Polycystic
ovary syndrome (PCOS) is a complex endocrine disorder and affects 1 in 15 women
worldwide with less than 50% of women diagnosed. [1] It
is responsible for 70 percent of infertility issues in women who have
difficulty ovulating, per the PCOS Foundation.[2] It
has now been recognized and diagnosed for 75 years. Genetic and
environmental factors play a part in its causation, but the exact etiology
remains unknown.
It has a multi-factorial etiology
that involves genetic, environmental and hormonal imbalance. Androgen excess is
clearly the culprit but insulin resistance also plays a major role in its
causation.
Although large number of women with obesity have PCOS, not all
obese women have PCOS. Apart from infertility, PCOS is responsible for many
chronic conditions. As per NIH, women with PCOS constitute the largest group at
risk for developing CVD and Type 2 DM. More than half will be diagnosed with
prediabetic or diabetic before the age of 40 years.[3]
Considering all the associated co-morbidities American College of
Obstetricians and Gynecologists and the Endocrine Society recommend that
all women diagnosed with PCOS should undergo screening for Dyslipidemias and
Impaired Glucose Tolerance Test in a recent paper published in November issue of American Journal of Obstetrics and Gynecology.[4]
The women are advised to have a full 2 hour 75 g oral glucose
tolerance test and fasting lipid profile at the time of diagnosis and
every 2-5 years and 2 years respectively.
The study
also stressed that gynecologists under-utilize the opportunity to
screen these women for metabolic abnormalities. In an internet survey with ACOG
fellows and junior obstetricians it was seen that 1 in 5 physicians will not
order any test in nearly half of their patients diagnosed with PCOS.
Nearly half of the patients of PCOS patients received hemoglobin
A1C test and about 40% were ordered to have fasting glucose. Only 7% of the patients were
ordered to have 2-hour oral glucose tolerance test.
ACOG and the Endocrine Society advocates the use of CME and other
educational activity to educate the obstetricians to address the metabolic
abnormalities in their PCOS patients because, they may be the only physician to come in contact with these patients in the reproductive years. So, no opportunities should be lost to
educate these patients about the screening for future metabolic disorders.
This promotes effective preventive health care and early diagnosis
in these at-risk women.
According to Endocrine society clinical practice guidelines:[5]
·
The Task Force
recommends that a physical examination should document cutaneous manifestations
of PCOS: terminal hair growth acne, alopecia, acanthosis nigricans, and skin
tags
·
The Task Force recommends screening adolescents and women with
PCOS for increased adiposity, by BMI calculation (Overweight = 25 to 29.9 kg/m2, ,Obese = ≥30 kg/m2) and measurement of waist circumference. (Abnormal>35 inches)
·
The Task Force recommends the use of an oral glucose tolerance
test (OGTT) consisting of a fasting (Fasting glucose >126 mg/dL or 2-hour
glucose >200 mg/dL) and 2-hour glucose level using a 75-g oral glucose load to screen for impaired glucose tolerance (IGT) and T2DM ( Fasting glucose 110
to 125 mg/dL or 2-hour glucose 140 to 199 mg/dL) in adolescents and adult women with PCOS
because they are at high risk for such abnormalities. A hemoglobin A1c (HgbA1c)
test may be considered if a patient is unable or unwilling to complete an OGTT.
Rescreening is suggested every 3–5 years, or more frequently if clinical
factors such as central adiposity, substantial weight gain, and/or symptoms of
diabetes develop.
·
The Task Force recommends that adolescents and women with PCOS be
screened for the following cardiovascular disease risk factors : family history
of early cardiovascular disease, cigarette smoking, IGT/T2DM, hypertension,
dyslipidemia, OSA, and obesity (especially increased abdominal adiposity).
Abnormal values are: HDL <50 mg/dL,TG >150 mg/dL and LDL >130 mg/dL.
·
The Task Force suggests screening women and adolescents with PCOS
for depression and anxiety by history and, if identified, providing appropriate
referral and/or treatment.
·
The Task Force suggests screening overweight/obese adolescents and
women with PCOS for symptoms suggestive of OSA and, when identified, obtaining
a definitive diagnosis using polysomnography. If OSA is diagnosed, patients
should be referred for institution of appropriate treatment.
[4]
http://www.ajog.org/article/S0002-9378(16)30478-1/fulltext
[5]
National Guideline Clearinghouse (NGC). Guideline summary: Diagnosis and
treatment of polycystic ovary syndrome: an Endocrine Society clinical practice
guideline. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville
(MD): Agency for Healthcare Research and Quality (AHRQ); 2013 Dec 01. [cited
2016 Nov 01]. Available: https://www.guideline.gov
