Gynaecological conditions – PCOS and ovarian cysts

The RCGP curriculum on gynaecology and breast lists a variety of conditions, many of which are covered in other pages of this toolkit; conditions not covered elsewhere include polycystic ovary syndrome (PCOS), benign ovarian cysts, benign conditions of the vulva and female genital mutilation (FGM).

When a pelvic scan is requested, it is common for a small ovarian cyst to be reported, which may not be relevant to the reason for the scan and may be a normal variant in the luteal phase. RCOG guidance advises that asymptomatic simple cysts of less than 50mm in a pre-menopausal women do not need any follow-up, with either a repeat scan or a Ca125 test, that those with a diameter of 50 – 70mm should have a repeat ultrasound in one year, and that those larger than 70mm should be considered for MRI or surgery, which from a primary care perspective means that a referral is needed. A cyst that is growing on repeat scan is unlikely to be functional and therefore needs further investigation or referral. It is also worth checking if you have a local pathway, as some of these vary in the cut-off size for investigation/referral and many will recommend repeat scanning earlier than one year. Cysts which are multilocular or have acoustic shadowing or solid components are not simple and secondary care advice should be sought. Post-menopausal women with an ovarian cyst should all have a Ca125 checked and a simple asymptomatic cyst of less than 50mm with a normal Ca125 can be managed with a repeat scan in 4-6 months, but any symptoms or complex features require a specialist opinion.

PCOS is one of the commonest endocrine disorders affecting women of reproductive age; the prevalence may be as high as one in four women, depending on the diagnostic criteria used. Diagnosis requires two out of a possible three criteria – infrequent or no ovulation, clinical and/or biochemical signs of hyperandrogenism and polycystic ovaries on ultrasound scan. A diagnosis can therefore potentially be made with no scan, if the first two criteria are present, and the presence of polycystic ovaries on scan with no clinical features does not mean that the woman has PCOS. Adolescent girls require both of the first two criteria to be present for a diagnosis of PCOS and in any case caution should be used in diagnosing PCOS within the first eight years after the menarche, when irregular cycles are common.

Management of PCOS is largely that of the metabolic risks, with screening advised for cardiovascular risk factors. Obesity and subfertility should be managed according to local pathways and appropriate action should be taken to manage any psychological sequelae. If there is less than one period every three months then there is a risk of endometrial hyperplasia – this can be managed using a combined oral contraceptive, the levonorgestrel intrauterine device, or a short course of a progestogen taken on demand when three months has passed without a period. Metformin is increasingly requested in women with PCOS who do not have diabetes – NICE suggest that we consider specialist advice and also that it may be beneficial in those at higher metabolic risk if lifestyle change does not achieve the required goals. This also fits with the guidance on diabetes prevention which suggests the use of metformin for those with non-diabetic hyperglycaemia who have a deteriorating blood sugar despite intensive lifestyle change, or who cannot participate in intensive lifestyle change, particularly if the BMI is > 35. International guidelines also recommend it for metabolic outcomes. Use of metformin is off-licence and may be associated with gastrointestinal side-effects and reduced vitamin B12 levels.

More information can be found in the following resources: