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New international PCOS guideline aims to streamline care
An international consortium of polycystic ovary syndrome professional societies and organizations issued new evidence-based recommendations and practice points to promote consistent, evidence-based care and improve health outcomes for women with PCOS, according to a new guideline published in Fertility & Sterility.
The guideline group, which included 37 PCOS professional societies and organizations across 71 countries, addressed 60 clinical questions involving 40 systematic and 20 narrative reviews before issuing 166 recommendations, including a refinement in individual diagnostic criteria, reducing unnecessary testing, increasing focus on education and lifestyle modification, and emphasizing evidence-based medical therapies and “cheaper and safer” fertility management.
“PCOS is a challenging experience for women, many remain undiagnosed and most experience delays in diagnosis, some of up to 2 years with multiple health professional visits,” Helena J. Teede, MBBS, PhD, FRACP, FAAHMS, of the National Health and Medical Research Council Centre for Research Excellence in PCOS at Monash University in Melbourne, Australia, told Endocrine Today. “Inadequate information provision and lack of satisfaction with care is also reported. Women with PCOS report limited consideration of psychological features, lifestyle and prevention and note that specialty services focus primarily on individual features of PCOS including infertility, rather than taking a holistic approach to care. There have also been concerns around potential overdiagnosis and whilst there is lack of evidence to support this, isolated polycystic ovarian morphology (PCOM) on ultrasound has been incorrectly equated with a diagnosis of PCOS.”
The International Guideline for the Assessment and Management of PCOS formally endorsed the Rotterdam PCOS diagnostic criteria in adults, defined as oligo- or anovulation, clinical and/or biochemical hyperandrogenism or polycystic ovaries on ultrasound, noting that ultrasound is not recommended for diagnosis in the presence of oligo-anovulation and hyperandrogenism. In adolescents, both oligo-anovulation and hyperandrogenism are required for diagnosis, with ultrasound not recommended for diagnosis. Anti-Mullerian hormone levels are considered inadequate for diagnostic purposes, the researchers wrote.
Insulin resistance, while recognized as a “key feature” of PCOS, is also not recommended for measurement for diagnosis.
“Timely, accurate diagnosis is important and needs greater clarity,” Teede said. “Also, there are no consistent, high-quality, evidence-based guidelines in PCOS and variation in care is significant.”
PCOS management
The guidelines also recommended screening and assessment of depressive and anxiety symptoms, and health professionals should be aware of other effects on emotional well-being and quality of life.
Recommended therapies include oral contraceptive pills as first-line pharmacotherapy for menstrual irregularity and hyperandrogenism, with no specific formulation recommended and low-dose preparations preferred. Metformin is recommended in addition to contraceptive pills or alone for metabolic features, according to the researchers. Letrozole is recommended for first-line pharmacological infertility therapy, followed by clomiphene and metformin alone or in combination. In women with PCOS and anovulatory infertility, gonadotropins are a recommended second-line therapy, the guideline states.
“The combined effects of the provision of a single source of evidence-based recommendations and a comprehensive international translation and dissemination program will amplify the impact of the guideline and recommendations globally,” the researchers wrote. “It will support and build the capability of health professionals to deliver high-quality, evidence-based assessment and management of PCOS and will augment the health literacy and self-management of PCOS health consumers.”
The guideline was also simultaneously published in Clinical Endocrinology and Human Reproduction. The guideline is also available in an app called AsKPCOS in the Apple iTunes store, with Android expected in the coming weeks, Teede said. – by Regina Schaffer
Reference:
Monash University. Detailed methods for stakeholder engagement and guideline development. Available at www.monash.edu/medicine/sphpm/mchri/pcos.
For more information:
Helena J. Teede, MBBS, PhD, FRACP, FAAHMS, can be reached at the National Health and Medical Research Council Centre for Research Excellence in PCOS at Monash University, Locked Bag 29, Clayton, 3168, VIC, Australia email: helena.teede@monash.edu.
Disclosures: One guideline author reports he holds shares in Virtus Health and past sponsorship from Merck, another author reports he has received grants or personal fees from Danone, Euroscreen, Ferring and Titus Healthcare. A third author reports a minor shareholder interest in an IVF unit.