Referral Guidance:

Polycystic Ovary Syndrome, Hirsutism and Menstrual disorders

 

University Hospitals of Leicester NHS Trust  

 

Department of Diabetes & Endocrinology

Leicester Royal Infirmary, Leicester, LE1 5WW

 

 

Polycystic Ovary Syndrome, Hirsutism and Menstrual disorders: About the Condition

Definition

·         Rotterdam international consensus criteria define PCOS as the presence of 2 out of 3 of:

1.       Clinical or biochemical evidence of hyperandrogenism 

2.       Evidence of anovulation and

3.       Polycystic ovary appearance on U/S

·         … having excluded other rare causes.

·         Rarer causes of some or all of these symptoms include Cushing’s syndrome, congenital adrenal hyperplasia, virilising tumours of ovary and adrenal, ovarian failure, hyperprolactinaemia and hypopituitarism.

·         Therefore, having excluded these conditions clinically and/or biochemically, PCOS can potentially be diagnosed by the clinical combination of excessive hirsutism ± acne and infrequent or absent periods – whatever the findings on biochemistry or U/S.

Symptoms

·         PCOS patients typically complain of hirsutism and/or acne and irregular periods from around the time of menarche – although some patients who satisfy the diagnostic criteria have normal skin and some others have regular periods.

·         Anovulation associated with oligo-/amen-orrhoea may often present with female infertility.

·         Patients will frequently (but not always) be overweight or obese and/or complain of difficulty in maintaining a normal weight.

·         PCOS is part of the spectrum of metabolic syndrome and in the long term there is an increased risk of diabetes, hypertension and cardiovascular disease – at least in some patients

Signs

·         Hirsutism and acne are present and are assessed clinically

·         Acanthosis nigricans (a sign of hyperinsulinaemia) is frequently found in axilla or on the neck of overweight patients – particularly in patients of Indo-Asian ethnic origin

Investigations

·         Patients with all typical symptoms of PCOS normally require measurement of Testosterone, LH/FSH, Oestradiol, Prolactin and Thyroid function

·         Serum testosterone is a useful screen for presence of a virilising tumour in patients with hirsutism – levels above 5pmol/L require prompt endocrine assessment – but total testosterone is often normal in PCOS.

·         Low SHBG is common in PCOS and is a marker of insulin resistance and obesity (as well as allowing calculation of free androgen index)

·         LH:FSH ratio may sometimes be increased – but the main role of these hormones and oestradiol level is to exclude ovarian failure and hypopituitarism.

·         Prolactin level is essential to exclude hyperprolactinaemia as a cause of oligo-/amen-orrhoea – but is frequently mildly elevated (<1000 IU/L) in PCOS per se.

·         Hypothyroidism in young women frequently causes oligo-/amen-orrhoea

·         Other biochemical markers of hyperandrogenism (Androstenedione, DHEAS, Free Androgen Index [(T/SHBG)*100]) may be elevated in some patients but are not routinely required for diagnosis.

·         17-α-OH-progesterone is normal in PCOS but elevated in the most common cause of CAH.

·         Ultrasound may confirm polycystic ovaries – but is not essential for diagnosis if the clinical syndrome is typical – and is often reported normal on a routine scan in patients with typical clinical PCOS.

Other factors

·         Biochemical and/or U/S findings of PCO may be present in as many as 20% of the female population. The severity of the clinical syndrome is the main factor in decision making about need for investigation, treatment options and/or specialist referral.

 

Polycystic Ovary Syndrome, Hirsutism and Menstrual disorders: When to Refer?

Referral Recommendations

·         We are happy to review any patient with symptoms and signs of PCOS or unexplained menstrual disturbance in the endocrine clinic in order to:

·         Establish a diagnosis and discuss the diagnosis and treatment options with the patient

·         Exclude other rare conditions which might cause similar symptoms

·         Recommend and monitor first line therapies (Pill or metformin)

·         Liaise with assisted conception unit for patients seeking fertility

·         Discuss, initiate and monitor second-line anti-androgen therapies (all currently off-licence)

Urgent Referral

·         Urgent referral may be appropriate in patients with markedly elevated testosterone (>5 pmol/L or with clinical signs of severe virilisation)

References or Guidelines

·          

Which Clinic or

Choose & Book Service?

·         A “Gynaecological Endocrinology Service - Endocrinology - LRI – RWE” referral will book the patient into the weekly Gynae-Endocrine clinic at LRI where we have extensive experience in the management of PCOS and its manifestations. One of these clinics each month is held jointly with gynaecologists from the LRI Assisted Conception Unit.

·         An “Adult Endocrinology Service - Endocrinology - LRI - RWE” referral will book an appointment on any of medical lists in clinics at Leicester Royal Infirmary where endocrine patients are seen – but this may not be a clinic or physician with a particular interest in PCOS.

 

Polycystic Ovary Syndrome, Hirsutism and Menstrual disorders: What to do before a hospital appointment?

Additional Investigations

·         In patients with obesity or with other signs of insulin resistance consider measurement of glucose, HbA1c and lipid profile.

·         17-α-OH-progesterone should be checked if testosterone is elevated (but will be checked at clinical attendance if the patient has been referred)

Treatment prior to specialty appointment

·         If the patient is being referred for a specialist opinion we would prefer to review them before treatment is commenced – so that we can fully evaluate clinically and biochemically and discuss all treatment options

How to manage the patient if you do not refer

·         For patients with moderate hirsutism and irregular periods but no current plans for fertility (and without contraindications) the first line treatment will often be a combined oral contraceptive with non-androgenic progestagen (Dianette, Marvelon, Yasmin) – many GP practices will be happy to commence and monitor this in primary care. In spite of the increased risk of thromboembolism this treatment remains one the best proven and safest therapies for long-term use.

·         Orlistat may be considered as an option in patients with obesity who meet NICE criteria for this drug

Patient Information

·         Polycystic Ovary Syndrome – LRI Information Sheet

 

Polycystic Ovary Syndrome, Hirsutism and Menstrual disorders: What will we do in the specialty Endocrinology clinics?

Outline of Management

·         We will assess the patient clinically and biochemically.

·         In the presence of any clinical features consistent with Cushing’s syndrome we will formally exclude that diagnosis with a dexamethasone suppression test.

·         We will exclude hyperprolactinaemia, hypopituitarism, ovarian failure, hypothyroidism and congenital adrenal hyperplasia biochemically (unless already performed)

·         Having excluded these conditions we will diagnose PCOS if Rotterdam criteria are met. Other patients with incomplete syndrome may be labelled “?PCOS” or treated on the basis of their primary symptoms.

·         We will discuss treatment options (including simple physical removal of hair and lifestyle changes) and initiate treatment where appropriate

·         We will provide the patient with appropriate information sheets about the treatments used and their potential side effects

Treatment options

·         For patients with moderate hirsutism and irregular periods but no current plans for fertility (and without contraindications) the first line treatment will often be a combined oral contraceptive with non-androgenic progestagen (Dianette or Marvelon)

·         For patients with severe hirsutism showing no response to at least 6 months treatment with the Pill, additional anti-androgen drugs may be recommended (cyproterone acetate, spironolactone, finasteride). These drugs are also sometimes used when the Pill is contraindicated.

·         Metformin is typically used where priorities include restoration of a normal ovulatory cycle or help with weight loss (although the latter effect is very variable)

·         More complex fertility induction is undertaken by the assisted conception unit – initiated in the joint clinic

Follow up plan

·         We will follow up patients to assess response to initial therapy and any subsequent changes (typically after 4-6 months on treatment)

Long term monitoring

·         We will normally continue to monitor patients on anti-androgens and other drugs used outside their normal licence – but will often review every 1-2 years on stable long-term treatment.

·         We will not normally follow up long term patients who are on no treatment, or who are stable on a simple therapy such as the Pill.

·         There is an increased risk of diabetes and other complications of the metabolic syndrome at least in some patients long-term. Screening for diabetes and vascular risk factors should be considered.

 

 

Referrals to all clinics can be arranged via Choose and Book.

We are also happy to receive written referrals and will allocate patients to the most appropriate clinic slot.

If you consider that your patient needs urgent assessment, then all consultants are happy to discuss directly (by phone or email) and arrange prompt review if appropriate.

In the case of a real or potential endocrine emergency we will almost certainly be happy to see the patient the same or the next working day whether or not a clinic is available.

Contact the endocrinologist:

By email: endocrinology@uhl-tr.nhs.uk or individual consultant emails

By phone: 0116 258 6140 and ask to talk to one of the consultants

Fax: is less reliable and usually no faster than written mail