What are the key recommendations and treatment approaches for common gynaecological issues such as polycystic ovary syndrome (PCOS), endometriosis, and urinary tract infections (UTIs)?

Management of Common Gynaecological Conditions: PCOS, Endometriosis, and Recurrent UTIs

Polycystic Ovary Syndrome (PCOS)

Diagnostic Approach

Screen all women with PCOS for type 2 diabetes using a fasting glucose followed by a 2-hour glucose tolerance test with 75-gram glucose load, and obtain a fasting lipid profile including total cholesterol, LDL, HDL, and triglycerides. 1, 2

• Measure total testosterone or bioavailable/free testosterone levels to assess ovarian hyperandrogenism 1
• Check thyroid-stimulating hormone and prolactin levels to exclude other causes of menstrual irregularity 1
• Calculate body mass index and waist-hip ratio to assess metabolic risk 1, 2

Treatment Based on Reproductive Goals

For Women NOT Attempting to Conceive

Combined oral contraceptive pills are first-line therapy, as they suppress ovarian androgen secretion, increase sex hormone binding globulin, and reduce endometrial cancer risk. 1, 2, 3

• Alternative: Medroxyprogesterone acetate (depot or intermittent oral) suppresses circulating androgen and pituitary gonadotropin levels 1
• For hirsutism specifically: Combine an antiandrogen (spironolactone) with oral contraceptives for optimal effect 3
• Topical eflornithine hydrochloride cream is the only FDA-approved topical treatment for hirsutism 1, 3

For Women Attempting to Conceive

Start with weight loss (minimum 5% of body weight) and regular exercise, then use clomiphene citrate as first-line pharmacological treatment—approximately 80% will ovulate and half will conceive. 1, 2, 3

• If clomiphene fails, use low-dose gonadotropin therapy rather than high-dose to minimize ovarian hyperstimulation risk 1, 2, 3
• Metformin improves ovulation frequency but its effects on early pregnancy are not well established 1, 3

Metabolic Management

Prescribe weight loss with an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day total), as even 5% weight loss significantly improves metabolic and reproductive abnormalities. 3

• Recommend minimum 150 minutes/week of moderate intensity exercise, even without weight loss 3
• Use metformin to improve insulin sensitivity and reduce diabetes/cardiovascular disease risk factors 1, 2
• No specific diet type has proven superior; follow general healthy eating principles 3

Long-term Monitoring

• Screen regularly for metabolic abnormalities and assess mental health, as PCOS patients have higher rates of depression, anxiety, and eating disorders 2
• Monitor for cardiovascular disease risk factors, though oral contraceptive use does not increase cardiovascular events in PCOS compared to the general population 1

---

Endometriosis

Diagnosis

Only an experienced surgeon familiar with the varied appearances of endometriosis should rely on visual inspection alone; otherwise, obtain histologic examination to confirm endometrial lesions, especially those with nonclassical appearance. 1

• Peritoneal biopsy should be used for questionable peritoneal lesions 1
• Serum CA-125 has limited utility, especially in mild or minimal disease 1
• Pain severity correlates with depth of lesions, not lesion type; painful lesions involve peritoneal surfaces innervated by peripheral spinal nerves 1

Medical Management for Pain

For pain relief, treat with a GnRH agonist for at least 3 months or danazol for at least 6 months—both are equally effective in most women. 1

• When continuing GnRH agonist therapy, add add-back therapy to reduce or eliminate bone mineral loss without reducing pain relief efficacy 1
• Oral contraceptives and oral or depot medroxyprogesterone acetate are effective compared to placebo and may be equivalent to more costly regimens 1
• Progestins, NSAIDs, and GnRH agonists all reduce lesion size, but no medical therapy eradicates lesions 1
• GnRH agonist therapy is appropriate for chronic pelvic pain even without surgical confirmation of endometriosis, if initial evaluation excludes other causes 1

Surgical Management

• Surgery provides significant pain reduction in the first 6 months, but up to 44% experience symptom recurrence within one year 1
• For severe endometriosis, medical treatment alone may not be sufficient 1
• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for endometriosis 1

Fertility Considerations

• No evidence proves that medical treatment affects future fertility in women with endometriosis 1
• With minimal and mild endometriosis, a cause-and-effect relationship with infertility has not been proven 1
• Studies lack evidence that absence of treatment is associated with fertility decline 1
• For asymptomatic patients, expectant management may be appropriate as endometriosis is unpredictable and may regress 1

---

Recurrent Urinary Tract Infections (rUTIs)

Definition and Approach

Use an algorithmic approach based on patient population: postmenopausal women, premenopausal women with sexually-associated infections, or premenopausal women with non-sexually-associated infections. 1

Treatment by Population

Postmenopausal Women

Use vaginal estrogen with or without lactobacillus-containing probiotics as first-line prevention. 1

Premenopausal Women with Sexually-Associated rUTIs

Prescribe low-dose post-coital antibiotics. 1

Premenopausal Women with Non-Sexually-Associated rUTIs

Prescribe low-dose daily antibiotic prophylaxis. 1

Non-Antibiotic Alternatives

• Methenamine hippurate and/or lactobacillus-containing probiotics can be used as non-antibiotic alternatives 1
• Education on lifestyle and behavioral modifications should be provided to all patients 1

Important Caveats

• The definition of rUTI is 2 or more symptomatic episodes in 6 months or 3 episodes in 1 year 1
• Between 20-30% of women with one UTI will have recurrence, and 25% of these will have subsequent recurrent episodes 1
• No multi-targeted treatment approach has been studied, and high-quality evidence for prevention strategies is lacking 1