New Guidelines for PCOS Diagnosis & Treatment
An Endocrine Society task force has developed new guidelines for the treatment of polycystic ovary syndrome (PCOS). The guidelines, published online in the Journal of Clinical Endocrinology & Metabolism, are aimed at helping physicians and patients understand a complex condition that often has diverse symptoms.
Together with his colleagues, Task Force Chair, Richard S. Legro, MD - a professor in obstetrics and gynaecology at the Penn State University College of Medicine in Hershey, Pennsylvania - developed the evidence-based guidelines using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to rate the strength and quality of recommendations.
"The Society's recommendations allow physicians to make the diagnosis [of PCOS] if clear symptoms are present without resorting to universal hormone tests or ultrasound screenings," Dr Legro said in a press release.
The guidelines advise that an adult woman is diagnosed with PCOS if she has at least two of the following symptoms:
- Excess androgens: Clinical or biochemical hyperandrogenism determined by the presence of total (TT) or free (FT) testosterone excess
- Ovulatory dysfunction: CharacteriZed by oligo-amenorrhea and chronic anovulation
- Polycystic ovaries: Found on ultrasound in adult women
In addition, any diagnosis of PCOS must rule out other androgen-excess disorders.
Physicians should also screen patients for endometrial cancer, mood disorders, obstructive sleep apnea, diabetes, and cardiovascular disease. Diagnosis of PCOS in adolescent girls should be based on clinical or biochemical signs of hyperandrogenism (after excluding other possible causes) in the presence of persistent oligomenorrhea, the task force advises.
A PCOS diagnosis during perimenopause and menopause should be based on a documented, long-term history of oligomenorrhea and hyperandrogenism in reproductive years, the report advises. A finding of PCO morphology via ultrasound would also provide supportive evidence, although the authors note this is least likely in menopausal women.
The guidelines recommend against routine ultrasound for endometrial thickness in women with PCOS. In diagnosing and treating women with PCOS, physicians should look for terminal hair growth, acne, alopecia, acanthosis nigricans, and skin tags during a physical examination, according to the new guidelines. Screening for ovulatory status using menstrual history is also recommended.
The guidelines further advise assessment of body mass index, waist circumference, blood pressure, and oral glucose tolerance. Overweight and obese patients with PCOS symptoms should be screened for obstructive sleep apnea. Both adults and adolescents should also be screened and treated for depression and anxiety.
The committee recommends treatment with hormonal contraceptives as the first-line therapy for menstrual abnormalities and hirsutism/acne. Exercise therapy is recommended to manage weight, alone or with a calorie-restricted diet.
The task force advises against the use of metformin as a first-line PCOS treatment. However, metformin is recommended for women with PCOS and type 2 diabetes or impaired glucose tolerance, who do not succeed with weight loss and exercise. Metformin is also recommended for women who cannot take hormonal contraceptives.
For infertility, the report recommends clomiphene citrate as a first-line treatment. For women undergoing in vitro fertilization, the guidelines recommend metformin as adjuvant therapy to prevent ovarian hyperstimulation.
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Legro, R. S., Arslanian, S. A., Ehrmann, D. A., Hoeger, K. M., Murad, M. H., Pasquali, R., Welt, C. K., & Endocrine Society (2013). Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. The Journal of clinical endocrinology and metabolism, 98(12), 4565–4592.