7.1.7 Polycystic ovarian syndrome

General notes

  • Polycystic ovary syndrome (PCOS) is a complex endocrine disorder with clinical features that include hirsutism and acne (due to excess androgens), oligomenorrhoea or amenorrhoea, and multiple cysts in the ovary. Refer to NICE CKS for further details on diagnosis, management and when to refer.
  • PCOS consists of a collection of symptoms, some or all of which may not require drug treatment; weight reduction is first essential line of management for obese patients.
  • If there are concerns regarding infertility, both the male and female partners should be referred to a clinic. Ovulation induction with anti-oestrogens may be required and should only be prescribed with appropriate monitoring.

Acne

For women with polycystic ovary syndrome and acne:

  • Treat their acne using a first line treatment option see 13.6.
  • If the chosen first-line treatment is not effective, consider adding co-cyprindiol or an alternative COC* to their treatment.

*Consider a COC containing a less androgenic progestogen e.g. Gedarel® 30/150 or Millinette® 30/75  – please refer to section 7.3.1

  • For those using co-cyprindiol, review at 6 months and discuss continuation or alternative treatment options.

Cautions

See 7.1.7(i) below.

(i) Hirsutism associated with PCOS

ChoiceDrugDosage
Formulary choicesCo-cyprindiol 2000/35 (cyproterone acetate 2mg, ethinylestradiol 35 microgram) tabletsDose:
Moderately severe hirsutism - 1 tablet daily for 21 days starting on day 1 of menstrual cycle and repeated after a 7 day interval, usually for several months.
Stop treatment 3-4 months after hirsutism has resolved

or

Gedarel® 30/150 (desogestrel 150 micrograms, ethinylestradiol 30 micrograms (3 x 21)

[Off-label indication]

 

See 7.3.1.

Prescribing Notes

  • See NICE CKS for information on the management of hirsutism and when to refer.
  • Consider simple cosmetic methods of hair removal, e.g. shaving, waxing, plucking and bleaching. If hirsutism is mild and does not significantly impact on the woman’s quality of life, reassure and advise that no additional treatment is required.
  • Topical eflornithine 11.5% cream (Vaniqa®) can be used as adjunct to laser therapy for facial hirsutism in women. Eflornithine should be discontinued in the absence of improvement after treatment for 4 months.
  • Hirsutism that has failed to respond to treatment in primary care may respond to systemic treatments such as anti-androgens, insulin-sensitizing drugs, and gonadotrophin-releasing hormone analogues – refer to a specialist.

Cautions

  • Venous thromboembolism risk with co-cyprindiol

Prescribers are reminded that the risk of venous thromboembolism is higher in women taking co-cyprindiol than those taking a low dose combined oral contraceptive. It is licensed for severe acne and moderately severe hirsutism and should not be used solely for contraception though it is occasionally used as a contraceptive (unlicensed indication) when acne is present. It is contraindicated in those with a personal or close family history of venous thromboembolism. See MHRA for further information.

  • Use of cyproterone is contraindicated in patients with previous or current meningioma (for all indications). See MHRA for further information.