Tool Polycystic ovary syndrome - (PCOS) - Jean Hailes
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Polycystic
ovary Health
professional tool
syndrome Assessment, investigations & management
(PCOS)PCOS assessment
Clinical presentation
• Prevalence – most common endocrine disorder in women of reproductive age (8-13%)
• Consider PCOS if female presents with: menstrual irregularity, overweight, hirsutism, acne, fertility issues, prediabetes, gestational
diabetes or early onset type 2 diabetes
• Note high-risk ethnic groups (Asian, Indigenous, Nth African)
Diagnosis: according to Rotterdam diagnostic criteria
Step 1: Irregular Irregular cycles Clinical hyperandrogenism
cycles + clinical
In women >3 years post menarche to In adolescents: • hirsutism (severe in adolescents)
hyperandrogenism
perimenopause: • no period by age 15 • acne (severe in adolescents)
(exclude other causes)*
• 35 day cycles indicating • >1 year post menarche • alopecia (androgenic)
= diagnosis
anovulation cycles >90 days
• >1 to 20% above normal limit
(exclude other causes)*
index or calculated free testosterone
= diagnosis
Step 3: If ONLY Adolescents Adults
irregular cycles OR • Ultrasound should not be used for the diagnosis of • In patients with irregular menstrual cycles and
hyperandrogenism- PCOS in thosePCOS management
PCOS management should be Referral guidance Lifestyle
In those with more complex PCOS or
considered across the lifespan with challenges in differential diagnosis,
Healthy lifestyle behaviours encompassing
and individualised, making healthy eating and regular physical activity
consider referral to an endocrinologist or should be recommended in all those with
sure that patient priorities are multidisciplinary service PCOS to:
identified. Consider early referral to fertility specialist ºº achieve and/or maintain healthy
particularly if age >/= to 35 years. In younger weight
Consider the benefit of a GP women consider up to 12 months of intensive ºº optimise hormonal outcomes, general
Management Plan and Team lifestyle intervention such as weight loss, health, and quality of life across the
Care Arrangement. where appropriate, before referral. life course.
• Realistic weight loss goals vital (5-10%
A team/multidisciplinary PCOS management areas include: body weight)
approach with GP coordination • lifestyle • No specific diet, focus on:
should be considered, where • clinical hyperandrogenism (eg hirsutism) ºº reducing overall caloric intake
appropriate and available. • menstrual cycle regulation ºº sustainable behavioural change
• fertility ºº regular GP and self-weighing/
monitoring
• weight management
• 30 minutes of moderate to vigorous
• cardiometabolic health exercise daily for health goals – won’t
• sleep apnoea reduce weight alone, need diet. Increase
• mental and emotional health. opportunistic movement, consider
referral to exercise physiologist
Note: this is a heterogeneous chronic
condition and there is a need to engage
each woman in prioritising her own
management issues.Clinical hyperandrogenism ºº Cyproterone containing COCPs should Fertility
(hirsutism/acne/alopecia) be considered second-line due to • BMI >25 – weight loss first-line
• Cosmetic options: laser hair removal, increased VTE risk
• 5-10% weight loss may assist in cycle
depilatory creams, threading, plucking, • Progestogens alone may be used
control and fertility
waxing and electrolysis cyclically or as an IUD where COCP is
contraindicated or not preferred (eg • Pharmacological therapies for infertility
• Pharmacological therapy options (6-12 Medroxyprogesterone acetate (MPA) include letrozole or clomiphene, but
months to see benefit): 10mg days 1-10 in January, April, July, in primary care, metformin can be
ºº COCP – (all will assist) aim for lowest September) started before fertility specialist referral
effective dose informing women that it is not as
• Metformin – improves ovulation,
• Combination therapy – if ≥6 months of effective
re-establishes cycles, reduces insulin
COCP is ineffective, consider adding resistance, reduces progression to • Referral to fertility specialist if unable to
anti-androgen to COCP diabetes, may prevent weight gain, conceive at
ºº Anti-androgen (eg spironolactone, but does not cause weight loss ºº 12 months if 35 years
ºº Minimise side effects with starting dose
ºº Contraception is vital to prevent 1 x 500mg daily, increase by 500mg
pregnancy while on anti-androgens per fortnight up to 1500mg-2000mg Key messages:
average dose • PCOS may limit fertility, but can be
ºº Alcohol excess should be avoided treated
Menstrual cycle regulation
on metformin • Women with PCOS have similar family
• Lifestyle efforts can improve cycle sizes overall, but often need some
regularity Key messages: assistance
• Combined oral contraceptive pill (COCP) • Women with PCOS have increased risk • Fertility for all women decreases in early
ºº All COCP pills increase SHBG thereby of endometrial cancer with prolonged 30s and significantly after 35 years
reducing free androgens; provide amenorrhoea; aim for >4 periods/ year
• Advise early family initiation (Weight management ºº medical and/or surgical weight loss Mental & emotional health
• Monitor weight regularly, important for: treatments • In women with PCOS there is a high
prevalence of moderate to severe
ºº targeting prevention of weight gain in
all (if a healthy weight or overweight) Key message: anxiety and depressive symptoms
ºº achieving at least 5-10% weight loss if 5-10% weight loss will greatly assist in • Screen for anxiety and depressive
overweight symptom control symptoms at diagnosis
• Note: education alone and setting • Eating disorders, negative body image,
unachievable goals are generally Cardiometabolic health low self-esteem and psychosexual
unsuccessful dysfunction should also be considered
Screen for cardiovascular risk factors:
• Encourage simple behaviour change – • smoking – advise cessation • If screening is positive, assess risk factors
prioritisation of healthy lifestyle, family and symptoms using an appropriate
support, lifestyle and exercise planning, • BP: check annually assessment tool (GAD7 or PHQ)
setting of small achievable goals • Lipid profile at baseline if BMI >25, then
according to overall CVD risk: check every If treatment is required, consider a Mental
• Calorie deficit of 500-750 cal daily 2-4 years Health Treatment Plan (MHTP), ongoing
required for weight loss (ie 1200-1500 cal support and/or referral to a mental health
daily intake), with no one diet preferred Diabetes: professional
• 3-5 fold increased risk and earlier onset
• 250 min moderate exercise/week or of gestational, prediabetes and diabetes
150 min vigorous exercise/week required Key message:
in PCOS; these also occur in lean and in Assess mental and emotional health for:
for weight loss young PCOS women
• Consider referral via team care • depression and/or anxiety
• Screen with OGTT, fasting glucose
arrangement if appropriate: • body image
or HbA1c. If high risk use OGTT (eg,
ºº dietitian (tailored dietary advice, history of GDM, IFG, IGT, family history • eating disorders and disordered eating
education, behavioural change support) of diabetes, hypertension or high-risk • psychosexual dysfunction
ºº exercise physiologist (exercise ethnicity)
motivation, education)
ºº Every 1-3 years (annually if IFG/IGT)
ºº psychologist (motivational interviewing, Sleep apnoea
behaviour management techniques,
Key message: • Monitor clinically for sleep apnoea
emotional health and motivation)
Increased cardiovascular risk factors and (strongly associated with excess weight)
ºº group support (diet and exercise
program) prevalence of GDM, IGT and type 2 • The Berlin tool can be useful for
diabetes in PCOS screeningAdditional information
Health practitioner tools and resources
jeanhailes.org.au/health-professionals/tools
jeanhailes.org.au/health-professionals/active-learning-modules/diagnosis-and-
management-of-polycystic-ovary-syndrome-pcos-2019
monash.edu/medicine/sphpm/mchri/pcos/resources/practice-tools-for-health-practitioners To order copies:
jeanhailes.org.au
Mental and emotional wellbeing
Use assessment tools such as:
• Patient Health Questionnaire (PHQ)
Education and
• Generalised Anxiety Disorder Scale (GAD7)
Knowledge Exchange
phqscreeners.com Jean Hailes for Women’s Health
PO Box 33314, Domain LPO
Clinical hyperandrogenism Melbourne VIC 3004
Hirsutism Phone: 1800 JEAN HAILES (532 642)
Use standardised visual scale eg Email: education@jeanhailes.org.au
• Modified Ferriman Gallwey score (mFG)
Alopecia Clinics
• Ludwig visual score Jean Hailes Medical Centre for Women
173 Carinish Road
Patient resources Clayton VIC 3168
jeanhailes.org.au/health-a-z/pcos Jean Hailes at Epworth Freemasons
monash.edu/medicine/sphpm/mchri/pcos/resources/resources-for-women-with-pcos 412 Victoria Parade
East Melbourne VIC 3002
This resource is informed by the ‘International
Phone: 03 9562 7555
evidence-based guideline for the assessment
and management of polycystic ovary syndrome’
(Monash University 2018).
Jean Hailes for Women’s Health gratefully acknowledges the support of the Australian Government.
© Jean Hailes for Women’s Health 2012 Updated October 2018You can also read
