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Overview

This Guidelines summary outlines the key points for primary care. Please refer to the full guideline for the complete set of recommendations.

Other resources available from Monash University include:

Screening, diagnostic assessment, risk assessment, and life-stage

Algorithm 1: Diagnosis of polycystic ovary syndrome

Diagnosis algorithm

Modified Rotterdam diagnostic criteria

  • Rotterdam diagnostic requires two of:
    1. oligo—or anovulation
    2. clinical and/or biochemical hyperandrogenism (calculated bioavailable, calculated free testosterone, sex hormone binding globulin, free androgen index)
    3. polycystic ovaries on ultrasound in adults[A] (and exclusion of other aetiologies such as: thyroid disease, hyperproplactinemia, follicle stimulating hormone (if pre‑mature menopause is suspected) and non-classic congenital adrenal hyperplasia—note that PCOM is nonspecific in adolescents and is not recommended in diagnosis.

[A] Vaginal ultrasound is not needed if 1 and 2 are present and not recommended in diagnosis for <20 years of age due to the high incidence of polycystic ovary morphology.

Irregular cycles and ovulatory dysfunction

  • Irregular menstrual cycles are defined as:
    • normal in the first year post menarche as part of the pubertal transition
    • >1 to <3 years post menarche: <21 or >45 days
    • >3 years post menarche to perimenopause: <21 or > 35 days or <8 cycles per year
    • >1 year post menarche >90 days for any one cycle
    • primary amenorrhea by age 15 or >3 years post thelarche (breast development)
  • When irregular menstrual cycles are present a diagnosis of polycystic ovary syndrome (PCOS) should be considered and assessed according to the guideline.

Clinical hyperandrogenism

  • A comprehensive history and physical examination should be completed for symptoms and signs of clinical hyperandrogenism, including acne, alopecia and hirsutism and, in adolescents, severe acne and hirsutism
  • Health professionals should be aware of the potential negative psychosocial impact of clinical hyperandrogenism. Reported unwanted excess hair growth and/or alopecia should be considered important, regardless of apparent clinical severity
  • Standardised visual scales are preferred when assessing hirsutism such as the modified Ferriman Gallway score (mFG). A cut-off score of ≥4–6 indicates hirsutism, depending on ethnicity. It is acknowledged that self-treatment is common and can limit clinical assessment
  • Hirsutism prevalence is same across ethnicities. mFG cut-offs for hirsutism and severity, vary by ethnicity
  • Only terminal hairs relevant in pathological hirsutism (untreated >5 mm long, variable shape and pigmented)
  • The Ludwig Visual Score is preferred for assessing the degree and distribution of alopecia
  • There are no universally accepted visual assessments for evaluating acne.

Ultrasound and polycystic ovarian morphology 

  • Ultrasound should not be used for the diagnosis of PCOS in those with a gynaecological age of < 8 years (< 8 years after menarche), due to the high incidence of multi-follicular ovaries in this life stage
  • The threshold for PCOM should be revised regularly with advancing ultrasound technology, and age-specific cut off values for PCOM should be defined
  • The transvaginal ultrasound approach is preferred in the diagnosis of PCOS, if sexually active and if acceptable to the individual being assessed
  • Using endovaginal ultrasound transducers with a frequency bandwidth that includes 8MHz, the threshold for PCOM should be on either ovary, a follicle number per ovary of ≥ 20 and/or an ovarian volume ≥ 10ml, ensuring no corpora lutea, cysts or dominant follicles are present
  • If using older technology, the threshold for PCOM could be an ovarian volume ≥ 10ml on either ovary
  • In patients with irregular menstrual cycles and hyperandrogenism, an ovarian ultrasound is not necessary for PCOS diagnosis; however, ultrasound will identify the complete PCOS phenotype
  • In transabdominal ultrasound reporting is best focused on ovarian volume with a threshold of ≥ 10ml, given the difficulty of reliably assessing follicle number with this approach
  • Clear protocols are recommended for reporting follicle number per ovary and ovarian volume on ultrasound. Recommended minimum reporting standards include:
    • last menstrual period
    • transducer bandwidth frequency
    • approach/route assessed
    • total follicle number per ovary measuring 2–9 mm
    • three dimensions and volume of each ovary
    • reporting of endometrial thickness and appearance is preferred—three-layer endometrial assessment may be useful to screen for endometrial pathology
    • other ovarian and uterine pathology, as well as ovarian cysts, corpus luteum, dominant follicles ≥ equal 10 mm
  • There is a need for training in careful and meticulous follicle counting per ovary, to improve reporting.

Anti-Müllerian Hormone (AMH)

  • Serum AMH levels should not yet be used as an alternative for the detection of PCOM or as a single test for the diagnosis of PCOS
  • There is emerging evidence that with improved standardisation of assays and established cut off levels or thresholds based on large scale validation in populations of different ages and ethnicities, AMH may become assays will be more accurate in the detection of PCOM.

Ethnic variation

  • Health professionals should consider ethnic variation in the presentation and manifestations of PCOS, including:
    • a relatively mild phenotype in Caucasians
    • higher body mass index (BMI) in Caucasian women, especially in North America and Australia
    • more severe hirsutism in Middle Eastern, Hispanic and Mediterranean women
    • increased central adiposity, insulin resistance, diabetes, metabolic risks and acanthosis nigricans in South East Asians and Indigenous Australians
    • lower BMI and milder hirsutism in East Asians
    • higher BMI and metabolic features in Africans.

Cardiovascular disease risk

  • All with PCOS should be offered regular monitoring for weight change and excess weight, in consultation with and where acceptable to the individual. Monitoring could be at each visit or at a minimum six- to 12-monthly, with frequency planned and agreed between the health professional and the individual
  • Weight, height and ideally waist circumference should be measured and BMI calculated:
    • BMI categories and waist circumference should follow World Health Organization guidelines also noting ethnic and adolescent ranges
    • consideration for Asian and high risk ethnic groups including monitoring waist circumference
  • All with PCOS should be assessed for individual cardiovascular risk factors and global cardiovascular disease (CVD) risk
  • If screening reveals CVD risk factors including obesity, cigarette smoking, dyslipidaemia, hypertension, impaired glucose tolerance and lack of physical activity, women with PCOS should be considered at increased risk of CVD
  • Overweight and obese women with PCOS, regardless of age, should have a fasting lipid profile (total cholesterol, low- density lipoprotein cholesterol, high density lipoprotein cholesterol and triglyceride level at diagnosis). Thereafter, measurement should be guided by the results and the global CVD risk
  • All women with PCOS should have blood pressure measured annually.

Gestational diabetes, impaired glucose tolerance, and type 2 diabetes

  • Regardless of age, gestational diabetes, impaired glucose tolerance and type 2 diabetes (five-fold in Asia, four-fold in the Americas and three-fold in Europe) are increased in PCOS, with risk independent of, yet exacerbated by obesity
  • Glycaemic status should be assessed at baseline in all with PCOS and thereafter, every one to three years, based on presence of other diabetes risk factors
  • In high risk women with PCOS (including a BMI >25 kg/m2 or in Asians >23 kg/m2, history of abnormal glucose tolerance or family history of diabetes, hypertension or high risk ethnicity) an oral glucose tolerance test (OGTT) is recommended. Otherwise a fasting glucose or HbA1c should be performed
  • An OGTT should be offered in all with PCOS when planning pregnancy or seeking fertility treatment, given increased hyperglycaemia and comorbidities in pregnancy
  • If not performed preconception, an OGTT should be offered at <20 weeks gestation, and all women with PCOS should be offered the test at 24–28 weeks gestation.

Obstructive sleep apnoea

  • Screening should only be considered for obstructive sleep apnoea (OSA) in PCOS to identify and alleviate related symptoms, such as snoring, waking unrefreshed from sleep, daytime sleepiness, and the potential for fatigue to contribute to mood disorders. Screening should not be considered with the intention of improving cardiometabolic risk, with inadequate evidence for metabolic benefits of OSA treatment in PCOS and in general populations
  • A simple screening questionnaire, preferably the Berlin tool, could be applied and if positive, referral to a specialist considered.

Endometrial cancer

  • Health professionals and women with PCOS should be aware of a two- to six-fold increased risk of endometrial cancer, which often presents before menopause; however absolute risk of endometrial cancer remains relatively low.

Prevalence, screening, diagnostic assessment, and treatment of emotional wellbeing

Quality of life

  • Health professionals and women should be aware of the adverse impact of PCOS on quality of life
  • Health professionals should capture and consider perceptions of symptoms, impact on quality of life and personal priorities for care to improve patient outcomes
  • The PCOS quality of life tool (PCOSQ), or the modified PCOSQ, may be useful clinically to highlight PCOS features causing greatest distress, and to evaluate treatment outcomes on women’s subjective PCOS health concerns.

Depressive and anxiety symptoms, screening, and treatment

  • Health professionals should be aware that in PCOS, there is a high prevalence of moderate to severe anxiety and depressive symptoms in adults; and a likely increased prevalence in adolescents
  • Anxiety and depressive symptoms should be routinely screened in all adolescents and women with PCOS at diagnosis. If the screen for these symptoms and/or other aspects of emotional wellbeing is positive, further assessment and/or referral for assessment and treatment should be completed by suitably qualified health professionals, informed by regional guidelines
  • If treatment is warranted, psychological therapy and/or pharmacological treatment should be offered in PCOS, informed by regional clinical practice guidelines
  • Assessment of anxiety and or depressive symptoms involves assessment of risk factors, symptoms and severity. Symptoms can be screened according to regional guidelines, or by using the following stepped approach:
      • step one: initial questions could include:
        • over the last two weeks, how often have you been bothered by the following problems?
          • feeling down, depressed, or hopeless?
          • little interest or pleasure in doing things?
          • feeling nervous, anxious or on edge?
          • not being able to stop or control worrying?
    step two:
       if any of the responses are positive, further screening should involve:
      • assessment of risk factors and symptoms using age, culturally and regionally appropriate tools, such as the Patient Health Questionnaire (PHQ) or the Generalised Anxiety Disorder Scale (GAD7) and/or refer to an appropriate professional for further assessment
  • Factors including obesity, infertility, hirsutism need consideration along with use of hormonal medications in PCOS, as they may independently exacerbate depressive and anxiety symptoms and other aspects of emotional wellbeing.

Lifestyle

Effectiveness of lifestyle interventions

  • Healthy lifestyle behaviours (healthy eating and regular physical activity) should be recommended in all women with PCOS including those with excess weight, to achieve and/or maintain healthy weight and to optimise health, and quality of life across the life course. Ethnic groups at high cardiometabolic risk require more consideration
  • Achievable goals such as 5–10% weight loss in those with excess weight yields significant clinical improvements and is considered successful weight reduction within six months. Ongoing monitoring is important in weight loss and maintenance. Consider referral to a professional to assist with healthy lifestyle
  • SMART (specific, measurable, achievable, realistic and timely) goal setting and self-monitoring can enable achievement of realistic lifestyle goals
  • Psychological factors such as anxiety and depressive symptoms, body image concerns and disordered eating need consideration to optimise healthy lifestyle engagement
    • see the full guideline for recommendations on eating disorders and body image
  • All patient interactions should be patient-centred and value women’s individualised healthy lifestyle preferences and cultural, socioeconomic and ethnic differences
  • Adolescent and ethnic-specific body mass index and waist circumference categories should be considered when optimising lifestyle and weight.

Behavioural strategies

  • Lifestyle interventions (may also include cognitive behavioural interventions) could include goal setting, self-monitoring, stimulus control, problem solving, assertiveness training, slower eating, reinforcing changes and relapse prevention, to optimise weight management, healthy lifestyle and emotional wellbeing in women with PCOS.

Dietary intervention

  • General healthy eating principles should be followed for all women with PCOS across the life course, with no one dietary type recommended in PCOS
  • To achieve weight loss in those with excess weight, an energy deficit of 30% or 500–750 kcal/day (1200–1500 kcal/day) could be prescribed for women, also considering individual energy requirements, body weight, food preferences and physical activity levels and an individualised approach.

Exercise intervention

  • Health professionals should encourage and advise the following for prevention of weight gain and maintenance of health:
    • in adults from 18–64 years, a minimum of 150 min/week of moderate intensity physical activity or 75 min/week of vigorous intensities or an equivalent combination of both including muscle strengthening activities on two non-consecutive days/week
    • in adolescents, at least 60 minutes of moderate to vigorous intensity physical activity/day including those that strengthen muscle and bone at least three times weekly
    • activity be performed in at least 10 minute bouts or around 1000 steps, aiming to achieve at least 30 minutes daily on most days
  • Health professionals should encourage and advise the following for modest weight loss, prevention of weight regain and greater health benefits including:
    • a minimum of 250 min/week of moderate intensity activities or 150 min/week of vigorous intensity or an equivalent combination of both, and
    • muscle strengthening activities involving major muscle groups on two non‑consecutive days/week and minimised sedentary, screen or sitting time
  • Physical activity can be incidental or structured. Self-monitoring, including with fitness tracking devices and technologies, could support and promote active lifestyles.

Pharmacological treatment for non-fertility indications

Algorithm 2: Pharmacological treatment for non-fertility indications

Pharmacological treatment algorithm for non-fertility indications

  • Please refer to the full guideline for further information on pharmacological treatment for non-fertility indications.

Other resources

Full guideline:

Teede H, Misso M, Costello M, Dokras A, Laven J, Moran L, Piltonen T and Norman R on behalf of the International PCOS Network. International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2018.  Available at: www.monash.edu/medicine/sphpm/mchri/pcos/guideline

Published date: February 2018.