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Definition
Polycystic ovary syndrome is defined as a clinical syndrome with a combination of androgen excess and ovarian dysfunction in the absence of other specific diagnoses, for which there is no cure (Escobar Morreale, 2018). The syndrome is a long-term chronic endocrine disorder, with symptoms beginning during puberty and varying in severity; no two patients will have the same clinical presentation.
Symptoms
Symptoms of polycystic ovary syndrome typically begin during puberty and worsen over time. One of the key symptoms in young women is amenorrhoea, so polycystic ovary syndrome is unlikely if regular menstruation occurred before its cessation (Pinkerton, 2023). Problems associated with menstruation occur in about seven in ten women with polycystic ovary syndrome (Tidy, 2023), manifesting as infrequent menstruation (oligomenorrhoea), very light bleeding or complete absence of monthly menstruation.
Many people with polycystic ovary syndrome are overweight and may struggle to control weight gain. Excess hair growth occurs in more than half of affected women (Tidy, 2023). This symptom can be particularly distressing, as it frequently follows a male pattern of hair growth, with androgenic symptoms caused by an excess of androgens. Excess hair growth is seen at sites such as the upper lip, chin, back, toes, thumbs, chest and around the nipples. Some women also experience thinning of the hair on the scalp, similar to male pattern baldness.
Symptoms are very variable and may be mild, but those with more severe symptoms may experience excessive hair growth, fertility problems and excessive weight gain. Additional symptoms are shown in Table 1.
| Table 1. Symptoms of polycystic ovary syndrome | |
| Symptom | Additional information |
| Depression and/or anxiety | Depression and/or anxiety may be caused by unwanted hair growth and other symptoms. Hormonal imbalance can impact mood, resulting in mood swings |
| Poor sleep pattern and sleep apnoea | Sleep problems are commonly reported by women with polycystic ovary syndrome, and the condition has been associated with sleep apnoea |
| Fatigue and reduced energy levels | Poor sleep patterns may cause tiredness and lack of energy |
| Hair thinning | Hair thinning and hair loss worsens in middle age |
| Headaches | Headaches may occur as a result of hormonal changes |
| Skin changes | Dark patches of thickened skin may develop under the arms, breasts or on the nape of the neck |
| Pelvic pain | Pelvic pain may occur in some women at any time during the month or during menstruation and can be accompanied by heavy bleeding |
| From: Polycystic Awareness Association, 2021 | |
Lean polycystic ovary syndrome
People with polycystic ovary syndrome usually have obesity, but it can affect people without obesity – known as lean polycystic ovary syndrome. Hormonal, metabolic and haematological profiles are altered in women with lean polycystic ovary syndrome, and can be comparable or less obvious (on testing) than those seen in women with obesity with the syndrome (Toosy et al, 2018).
Aetiology
The underlying aetiology is poorly understood and, given the lack of a specific test to confirm diagnosis, prevalence rates are difficult to confirm. Current estimates suggest around 2.2–2.6% of women may have symptoms. However, these statistics vary between ethnic groups, with south Asian women having more severe symptoms and frequently presenting at a younger age (Royal College of Obstetricians (RCOG), 2015).
The menstrual cycle is regulated by a hormonal system which comprises a negative feedback mechanism. In polycystic ovary syndrome, the hypothalamic–pituitary–ovarian system is disturbed, affecting the normal actions of several hormones.
In polycystic ovary syndrome, insulin resistance disrupts the hypothalamic–pituitary–ovarian system. Androgens, including testosterone, are produced by the ovaries. The production of excess amounts of androgens – known as hyperandrogenism – is responsible for many of the symptoms associated with the condition. Luteinizing hormone, produced by the pituitary gland, normally stimulates ovulation, but approximately four in ten women with polycystic ovary syndrome have elevated levels of the hormone, which in combination with raised levels of insulin, further increases the production of testosterone by the ovaries, leading to onset of symptoms (Tidy, 2023).
Diagnosis
A thorough history should reveal information relating to menstrual patterns, taking into consideration a history of amenorrhoea, irregular menstruation, menorrhagia and fertility issues. A family history of polycystic ovary syndrome should also be noted. Weight, body mass index and waist circumference should be recorded, together with past weight gain, exercise patterns, smoking history and alcohol intake. Acne and hirsutism may or may not be visible, so should be discussed during the consultation.
There are currently no universal criteria to confirm a diagnosis of polycystic ovary syndrome. It is generally accepted that two of the three below criteria should be met to confirm the diagnosis:
- Irregular menstrual pattern, with light or missed menstruation occurring as a result of a long-term absence of ovulation
- Raised androgen levels that cannot be attributed to other conditions (eg acromegaly or Cushing’s syndrome) – excess facial or body hair suggestive of hyperandrogenism
- The presence of 12 or more cysts found in one or more ovary on an ultrasound scan (National Institute for Health and Care Excellence (NICE), 2023)
It is important to note that a normal ultrasound and regular menstruation does not exclude polycystic ovary syndrome if the patient meets two of the other above criteria.
A pelvic examination may not be recommended in women with obesity, as it may not be possible to feel the ovaries. Blood tests and additional investigations may be useful to confirm the diagnosis (Table 2).
| Table 2. Investigations to confirm a diagnosis of polycystic ovary syndrome | |
| Investigation | Description |
| Pelvic ultrasound | The presence of polycystic ovaries (12 or more follicles in one ovary) should not be used alone to confirm the diagnosis; ultrasound scans should not be used for diagnosis in adolescents |
| Testosterone | May be normal or moderately elevated in women with polycystic ovary syndrome |
| Sex hormone binding globulin | Normal to low levels, indicating the degree of elevated insulin levels (low levels of sex hormone binding globulin indicate high levels of insulin) |
| Free androgen index | The total testosterone value multiplied by 100, divided by the amount of sex hormone binding globulin produces the amount of active testosterone present. This amount is normal or elevated in polycystic ovary syndrome |
| Luteinising hormone and follicle stimulating hormone | Used to rule out other causes for symptoms, such as premature ovarian failure. In polycystic ovary syndrome, luteinising hormone is often 2–3 times higher than follicle stimulating hormone, and correlates with failed ovulation on ultrasound. Luteinising hormone and follicle stimulating hormone are elevated in women who have the menopause |
| Prolactin level | Usual range is below 500 mU/litre but may be elevated in polycystic ovary syndrome |
| Thyroid-stimulating hormone | Measured to exclude hypothyroidism |
| From: NICE, 2023 | |
Management
Lifestyle changes
Healthy lifestyle behaviour plays an important role in the management of polycystic ovary syndrome, can help to improve some symptoms and prevent the development of some complications. If needed, weight loss can provide benefits in reducing symptoms and preventing other long-term health problems, such as type 2 diabetes, heart disease and sleep apnoea. Additional benefits include improving insulin resistance and increasing the chances of conceiving, facilitating return to regular menstruation, and improving acne and hirsutism over time (RCOG, 2015). Reduced alcohol intake and increased fruit and vegetable intake, together with increased exercise, can play a crucial role in improving symptoms as well as mood and self-esteem.
Management of comorbidities
Patients at increased risk of cardiovascular disease may need referral to a cardiologist for specialist intervention, particularly those with a family history of:
- early-onset cardiovascular disease
- diabetes
- hypertension
- abnormal lipid levels
- abdominal obesity (Pinkerton, 2023)
Managing menstrual problems
Management of menstrual problems will be determined by the woman’s preferences and whether she wishes to conceive or not. For those who do not wish to conceive, a combined oral contraceptive pill can be prescribed if there are no contraindications, which will cause regular withdrawal bleeding. The combined oral contraceptive pill lowers raised testosterone levels and can treat symptoms of androgen excess. There are many options available and nurse prescribers are advised to consult their local formulary for guidance.
A progesterone-only pill or an intrauterine device can be offered if a combined oral contraceptive pill is unsuitable or declined, but neither contains oestrogen. In patients with very low oestrogen levels, there is a low risk of developing osteoporosis. Metformin is an alternative option, but its use in polycystic ovary syndrome is unlicenced (normally prescribed in type 2 diabetes) and it is therefore initiated under specialist guidance in the secondary care setting. If prescribed, metformin improves insulin resistance and helps to lower glucose levels, but if pregnancy is to be avoided, a reliable method of contraception will be needed in addition.
Acne
Treating acne in women with polycystic ovary syndrome is no different than for other people. There are many over-the-counter treatment options available, but if the problem is more severe, prescription medication will be needed. Prescription medication can include a daily antibiotic, such as doxycycline or lymecycline, in addition to a topical agent (eg Duac or Zineryt). Patients should be advised that it may take several weeks before improvements are seen.
Hirsutism
Women can remove excess hair with shaving, waxing and hair removal creams which can be purchased from local pharmacies. Options such as laser treatment and electrolysis may not be available on the NHS, given their cost and perceived limited clinical value. Laser treatment is effective for some patients, but results can vary depending on skin type. Minoxidil is available over the counter in shampoos or may be recommended by a dermatologist if the patient is experiencing thinning of the hair on the scalp. Oral medications which may help treat excess hair growth include:
Patient should be advised that oral treatments will take 3–9 months to achieve an effect, and the problem is likely to recur if treatments are stopped. If prescribed, it is recommended that oral contraceptive is stopped when acne has resolved, as there is an increased risk of thromboembolism associated with use (GP Notebook 2020; Tidy, 2023)
Fertility problems
Fertility problems arise as a result of irregular ovulation or a complete lack of ovulation, making it difficult to conceive. Failure to ovulate occurs as a result of insulin resistance; the egg reserve is unaffected. Referral and guidance of a specialist is needed for treatment to commence.
Letrozole is an anti-oestrogen drug used to induce ovulation, although it is used off licence (Medscape UK, 2020). Clomiphene citrate is an alternative option, but it requires specialist monitoring with ultrasound scanning, as its use carries a 10% risk of multiple births (Medscape UK, 2020). Women with polycystic ovary syndrome who do conceive have a greater risk of health problems during their pregnancy, including:
- hypertension
- pre-eclampsia and gestational diabetes
- caesarean delivery
- miscarriage
- perinatal death (Yu et al, 2016)
Polycystic ovary syndrome is a lifelong condition with no cure. Treatment is aimed at improving symptoms and reducing the development of complications. Nurses and non-medical prescribers play a key role in helping women with self-help measures, such as weight loss and increasing activity levels.
Resources
Escobar-Morreale HF. Polycystic ovary syndrome: definition, aetiology, diagnosis and treatment. Nat Rev Endocrinol. 2018;14(5):270-284. https://doi.org/10.1038/nrendo.2018.24
GP Notebook. Dianette (R). 2020. https://gpnotebook.com/simplepage.cfm?ID=-261423050 (accessed 7 September 2023)
Medscape UK. Diagnosis and management of polycystic ovary syndrome. 2020. https://www.guidelines.co.uk/womens-health/pcos-uk-guideline/236071.article (accessed 7 September 2023)
National Institute for Health and Care Excellence. Polycystic ovary syndrome. 2023. https://cks.nice.org.uk/topics/polycystic-ovary-syndrome/diagnosis/investigations/ (accessed 7 September 2023)
Pinkerton JV. Polycystic ovary syndrome (PCOS). 2023. https://www.msdmanuals.com/en-gb/professional/gynecology-and-obstetrics/menstrual-abnormalities/polycystic-ovary-syndrome-pcos (accessed 7 September 2023)
Polycystic Awareness Association. PCOS overview. 2021. https://www.pcosaa.org/pcosinfo (accessed 7 September 2023)
Royal College of Obstetricians (RCOG). Polycystic ovary syndrome: what it means for your long-term health. 2015. https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/gynaecology/pi-pcos.pdf (accessed 7 September 2023)
Tidy C. Polycystic ovary syndrome. 2023. https://patient.info/womens-health/polycystic-ovary-syndrome-leaflet#nav0 (accessed 7 September 2023)
Toosy S, Sodi R, Pappachan JM. Lean polycystic ovary syndrome (PCOS): an evidence-based practical approach. J Diabetes Metab Disord. 2018;17(2):277-285. https://doi.org/10.1007/s40200-018-0371-5
Yu HF, Chen HS, Rao DP, Gong J. Association between polycystic ovary syndrome and the risk of pregnancy complications: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore). 2016;95(51):e4863. https://doi.org/10.1097/MD.0000000000004863