Polycystic

ovary GP Tool
syndrome
This resource is informed by the evidence-based guideline for
the assessment and management of polycystic ovary syndrome
(PCOS), authored by the PCOS Australian Alliance and auspiced by
Jean Hailes for Womens Health. We are grateful to the Australian
Government Department of Health and Ageing for their support
and funding of the national evidence-based guideline project and
subsequent translational programme.
PCOS Management
This should be considered across the lifespan Emotional health Cardiometabolic health
and individualised.
Depression (prevalence 28-64%) and/or
Consider the benefit of a GP management Key message:
anxiety (prevalence 34-57%) should be
plan and/or team care arrangement. Increased cardiovascular
routinely screened for
Eating disorders, negative body image, risk factors
Referral guidance:
low self-esteem and psychosexual
In those with more complex PCOS or with dysfunction should also be considered Screen for CVRF:
challenges in differential diagnosis, consider referral Emotional health screening questionnaire Smoker-advise cessation
to an endocrinologist for initial work-up but for (see back of this tool)
ongoing care by the GP. Check annually:
BP <135/85mmHg
Fertility specialist referral is appropriate in
overweight women AFTER 6 months of intensive Lifestyle Lipid profile: check every 2 years
lifestyle intervention and potentially after metformin Lifestyle
with targets
is first line treatment for all with
therapy, if no other fertility factors are suspected TC <4 mmol/L
PCOS addressing high risk of weight gain
and if age is less than 35 years. If age is greater LDL (without additional CVD risk
through prevention and where needed
than 35 years refer early. factors) <3.4 mmol/L
enabling weight loss
LDL (with metabolic syndrome
PCOS Management areas include; Realistic weight loss goals vital

(5-10% body weight) or diabetes) <1.8

Emotional health
No specific diet, focus on low energy HDL - >1.0 mmol/L
Lifestyle
Triglycerides - < 1.7 mmol/L
density, sustainable behavioural change,
Cardiometabolic health
GP and self-weighing/monitoring regularly
Weight management
30 minutes of moderate to vigorous
Fertility
exercise daily for health goals - won t
Menstrualcycle regulation
reduce weight alone, need diet. Increase
Clinical
hyperandrogenism (eg. hirsutism)
opportunistic movement, consider referral
Sleep apnoea
to exercise physiologist
Note: this is heterogeneous chronic condition
and there is a need to engage each woman in
prioritising her own management issues.

Diabetes:
Note: 4-8 fold increased risk and earlier
onset of gestational, prediabetes and
diabetes in PCOS, these occur in lean and
in young PCOS women. OGTT: (fasting BSL
alone inadequate to detect IFG, IGT).
every two years (annually if elevated
glucose levels and additional risks factors)
Impaired fasting glucose - 6.1-6.9 mmol/L
Impaired glucose tolerance -2 hour
glucose level: 7.8-11 mmol/L
Type II diabetes - fasting plasma glucose:
7.0 mmol/L or 2 hour oral glucose
tolerance test: 11.1 mmol/L
Weight management
Weigh and monitor women regularly, vital to:
targetprevention of weight gain in all, and
achievable 5-10% weight loss if overweight
Note: education alone and unachieveable
goals are generally unsuccessful.
Key message:
5 10% weight loss will greatly
assist in symptom control
Weigh
and measure women regularly;
avoiding weight gain (if a healthy weight
or overweight) is an important objective
Encourage simple behaviour change
prioritisation of healthy lifestyles, family
support, lifestyle and exercise planning,
pedometers, setting of small achievable goals
Consider referral, via Team Care
Arrangement if appropriate
dietitian (tailored dietary advice,
education, behavioural change support)
exercise physiologist (exercise
motivation, education)
psychologist (motivational interviewing,
behaviour management techniques,
emotional health and motivation)
group support (diet and exercise program)
Fertility
Key message:
Prevent weight gain and address
weight loss if needed as BMI> 30
limits fertility and consider starting
family as soon as practicable as
infertility risk increases for women
over 30 years
BMI >25 30+ lifestyle interventions 1st line
5 10% weight loss will greatly assist in
cycle control and fertility
Clomiphene is first line pharmacological
therapy but in primary care metformin can be
started before specialist referral for clomid
Metformin -Improves ovulation, re-
establishes cycles, reduces insulin
resistance, reduces progression to
diabetes, may prevent weight gain but
does not cause weight loss
Minimise side effects with starting
dose 1 x 500mg daily, increase by 500mg
per fortnight up to 1500mg 2000mg
average dose
Binge drinking should be avoided
on metformin
Menstrual cycle regulation
Key message:
Women with PCOS have
increased risk of Endometrial
Cancer with prolonged
amenorrhoea; aim for >4 periods/
year unless on contraception
Lifestyle and metformin usually
improve cycles
OCP all pills increase SHBG thereby
reducing free androgens, provide
contraception & endometrial protection
and cycle regulation (monitor glucose
tolerance in those at risk of diabetes as
may increase insulin resistance)
Specialist pills- (e.g. cyproterone acetate
containing) are not more advantageous in
reducing acne and hirsutism and longer
term the lowest effective dose pill may
be optimal
Progestagens alone may be used
cyclically or as an IUD where OCP is
contraindicated or not preferred (e,g.
Provera 10mg days 1-10 in January, April,
July, September)
Clinical hyperandrogenism
(e.g Hirsutism)
1st line-Cosmetic options laser,
depilatory creams, shaving, threading,
plucking, shaving and electrolysis
Pharmacological therapy options include:
OCP (all will assist) aim for lowest
effective dose , takes 6-12 months to see
benefit
Combination therapy if 6months
of OCP is ineffective, consider adding
anti-androgen to OCP (e.g.twice daily
spironolactone >50mg) 6-12 months to
reach optimal effectiveness. Variable results
Contraception is vital to prevent
pregnancy whilst on anti-androgens
Sleep apnoea
Monitor for sleep apnoea
(strongly associated with overweight)
For more information
www.managingpcos.org.au/health-
professionals/hp-about-pcos/treatment
Provide PCOS booklet or link:
www.managingpcos.org.au/images/
stories/pcos_booklet/index.html
Managing PCOS website:
www.managingpcos.org.au
Support - Polycystic Ovary Syndrome
Association of Australia Inc. (POSAA) link:
main.posaa.asn.au
Emotional health screening questionnaire:
(Guide to interpretation for health professional)
www.managingpcos.org.au/pcos-
evidence-based-guidelines/appendix-i-ix/
appendix-v-emotional-health-screening-
questionnaire
Questions focus on the following areas;
1. Depression and/or anxiety
2. Body image
3. Disordered eating
4. Psychosexual dysfunction
If positive consider Mental Health Care
Plan, ongoing support and/or referral
to a mental health professional.
PCOS Assessment
Clinical presentation Rotterdam diagnostic criteria
Presentation

Prevalence most common endocrine Requires two of:

disorder in reproductive aged women 1. Oligo- or anovulation
- 12-18% 2. Clinical and/or biochemical hyperandrogenism
Consider if female presents with 3. Polycystic ovaries; and exclusion of other aetiologies
one or more - menstrual irregularity
(>35 or <21day cycles), overweight, Confirm diagnosis PCOS 1. Biochemical androgens; * If significant
hirsutism, fertility issues, prediabetes, measure after 3 month hyperandrogenism
gestational diabetes or early onset type (2 out of 3 required) clinically, rapid
cessation of OCP (ensure
II diabetes, note high risk ethnic groups alternate contraception) onset or severe
(Asian, Indigenous, Nth African) 1. Hyperandrogenism: and androgen
measures of free
clinically (hirsutism, acne) levels >20% above
not total testosterone
Differential diagnosis or biochemically normal limit refer to
Investigations

(free androgen index or endocrinologist for

investigations free testosterone) varies
2. Vaginal ultrasound exclusion of other
TSH
women >18 yrs age between laboratories rarer causes
Prolactin
(PCO alone is nonspecific
FSH(if premature menopause
68% in young women)*
suspected)
3. Menstrual Hx - 2. Vaginal ultrasound not recommended for
(>35 or <21 day cycles non-sexually active women and is unreliable in
indicating anovulation) adolescents with high false positives. Abdominal
ultrasounds can be used >18yrs for PCOS
diagnosis, but are less accurate

For more comprehensive information:

PCOS guideline: www.managingpcos.org.au/pcos-evidence-based-guidelines/1-challenges-in-diagnostic-assessment-of-pcos
MJA clinical practice article: www.mja.com.au/journal/2011/195/6/assessment-and-management-polycystic-ovary-syndrome-summary-evidence-based
Managing PCOS website: www.managingpcos.org.au
Emotional health
screening questionnaire
If any of the questions in any of the sections are positive, further exploration of that
area is required (see guidelines for other tools as needed) and consider Mental Health
Care Plan, ongoing support and/or referral to a mental health professional.
Ask patient the following questions;
1. a) During the last month, have you 3. a) Does it make it hard to do your work For further information about
often been bothered by feeling or be with your friends and family? this booklet contact:
down, depressed, anxious or hopeless? b) Do you worry you have lost control Education Unit
b) During the last month, have you over your eating?
Jean Hailes for Womens Health
often been bothered by having little c) Do you ever feel disgusted, depressed,
173 Carinish Road,
interest or pleasure in doing things? or guilty about eating?
Clayton, VIC 3168
c) During the last month, have you d) Have you tried fasting or skipping
often been bothered by feeling meals in an attempt to lose weight? PO Box 1108,
excessively worried or concerned? e) Have you tried vomiting, laxatives or Clayton South, Vic 3169
2. a) Do you worry a lot about the way diuretics in an attempt to lose weight? Phone: 1800 JEAN HAILES (532 642)
you look and wish you could think f) Have you had significant (e.g. >5-7%),
recurrent fluctuation in body weight? Email: education@jeanhailes.org.au
about it less?
b) On a typical day, do you spend 4. a) During the last few months, have
more than 1 hour day worrying you often been bothered by problems
about your appearance? If so what with your sex life such as reduced
concerns do you have and what satisfaction, desire, pain, or any
effect does it have on your life? other problems?
b) Do you feel that PCOS affects your
sex life?
c) Do sexual problems affect your
current relationship and/or have
sexual problems affected your
past relationships?