¶ Intro / Opening
You're listening to The Good GP, the podcast for busy GPs. Hello and welcome to another episode of The Good GP. and today I am joined once again by Dr. Ben Croon to have a chat about polycystic ovary syndrome. Welcome back Ben and thanks so much for giving up some more time to chat about this topic.
Christine in my place.
So Ben, we mentioned last time you're an obstetrician and gynecologist at Eve Health and Queensland Fertility Group in Brisbane and you know you have a subspecialized interest in fertility and reproductive endocrinology.
¶ Understanding PCOS Management Principles
And on the last episode, we started off our chat about PCOS talking around the workup for it and some of the specifics around diagnostics. But today we're meeting up again to go a little bit further into some of the principles around managing PCOS. So let's get into it. Let's talk about the overarching principles when it comes
Thanks Christina. I think obviously making a diagnosis can be tricky as we discuss When once a diagnosis is made, managing whatever the presenting problem is is what happens at from my end of things, you know, and I guess maybe the same with you, with GPs. So if the problem is an acne or herseutism, that's one thing. If the problem is maybe fertility, that's another thing. So
It's irregular cycles, that's another thing. So I think focusing on what that actual problem is. So you think you have to be really quite goal focused in that. But then at the same time screen for complications. And that screening for complications is a long term thing and from a GP point of view you guys are great at that sort of thing. And I think that's a really important role for the GP because for us
They come to us for one thing. We try to touch on all the other things, but often we're getting really deeply into whatever that one presenting problem.
¶ Screening for PCOS Complications
Ben, let's talk about lifestyle advice first of all. What things do you generally talk about with women, you know, in your practice?
From my point of view again it really depends on what the particular problem is the woman has. So often as you know, And when I mentioned before screening for complications, what I'm thinking Cardiovascular complications, the hypertension, the diabetes, as well as screening for things like Cancer, the increased risk for depression and anxiety and body image issues and the psychosexual dysfunction that comes along with this syndrome. And I think GPs are very well placed to screen for all of this.
And I'll just give you my take on it and please interrupt me if you do things differently because I I'm very conscious that the reality is that I see people for small hunks of care around their specific problems, um, whereas you have the long-term interactions with them. So Uh from a diabetes point of view, I think clearly if you've got a a woman with slim PCOS who has no other
She's slim, she's Caucasian, then yeah, she probably does have an increased risk of PCRS and an increased risk of gestational diabetes over and above a woman of the same BMI who does not have PCRs. So I'd do a fasting glucose on everybody at the beginning or Well and an H B A one C I guess. But I'd really leave the glucose tolerance test for those women who Or who are of ethnicities where we have to be able to do that? So really those high risk women. And once you've done that screening test,
the the ongoing screening for those complications or screening for diabetes every couple of years I think would be what I'd recommend. But more frequently I guess if they're very Hypertension, dual blood pressure every year, and same with cardiovascular disease. when you first diagnose somebody a full lipid screen of course but you're not gonna On a slim Caucasian woman, uh But if you've got a higher risk woman, then yes, probably every year or every couple of years.
One of the things that we are very conscious of is the endometrial cancer risk and endometrial hyperplasia risk, which occurs at an earlier age than in the um in women And this is essentially because women with PCRS have unopposed Unopposed estrogen without having periods. Now women don't really need to have periods, so you know when you're talking Hey, listen, you can be on a pill for months and months.
So as being protective of the endometrium. Whereas when you're someone with PCOS, you're having months and months potentially at a time where you've just got unimposed low level of estrogen with no progesterone and no And so there's not really a screening test per se, but I suppose from a GP point of view, just being aware that women should be having regular periods and if they're not, they probably need something to
What else in terms of screening and management? Well, again, GPs are so good at this, I know, is screening for that depression and anxiety and discussing some of the things that we're going to
Ben, let's come back to the endometrial hyperplasia. And you mentioned that sort of difference between being on the pill and skipping periods, and actually that's very different to having. oligomenorrhea oramorrhea where you're, you know, not having a period physiologically and you know you've got that unopposed estrogen. So you mentioned sort of having to protect, I guess, the endometrium.
¶ Pharmacological Interventions: OCP
For that. And that probably is a nice segue into pharmacological interventions. So, did you want to talk a little bit about when to use pharmacological interventions? When are they indicated and what are we actually aiming to achieve with that?
Yes, I just realized when you asked that question that I don't think I actually answered your last question. So pharmacological management should always well usually come after lifestyle advice. So so I think that Many women have problems with weight associated with PCRS and so clearly lifestyle advice.
management in most situations. So if someone has excessive weight, assisting the Referral to a nutritionalist, discussion about an exercise program, you know, losing five to ten percent of weight over six months is a real win, you know, and that can make a big difference. And certainly reducing the
the pill or the need for metformin. But I think where the pharmacological intervention comes in, so with respect to hyperplasia, which we're talking about before, is you know, that pill is an uh I think can really be used adolescence if you if you feel you need to. Any women with prolonged irregular cycles, and those often come with quite heavy bleeding and sometimes quite painful bleeding. I think has a great role there because Minstral regularity.
So I really think someone who comes in with cycle irregulation. is good and I think that we need to remember that the pill you don't need
Straight to a
heavy pills, the ones the thirty-five microgram pills with the cyproterone acetate. You know, remember I think in the past there's been a a trend to put everyone on Brenda or Diane or whichever brand you want to use, but that's not the you know, they is those have a high risk clots and really they're not your first line you go for a 20 microgram or thirty microgram low dose
can run them together for a few months no problem uh so that's where i would use that and remember of course it the pill does a great job at mopping up all the of the androgens so increasing the sex hormone binding globule and then that Yeah.
And so again, for me that would be And along with you know, for people who are having problems especially with the hiresutism, putting them on the pill, but reminding them, don't expect this just going to work in a month because that's not how the hair growth cycle. They would need to be on it for at least a good six months. time plucking or waxing or shaving or whatever they use for for their hair growth and only after they hadn't worked you know after Yeah.
¶ Metformin and Progestogen Options
And what about for women who might not want to use or you know the oral contraceptive pill might be contraindicated? You you touched on blood clots. Have migraine with aura or other personal or family history that stops them from using the oral contraceptive pill. What other things could be considered in that?
Yeah, well it depends on exactly what it is that they're asking for. Sometimes those women again going back to that they can get their weight down and achieve psycho regulation.
shouldn't I?
Then that would be ideal. Obviously, metformin can be added, some people who are really not achieving the gains that they want just being on the pill. And certainly in those women, and in any women with PCOS who are at high risk. So those with uh BMI over twenty five and really annoying quite freely. Obviously sometimes it's not tolerated so well, but it's a great drug so long as it's slowly so I always use the the slow release preparation. Time with a meal.
five hundred milligrams at night time, sit on that dose for a week or so, and then only when that's been tolerated well, then increase.
Thank you.
fifteen hundred milligrams. But again, even if they can only tolerate a smaller amount, that's fine because there is from a mission. Yeah, sometimes a kilo or two weight loss can be associated with it. So I think it's a good drug. I guess your question about the pill and people that So I would get quite a few referrals for that specific. Again environment. Because if you've got someone who's completely amenorrhec or very, very oligomenorrhic, Thank you.
Sometimes use progestogens for two weeks of a or consider a Myrena. There are side effects with that and it's not a perfect drug. The pill's a perfect drug for PCOS, whereas whereas progestogen They do have some androgenic effects. given increased greasiness of the skin, some increase in acne, there can be some mood disturbance.
Mm.
Unfortunately for those people who don't tolerate They think the other options do have some limitations.
But potentially a worthwhile discussion for for some women. You know, I guess some of those progesterone only contraceptives, especially if women, you know, are needing a contraception and are unable to take the combined pill. indication or something sometimes those can be helpful and you know you
about giving some progesterone cyclically, not so much for the well, not for contraceptive. That's not a contraceptive You know, but from a purely from the endometrial hyperplasia, the endometrial protection. You mentioned monthly, so let's say someone who doesn't need contraception and they they've not tolerated the IUD. I mean we see these women all the time, they can't take the pill, they didn't tolerate the IUD, you know, and then for those women, you know, you might trial doing
some cyclical progesterone. But how often would you say that they do is it monthly? They you should be saying yep monthly, or is it sort of second monthly or quarterly? What would you normally recommend in that situation?
I don't think we really have good evidence uh regarding this and I mean I I tend to give it monthly, but I have to say that not that Monthly. Listen, I don't know. I I really am not often sent people who have already. I have to say. So I feel like more often than not, by the time people are talking about Plasia risk reduction, they are quite often already at that point they're saying, hmm, this person's had quite a long time of irrigating.
They've got really heavy periods and they've got a thickened endometrium. At that point it's not unreasonable to refer on for Just to exclude hyperplasia before they go on to that kind of management. I'm not saying that it has to be done, of course I you know, I always leave that to the referring GP to see what they think, but but often those people will have already Of irregular cycles before they front up for that and may well need some initial screening before they are put on.
Progestion, although you know not not necessarily so, but yeah, I think once a month is fine, once every couple of months is also read.
You know, you raise a good point with that. I mean, it is something that I'm always hyper aware of. We always are hyper aware of things that we've had experience with or seeing sort of the worst things happen. You know, and when I did some O and G training before I came out to general practice, that was something that I sort of someone quite a young woman who had this long history of amenorrhea.
And she did have endometrial hyperplasia at quite a young age. And so, you know, I guess that's something that's stuck in my head. So I think that that's, you know, a good point to raise in terms of making sure that we're mindful of that.
¶ Comprehensive Lifestyle Strategies
Yes. You know, you mentioned about that lifestyle advice. Let's go back there for a minute in terms of some of the other things we see, specifically around the weight. We often talking to women about healthy eating and exercise for their health. Is there any particular evidence
in this area, like in terms of one diet above another, what do we do with women who sort of are in a healthy weight range? Do we still talk to them about these sorts of lifestyle interventions? What's your sort of general approach?
It's really hard, as you know. Uh it is very difficult. Um I think that there is no best diet. So people will often come in having Googled at all. And I think that particularly because you'll have multiple different ethnicities coming in with this condition, I I think the diet that people are on has to just be specific to what fits with them and their life and their
Thank you.
And I would think that it is worthwhile at least touching on it with those nor those women with a normal BMI and just saying cycle is currently slightly out of whack, not terrible. disappear entirely. And it's useful just that they know that there isn't. I think that when people are trying to lose weight, the general principle is they, you know, need an energy deficit. I think diets that give them
potentially around a thirty percent energy deficit is supposed to be good. Now can I work that out what that entails for an individual? I have no idea. It's not my area, so I would definitely refer to a nutritionist. But you they don't just need to see They need to have someone who's going to be engaged and who's going to review them on a semi-regular basis to make sure they're not slipping up on.
And I think involving a psychologist is a good And if they've got some good behavioural management and goal setting and stimulus control and slower eating behaviour and all those kind of behavioural things that are critical here, i it is You're going to have some additional benefit over
Yeah. I really think that that can help them. And and from an exercise point of view, most people And I think when we give people advice we have to accept that people just think about going out and going to the gym. Just it's very hard to take someone who doesn't do that stuff and say, You need to go to the gym five times.
but involve their activities of daily living and say, well listen, you're doing some vacuum cleaning now, listen, if you're moving around and you're doing that at at moderately high intensity and sweating a little bit while you're doing it, that counts. That's exercise. You know, if you're walking your kids to school, that's exercise, that's great. People need to be doing five times a week.
half an hour. I don't know what you advise people, but I'd I always say five times a week, 30 minutes of moderate intensity. To keep themselves alive. You know, that's what everyone should be doing. Now, if you do more and you do some high intensity exercise, then that's great. And maybe you can reduce that moderate intensity exercise. But that's what everyone should be doing if they're actually trying to lose weight. you know, that should probably be up around fifty minutes five times a week.
That's a big change for a lot of people.
Yeah. And I think you raise a good point. It's gotta be achievable and it's gotta be sustainable too, gotta find something that actually works.
Absolutely. And they really need to include, you know, do an exercise diary where they include their chores as long as they're done at a reasonable
You know.
Level of intensity. They include their walk into work. They include their, you know, their travel, their all those things. Lots of people use Fitbits to try to get to those 10,000 steps. All those kind of activities of daily living have to be included because at least that gives them a a basis to go, at least I'm doing something, or I just need to do some more on.
¶ Essential Resources for PCOS
Great. Okay, so you know, I think we could keep talking about this all day, Ben, but we better wrap it up soon. I wanted to just ask the last question: where do you send your patients to have a look when 'Cause I think this is always a a good thing to be able to direct people that the internet is a wealth of information and women can get on and Google a lot of things and come up with some good things
Some not so good things that I'm all for our patients being informed, but I think a very important part of our role is making sure we direct them to the right place to get. So where do you send your patients to have a look when
Uh Jean Haley.
found. Yeah, excellent. And I mean I hope that most of our listeners would be aware of that website. I'd give it a shout out to it's got great information for patients, but there's also some great health professional tools there and there's specific ones and a whole heap of
Which gives a good framework. And the other one I wanted to mention as well, Ben, for GPs is Monash University also has a PCOS GP tool. So it's specific for GPs. I would encourage listeners to jump on that. Just Google Monash University. PCOS GP tool. I have no affiliation with either of those things, so no conflict of interest to declare. They're just things that I find helpful in my own practice.
They've got uh the the head researcher for
Yeah, that's right. Excellent. Well Ben, we should probably finish it up there, but thank you so much for giving up your time. Um really appreciate it and I've really thoroughly enjoyed these chats and I hope that our listeners get something out of it too.
Thanks so much, Christina.
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