VOLUME 10 NUMBER 3 • SEPTEMBER 2013
93
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
Screening for diabetes and cardiometabolic disease
in women with polycystic ovary syndrome
Julie A Tomlinson, Jonathan H Pinkney, Phil Evans, Ann Millward, Elizabeth Stenhouse
Abstract
Polycystic ovary syndrome (PCOS) is a significant risk factor
for developing type 2 diabetes and increased cardiovascular
disease risk (together referred to as ‘cardiometabolic disease’,
CMD). Primary prevention of CMD may be possible in women
withPCOSbut thediagnostic criteria for PCOSare controversial
and this often hampers optimal clinical management. PCOS
affects as many as 18% of women of reproductive age, and
at least 70% remain undiagnosed in primary care. Screening
women with PCOS for diabetes is seldom undertaken, largely
through difficulties in diagnosis due to identification and
management of PCOS continuing to focus on treatment of
infertility and hirsutism. This article focuses on the diagnostic
challenges of making the initial diagnosis of PCOS and
considers how screening, detection and prevention of CMD
might become routine clinical practice. It explores the unique
challenges associated with PCOS and highlights the need for
better evidence to justify screening and intervention. Finally,
a pragmatic approach to assessing women with PCOS is
suggested for use within primary care.
Keywords
: cardiometabolic disease, cardiovascular risk, CMD,
CVR, PCOS, polycystic ovary syndrome, primary care, primary
prevention, screening for type 2 diabetes
Introduction
PCOS affects as many as 18% of women of reproductive age, but at
least 70% of PCOS remains undiagnosed in primary care.
1
Although
screening women with PCOS for diabetes and diabetes risk has
been recommended,
2–4
this is seldom undertaken routinely in clinical
Correspondence to: Julie Tomlinson
Plymouth University Peninsula Schools of Medicine & Dentistry, Pool Health
Centre, Station Road, Pool, Redruth, Cornwall TR15 3DU, UK.
e-mail:
Jonathan H Pinkney
Plymouth University Peninsula Schools Medicine & Dentistry, University Med-
icine, Level 7 Derriford Hospital, Crownhill, Plymouth, Devon, UK
Phil Evans
St Leonard’s Practice, Exeter and University of Exeter Medical School (Primary
Care), Athelstan Road, Exeter, UK
Anne Millward
Plymouth University Peninsula Schools Medicine and Dentistry, Plymouth,
Devon, UK
Elizabeth Stenhouse
School of Nursing and Midwifery, Faculty of Health, University of Plymouth,
Derriford, Plymouth, Devon, UK
Originally in:
Br J Diabetes Vasc Dis
2013;
13
(3): 115–123.
S Afr J Diabetes Vasc Dis
2013;
10
: 93–99
Abbreviations:
ADA
American Diabetes Association
AES
Androgen Excess Society
ASRM
American Society for Reproductive Medicine
BH
biochemical hyperandrogenism
BMI
body mass index
CH
clinical hyperandrogenism
CMD
cardiometabolic disease
COC
combined oral contraceptives
CVD
cardiovascular disease
DUK
Diabetes UK
ESHRE
European Society for Human Reproduction
and Embryology
FAI
free androgen index
FG
Ferriman Gallwey
f-T
free testosterone
HbA
1C
glycated haemoglobin A
1C
IGR
impaired glucose regulation
IGT
impaired glucose tolerance
NIH
National Institutes of Health
OGTT
oral glucose tolerance test
PCO
polycystic ovaries
PCOS
polycystic ovary syndrome
SHBG
sex hormone binding globulin
s-T
serum testosterone
t-T
total testosterone
WHO
World Health Organisation
practice, largely through difficulties in diagnosis. Identification and
management of PCOS continues to focus on treatment of infertility
and hirsutism with little regard to opportunities for primary
prevention of CMD.
5
PCOS carries a substantial risk of developing
type 2 diabetes and is a risk factor for CVD.
6
These are collectively
referred to as CMD. Several studies from the USA report 7.5–10%
of women with PCOS have type 2 diabetes and 31–35% with
IGT7,
8
although in Italy, lower rates of 6.4% with IGT and 0% with
type 2 diabetes were observed.
9
The wide variations in prevalence
are generally considered to reflect different populations and
varying diagnostic criteria. Although the principal clinical features
of PCOS are oligomenorrhoea, infertility and clinical evidence of
hyperandrogenism including hirsutism and acne,
5,10
symptoms are
variable, and in their absence, PCOS is often unrecognised.
The aimof this article is to consider the problemof how to identify
women with PCOS in the community, who could then be screened
for CMD. There is already good evidence for increased CMD in
women with PCOS and this has been reviewed previously.
6
Prevalence of PCOS
The reported prevalence of PCOS in young women in the USA was
6–10%.
11–14
However, European and Australian data suggest this
is an underestimate. A cross-sectional study of 230 women aged
