General practice management of type 2 diabetes


Polycystic ovary syndrome
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Clinical context


PCOS is a metabolic and endocrine disorder affecting about one in 15 women worldwide.224 The endocrine disruptions consist of excessive androgen secretion or activity, and a large proportion of women also have insulin resistance and metabolic syndrome. The cause of PCOS is unknown, but studies suggest a strong genetic component that is affected by gestational environment, lifestyle factors or both.

Clinical manifestations include menstrual dysfunction, infertility, hirsutism, acne, obesity and glucose intolerance. Women with PCOS have an established increased risk of developing type 2 diabetes and a 2.4-fold increased odds of GDM, independent of age, race/ethnicity and multiple gestation.225 Refer to Section 3.1. Identifying risk of diabetes in asymptomatic potients for identifying risk of diabetes in women with PCOS.

The diagnostic criteria of PCOS are hyperandrogenism, chronic anovulation and polycystic ovaries, after exclusion of other conditions that cause these same features (refer to Table 13).226,227 A consensus definition of the disorder based on the importance of the three diagnostic criteria relative to each other remain controversial.
 

Table 13. Criteria for diagnosis of PCOS

The Rotterdam criteria are inclusive of National Institutes of Health (NIH) criteria however, the Rotterdam criteria may not meet NIH criteria

The Rotterdam diagnostic criteria requires two of:

  • Oligo-ovulation or anovulation
  • Clinical and/or biochemical signs of hyperandrogenism
  • Polycystic ovaries

and exclusion of other aetiologies such as hyperthyroidism, hyperprolactinaemia, congenital adrenal hyperplasia, androgen-secreting tumours and Cushing’s syndrome

The NIH diagnostic criteria requires:

  • Oligo-ovulation or anovulation
  • Clinical and/or biochemical signs of hyperandrogenism

and exclusion of other aetiologies such as congenital adrenal hyperplasia, androgen-secreting tumours and Cushing’s syndrome

Reproduced with permission from Teede HJ, Misso ML, Deeks AA, et al. Assessment and management of polycystic ovary syndrome: Summary of an evidence-based guideline. Med J Aust 2011;195 (6):65–112.


In practice


Lifestyle modification is the foundation of management. The principles are similar to those for diabetes prevention (ie weight control and ideally weight loss, support for a balanced individual healthy eating plan, increased physical activity). There are several targeted interventions for other manifestations of PCOS.

Oligomenorrhoea and amenorrhoea

Options include:

  • an oral contraceptive pill (OCP; low oestrogen doses [eg 20 μg] may have less impact on insulin resistance but also less impact on clinical hyperandrogenism)
  • cyclic progestins (eg 10 mg medroxyprogesterone acetate, 10–14 days every two to three months)
  • metformin (improves ovulation and menstrual cycles – though it is not PBS reimbursed for this option).228

Hirsutism

Choice of options depends on patient preference, impact on wellbeing, and access to and affordability of professional cosmetic laser therapy. Eflornithine cream can be added and may induce a more rapid response.
Pharmacological therapy is as follows:

  • Primary therapy is the OCP.
  • Anti-androgen monotherapy (eg spironolactone or cyproterone acetate) should not be used without adequate contraception. Therapies should be trialled for ≥6 months before changing dose or medication.
  • Combination therapy – if ≥6 months of OCP is ineffective, add anti-androgen to OCP (twice daily spironolactone >50 mg or cyproterone acetate 25 mg/day, days one to 10 of OCP).229

Infertility

Patients and their partner may need advice and appropriate referral for fertility management.


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  2. Lo JC, Feigenbaum SL, Escobar GJ, Yang J, Crites YM, Ferrara A. Increased prevalence of gestational diabetes mellitus among women with diagnosed polycystic ovary syndrome: a population-based study. Diabetes Care 006;29(8):1915–17.
  3. Legro RS, Arslanian SA, Ehrmann DA, et al. Diagnosis and treatment of polycystic ovary syndrome: An endocrine society clinical practice guideline. J Clin Endocrinol Metab 2013;98(12):4565–92.
  4. Teede HJ, Misso ML, Deeks AA, et al. Assessment and management of polycystic ovary syndrome: Summary of an evidence-based guideline. Med J Aust 2011;195(6):S65–112.
  5. Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol 2013;6:1–13.