Polycystic ovary syndrome: Diagnosis - Episode 84

Then this is a great opportunity to shine the spotlight on a condition that actually affects a lot of women. And doing a bit of background for this podcast, I was. Surprised to see some of these statistics. As a GP, I certainly see PCOS quite a bit in my practice, but I'm always surprised when I see the statistics and just how common it is. I think I was reading that's the most common endocrinopathy in women and potentially affects.

like one in six women, maybe even one in four Indigenous Australian women. So it's it's quite staggering really how frequent it is. And despite this prevalence, we still get many women reporting sort of a delay in diagnosis and And sometimes even a lack of or inconsistent information about the condition and about its management.

So I'm really excited to have you here and to be discussing this and to be really empowering GPs to learn a little bit more about this topic or just I guess have a refresher for those that are quite experienced with it as well.

So they might not not even know, might not have any of the stigmata of the disease, then suddenly put on ten or fifteen kilos. and all of a sudden become amenrore or oligomenorrhec um and might notice an increase in her seutism and acne. So it is really interesting that the the environmental factor and and weight in particular do play into it, but we really don't know what causes it.

One of those things is ovulatory dysfunction. Okay, so that's irregular menstrual cycles. From a practical point of view, it really is just cycle irregularity. So where a cycle sits less than twenty one days or more than thirty. I mean, so if you're having consistently irregular cycles, that's one of the criteria. The second one is either clinical or biochemical evidence of high. And so that can just be uh from a clinical point of view, can be herseutism.

And baldness, and from a biochemical point of view, that is basically raised androgens, and we tend to test free testosterone or free androgen index, are the best measures for that. The third thing is uh the ultrasound error. And so again, that's that appearance of the classical appearance, it's just a ring of antral follicles around the ovary.

Scan, they've more recently altered that diagnostic criteria because of course as ultrasounds become more advanced, we've got the ability to see more follicles. So it's essentially 20 or more. Or 20 more little little follicles being seen on the ultrasound at the time of a scan, or an ovarian volume of 10 minutes. And and I think this is the area that really trips up the radiologists and hence the GPs and I feel really sorry for my GP colleagues because

Often the reporting is completely substandard. So uh inaccurate counting or or an absence of counting of following and a lack of knowledge of what the cutoff is. So often, you know, I'll get people into my rooms with a scan that shows it I might say suggestive of PCO.

many entral follicles are seen. And when you get them in there and count them, you can clearly say that these have a polycystic ovarian morphology. So really frustrating for a GP trying to make a diagnosis when they, you know, just don't get an adequate scan report.

Does it matter then what ultrasound is being used by your local radiology? You know, do you have to be alert that if a local radiology business uh is using maybe an older some older technology, would you still count It as polycystic ovarian morphology with a lower number, or can you give any guidance around the other?

They should all have adequate training but whether And I think that's where they often the local radiology service also X-rays knees and provides MRI services and all of those things. You know, sometimes the the the radiologists it's difficult to be over everything and they might lack a little bit of specificity in terms of their language and their their desire to make a call about politics.

Which is a shame. And you know, I've got the luxury of being able to do it myself in my rooms. But also, I think the key thing for a GP would be know where your local provider is that has the best knowledge.

So in town where we are, we've got various groups that deliver great services specifically for women's ultrasound. Um but of course when you're in a rural setting it's much more tricky and and it could be something that you actually engage your radiologist with a a bit of a discussion if they're Clear diagnostic assessment, just engage them, you know, a bit of discussion to ask if they can, and that will heighten their skills in terms.

So in that setting where you either have a, if you know that your radiologist or sonographer is not particularly skilled in this area, or they have to do a transabdominal scan because someone hasn't been sexually.

While you're interested in that anchal follicle count, if they can record more than 20 anchal follicles, then there's certainly going to be more than 20 there if they can count those abdominally. But actually the ovarian volume is much easier to measure. So if they measure the ovarian volume, that's absolutely

So remember you only have to have 20 or more follicles on one or other ovary or an ovarian volume of 10 mils or more on one or other ovary. So just one ovary that's big or multifollicular gives you the

So you kinda can't get it right. Um and and and clearly early cycle before a dominant follicle arises and when there's no corpus lutein would be ideal, but I I honestly wouldn't Do the scam because remember y there's always going to be another ovary that doesn't I just order the test and see what you get back and you may have to reorder the test another time if you

information but I wouldn't worry too much about that. Just on that note, it is interesting. What we are going to see with time is the addition of AMH to the Because as you pointed out, ultrasound. Inter and intra observer variability depends on how good your machine is, how good you are at reporting it. Whereas AMH is And hormone assays become more rigorous and more standardized, we're probably going to see AMH, which is essentially a surrogate.

In all of the little antral follicles you see in an ovary, they're lined by granulosis. granulosa cells are what release AMH. malarian hormones. So essentially they're equivalent. So if you've got lots of antral follicles in an ovary, then you will have So at some point. But currently we can't use that. In my hands, I guess I use it as a another marker, I suppose, to to look at if if I'm unhappy with the quality of a scan, but it doesn't.

The future in terms of being included in the diagnosis, so very helpful. So let's talk about adolescents versus adults because this is something that can be hard as well. Some of the features of PCOS can occur kind of physiologically post- puberty, so post-menarchy. So I guess just talking about how there might be some differences and how you might approach this differently between um, you know, sort of the adult and the adolescent.

because some people are struggle with having a diagnosis and others don't. So I think, you know, given that it is very hard to make a diagnosis, I think there is no shame and I think it is useful in Saying, listen, it's really hard to diagnose you at this point, but you have some risk factors, you have possible or you're at increased risk of having PCOS in those girls who maybe have an increase in weight gain, have excessively irregular.

Or have significant acne out of keeping with what is usual. In the adolescent, within those first few years of menarchy, of course, you expect the cycles to be more. So while in the adult a cycle that's less than twenty one days or greater than thirty five days is what we would say is in a regular In the adolescent at least in that first few years.

We'd probably accept twenty one to forty five days. So, you know, you're allowed for the cycles to be more irregular. You really would only start trying to diagnose someone or giving someone a label if they Clearly were very hyper androgenic, clearly very irrigated. Had a lot of those metabolics. And you're often unable to do it.

Scans you're going to go by polycystic ovarian morphology. Again, very difficult because the younger you are, the more follicles you have. Remembering, of course, that women are born with all the follicles.

So when you see them in as an adolescent, they're going to have by definition more follicles than they will ever have again in their life. And so they're you know the ultrasound criteria are much less So I guess my advice would just be talk to people about the fact if you think clinically they are someone who is likely to have PCOS There being a likely diagnosis of PCS or possible diagnosis of PCRS, and that it's something reassess for over the coming years.

gain their reproductive maturity and then look at reassessing things, you know, once eight years or so past menarchy, then they really are reproductively mature. And I think at that point you might want to clearly give them that label.

telling people they're at risk, managing that because in the end all you're not going to do anything different from a practical point of view. If they're overweight, you're going to recommend weight loss. If they're, you know, if they had their regular cycles, you're allowed to offer them the pill. You're allowed to manage

hyperandrogenism in the same way. You're not going to do anything different. But I think giving them a firm label until they've reached that age of reproductive maturity, I think, is probably not necessarily that helpful, but talking to them about all the risks They're not going to be able to do that Is helpful and and managing.

function and it is hard. You know, I use a very clinical definition of that. I actually don't do a lot of day 21 progesterone testing or mid-luteal progesterone testing, which is weird for A fertility guy. But you know, I think that the clinical discussion about what are your parents like is as useful as doing. produce strain because of course

Do it because it can help you. Uh remember when you're going to do that progesterone level. I'd always do it with a lucinizing hormone and an estradiol to again get a better picture of kind of where they are and where they might be in the cycle. But I really think your own clinical intuition about whether their cycle is regular or irrelevant. When it comes to looking at the hand hyperandrogenism, again the free androgen index and the f or the free test.

And each lab will only offer one of those, so if you just say a free entry and it Chosen one, they will do a free T you need to exclude other causes for irregular cycles. And so those are thoughts Yeah. Also in the back of your mind you gotta think about the differentials of a non classic pretty rare, but often present as a teenager with some increase in androgenic symptoms and some cycle.

So I would always do a 17 hydroxy progesterone in there. So that really that's the main other test. So thyroid, prolactin, and a 17 hydroxy. Because if that's normal, then you don't. Of course cushions, you know, very rare. You guys probably pick them up more I don't you know, pick the pick them up more than I do, but uh c cushings it that's often has that very typical

And moon faces and and all of those kind of things, hypertension. Um, so that is a differential, but I wouldn't be chasing that differential unless someone had a very clear presentation. th those kind of things. So really yeah, those are the tests that I would do. That's outside of I suppose screening