Tips in managing PCOS
NASHVILLE, Tenn. — Despite being extremely prevalent, polycystic ovary syndrome remains a challenging condition to diagnose and manage, in part due to variations in presentation, according to a speaker at the American College of Obstetricians and Gynecologists Annual Clinical and Scientific Meeting.
“PCOS is the most common endocrine abnormality that we will see in our practices, and the most common cause of anovulation that leads to infertility in the United States,” Lori McKenzie, MD, of the obstetrics and gynecology department at Baylor College of Medicine, told attendees.
She provided five recent practice reminders and updates to ACOG attendees to reduce the apprehension that clinicians may have about treating it.
Patients who show or mention symptoms of PCOS may instead be pregnant, or have adult-onset congenital adrenal hyperplasia, hyperprolactinemia and/or androgen-secreting neoplasms, McKenzie said. These conditions must be ruled out before commencing with PCOS treatments, she added.
Testing for PCOS
McKenzie noted that total testosterone and sex hormone-binding globulin or bioavailable and testosterone tests can help make the distinction between PCOS and some of similar conditions.
“Quite frankly, I don’t see a lot of utilization of the sex hormone-binding globulin test. I typically order the total testosterone test because it is a lot less expensive,” she said.
OK to be selective in some screening situations
The ACOG Practice Bulletin allows clinicians to pick and choose who they screen to ascertain 17-hydroxyprogesterone levels in, McKenzie continued.
“If they are of Italian, Hispanic, Yugoslavs, Native American Inuits and Ashkenazi Jewish descents you should absolutely determine those levels,” she said.
Nonclassical congenital adrenal hyperplasia, which has higher prevalence in those population cohorts, is sometimes mistaken for PCOS on ultrasound, McKenzie explained, noting that 17-hydroxyprogesterone levels may be able to distinguish between the two conditions.
However, McKenzie added that she adds an exception to the exceptions.
“Every patient with a diagnosis of PCOS deserves at least a one-time check of their 17-hydroxyprogesterone levels,” she said.
“Gold standard” for glucose assessment still applies
McKenzie said that the 2-hour glucose tolerance test is still the gold standard in determining glucose abnormalities in patients with PCOS.
“In March, a study was published that compared the 75-gram glucose tolerance test and HbA1c levels of about 9,000 patients. Researchers found about 77% of individuals diagnosed with diabetes with the glucose tolerance test were missed if only their HbA1c level was tested,” McKenzie said.
Letrozole remains first-line therapy
According to McKenzie, letrozole should be considered as first-line therapy for ovulation induction in patients with PCOS due to the increased live birth rate that can occur after five cycles.
She added that it is critical that clinicians tell their patients to understand the FDA has not approved letrozole for this purpose, and to let patients know that “we use a lot of medications in our field that are off label.”
“When prescribing letrozole, start at a dose of 2.5 mg a day for 5 days on day 3, 4, or 5 after a spontaneous menses or progestin-induced bleed. If ovulation does not occur, the dosage can be increased to 5 mg a day for 5 days with a maximum dosage of 7.5 mg a day,” she continued.
McKenzie said clinicians with further questions should consult the ACOG’s 2018 practice bulletin on PCOS. – by Janel Miller
For more information:
“ACOG Practice Bulletin No. 194. Polycystic ovary syndrome.” https://journals.lww.com/greenjournal/Fulltext/2018/06000/ACOG_Practice_Bulletin_No__194___Polycystic_Ovary.54.aspx. Accessed May 14, 2019.
McKenzie L, et al. “Young physician practice updates for the busy Ob-Gyn and REI.” Presented at: American College of Obstetricians and Gynecologists Annual Clinical and Scientific Meeting; May 3-6, 2019; Nashville.
Disclosures: Healio Primary Care was unable to determine McKenzie’s relevant financial disclosures prior to publication.