Polycystic ovary syndrome (PCOS) is an endocrine disorder characterised by ovulatory dysfunction, metabolic changes (e.g., obesity and insulin resistance) and hyperandrogenism (e.g., hirsutism and acne) (1). Around 40-60% of people with PCOS live with obesity, which itself is a risk factor for metabolic syndrome and cardiovascular disease risk (2). A common metabolic symptom of PCOS is insulin resistance (IR), which was initially thought to be a complication secondary to obesity. However, it is understood that 44-70% of people with PCOS have IR independent of their body mass index (BMI) (3). PCOS has a prevalence of 8-13% amongst people of reproductive age (1). This article will focus on PCOS in adults over 18 years old.

PCOS presents in several different ways. Common features include:

• Infertility secondary to oligomenorrhea and/or amenorrhea (4).

• Overweight or obesity; seen in 30-80% of people with PCOS (5).

• Hirsutism (excessive hair growth) and the presence of hairs in androgen-dependent areas (e.g., upper lip, chin, chest, back, upper arm, and shoulders). Hirsutism can be classified using the modified Ferriman-Gallwey score, with levels ≥4-6 indicating hirsutism (1,5).

• Severe acne persisting beyond adolescence. There are no universally accepted visual assessments for evaluating acne (1,5).

• Alopecia is a rare symptom but can occur in PCOS. Scalp hair loss tends to be at the vertex and crown (4).

• Acanthosis nigricans occur as a result of insulin resistance. It appears as brown or grey, velvety, occasionally verrucous, hyperpigmented areas over the nape, groin, umbilicus, sub-mammary areas, elbows, and knuckles (4).

People with PCOS are at increased risk of:

• Pregnancy complications including gestational diabetes, preeclampsia and premature delivery (6).

• Endometrial cancer in the presence of prolonged oligomenorrhea and/or amenorrhea (1,4).

• Long-term health complications including type 2 diabetes (secondary to IR causing raised blood glucose levels), cardiovascular disease (CVD), sleep apnea and depression. Annual monitoring, including screening for metabolic and cardiovascular risks, should be conducted (1,7).

Although there is some controversy regarding the diagnosis of PCOS, international guidelines for the assessment and management of PCOS endorse the Rotterdam 2003/4 criteria. Diagnosis of PCOS in adults requires at least two of the following three clinical features (1):

• Oligoovulation or anovulation (usually manifested as oligomenorrhea or amenorrhea) (1). Anovulation is the leading cause of secondary amenorrhea in people with PCOS attending fertility clinics (8). Irregular menstrual cycles are defined as <21 or >35 days, or less than eight cycles per year for people over three years post menarche to perimenopause (1).

• Clinical and/or biochemical signs of hyperandrogenism.

• Polycystic ovaries on ultrasound.

The table below outlines the pathway of investigations as advised by the National Institute for Health and Care Excellence (NICE), 2018 (7).

Management of PCOS is tailored towards the individual goals and needs of the patient. Therapy is focused on alleviating symptoms of hyperandrogenism and/or improvement of fertility. Long-term measures should also be taken to restore regular menstruation to prevent endometrial hyperplasia (4).

Pharmacotherapy

• The oral contraceptive pill (OTC) or the levonorgestrel-releasing intrauterine device can help to induce or regulate menstruation (4,7).

• If fertility is desired, medications including letrozole or clomifene (Clomid) are used for ovulation induction (4).

• Metformin is used to improve IR, decrease testosterone levels, promote weight loss and induce ovulation (4,7).

• Topical therapies for hirsutism include eflornithine and minoxidil (4).

Surgical Intervention

Laparoscopic ovarian drilling (LOD) uses lasers to reduce the amount of functional ovarian tissue present which in turn reduces androgen production. This has been proven to restore ovulation and result in pregnancy rates of 25% to 65% (4). It is offered when there has been a poor response to medication.

Nutrition and Lifestyle Changes

People who are overweight or obese should be offered weight loss advice and referral to a dietitian should be considered. Healthy lifestyle changes should be encouraged, focusing on improving diet and activity levels. The health benefits of achieving a 5% weight loss via a healthy energy-restricted diet and regular exercise should be discussed (e.g., reduces hyperinsulinism, can improve menstrual regularity and efficacy of pregnancy, if desired) (7,11). Evidence has shown that low glycemic index (GI) and low carbohydrate dietary interventions have demonstrated improved insulin sensitivity and weight loss, in people with PCOS (12,13).

It should be noted that not all people with PCOS are overweight. Dietary changes, however, can still be beneficial. For example, a Mediterranean diet has been shown to reduce IR and improve ovarian function and should be encouraged in place of a ’western style’ diet (14). A Mediterranean diet is characterised by one that is high in vegetables, legumes, fruits, nuts, olive oil and fish, with moderate amounts of dairy products and wholegrains, and low in red meat, processed foods and saturated fats.

Mental Health Support

A systematic review found that PCOS is associated with an increased risk of depression or anxiety (15). PCOS affects a person’s life in various ways, such as impacting self-esteem, appearance and/or the ability to start a family. It is inevitable that this will impact mental health. Early screening by healthcare professionals (HCPs) can help people with PCOS to access early and effective interventions.

HCPs can signpost people with PCOS to Verity, the national PCOS charity. The charity hosts an online community to enable people with PCOS to give and receive peer support, which can help break the isolation that often accompanies the diagnosis.

Recently, myo-inositol (MI) supplementation has gained momentum in the management of PCOS patients, due to its evidence base and the absence of side effects (16).

What is Myo-Inositol?

Myo-Inositol (MI) is one of nine different forms of inositol. It is a naturally occurring sugar alcohol found in dietary sources such as fruits, vegetables, nuts and cereals (17,18). MI acts as an intracellular messenger to regulate several hormones including thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH) and insulin (17).

How does Myo-Inositol help people with PCOS?

There is much interest in the role of MI in the management of people living with PCOS. Emerging data from small studies is promising, however further large-scale studies are needed. Table 2 provides an overview of the clinical benefits of MI in people living with PCOS.

MyOva Myoplus is a natural food supplement for adults aged 18 years and over, who are experiencing PCOS symptoms (see Table 3). MyOva Myoplus presents in a convenient, easy to swallow tablet format which can easily be crushed and taken with food. The optimum dose is achieved by taking two tablets in the morning and two in the evening, daily with water or food. Patients should seek advice from their GP if they are taking regular medication, pregnant or lactating. MyOva Myoplus should not be taken as a substitute for a healthy and balanced diet.

MyOva Preconception is a natural food supplement for adults aged 18 years and over, who have PCOS and are trying to conceive. It is a natural preconception supplement containing essential micronutrients to help support reproductive health for pregnancy. It contains additional nutrients that have been found to support ovulation and metabolic health specifically for people living with PCOS (as outlined in table 4).

MyOva Preconception presents in a convenient, easy to swallow tablet format which can easily be crushed and taken with food. The optimum dose is achieved by taking two tablets in the morning and two in the evening, daily with water or food. Patients should be advised to discuss with their GP first if they are taking regular medication or are lactating. MyOva Preconception should not be taken as a substitute for a healthy and balanced diet.

The clinical features and challenges faced by people with PCOS can negatively affect their quality of life and mental health. Medications and surgery are effective at improving symptoms and supporting fertility to an extent. HCPs can further support people living with PCOS to make sustainable and positive dietary and lifestyle changes to benefit their health via education on diet and physical activity as well as providing advice on targeted supplementation using a suitable brand for PCOS such as MyOva.

The information included in this booklet is not a substitute for professional medical advice, examination, diagnosis or treatment. The content in this booklet is aimed at a healthcare professional audience only. MyOva is a food supplement and is not listed within the British National Formulary, and therefore cannot be prescribed. MyOva supplements can be purchased online. Individuals should consult with their own healthcare professional before taking a food supplement.

1. Teede H, et al. (2018). International evidence-based guideline for the assessment and management of polycystic ovary syndrome. National Health and Medical Research Council (NHMRC).[Internet]. Available online: https://www.monash.edu/__data/assets/pdf_file/0004/1412644/PCOS_Evidence-Based-Guidelines_20181009.pdf