New guideline for polycystic ovary syndrome management

The guideline for the assessment and management of polycystic ovary syndrome follows international best practice recommendations for the diagnosis, assessment and treatment of this often neglected condition.

The 2023 International evidence-based guideline for the assessment and management of polycystic ovary syndrome (PCOS) aims to provide clear information, promote shared decision making and support optimal patient care and better health outcomes for women affected by PCOS.

The Australian-led initiative sought engagement from over 3000 health professionals, and over 100 clinical and lived experience experts from 71 countries.

In a summary published in the Medical Journal of Australia, Professor Helena Teede of Monash University and her colleagues have outlined the key recommendations of the guideline.

“Responding to strong calls from patient and consumer groups, the guideline addresses a condition that affects one in eight Australian women, 140 million women globally, and is complex, underdiagnosed, undertreated, underfunded, under-researched, misnamed and misunderstood,” Professor Teede and colleagues wrote.

“The 2023 guideline is approved by the National Health and Medical Research Council and provides clinicians and patients with clear advice on best practice in a common and neglected condition, based on the best available evidence, expert multidisciplinary input and consumer preferences.”

The recommendations outlined in the guideline include:

Refined diagnostic criteria

The guideline recommends refining the individual diagnostic criteria according to international, evidence-based criteria.

For adults, at least two of the following criteria must be met:

• clinical or biochemical hyperandrogenism;
• ovulatory dysfunction or irregular cycles; and
• polycystic ovarian appearance or morphology (PCOM) identified through ultrasound or anti-Müllerian hormone levels.

Due to the risk of underdiagnosis and long term complications when PCOS is not identified early, the guideline recommends that adolescents who meet only one criterion are identified for follow-up.

“Timely diagnosis allows for identification and prevention in individuals who are at high risk of long term complications, before potential long term use of contraception, which can mask PCOS symptoms,” Professor Teede and colleagues wrote.

Recognising the broad features of PCOS

Various comorbidities associated with PCOS are now recognised, such as metabolic effects, cardiovascular disease, dermatological symptoms, sleep apnoea, a high prevalence of psychological features and a high risk of adverse pregnancy outcomes.

“It is now recommended that individuals with PCOS be recognised as having increased cardiovascular disease risk factors, cardiovascular disease and potentially cardiovascular mortality,” Professor Teede and colleagues wrote.

“Potential increased cardiometabolic risk in first-degree family members including diabetes, metabolic syndrome and hypertension were also recognised.”

Improved models of care

The guideline emphasises the need for high quality information for patients, enhanced professional education for clinicians, and a focus on shared decision making and person-centred care.

“Provision of comprehensive and accurate information is paramount for shared, informed decision making, and to enhance knowledge and self-management,” the authors wrote.

“Health care professionals have a vital role in engaging in open and respectful communication and providing guidance and support in individualised person-centred care.”

Physical and psychological health

The guideline maintains an emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma.

“Lifestyle management should be recommended to all individuals with PCOS and encompass both prevention of weight gain, and support for individuals with overweight or obesity,” Professor Teede and colleagues wrote.

“Healthy lifestyle behaviours encompassing healthy eating and physical activity should be recommended to optimise general and metabolic health, and improve quality of life, noting benefits even without weight loss.”

The guideline also recommends screening for depression, anxiety and, in some cases, eating disorders.

“All health professionals should be aware that PCOS carries increased risks of negative psychosocial outcomes and mental health conditions, including depression, anxiety, eating disorders, disordered eating, body image distress, low self-esteem and problems with feminine identity,” the authors wrote.

Fertility

Although PCOS is associated with adverse pregnancy outcomes, patients should be reassured that pregnancy can be successfully achieved, especially with an early PCOS diagnosis.

The guideline recommends evidence-based medical therapy and fertility management, including the use of oral ovulation induction, prenatal vitamin supplementation, and optimisation of lifestyle factors such as weight, exercising, smoking and blood pressure.

Low dose gonadotrophins and laparoscopic ovarian surgery are recommended as second-line treatment options.

Read the guideline summary in the Medical Journal of Australia.

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