Polycystic Ovarian Syndrome (PCOS) is a
very common condition affecting at least
14% of all women of reproductive age.
In 2003, the Rotterdam ESHRE/ASRM
Consensus Group revised Diagnostic
Criteria for PCOS which are:
1. Oligo- and/or anovulation
2. Hyperandrogenism (Clinical [hirsutism,
acne] and/or biochemical)
3. Polycystic ovaries (at least 10 antral
follicles in periphery ± increased
2 out of 3 criteria are required for
diagnosing the syndrome
• Unknown but results from a
combination of several related factors.
•Women with PCOS frequently
have a mother or sister with PCOS.
But there is not enough evidence
yet to say there is a genetic link to
• An imbalance between the pituitary
gonadotropin luteinizing hormone
(LH) and follicle-stimulating hormone
(FSH), resulting in a lack of ovulation
and an increased testosterone
production, a male sex hormone.
• Many women with PCOS have a
weight problem. So researchers are
looking at a relationship between
PCOS and the body’s ability to
make insulin. Insulin is a hormone
that regulates the change of sugar,
starches and other food into energy
for the body’s use or for storage.
Many women with PCOS have
insulin resistance, in which the body
cannot use insulin efficiently. Since
some women with PCOS make
too much insulin, this leads to high
circulating blood levels of insulin,
called hyperinsulinemia. It is believed
that hyperinsulinemia is related to
increased androgen levels and it is
possible that the ovaries react by
making too many male hormones,
androgens.This can lead to acne,
excessive hair growth, weight gain
(obesity), and ovulation problems as
well as type 2 diabetes. In turn, obesity
can increase insulin levels, causing
PCOS to get worse.
Treatment of PCOS
Lifestyle change and change in diet are
absolutely paramount.The long-term
consequences of PCOS should also
be highlighted. Prophylactic use of
Metformin in women with impaired
glucose tolerance to prevent progression
of diabetes is gaining increasing acceptance.
The effectiveness of Metformin, in relation
to ovulation induction, has been evaluated
and the most recent meta-analysis of
27 trials (Moli et al November 2007)
concluded that Clomiphene Citrate
(CC) should still be the first choice
therapy for women with therapy naïve
PCOS (no previous treatments). In CC
resistant women, a combination of CC
plus Metformin is more effective than
laparoscopic ovarian drilling or FSH.
Polycystic Ovarian Syndrome
• Irregular periods (cycle greater than
35 days or lack of periods).
• Irregular ovulation or no ovulation.
• Infertility; difficulty in becoming
• Recurrent miscarriages.
• Unwanted facial and/or body hair
• Oily skin, acne.
• Being overweight, rapid weight gain
especially around the waist and
abdomen (central obesity); difficulty
in losing weight.
Investigation of PCOS:
• Transvaginal Ultrasound (specific
reporting on numbers of antral
• FSH/LH ratio (on day 3-5 of menses
or after progesterone challenge, avoid
mid-cycle day 18-20 in women with
cycles less than 35 days).
• Androgen profile.
• Oral glucose tolerance test if BMI
>27 /Thyroid function tests.
• Lipid profile (cholesterol, LDL and
Mr Joseph Aquilina FRCOG is
a Consultant Obstetrician and
Gynaecologist at St.Bartholomew’s
and The Royal London Hospitals.
He provides a specialist service
in Gynaecological Ultrasound and
is recognised as a Preceptor for
training in gynaecological scanning by
the Royal College of Obstetricians
and Gynaecologists. He offers a
comprehensive one-stop service
in the management of menstrual
disorders, pelvic pain and polycystic
ovarian syndrome. He is available
for consultations at London Bridge
Hospital on Tuesday afternoons/early
evenings. Appointments can be made
by telephoning Mr Aquilina’s personal
020 8504 5381
or email[email protected]
Take home messages:
• Presenting symptoms are highly variable.
• Not all women with PCOS are infertile.
• Treatment of PCOS is highly
• Lifestyle changes and exercise are
mandatory as part of the management
of the condition.
• Metformin may have a role in treatment
of POC and a six-month trial is
worthwhile, especially in obese PCOS.
• For women requesting cycle control, oral
contraceptive pill with anti-androgen
activity (Yasmin) should be offered.
• Clomiphene is the initial treatment of
choice in infertility.
• Clomiphene plus Metformin may be
more effective than ovarian drilling or IVF.
PCOS is a very common problem that
has both short-term effects upon
reproductive function and longer term
effects upon the risk of diabetes and
cardiovascular disease. Challenges for
the future are the management of
overweight adolescents with PCOS
and the use of Metformin as an adjunct
to IVF treatment in women with PCOS
and its use in antenatal period.