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Tailor PCOS interventions to patient’s desired outcomes
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NEW ORLEANS — When managing a patient with polycystic ovarian syndrome, physicians should discuss goals, such as regulating the menstrual cycle, addressing the cosmetic issues of hyperandrogenism, managing infertility or preventing comorbidities, and personalize interventions to address those targets, according to a presentation at the ACP Internal Medicine Meeting.
“Polycystic ovarian syndrome (PCOS) is very common and affects 5% to 20% of reproductive-aged women, making it the most common endocrine disorder in this age group,” Christine Robillard Isaacs, MD, from Virginia Commonwealth University, said during her presentation.
Identifying PCOS
“PCOS is a complex disease,” Isaacs said. “It is not ‘one size fits all.’”
There is no universally accepted definition of PCOS, according to Isaacs.
Women with PCOS typically present to the clinician with menstrual irregularity, infertility issues or clinical signs of high androgen levels, such as acne or hirsutism, she said.
Obesity is also very common within the syndrome; therefore, PCOS suspicion should be heightened in women who are overweight or obese, according to Isaacs. However, obesity is not part of the diagnostic criteria for PCOS because 20% of patients with the condition are not obese, she noted.
Additionally, polycystic ovaries may be present, but are not necessary for the diagnosis, she said.
For patients going through puberty, many of these symptoms, including acne, hyperandrogenemia and menstrual irregularity, are normal, she noted. Therefore, it is important to reassure the normal and focus on the lifestyle before going down the PCOS path in such patients, she said.
“Ultimately, diagnosis is hard because there is no perfect test to do and a lot of the signs and symptoms are heterogenous,” Isaacs said.
Treating symptoms of PCOS
“Because PCOS is a syndrome with a spectrum of presentations, interventions and desired outcomes should be customized to the patient’s aspirations,” Isaacs told Healio Internal Medicine. “Regulating the menstrual cycle with hormones, addressing the cosmetic issues associated with androgen excess with various treatments or managing infertility efforts are the typical goals that need to be discussed.”
In many younger patients, their goal is often to get rid of the hyperandrogenism cosmetic complaints, according to Isaacs. She noted that hirsutism is associated with anxiety and depression.
The most effective way to reduce hirsutism is with combined hormonal contraceptive therapy, she said. Such therapy can also improve acne, she said.
“It is important to tell patients that this is not an instant fix,” Isaacs said.
Physicians must create the expectation that results from hormone therapy can take 6 or more months, she said.
When the goal is to help a patient get pregnant, it is important to emphasize lifestyle modifications because weight reduction can trigger ovulation, she said.
“For patients who are overweight or obese, even modest amounts of weight loss improves one’s symptoms and prognosis,” Isaacs said in the interview.
If patients lose weight, but are still unable to ovulate, their weight reduction can improve their response to ovulation-induction medications, according to Isaacs.
Once acne and hirsutism are cleared and the patient is able to get pregnant, the focus can turn to preventing comorbidities associated with PCOS, she said.
“PCOS is commonly associated with insulin resistance and thus, lifelong screening for metabolic syndrome should be encouraged,” Isaacs said in the interview. “Lifestyle modifications and efforts to maintain a healthy weight should be at the core of patient counseling.” – by Alaina Tedesco
Reference:
Isaacs CR. Menstrual disorders and infertility. Presented at: ACP Internal Medicine Annual Meeting; April 19-21, 2018; New Orleans.
Disclosure: Isaacs reports no relevant financial disclosures.