Women with polycystic ovary syndrome have substantially higher rates of insulin resistance, impaired glucose tolerance, type 2 diabetes, dyslipidemia, and metabolic syndrome when compared with women without the disease. Given the high prevalence of these comorbidities, guidelines issued by the American College of Obstetricians and Gynecologists and the Endocrine Society recommend that all women with polycystic ovary syndrome undergo screening for impaired glucose tolerance and dyslipidemia with a 2 hour 75 g oral glucose tolerance test and fasting lipid profile upon diagnosis and also undergo repeat screening every 2–5 years and every 2 years, respectively. Although a hemoglobin A1C and/or fasting glucose are widely used screening tests for diabetes, both the American College of Obstetricians and Gynecologists and the Endocrine Society preferentially recommend the 2 hour oral glucose tolerance test in women with polycystic ovary syndrome as a superior indicator of impaired glucose tolerance/diabetes mellitus. However, we found that gynecologists underutilize current recommendations for metabolic screening in women with polycystic ovary syndrome. In an online survey study targeting American College of Obstetricians and Gynecologists fellows and junior fellows, 22.3% of respondents would not order any screening test at the initial visit for at least 50% of their patients with polycystic ovary syndrome. The most common tests used to screen for impaired glucose tolerance in women with polycystic ovary syndrome were hemoglobin A1C (51.0%) and fasting glucose (42.7%). Whereas 54.1% would order a fasting lipid profile in at least 50% of their polycystic ovary syndrome patients, only 7% of respondents order a 2 hour oral glucose tolerance test. We therefore call for increased efforts to encourage obstetrician-gynecologists to address metabolic abnormalities in their patients with polycystic ovary syndrome. Such efforts should include education of physicians early in their careers, at the medical student and resident level. Efforts should also include implementation of continuing medical education activities, both locally and at the national level, to improve understanding of the metabolic implications of polycystic ovary syndrome. Electronic medical record systems should be utilized to generate prompts for appropriate screening tests in patients with a diagnosis of polycystic ovary syndrome. Because obstetrician-gynecologists may be the only physicians seen by many polycystic ovary syndrome patients, particularly those in their young reproductive years, such interventions could effectively promote optimal preventative health care and early diagnosis of metabolic comorbidities in these at-risk women.
THE PROBLEM: Polycystic ovary syndrome is a common disorder of anovulation and hyperandrogenism, affecting 4–12% of reproductive-aged women. In addition to abnormalities of the reproductive system, women with polycystic ovary syndrome are at a substantially increased risk of metabolic abnormalities when compared with control women matched by age and body mass index.
Insulin resistance occurs in 50–75% of women with polycystic ovary syndrome and up to 95% of obese women with polycystic ovary syndrome. Forty percent of women with polycystic ovary syndrome will develop impaired glucose tolerance or diabetes mellitus by the fourth decade of life. In the United States, 70% of women with polycystic ovary syndrome have at least 1 borderline or elevated lipid laboratory value.
Impaired glucose tolerance/diabetes mellitus and dyslipidemia are central components of metabolic syndrome, a significant risk factor for cardiovascular disease. Patients with polycystic ovary syndrome are at a substantially higher risk for metabolic syndrome, with an estimated prevalence of 45–53% in women with polycystic ovary syndrome. The identification and management of metabolic abnormalities in women with polycystic ovary syndrome is therefore crucial. Indeed, the American College of Obstetricians and Gynecologists and the Endocrine Society published recommendations that all patients with polycystic ovary syndrome should be screened for impaired glucose tolerance with a 2 hour, 75 g oral glucose tolerance test and be screened for dyslipidemia with a lipid profile. Underutilization of these guidelines will result in missed opportunities for early intervention to minimize long-term morbidities.
THE SOLUTION: Physicians should be educated regarding the metabolic risks of polycystic ovary syndrome early on in their careers at the medical student and resident level. Continuing medical education activities should be developed for providers caring for women with polycystic ovary syndrome, focusing on the increased risks of glucose intolerance, dyslipidemia, metabolic syndrome, and possibly cardiovascular disease. Health care institutions should consider incorporating the recommended guidelines into algorithms within their electronic medical record systems, which may prompt providers to perform the appropriate screening, and provide suggestions for management of abnormal results.
The presentation
To describe how often obstetrician-gynecologists order the appropriate metabolic screening tests in women with a diagnosis of polycystic ovary syndrome, we conducted an online survey. The survey was distributed to a total of 300 American College of Obstetricians and Gynecologists fellows and junior fellows who were also Collaborative Ambulatory Research Network members. The Collaborative Ambulatory Research Network is composed of practicing obstetrician-gynecologists who voluntarily participate in survey research aimed to assess and inform practice patterns and educational guidelines. The initial study e-mail was sent in June 2015, and data collection ended July 2015. The study was approved by the Rutgers Health Sciences Institutional Review Board (Newark, NJ).
Of the 300 obstetrician-gynecologists initially contacted, 281 were eligible potential responders (providers who see patients with polycystic ovary syndrome and are not retired). Of these, 157 (55.9%) provided complete responses and were therefore included in the data analyses. The vast majority of providers who participated in the survey practiced general obstetrics and gynecology (80.3%). About half of the respondents (49.0%) reported that 10% or more of their patients have polycystic ovary syndrome.
The responding physicians self-reported generally being comfortable managing patients with polycystic ovary syndrome (23.6% somewhat comfortable, 36.3% comfortable, 38.2% very comfortable, none answered not comfortable). Physicians reporting that polycystic ovary syndrome affected 10% or more of their patients reported a higher level of comfort with managing patients with polycystic ovary syndrome ( P < .001).
The most frequently ordered screening tests that providers stated they order in at least 50% of patients with polycystic ovary syndrome during an initial office visit were the lipid profile (54.1%), followed by hemoglobin A1c (51.0%) and fasting glucose (42.7%). The majority of respondents (55.4%) never ordered a 2 hour oral glucose tolerance test at an initial visit with a patient with polycystic ovary syndrome ( Table 1 ). Only 9 respondents (5.7%) reported ordering both a lipid profile and a 2 hour oral glucose tolerance test at the initial visit for most patients with polycystic ovary syndrome. About 1 in 5 respondents (22.3%) would not order any metabolic screening test at the initial visit for 50% or more of their patients with polycystic ovary syndrome. The main reason given by the physicians not to order a 2 hour oral glucose tolerance test was patient inconvenience (53.0%); 22.0% reported that the results of this test would not affect their clinical management.
| Responses | Lipid profile | Hemoglobin A1c | Fasting glucose | Fasting insulin | Two hour OGTT |
|---|---|---|---|---|---|
| Would never order | 12 (7.6%) | 14 (8.9%) | 26 (16.6%) | 83 (52.9%) | 87 (55.4%) |
| Would order in <50% of patients with PCOS | 58 (36.9%) | 63 (40.1%) | 63 (40.1%) | 30 (19.1%) | 57 (36.3%) |
| Would order in ≥50% of patients with PCOS | 59 (37.6%) | 60 (38.2%) | 42 (26.8%) | 28 (17.8%) | 7 (4.5%) |
| Would always order | 26 (16.6%) | 20 (12.7%) | 25 (15.9%) | 16 (10.2%) | 4 (2.5%) |
| Did not answer | 2 (1.3%) | 0 (0.0%) | 1 (0.6%) | 0 (0.0%) | 2 (1.3%) |
Among physicians who would order a particular test, there was considerable variation in the timing of repeat testing when the initial screening test was normal ( Table 2 ). For glucose metabolism tests (ie, fasting glucose, fasting insulin, hemoglobin A1c, and/or a 2 hour oral glucose tolerance test), the most common response was that the physician would not repeat the test unless there is a change in the patient’s medical history. This was not true for the lipid profile, in which in the event of a normal initial test result, 76.3% of the respondents indicated they would repeat the lipid profile in 1–5 years ( Table 2 ).
