a test at diagnosis, 86% did not offer such annual check but 9% offered hba1c.

All overweight women with PCOS should be provided with dietary and lifestyle advice.  Result: 91% of GPs provided advice on weight loss to reduce type 2 diabetes and cardiovascular disease.

Women with no periods or very scanty periods should have induced withdrawal bleeds at regular intervals to reduce the risk of endometrial hyperplasia. This is a build-up of the lining of the womb that can put the woman at increased risk of endometrial cancer.  In addition they recommend that after an induced bleed the endometrial thickness should be assessed by ultrasound referral. Result: 9% of GPs knew about the need to induce bleeding. A further 9% would refer to a specialist.

It seems to me that PCOS is rather a Cinderella condition. When I think of how many women have diabetes or a thyroid disorder and the number of women that actually are diagnosed with polycystic ovaries, it seems to me that the condition is significantly underdiagnosed. It would also seem that primary care isn’t the place where management protocols should be established for individual women, not only because of the lack of knowledge about how to manage the condition, but because of the variability in the presentation of the condition and the differences in the individual woman’s requirements for symptom control and family planning.

Having realised that I am one of the majority of GP’s who despite an interest in women’s health are still not up to the mark in management of this condition, I took a module on BMJ learning to see if it had any tips for me.

BMJ course authors stated that PCOS presented most commonly in adolescence and that it was more common in women on South Asian or Mediterranean extraction.

They said that anyone fitting the typical symptom profile should get hormones tested initially. FSH, LH, Prolactin, Oestrogen and Testosterone were the ones to go for. These can be done from a single sample at any time of day.  If these were abnormal, the ovaries should be scanned by ultrasound.

When the diagnosis is made based on the combination of physical, endocrine and ovarian scan findings, management and referral will depend on the woman’s reproductive goals and how confident the GP is in managing the condition.

For South Asian women they recommend an oral glucose tolerance test if the BMI is over 25 or the waist circumference is over 80cm. That’s 32 inches, yikes!

Like most official guidelines, a “healthy, balanced eating, calorie restricted” diet is recommended. Unfortunately, this usually is interpreted as “low fat/high carb” by dieticians.

It is true that any weight loss by whatever means will help an overweight woman who has PCOS, but low carbing has the extra advantages of naturally reducing blood sugars and insulin resistance, addressing all the important cardiovascular risk factors, and being somewhat easier to stick to compared to low fat diets mainly due to its palatability, satiety and not needing to count calories.

BMJ reported that a cream could be used for the effective treatment of hirsutism called Eflornithine. The contraceptive pill Dianette contains an anti-androgen that also helps this, and also gives the necessary withdrawal bleeds to prevent endometrial hyperplasia. Metformin was advocated by BMJ and slated by RCOG and NICE. I told you that guidelines are often contradictory!

My guess would be that some people respond to it and some don’t but the effect may be too small to be evident in large studies. My own view is that Metformin is a cheap, well tested drug, that’s only common side effect is diarrhea. This can be overcome with the long acting formulation in most cases. There are some caveats about renal function, vitamin b12 absorption, and use of dye in radiological procedures but these don’t affect many people.  There seems little  to lose by trying it in an insulin resistant woman who is trying to lose weight. A low carb diet and appropriate weight training/ resistance exercise would be likely to help too.

One piece of good news from long term studies is that women with PCOS do NOT apparently die of cardiovascular disease despite their extra risk factors. The cause of this is not known.

There is a support group for women with PCOS called Verity.

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