Polycystic ovary syndrome (PCOS)

Patient presents with symptoms indicative of PCOS:

• infrequent or absent periods
• subfertility
• signs of androgen excess (acne/hirsutism/alopecia)
• raised BMI (60% women with PCOS are overweight)
• +/- risk factors such as family history or South Asian ethnicity.

Primary care investigations

• Androgen profile
• Day 1-5 LH:FSH ratio, E2E2
• Thyroid profile
• Prolactin
• HbA1c
• LFT’s/U&E’s/lipid profile.

Pelvic ultrasound (USS) only if:

• androgen profile normal, but suspicion of PCOS.

OR

• another indication for scan (i.e. pelvic pain)

Include androgen profile results, plus clinical summary in referral and ask for ovarian volumes and follicle count.

NB: Not recommended for diagnosing PCOS in adolescents, particularly those within 8 years of their first period (menarche).

Gynaecology

Refer where diagnostic uncertainty following initial investigations/management.

Include all relevant clinical information.

Adolescents can be referred to joint paediatric/gynaecology clinic for advice.

Fertility

Refer based on the local pathway where fertility is the primary concern of patients.

Fertility Scotland Network. Referral from primary to secondary/tertiary care.

Refer follows initial interventions for weight management, diabetes prevention, smoking cessation and other routine fertility investigations.

Endocrinology

Refer for advice for specialist investigation and management where there are specific endocrine concerns or underlying disorders. 

Cushing’s syndrome where many symptoms may mimic PCOS (Cortisol tests needed)

Elevated 17-hydroxyprogesterone (17-OHP) levels can be indicative of several conditions, most commonly congenital adrenal hyperplasia (CAH)

Prolactin excess is present in 15-25% of women with PCOS especially those who are obese and insulin-resistant, at the pre-diabetic end of the spectrum.  Literature suggests a significant minority will have a structural pituitary abnormality. Therefore, persistently raised prolactin levels, especially macroprolactin, will need a referral.

Dermatology

Refer where there is a non-response to initial treatments and ongoing symptoms.

Discuss up-to-date referral criteria for hirsutism and androgenic alopecia with the specialty in advance, to ensure appropriate patient advice can be given.

Pregnancy/Maternity

Beyond scope of this pathway- but women with diagnosis of PCOS may require a OGTT during pregnancy due to an increased risk of gestational diabetes.

Managed via standard maternity pathways.

Primary Care led management

Risk awareness

Discuss increased risk of CVD, T2DM, benefits of weight loss, physical activity and smoking cessation.

Refer to support services including smoking cessation. Provide patient information/ signposting.

Acne

Combined Oral Contraceptive Pills (COCP) (due to hormonal imbalance)

Additional therapies as per routine treatment.

Hirsutism

Cosmetic treatment, consider COCP (may take 12-18months for effect), Eflornithine cream as second line treatment.

Sub-fertility

Investigation and management as per local/national pathway.

Weight management/diabetes prevention

As per usual referral protocols, accepted for adults BMI >25 (23 for specific ethnicity with increased comorbidity risk)

Separate child/adolescent referral for those aged 12-18.

Oligo/amenorrhoea

Aim to achieve 3-4 periods a year with COCP 

or Cyclical progesterone or Levonorgestral-releasing IUD (endometrial protection for unopposed oestrogen where COCP contraindicated or not required)

Androgenic alopecia

Aesthetic options (not NHS funded), medical management via non-formulary/unlicensed treatments (OTC or private prescription)

Secondary care referral.

International Evidence-based Guideline for the assessment and management of polycystic ovary syndrome. 2023. Available from: https://www.monash.edu/medicine/mchri/pcos/guideline