Diabetes and Cardiometabolic Disease in Women With PCOS
It is widely considered that PCOS is a significant risk factor for CMD – making it as important to consider as dyslipidaemia or hypertension. While primary care focuses largely on hirsutism and fertility issues in PCOS management, the question of identifying all women with PCOS, and offering general screening for type 2 diabetes and CVD risk assessment is currently not addressed. However, we propose that interim clinical recommendations can and should be made.
This could be achieved through (i) greater public awareness of PCOS among women, (ii) increased symptom enquiry by primary care professionals, and (iii) greater attention given to the investigation of oligomenorrhoea or hirsutism by simple blood tests. Women who meet the clinical/biochemical diagnostic criteria for PCOS may need investigation to exclude other diagnoses, through discussion with, or referral to an endocrinologist. Most of the differential diagnoses are relatively uncommon or rare. Differential diagnoses may be excluded (see Table 4 ) and CMD risk may be determined through the following investigations ( Table 5 ).
The identification of women with PCOS, who then could be screened for type 2 diabetes, would be helped considerably if there were a universally accepted definition. Current discrepancies between definitions lead to uncertainty in primary care. Using the NIH classification which does not require ultrasound, will result in missing the diagnosis of some PCOS phenotypes and perpetuating low detection rates. Yet, even in the UK where the Rotterdam criteria are used to diagnose this condition, unless women with either oligomenorrhoea or hyperandrogenism are referred for ultrasound investigation, clinicians are essentially basing their diagnosis upon the NIH criteria. It would be pragmatic therefore to first identify if a woman has hyperandrogenism and oligomenorrhoea and when only one criteria is found, to refer for a transvaginal ultrasound to confirm diagnosis. Laboratory referral guidelines would need to reflect this and also ensure that reporting detail is sufficient to base a diagnosis upon.
PCOS is a common condition which identifies many women at risk of CMD. Diabetes screening protocols for women with PCOS need agreement. Fasting glucose will miss 80% of pre-diabetes but whilst the WHO and ADA now recommend the use of HbA1C to diagnose diabetes they acknowledge the limitations of this test. This includes the poor sensitivity in identifying IGR in PCOS, making the test unsuitable for identifying small degrees of IGR in this population. It is noted, therefore, that despite a general move towards using HbA1C, the OGTT remains the only proven test for accurate classification of IGR and potentially for the diagnosis of type 2 diabetes in PCOS. For this to work successfully in primary care settings, disease registers and recall systems would be required to ensure that regular type 2 diabetes screening and CVD risk assessment can be undertaken. Until there is formal UK guidance a pragmatic approach is required to ensure that women with PCOS are recognised, diagnosed and their CMD risk managed. European guidelines recommend screening for diabetes in women with PCOS who have a BMI >30 kg/m despite evidence of profound insulin resistance in lean women with PCOS and the guidance of screening PCOS with a BMI≥25 kg/m by the ADA. Australian guidelines address this by recommending an OGTT every two years on all women with PCOS or annually in those with other risk factors including pre-existing IGR. Table 6 provides suggestions for CMD assessment based upon information provided by these sources (Table 6).
The wide range of PCOS phenotypes and women's own concerns suggest that clinical management should be individualised according to symptoms and risks. However, whether it is treating hyperandrogenism, managing infertility or screening for CMD, it would be in the interests of the woman involved and their healthcare professionals to have evidenced-based guidelines to improve quality and equity of care. Many of the issues raised in this article have been addressed recently, although it should be noted that whilst adopting the Rotterdam diagnostic criteria, the authors of the Australian guidelines are not in complete concordance with the recommendations of the 3 ESHRE consensus workshop in terms of defining oligomenorrhoea and recommendations to screen for CMD.
Recommendations for Clinical Practice
It is widely considered that PCOS is a significant risk factor for CMD – making it as important to consider as dyslipidaemia or hypertension. While primary care focuses largely on hirsutism and fertility issues in PCOS management, the question of identifying all women with PCOS, and offering general screening for type 2 diabetes and CVD risk assessment is currently not addressed. However, we propose that interim clinical recommendations can and should be made.
1. Improve the Identification of Women With PCOS in Primary Care
This could be achieved through (i) greater public awareness of PCOS among women, (ii) increased symptom enquiry by primary care professionals, and (iii) greater attention given to the investigation of oligomenorrhoea or hirsutism by simple blood tests. Women who meet the clinical/biochemical diagnostic criteria for PCOS may need investigation to exclude other diagnoses, through discussion with, or referral to an endocrinologist. Most of the differential diagnoses are relatively uncommon or rare. Differential diagnoses may be excluded (see Table 4 ) and CMD risk may be determined through the following investigations ( Table 5 ).
2. Standardisation of the PCOS Definition
The identification of women with PCOS, who then could be screened for type 2 diabetes, would be helped considerably if there were a universally accepted definition. Current discrepancies between definitions lead to uncertainty in primary care. Using the NIH classification which does not require ultrasound, will result in missing the diagnosis of some PCOS phenotypes and perpetuating low detection rates. Yet, even in the UK where the Rotterdam criteria are used to diagnose this condition, unless women with either oligomenorrhoea or hyperandrogenism are referred for ultrasound investigation, clinicians are essentially basing their diagnosis upon the NIH criteria. It would be pragmatic therefore to first identify if a woman has hyperandrogenism and oligomenorrhoea and when only one criteria is found, to refer for a transvaginal ultrasound to confirm diagnosis. Laboratory referral guidelines would need to reflect this and also ensure that reporting detail is sufficient to base a diagnosis upon.
3. Standardisation of PCOS Screening Recommendation
PCOS is a common condition which identifies many women at risk of CMD. Diabetes screening protocols for women with PCOS need agreement. Fasting glucose will miss 80% of pre-diabetes but whilst the WHO and ADA now recommend the use of HbA1C to diagnose diabetes they acknowledge the limitations of this test. This includes the poor sensitivity in identifying IGR in PCOS, making the test unsuitable for identifying small degrees of IGR in this population. It is noted, therefore, that despite a general move towards using HbA1C, the OGTT remains the only proven test for accurate classification of IGR and potentially for the diagnosis of type 2 diabetes in PCOS. For this to work successfully in primary care settings, disease registers and recall systems would be required to ensure that regular type 2 diabetes screening and CVD risk assessment can be undertaken. Until there is formal UK guidance a pragmatic approach is required to ensure that women with PCOS are recognised, diagnosed and their CMD risk managed. European guidelines recommend screening for diabetes in women with PCOS who have a BMI >30 kg/m despite evidence of profound insulin resistance in lean women with PCOS and the guidance of screening PCOS with a BMI≥25 kg/m by the ADA. Australian guidelines address this by recommending an OGTT every two years on all women with PCOS or annually in those with other risk factors including pre-existing IGR. Table 6 provides suggestions for CMD assessment based upon information provided by these sources (Table 6).
Standardisation of Clinical Assessment
The wide range of PCOS phenotypes and women's own concerns suggest that clinical management should be individualised according to symptoms and risks. However, whether it is treating hyperandrogenism, managing infertility or screening for CMD, it would be in the interests of the woman involved and their healthcare professionals to have evidenced-based guidelines to improve quality and equity of care. Many of the issues raised in this article have been addressed recently, although it should be noted that whilst adopting the Rotterdam diagnostic criteria, the authors of the Australian guidelines are not in complete concordance with the recommendations of the 3 ESHRE consensus workshop in terms of defining oligomenorrhoea and recommendations to screen for CMD.
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