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PCOS and Long-term Health Dr Vikram Talaulikar MD FRCOG PhD Associate Specialist in Reproductive Medicine, UCLH Hon. Associate Professor in Women's Health, University College London BMS certified Menopause Specialist Trainer in Menopause Care for GPs Background • Polycystic ovary syndrome (PCOS) is the most common endocrinopathy • 8-13% reproductive age women (depending on the population studied) • PCOS is complex with reproductive, metabolic, and psychological aspects PCOS and CVD risk • CVD risk in women with PCOS remains unclear pending high quality studies, however prevalence of risk factors is increased, warranting consideration of screening (differences based on ethnicities) • Assessment for cardiovascular risk factors and global CVD risk – if risk factors including lack of physical activity are present - consider at increased risk of CVD, diabetes, and PCOS and CVD risk • All women with PCOS should have blood pressure measured at least annually • Regular monitoring for weight changes and excess weight, in consultation with and where acceptable to the individual woman • Monitoring could be minimum 6–12 monthly - Weight, height, BMI and ideally waist circumference • Women with PCOS and high BMI should have a fasting lipid profile at diagnosis and regular monitoring thereafter PCOS and CVD risk • Healthcare professionals need to be aware that conventional cardiovascular risk calculators have not been validated in women with PCOS • Risk factors should be treated/managed accordingly • Lifestyle changes – healthy diet, exercise and weight loss are first line before pharmaceutical • Metformin/insulin sensitisers not licensed for PCOS but remain underutilised in my opinion • a high-risk obesity-related condition when standard weight loss strategies failr more with PCOS and Diabetes risk • Prevalence of gestational diabetes, impaired glucose tolerance and type 2 diabetes (5-fold in Asia, 4-fold in the Americas and 3-fold in Europe) are significantly increased with PCOS (exacerbated by high BMI) • Glycaemic status should be assessed at baseline in all women with PCOS. presence of other diabetes risk factorsone to three years, influenced by the PCOS and Diabetes risk • An oral glucose tolerance test (OGTT), fasting plasma glucose or HbA1c should be performed to assess glycaemic status – availability varies • In high-risk women with PCOS (BMI > 25 or in Asians >23, history of impaired fasting glucose or gestational diabetes, family history of diabetes type 2, hypertension), an OGTT is recommended • A OGTT should be offered in all women with PCOS preconception or at < 20 weeks gestation, and at 24–28 weeks gestation – if abnormal refer to obstetric diabetic teamPCOS and Obstructive sleep apnea • snoring, waking unrefreshed from sleep, daytime sleepiness and fatigueoms, such as • A simple screening questionnaire and if positive, referral to a specialist consideredPCOS and Endometrial (womb lining) cancer • Health professionals and women with PCOS should be aware of a 2- to 6-fold increased risk of endometrial cancer (absolute risk low) • Health professionals should have a low threshold for investigation of endometrial cancer in women with PCOS or a history of PCOS (by transvaginal ultrasound and/or endometrial biopsy) – if persistent thickened endometrium and/or risk factors including prolonged amenorrhea, abnormal vaginal bleeding or excess weight • Routine ultrasound screening of endometrial thickness in PCOS is not recommendedPCOS and Endometrial (womb lining) cancer • Optimal prevention for endometrial hyperplasia and endometrial cancer is not known • COCP or progestin therapy in those with cycles longer than 90-120 days • There does not appear to be an association with breast or ovarian cancer and no additional surveillance is requiredPCOS, Quality of life and Emotional wellbeing • Health professionals and women should be aware of the adverse impact of PCOS on quality of life • Health professionals should capture and consider perceptions of symptoms, impact on quality of life and personal priorities for care to improve patient outcomes • The PCOS quality of life tool (PCOSQ), or the modified PCOSQ PCOS, Quality of life and Emotional wellbeing • High prevalence of moderate to severe anxiety and depressive symptoms • Depression and/or anxiety should be routinely screened for and, if present, further assessment and appropriate counselling and intervention (including pharmaceutical) should be offered by a qualified professional • The optimal interval for anxiety and depressive symptom screening is not known. Repeat screening based on clinical judgment, considering risk factors, comorbidities and life events • Agents/hormones that exacerbate PCOS symptoms, including weight gain, need careful considerationPCOS – Psychosexual function and Body image • Increased prevalence of psychosexual dysfunction and these can impact on sex life and relationships • Screening tools and referral should be considered as per local arrangements • Also, increased prevalence of eating disorders and disordered eating associated with PCOS • offered by appropriately trained health professionals (as per local arrangements)d be Interventions • Weight loss - Achievable goals such as 5–10% weight loss yields significant clinical improvements and is considered successful weight reduction within 6 months • Ongoing assessment and monitoring is important during weight loss and maintenance in all women with PCOS • SMART (Specific Measurable, Achievable, Realistic and Timely) goal setting and self- monitoring • Health professionals need to consider personal sensitivities and potential weight-related stigma Diet and Physical activity • A variety of balanced dietary approaches could be recommended • General healthy eating principles • An energy deficit of 30% or 500–750 kcal/day (1200–1500 kcal/day) could be prescribed • No or limited evidence that any specific energy equivalent diet type is better • Tailoring of dietary changes to food preferences, allowing for a flexible and individual approach – self monitoring should be encouraged • A minimum of 150 min/week of moderate intensity physical activity or 75 min/week of vigorous intensities including muscle strengthening activities or 10,000 steps daily Behavioural strategies • Comprehensive health behavioural or cognitive behavioural interventions could be considered to increase support, engagement, retention, adherence and maintenance of healthy lifestyle and improve health outcomes • Prevention of weight gain, monitoring of weight and encouraging evidence- based and socio-culturally appropriate healthy lifestyle is important in PCOS particularly from adolescence Metformin • All guidelines do not agree on use of insulin sensitisers • Metformin in addition to lifestyle, should be considered in adult women with PCOS with BMI ≥ 25 for management of weight and metabolic outcomes • Metformin may offer greater benefit in high metabolic risk groups including those with diabetes risk factors, impaired glucose tolerance or high-risk ethnic groups Metformin • Adverse effects - gastrointestinal side-effects are generally dose dependent and self-limiting • Start at a low dose, with 500 mg increments 1–2 weekly and extended release preparations may help • Metformin use appears safe long-term (monitor for low vitamin B12 levels) • Use is off label Anti-obesity pharmacological agents • Could be considered for the management of obesity after lifestyle intervention • Cost, contraindications, side effects, variable availability and regulatory status need to be considered and pregnancy needs to be avoided whilst taking Inositol • Inositol (in any form) – there is emerging evidence on efficacy but need for further research • Women can take inositol and other complementary therapies but limited evidence should be highlighted