Comprehensive Guide to Polycystic Ovarian Syndrome in Adults and Adolescents
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Initial Presentation in Primary Care
•
Delayed or less frequent periods/menarche/cycle length/duration of complaint(s)/cycle
length/heaviness of bleeding/LMP
+/-
•
Excessive/abnormal hair growth and acne
+/-
•
Subfertility (due to anovulation) – other causes of subfertility have been ruled out
RULE OUT
•
Pregnancy
•
Hypothyroidism
•
Hyperprolactinoma
•
CAH
•
Ovarian tumour
Pathway Guide – PCOS in adults and Adolescent—Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
Two out of three :-
1)
Anovulation/ oligomenorrhea
2)
Clinical and/or biochemical evidence of hyperandrogenism – hirsutism/acne/raised testosterone/
androstenedione/DHEAS and FAI
3)
Polycystic ovaries - >10cc and more than 12 follicles of 2-9mm
and
o
CAH/Hperprolactinemia/hypothyroidism/ovarian tumour have been excluded
Relevant examination for history related to anovulation and hyperandrogenism
Please check
Investigations
BMI
FSH, LH, E2, androstenidione, DHEAS, TFT, PRL, 17-OH progesterone,
BP
Free androgen index (day 2 or 5 of spontaneous period
Acanthosis nigricans
Oral glucose tolerance test
Hirsutism and acne
USS – for PCOS (not adolescents) and exclude ovarian mass (testosterone
producing tumour
Diagnostic criteria for PCOS
Pathway Guide – PCOS in adults and Adolescent—Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
Management in Primary Care For Irregular Periods
General Measures:-
o
If BMI (>25), to encourage 5-10% weight loss and referral to dietician for advice. This in itself can start
to regularise period and also increase chance of spontaneous conception
o
Screening an management of mental health condition is essential
o
Counselling for long term consequence of PCOS like Metabolic syndrome, Type 2 diabetes,
Cardiovascular complications, sleep apnoea, Endometrial hperplasia and cancer
Ensure at least 4 periods per year – withdrawal
bleed with 5 days NET 5mg tds or Provera 10mg BD
after 12 weeks of amenorrhea after ruling out
pregnancy
Management of Polycystic Ovarian Syndrome
Any CHC/Mirena/Implant/Depot as per
UKMEC and patient choice
Wants contraception:
Does NOT want contraception:
Pathway Guide – PCOS in adults and Adolescent—Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
Management of irregular bleeding in confirmed PCOS with persistence of
anovulation
o
Cyclical CHC – 1
st
choice
If CHC contraindicated or not tolerated – Provera 10mg BD cyclically (3weeks
on/1 week off)
o
Metformin
Referral to Secondary Care:
Management of Polycystic Ovarian Syndrome
Pathway Guide – PCOS in adults and Adolescent—Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
If subfertility (trying for pregnancy for 1 years) -
Refer to
Saint Mary’s Reproductive Medicine
unit
May need treatment with ovulation induction
agents/surgery
Management of Polycystic Ovarian Syndrome
Hyperandrogenic features
a) Hirsuitism and acne and male
pattern baldness
i)
CHC
ii)
Metformin
iii)
Spironolactone
b) Only acne and no
hyperandrogenism –
refer to
dermatologist
c) Unresponsive hirsutism ? Genetic
i)
Eflornithin cream
ii)
Electrolysis
iii)
Laser therapy
iv)
Reassurance and support
Refer to secondary care:
Refer to secondary care
Refer to
Endocrinology
if new diagnosis of CAH –
increased 17-OH
Or
Hyperprolactinemia
Ovarian Mass – 2WW referral
Pathway Guide – PCOS in adults and Adolescent—Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
Pathway Guide – PCOS in adults and Adolescent—Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
National Guidance
ESRE 2018
NICE 2018
RCOG
Patient Information
NHS website
Referral Proforma
2WW where
appropriate
Managing polycystic ovarian syndrome (PCOS) requires a thorough understanding of its presentation, diagnosis, and management. This guide outlines the initial presentation in primary care, relevant examinations, diagnostic criteria, and management strategies for PCOS in both adults and adolescents. From screening to follow-up care, this resource covers essential considerations for healthcare professionals treating individuals with PCOS.
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Saint Mary's Managed Clinical Service Manchester University NHS Foundation Trust Pathway Guide Pathway Guide Polycystic Ovarian syndrome in adults and in adolescents Polycystic Ovarian syndrome in adults and in adolescents Initial Presentation in Primary Care Delayed or less frequent periods/menarche/cycle length/duration of complaint(s)/cycle length/heaviness of bleeding/LMP +/- Excessive/abnormal hair growth and acne +/- Subfertility (due to anovulation) other causes of subfertility have been ruled out RULE OUT Pregnancy Hypothyroidism Hyperprolactinoma CAH Ovarian tumour Pathway Guide PCOS in adults and Adolescent Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
Saint Mary's Managed Clinical Service Manchester University NHS Foundation Trust Relevant examination for history related to anovulation and hyperandrogenism Please check BMI BP Acanthosis nigricans Hirsutism and acne Investigations FSH, LH, E2, androstenidione, DHEAS, TFT, PRL, 17-OH progesterone, Free androgen index (day 2 or 5 of spontaneous period Oral glucose tolerance test USS for PCOS (not adolescents) and exclude ovarian mass (testosterone producing tumour Diagnostic criteria for PCOS Two out of three :- 1) 2) Anovulation/ oligomenorrhea Clinical and/or biochemical evidence of hyperandrogenism hirsutism/acne/raised testosterone/ androstenedione/DHEAS and FAI Polycystic ovaries - >10cc and more than 12 follicles of 2-9mm 3) and o CAH/Hperprolactinemia/hypothyroidism/ovarian tumour have been excluded Pathway Guide PCOS in adults and Adolescent Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
Saint Mary's Managed Clinical Service Manchester University NHS Foundation Trust Management of Polycystic Ovarian Syndrome Management in Primary Care For Irregular Periods General Measures:- o If BMI (>25), to encourage 5-10% weight loss and referral to dietician for advice. This in itself can start to regularise period and also increase chance of spontaneous conception Screening an management of mental health condition is essential Counselling for long term consequence of PCOS like Metabolic syndrome, Type 2 diabetes, Cardiovascular complications, sleep apnoea, Endometrial hperplasia and cancer o o Wants contraception: Does NOT want contraception: Ensure at least 4 periods per year withdrawal bleed with 5 days NET 5mg tds or Provera 10mg BD after 12 weeks of amenorrhea after ruling out pregnancy Any CHC/Mirena/Implant/Depot as per UKMEC and patient choice Pathway Guide PCOS in adults and Adolescent Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
Saint Mary's Managed Clinical Service Manchester University NHS Foundation Trust Management of Polycystic Ovarian Syndrome Referral to Secondary Care: Management of irregular bleeding in confirmed PCOS with persistence of anovulation o Cyclical CHC 1st choice If CHC contraindicated or not tolerated Provera 10mg BD cyclically (3weeks on/1 week off) o Metformin Pathway Guide PCOS in adults and Adolescent Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
Saint Mary's Managed Clinical Service Manchester University NHS Foundation Trust Management of Polycystic Ovarian Syndrome Refer to secondary care: Refer to secondary care If subfertility (trying for pregnancy for 1 years) - Refer to Saint Mary s Reproductive Medicine unit Hyperandrogenic features a) Hirsuitism and acne and male pattern baldness May need treatment with ovulation induction agents/surgery i) ii) iii) CHC Metformin Spironolactone Refer to Endocrinology if new diagnosis of CAH increased 17-OH b) Only acne and no hyperandrogenism refer to dermatologist Or Hyperprolactinemia c) Unresponsive hirsutism ? Genetic i) ii) iii) iv) Eflornithin cream Electrolysis Laser therapy Reassurance and support Ovarian Mass 2WW referral Pathway Guide PCOS in adults and Adolescent Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
Saint Mary's Managed Clinical Service Manchester University NHS Foundation Trust National Guidance ESRE 2018 NICE 2018 RCOG Referral Proforma 2WW where appropriate Patient Information NHS website Pathway Guide PCOS in adults and Adolescent Montila Ghosh(Speciality Doctor) and Dr Gail Busby 03/02/21
