The Polycystic Ovary Syndrome: Guidance for Healthcare Professionals
The Polycystic Ovary Syndrome (PCOS) – Information for patients
The Polycystic Ovary Syndrome: Guidance for Healthcare Professionals
• Hyperandrogenism (hirsutism, acne, alopecia)
• Menstrual disturbance
• Asymptomatic, with polycystic ovaries on ultrasound scan
Possible late sequelae
• Type 2, Diabetes mellitus
• Cardiovascular disease
• Endometrial carcinoma
Raised androgens (testosterone and androstenedione)
Raised luteinising hormone (LH) in 40%, normal follicle stimulating hormone (FSH)
RaisedFasting insulin (not routinely measured; insulin resistance assessed by GTT)
Supressed sex hormone binding globulin (SHBG), results in elevated “free androgen index”
Normal or elevated oestradiol, oestrone
Normal or elevated Prolactin
Normal or elevated Anti-Mullerian hormone (AMH)
(may vary with local laboratory assays)
|Pelvic ultrasound||To assess ovarian morphology and endometrial thickness||Transabdominal scan satisfactory in women who are not sexually active.|
0.5 – 3.5 nmol/l
new assays may be 0.5-1.8 nmol/l
|It is unnecessary to measure other androgens unless total testosterone is > 5 nmol/l, in which case referral is indicated. Normal ranges vary with different assays.|
|Sex hormone binding globulin (SHBG)||16 – 119 nmol/l|
|Free androgen index:
T x 100 / SHBG
|< 5||Insulin suppresses SHBG, resulting in a high FAI in the presence of a normal total T|
|Oestradiol||measurement is unhelpful to diagnosis||Oestrogenisation may be confirmed by endometrial assessment.|
|Luteinising hormone (LH)||2 – 10 IU/L||FSH and LH best measured during days 1-3 of a menstrual bleed. If oligo-/ amenorrhoeic then random samples are taken.|
|Follicle stimulating hormone (FSH)||2 – 8 IU/L|
thyroid function, TSH
|< 500 mU/L
0.5 – 5 IU/L
|Measure if oligo-/ amenorrhoeic|
|Fasting insulin (not routinely measured; insulin resistance assessed by GTT)||< 30 mU/L||Additional points|
Women who are obese, and also many slim women with PCOS, will have insulin resistance and elevated serum concentrations of insulin (usually < 30 mU/L fasting). We suggest that a 75 gram oral glucose tolerance test (GTT) be performed in women with PCOS and a BMI > 30 kg/m2, with an assessment of the fasting and two hour glucose concentration. It has been suggested that South Asian women should have an assessment of glucose tolerance if their BMI is greater than 25 kg/m2 because of the greater risk of insulin resistance at a lower BMI than seen in the Caucasian population.
Definitions of glucose tolerance after a 75 g glucose tolerance test (GTT)
|Diabetes Mellitus||Impaired Glucose Tolerance (IGT)||Impaired Fasting Glycaemia|
|Fasting glucose (mmol/l)||> 7.0||< 7.0||> 6.1 and < 7.0|
|2 hour glucose (mmol/l)||> 11.1||> 7.8, < 11.1||< 7.8|
|Action||Refer Diabetic Clinic||Dietary advice. Check fasting glucose annually||Dietary advice. Check fasting glucose annually|
In summary, the PCOS is a heterogeneous, familial condition.
• Ovarian dysfunction leads to the main signs and symptoms
• The ovary is influenced by external factors in particular the gonadotrophins, insulin and other growth factors, which are dependent upon both genetic and environmental influences.
• There are long term risks of developing diabetes and possibly cardiovascular disease.
• Therapy to date has been symptomatic but by our improved understanding of the pathogenesis treatment options are becoming available that strike more at the heart of the syndrome.
• PCOS is the commonest endocrine disorder in women (prevalence 15-20%).
• PCOS is a heterogeneous condition. Diagnosis is made by the ultrasound detection of polycystic ovaries or one or more of a combination of symptoms and signs (hyperandrogenism [acne, hirsutism, alopecia], obesity, menstrual cycle disturbance [oligo/ amenorrhoea]) and biochemical abnormalities (hypersecretion of testosterone, luteinizing hormone and insulin).
• Management is symptom orientated.
• If obese, weight loss should be encouraged to improve symptoms, reproductive function and long term health. A glucose tolerance test should be performed if the BMI is > 30 kg/m2 (or > 25 kg/m2 if from South Asia).
• Menstrual cycle control is achieved by cyclical oral contraceptives, progestogens or a Mirena intrauterine system can be used to protect the endometrium.
• Ovulation induction may be difficult and require progression through various treatments which should be monitored carefully to prevent multiple pregnancy.
• Hyperandrogenism is usually managed with the COCPs Dianette or Yasmin. Alternatives include spironolactone. Flutamide and finasteride are not routinely prescribed because of potential adverse effects. Reliable contraception is required with anti-androgen therapy.
• Insulin sensitizing agents (e.g. metformin) appear to be of limited, if any, benefit.
Indications for referral to specialist clinic
• Serum testosterone > 5 nmol/l (to exclude other causes of androgen excess, e.g. tumours, late onset congenital adrenal hyperplasia, Cushings syndrome)
• Rapid onset hirsutism (to exclude androgen secreting tumours)
• Glucose intolerance / diabetes
• Amenorrhoea of more than 6 months – for pelvic ultrasound scan to exclude endometrial hyperplasia
• Refractory symptoms
1. Balen AH. The pathogenesis of polycystic ovary syndrome: the enigma unravels. Lancet 1999; 354: 966-7.
2. The Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Authors: Fauser B, Tarlatzis B, Chang J, Azziz R, Legro R, Dewailly D, Franks S, Balen AH, Bouchard P, Dahlgren E, Devoto, Diamanti E, Dunaif A, Filicori M, Homburg R, Ibanez L, Laven J, Magoffin D, Nestler J, Norman R, Pasquali R, Pugeat M, Strauss J, Tan SL, Taylor A, Wild R, Wild S. Human Reproduction 2004; 19: 41-47.
3. Balen AH, Laven JSE, Tan SL, Dewailly D. Ultrasound Assessment of the Polycystic Ovary: International Consensus Definitions. Human Reproduction Update 2003; 9: 505-514.
4. Balen AH, Conway GS, Kaltsas G, Techatraisak K, Manning PJ, West C, Jacobs HS. Polycystic ovary syndrome: The spectrum of the disorder in 1741 patients. Human Reprod 1995; 10:2705-2712
5. Franks S, Gharani N, Waterworth D, Batty S, White D, Williamson R, McCarthy M. The genetic basis of polycystic ovary syndrome. Hum Reprod 1997; 12: 2641-2648.
6. Clark AM, Ledger W, Galletly C, Tomlinson L, Blaney F, Wang X, and Norman RJ: Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women. Human Reprod 1995; 10: 2705-2712
7. Dunaif A. Insulin resistance and the polycystic ovary syndrome: mechanisms and implication for pathogenesis. Endocrine Review 1997; 18: 774-800.
8. Jones GL, Benes K, Clark TL, Denham R, Holder MG, Haynes TJ, Mulgrew NC, Shepherd KE, Wilkinson VH, Singh M, Balen A, Lashen H, Ledger WL (2004) The Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire (PCOSQ): a Validation. Human Reproduction. 19: 317- 377
9. Colwell H, Mathias SD, Pasta DJ, Henning JM, Steege JF (1998) A health-related quality of life instrument for symptomatic patients with endometriosis: a validation study. Am. J. Obstet. Gynecol. 179, 47-55
10. Naughton MJ, McBee WI (1997) Health –related quality of life after hysterectomy. Clin. Obstet.Gynecol. 40, 947-57
11. Sonino N, Fava GA, Mani L, Belluardo P, Boscaro M (1993) Quality of life of hirsute women. Postgrad. Med. J. 69, 186-9
12. Paulson JD, Haarman BS, Salerno RL, Asmar P (1988) An investigation of the relationship between emotional maladjustment and infertility. Fertil. Steril. 49, 258-62
13. Downey J, Yingling S, McKinney M, Husami M, Jewelewicz R, Maidman J (1989) Mood disorders, psychiatric symptoms and distress in women presenting for infertility evaluation. Fertil. Steril. 52, 425-32
14. Lord JM, Flight IHK, Norman RJ. Metformin in polycystic ovary syndrome: systematic review and meta-analysis. British Medical Journal 2003; 327: 951-5.
15. Cussons AJ, Stuckley BG, Walsh JP, Burke V, Norman RJ (2005) Polycystic ovarian syndrome: marked differences between endocrinologists and gynaecologists in diagnosis and management. Clin. Endocrinol (Oxf). Mar; 62(3)289-95
16. Jayagopal V, Kilpatrick ES, Holding S, Jennings PE and Atkin SL. Orlistat is as Beneficial as Metformin in the Treatemnt of Polycystic Ovarian Syndrome. Journal of Clinical Endocrinology and Metabolism Vol. 90, No.2, 729-733
17. Sabuncu T, Harma M, Harma M, Nazligul Y, Kilic F. Sibutramine has a positive effect on clinical and metabolic parameters in obese patients with Polycystic Ovary Syndrome. Fertil Steril. 2003 Nov;80(5):1199-204
18. Guidelines on the initial investigation and management of infertility. RCOG Press, London 1998 and NICE Guidelines 2004.
19. Kousta E, White DM, Franks S: Modern use of clomiphene citrate in induction of ovulation. Human Reprod Update 1997; 3: 359-365.
20. Balen AH & Jacobs. Infertility in Practice, Third Edition, Informa Press, 2008.
21. Balen AH, Braat DDM, West C, Patel A, Jacobs HS: Cumulative conception and live birth rates after the treatment of anovulatory infertility. An analysis of of the safety and efficacy of ovulation induction in 200 patients. Human Reproduction, 1994 9: 1563-1570.
22. Bayram N, van Wely M, Kaaijk EM, Bossuyt PMM, van der Veen F. Using an electrocautery strategy or recombinant FSH to induce ovulation in polycystic ovary syndrome: randomised controlled trial. BMJ 2004; 328: 192-195.
23. Barth JH, Cherry CA, Wojnarowska F, Dawber RPR. Cyproterone acetate for severe hirsutism: results of a double-blind dose-ranging study. Clin Endocrinol 1991; 35: 5-10.
24. Thiboutot D, Chen WC. Update and future of hormonal therapy in acne. Dermatology 2003 206:57-67.
25. Jannsen OE, Mehlmauer N, Hahn S, Offner AH, Gartner B. High prevalence of autoimmune thyroiditis in patients with polycystic ovary syndrome. Eur J Endocrinol. 2004 Mar; 150(3): 363-9
26. Ghosh S, Kabir SN, Pakrashi A, Chatterjee S, Chakravarty B. Suclinical hypothyroidism: a determinant of polycystic ovary syndrome. Horm Res 1993; 39:61-6
27. Tang T, Glanville J, Barthh J, Hayden c, Balen AH. Combined lifestyle modification and metformin in obese patients with polycystic ovary syndrome. A randomised, placebo-controlled, double-blind multicentre study. Hum Reprod 2006; 21: 80–89
28. Moll E et al. Effect of clomifene citrate plus metformin and clomifene citrate plus placebo on induction of ovulation in women with newly diagnosed polycystic ovary syndrome: randomised double blind clinical trial. BMJ 2006; 332: 1485
29. Legro RS et al. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med 2007; 356: 551–566
Clinical Management of Polycystic Ovary Syndrome. Balen AH – Editor-in-chief, with co-editors: G. Conway, R. Homburg, R. Legro. Taylor & Francis, London & New York, 2005.
Current Management of Polycystic Ovary Syndrome. Edited by Adam Balen, Steve Franks, Roy Homburg and Sean Kehoe. Proceedings of 59th RCOG Study Group, RCOG Press, London 2010.
Last Updated June 2014
The polycystic ovary syndrome (PCOS) is the commonest hormonal disturbance to affect women. The main problems that women with PCOS experience are menstrual cycle disturbances (irregular or absent periods), difficulty in controlling body weight and skin problems (acne and unwanted hair growth on the face or body). Not all women with PCOS experience all of the symptoms and furthermore a woman’s problems may change over time. In particular if an individual becomes overweight then her problems are likely to worsen.
About 30% of women have polycystic ovaries, although a smaller proportion will have symptoms of the polycystic ovary syndrome – perhaps 15-20% of women. The problem therefore is extremely common, although many women have relatively mild symptoms.
What are polycystic ovaries ?
Women have two ovaries which are situated in the pelvis alongside the uterus (womb). The ovaries have two main functions: the release of eggs and the production of hormones. The ovaries contain thousands of eggs which are present from birth. Each egg is surrounded by a group of cells which develop into a small fluid filled blister/cyst, or follicle. If a woman is having regular periods and is ovulating one of these follicles grows to about 20mm diameter and then releases its egg, which then passes into one of the fallopian tubes. It is in the fallopian tube that fertilisation occurs and the fertilised egg (embryo) then travels into the uterus where it implants into the lining of the uterus (endometrium) and grows as a pregnancy. If fertilisation does not occur, the endometrium comes away as a menstrual period about 14 days after ovulation.
The second main function of the ovary is the production of hormones. Hormones are substances that are released into the blood stream and circulate around the body influencing other organs. The hormones from the ovary influence many parts of the body, in particular the uterus and breasts. There are many hormones that are released from the ovary and they fall into three main groups: oestrogens, androgens and progestogens. Women make all of these hormones, but sometimes in different proportions. Testosterone is the main androgen hormone, made by the ovaries of all women. Oestrogen is made out of testosterone and helps the lining of the womb (endometrium) to grow.
Polycystic ovaries contain many small follicles which each contain an egg and have started to grow but do not reach a mature size and instead remain at a size of about 2-9 mm in diameter. A polycystic ovary usually contains at least twelve of these small follicles or cysts. The ovaries are also slightly enlarged and their central hormone producing tissue (stroma) is also thickened. The diagnosis is best made by an ultrasound scan which visualises the ovaries and the small cysts within them. Sometimes blood tests show characteristic changes in hormone levels, although these changes are not universal and can vary considerably between different women.
The ultrasound picture is not always clear and some women with the polycystic ovary syndrome may have an ultrasound scan that does not demonstrate polycystic ovaries. The syndrome is defined by the presence of at least two out of the following three:
1) Signs or symptoms of high androgens (unwanted facial or bodily hair, loss of hair from the head, acne or an elevated blood level of testosterone) – after other causes for this have been excluded,
2) Irregular or absent menstrual periods – after other causes for this have been excluded,
3) Polycystic ovaries on ultrasound scan
Women with polycystic ovary syndrome may have the following hormonal disturbances:
Elevated levels of:
• Testosterone: an ovarian androgen hormone that influences hair growth;
• Oestrogen: an ovarian hormone that stimulates growth of the womb lining (endometrium);
• Luteinising hormone (LH, a pituitary hormone which influences hormone production by the ovaries and is important for normal ovulation);
• Insulin (a hormone that is principally involved in utilisation of energy from food), which when elevated may stimulate the ovary to over-produce testosterone and prevent the follicles from growing normally to release eggs and hence cause the ovary to become polycystic. Indeed it is high levels of insulin that is thought to be one of the main problems for women with polycystic ovary syndrome. Insulin becomes more elevated in women who are overweight.
There are many other subtle hormonal abnormalities that affect ovarian function and influence the menstrual cycle, fertility, bodily hair growth, body weight and general health.
Standard blood tests include measurements of:
The following hormones: testosterone, luteinising hormone (LH), follicle stimulating hormone (FSH), thyroid hormones, prolactin. Sex hormone binding globulin (SHBG) – the protein that carries testosterone around the blood is also sometimes, but not always, measured. Recently a test of anti-Mullerian hormone (AMH) has been found to correlate well with the presence of polycystic ovaries.
Glucose tolerance test – a sugary drink is given first thing in the morning on an empty stomach and blood taken at the time of the drink and then again after 2 hours. This helps to see how well the body handles sugar in food and is a screening test for diabetes. In essence it helps to assess the action of insulin.
Cholesterol levels (best done first thing in the morning before anything is eaten or drunk).
An ultrasound scan of the pelvis allows visualization of the ovaries and also the womb – it is important also to measure the thickness of the womb lining (endometrium).
It is now thought that having polycystic ovaries may run in families and there is evidence of a genetic cause. Some women may have polycystic ovaries and never have symptoms - or for that matter never know that they have polycystic ovaries. In fact, it appears that between 20 – 33% of women in the U.K. have polycystic ovaries, of whom perhaps three-quarters have symptoms of the polycystic ovary syndrome – often these symptoms are mild. There are racial differences, with women from Southern Asia, for example having a higher rate of PCOS and disturbed insulin metabolism than European Caucasian women.
Ovaries do not suddenly become polycystic, but women who have polycystic ovaries may develop symptoms at any time, for reasons that are not always clear. A gain in body weight is often the precipitating cause for the development of symptoms. The appearance of polycystic ovaries does not disappear although symptoms may improve, either naturally or as a result of therapy.
It appears that one of the fundamental problems is with over production of insulin due to inefficient handling of energy from food. Whilst the extra insulin is working hard, but ineffectively, to turn food into energy it fails and gets turned into fat. The high levels of insulin have other effects in the body – including stimulating the ovaries to over produce androgens (mainly testosterone), preventing normal ovulation and also longer term effects on the circulation (leading to high cholesterol levels and an increased risk of cardiovascular disease: heart attack and stroke). There is also an increased risk of diabetes occurring in later life.
The balance of hormones is affected by body weight and being overweight can greatly upset this balance and make the above symptoms worse. Some women with polycystic ovaries only develop symptoms if they put on weight. Being overweight (obesity) is commonly associated with the polycystic ovary syndrome and this increases the risk of heart disease and high blood pressure in later life. Many clinics now measure cholesterol levels and if they are abnormal dietary advice is given. A high fibre, low fat and low sugar diet at a young age, together with regular exercise, may help to reduce problems such as high blood pressure and heart attacks when older. Smoking cigarettes seriously worsens the risk of developing these problems. Another problem sometimes seen in later life is "late onset diabetes" in which the body is unable to use sugar efficiently. If this occurs it is then necessary to reduce the dietary intake of carbohydrates and sometimes to take oral medication. The risk of both cardiovascular disease and diabetes can be reduced by keeping to the correct weight for your height.
The small cysts in the ovaries do not get larger, in fact they eventually disappear and are replaced by new cysts. Unless they develop into a mature follicle that will ovulate when it is about 20mm in diameter, the cysts are on average 5mm and no greater than 9mm. These are not the type of ovarian cyst that require surgical removal, as such cysts are 50mm or larger. The cysts of the polycystic ovary do not cause ovarian cancer.
Women with infrequent or absent periods are at risk of excessive growth of the lining of the womb (endometrium). It is important that the endometrium is shed on a regular basis to prevent this from happening for if the endometrium becomes too thick it may sometimes develop into cancer of the womb (endometrial carcinoma). The endometrium can be seen on an ultrasound scan and if it appears too thick, or irregular, a dilatation and curretage (D & C) operation is advised in order to examine the endometrium under a microscope.
1. Menstrual irregularities.
Irregular and unpredictable periods can be unpleasant and a nuisance as well as suggesting irregular ovulation and the risk of endometrial thickening. If pregnancy is not desired the easiest approach is the use of a low dose combined oral contraceptive (that is a contraceptive pill). This will result in an artificial cycle and regular shedding of the endometrium. Some women cannot take the pill and require alternative hormonal therapy to induce regular periods, such as a progestogen for 5-10 days every 1-3 months, depending upon an individual’s requirements. We believe that it is important to have a period at least once every 3 – 4 months to prevent abnormal thickening of the womb lining. An alternative is to use a progesterone secreting coil (Mirena Intrauterine System) which releases the hormone progesterone into the womb, thereby protecting it and also often resulting in reduced or absent menstrual bleeding.
If ovulation occurs erratically it will take longer than average to get pregnant and if ovulation is not occurring it is not possible to conceive without treatment. If the menstrual cycle is irregular it is necessary to take steps to make it regular in order to achieve monthly ovulation and hence a better chance of conception. There are a number of treatments that are used to stimulate regular ovulation. The fertility clinic at the Leeds General Infirmary is at the forefront of research in this area.
First it is necessary to check that the fallopian tubes are open and that your partner’s sperm count is normal. The first drug to try is usually a tablet called clomifene citrate (Clomid), which induces ovulation in about 75% of women of whom perhaps 50-60% can expect to get pregnant after 6 months’ therapy. If clomifene does not work the alternatives include daily hormone injections of a drug that contains follicle stimulating hormone (FSH) or alternatively an operation performed by laparoscopic (“key hole”) surgery in which the ovaries are cauterized (called ovarian diathermy or “drilling”) – both will induce ovulation in about 80% of women.
Women who are overweight have a reduced chance of conception, whether naturally or with assistance and an increased risk of miscarriage and other pregnancy related complications. Weight loss is important before starting fertility therapy and this is best achieved by a strict diet and exercise programme.
Treatments to induce ovulation must be monitored by ultrasound observation of the developing follicle in the ovary. This requires attending the fertility clinic on a regular basis in order to prevent the main side effect, which is multiple pregnancy. The aim of the treatment is to induce the release of only one egg. Another risk of treatment is the ovarian hyperstimulation syndrome (OHSS), when the ovaries respond over-sensitively and can make the individual very unwell.
Metformin is a drug that has been used for many years for the treatment of diabetes. It helps the body use insulin more efficiently and therefore it was thought that it might help to correct one of the fundamental abnormalities of the syndrome, thereby improving ovarian function. Large studies however have failed to demonstrate any clear benefit from the use of metformin and so we only recommend it for women with a proven problem with high glucose levels.
3. Skin problems.
If androgen (testosterone) levels are high the skin may be affected. Acne (spots) may occur on the face, chest or back. Sometimes there is also unwanted hair growth on the face, chest, abdomen, arms and legs. These problems may be confined to small areas of the body, but sometimes they are more prominent, especially in women with darker hair or skin, simply because the unwanted hair is more noticeable than in fairer people. A less common problem is thinning of hair on the head, although if this occurs it is rarely serious. Being overweight probably causes the worst problems for women with the polycystic ovary syndrome as obesity aggravates imbalances of the hormones that control ovulation and that affect the skin and hair growth.
The contraceptive pill Dianette contains cyproterone acetate (an anti-androgen) and is an effective therapy for acne and unwanted hair growth. Spironolactone is another effective preparation, particularly for older women who may also have high blood pressure (for whom the contraceptive pill may not be allowable). There is a new contraceptive pill, Yasmin, which appears to combine the best qualities of Dianette and Spironolactone and has also shown to be effective with few side effects.
Physical treatments such as electrolysis and waxing may be helpful whilst waiting for the above medical treatments to work, as the drug therapies may take 6-9 months or longer before any benefit is perceived. However electrolysis and waxing are expensive and should only be performed by properly trained therapists as scarring can result from unskilled treatment. Recently laser therapy has proven effective, particularly for women with dark hair and fair skin. Shaving can help some women and does not make hair grow back faster.
There is a topical preparation, Vaniqa (Eflornithine) which appears to be very useful in helping reduce unwanted bodily hair. Vaniqa may cause some thinning of the skin and so high factor sun block is recommended if you are in the sun.
Being overweight worsens the symptoms of PCOS. It can be very hard to lose weight and there isn’t a simple solution. Having PCOS does not make you gain weight but women with PCOS find it easy to put on weight as their metabolism works inefficiently to deal with food. Regular physical exercise (at least 20-30 minutes of hard exercise 5-7 days per week) will increase the body’s metabolism and significantly improve the ability to lose weight and improve long term health.
Much has been written about diet and PCOS. The right diet for an individual is one that is practical, sustainable and compatible with your lifestyle. It is sensible to keep carbohydrate content down and to avoid fatty foods. It is often helpful to sit down with a dietician to work out the best diet for you. A number of drugs are available that may help with weight loss. These can be prescribed by general practitioners and their use must be closely monitored. Sometimes surgery to either reduce the size of the stomach or place a band around the stomach (bariatric surgery, gastric banding) may be helpful for those who find it very difficult to lose weight.
In Leeds we are performing a lot of research into various aspects of PCOS in order to increase our understanding of the condition and also improve the treatments of the different problems, from obesity, androgen excess and infertility to the long term problems.
Verity is the UK national support organisation for women with PCOS. We know that it is very tempting to read information on the Web – some is excellent, some can be misleading. We recommend that you use the Verity website to get reliable source of information and support. www.verity-pcos.org.uk
Last updated: June 2014