New international PCOS guidelines launched

By Rebecca Jenkins

A newly updated international polycystic ovary syndrome (PCOS) guideline recommends the use of hormone levels as part of the diagnosis for the condition in adults.

Led by experts from the Monash Centre for Health Research and Implementation (MCHRI) at Monash University, Melbourne, the International Evidence-Based Guideline for the Assessment and Management of Polycystic Ovary Syndrome 2023 builds on a 2018 guideline and includes 254 recommendations and practice points.

The document, a summary of which was published simultaneously in Fertility and Sterility, Human Reproduction, Journal of Endocrinology and Metabolism and European Journal of Endocrinology, recommends that diagnosis of PCOS in adults requires the presence of two of the following: clinical/biochemical hyperandrogenism, ovulatory dysfunction, and polycystic ovaries on ultrasound or elevated anti-Müllerian hormone (AMH) levels.

Where irregular menstrual cycles and hyper-androgenism are present, ultrasound or AMH are not required for diagnosis, the guideline states.

Deputy Project Director of guideline development Dr Anju Joham, Senior Research Fellow at the MCHRI said advancements in AMH assays enhancing their accuracy in adults had led to the new recommendation that either serum AMH levels or pelvic ultrasound can be used to define polycystic ovary morphology.

‘But it is recommended to avoid using both AMH and pelvic ultrasound simultaneously to avoid over diagnosis,’ she told Medicine Today.

‘AMH levels are not recommended in adolescents as AMH levels peak in adults in their early twenties.’

The guideline emphasises that PCOS must not be misclassified as a reproductive disorder given its far-reaching implications for metabolic, psychological, and pregnancy health.

‘Once diagnosed, assessment and management should address reproductive, metabolic, cardiovascular, dermatologic, sleep and psychological features,’ the guideline states.

Dr Joham noted the guideline recommends that people with PCOS should be considered at increased risk of cardiovascular disease.

‘Risks of early onset impaired fasting glucose, impaired glucose tolerance and type 2 diabetes are also reiterated,’ she said.

New recommendations also highlight the significantly higher risks in pregnancy, independent of age and BMI, including early miscarriage, excess gestational weight gain, gestational diabetes, hypertension in pregnancy and pre-eclampsia, small for gestational age babies, preterm delivery and higher risk of requiring caesarean section.

‘Health professionals should ensure that PCOS status is identified early in antenatal care, and that women with PCOS should be targeted for screening, monitoring and prevention before and during pregnancy,’ she said.

The guideline authors noted dissatisfaction with PCOS diagnosis and care is high and raised awareness and education are strongly recommended for women and healthcare professionals.

‘Shared decision making and self-empowerment are fundamental and integrated models of care should be developed, funded and evaluated,’ they wrote.

Fertil Steril 2023; S0015- 0282(23)00719-7; doi: https://doi. org/10.1016/j.fertnstert. 2023.07.025.