Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome

This international polycystic ovary syndrome guideline provides clinicians with clear advice on best practices based on available evidence, expert multidisciplinary input, and consumer preferences, supported by a comprehensive translation program.

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Volume 110, Issue 3, Pages 364–379

Authors:

Helena J. Teede, M.B.B.S., Ph.D., FRACP, FAAHMS, Marie L. Misso, Ph.D., B.Sc.(Hons.), Michael F. Costello, M.B.B.S., M.Med.(RH&HG), FRANZCOG, C.R.E.I., D.Med.Sc., Anuja Dokras, M.D., Ph.D., Joop Laven, M.D., Ph.D., Lisa Moran, B.Sc.(Hons.), BND, G. Cert. Pub. Health, Ph.D., Terhi Piltonen, M.D., Ph.D., Robert.J. Norman, FRANZCOG, FRCPA, FRCPath, FRCOG, C.R.E.I. on behalf of the International PCOS Network 

Abstract:

Study Question

What is the recommended assessment and management of women with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference?

Summary Answer

International evidence-based guidelines including 166 recommendations and practice points, addressed prioritized questions to promote consistent, evidence-based care and improve the experience and health outcomes of women with PCOS.

What Is Known Already

Previous guidelines either lacked rigorous evidence-based processes, did not engage consumer and international multidisciplinary perspectives, or were outdated. Diagnosis of PCOS remains controversial and assessment and management are inconsistent. The needs of women with PCOS are not being adequately met and evidence practice gaps persist.

Study Design, Size, Duration

International evidence-based guideline development engaged professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Appraisal of Guidelines for Research and Evaluation (AGREE) II-compliant processes were followed, with extensive evidence synthesis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength.

Participants/Materials, Setting, Methods

Governance included a six continent international advisory and a project board, five guideline development groups, and consumer and translation committees. Extensive health professional and consumer engagement informed guideline scope and priorities. Engaged international society-nominated panels included pediatrics, endocrinology, gynecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, public health and other experts, alongside consumers, project management, evidence synthesis, and translation experts. Thirty-seven societies and organizations covering 71 countries engaged in the process. Twenty face-to-face meetings over 15 months addressed 60 prioritized clinical questions involving 40 systematic and 20 narrative reviews. Evidence-based recommendations were developed and approved via consensus voting within the five guideline panels, modified based on international feedback and peer review, with final recommendations approved across all panels.

Main Results and the Role of Chance

The evidence in the assessment and management of PCOS is generally of low to moderate quality. The guideline provides 31 evidence based recommendations, 59 clinical consensus recommendations and 76 clinical practice points all related to assessment and management of PCOS. Key changes in this guideline include: i) considerable refinement of individual diagnostic criteria with a focus on improving accuracy of diagnosis; ii) reducing unnecessary testing; iii) increasing focus on education, lifestyle modification, emotional wellbeing and quality of life; and iv) emphasizing evidence based medical therapy and cheaper and safer fertility management.

Limitations, Reasons for Caution

Overall evidence is generally low to moderate quality, requiring significantly greater research in this neglected, yet common condition, especially around refining specific diagnostic features in PCOS. Regional health system variation is acknowledged and a process for guideline and translation resource adaptation is provided.

Wider Implications of the Findings

The international guideline for the assessment and management of PCOS provides clinicians with clear advice on best practice based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation program supports the guideline with an integrated evaluation program.

Study Funding/Competing Interest(S)

The guideline was primarily funded by the Australian National Health and Medical Research Council of Australia (NHMRC) supported by a partnership with ESHRE and the American Society for Reproductive Medicine. Guideline development group members did not receive payment. Travel expenses were covered by the sponsoring organizations. Disclosures of conflicts of interest were declared at the outset and updated throughout the guideline process, aligned with NHMRC guideline processes. Full details of conflicts declared across the guideline development groups are available at https://www.monash.edu/medicine/sphpm/mchri/pcos/guideline in the Register of disclosures of interest. Of named authors, Dr Costello has declared shares in Virtus Health and past sponsorship from Merck Serono for conference presentations. Prof. Laven declared grants from Ferring, Euroscreen and personal fees from Ferring, Euroscreen, Danone and Titus Healthcare. Prof. Norman has declared a minor shareholder interest in an IVF unit. The remaining authors have no conflicts of interest to declare. The guideline was peer reviewed by special interest groups across our partner and collaborating societies and consumer organizations, was independently assessed against AGREEII criteria and underwent methodological review. This guideline was approved by all members of the guideline development groups and was submitted for final approval by the NHMRC.


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Go to the profile of Marla Lujan
Marla Lujan about 2 months ago

We would like to congratulate Dr. Helena Teede and colleagues on the recent launch of the International Evidence-Based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (PCOS) (1). Publication of these recommendations represents a monumental multidisciplinary and global effort and promises to improve healthcare experiences and outcomes for women living with PCOS.

We especially appreciate that one of the five guideline chapters was dedicated to lifestyle behaviors and interventions (1). The recommendations provided therein highlight the importance of weight management in PCOS and encourage patients to adopt healthy dietary and physical activity patterns to optimize hormonal, metabolic, and psychological health across the lifespan (1). Women of normal weight are encouraged to follow government advice for diet and exercise to prevent weight gain, while those with overweight / obesity are counselled to initiate modest weight loss through caloric restriction and multicomponent lifestyle intervention (1). These recommendations and clinical practice points draw from decades of research in obesity and PCOS and acknowledge that lifestyle goals need to be individualized, attainable, and continuously evaluated for success (1).

We suggest that these recommendations speak to a necessity to strengthen physician-dietitian collaborations in current practice (2). Recent surveys have revealed that patients and providers agree weight management is a serious concern in PCOS (3,4) – with most reproductive endocrinologists and obstetrician / gynecologists already providing recommendations for lifestyle management (4,5). However, patients have reported feeling little control over their lifestyle behaviors (6) and have noted frustration with the lack of information, support, and empathy in their encounters with providers (4). It has been suggested that cognitive behavioral therapy and frequent interactions with providers could represent effective approaches for overcoming these challenges (1,7–9). Registered dietitians may be uniquely positioned to assist in these roles, given their extensive training in nutrition, anatomy and physiology, biochemistry, psychology, and communication (2). Dietitians are members of multidisciplinary healthcare and research teams in fields that commonly care for women with PCOS, including general medicine, pediatrics, endocrinology, obesity / weight management, wellness and disease prevention, and disordered eating. They can, therefore, provide frequent and individualized attention and continuous support for patients during behavior change programs (2). These skill sets are crucial in cases like PCOS, where anxiety, depression, and body image issues are common (10). As allied health professionals, dietitians often require a referral from a physician before nutrition therapy can be initiated and covered by insurance (2). Perhaps consequently, it has been estimated that fewer than one-third of women with PCOS have ever seen a dietitian (5,11,12) – and just 3% have been able to attend more than one visit (11).

We strongly recommend that efforts to increase physician-dietitian collaborations be prioritized in routine care for women with PCOS. It would be ideal for dietitians to work with patients from diagnosis and on a routine basis to manage weight and any barriers to the adoption of healthy lifestyle behaviors across the lifespan. Based on evidence from other populations, we maintain that such an approach will “promote best-practice models of care for PCOS,” (1) and increase the cost- and clinical- effectiveness (13) of the new international guideline in practice (1).


Sincerely,

Brittany Y. Jarrett, PhD, RD

Annie W. Lin, PhD, RD

Marla E. Lujan, PhD, MSc

Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA 14853


References:

1.          Teede H, Misso M, Costello M, Dokras A, Laven J, Moran L, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril 2018;110(3):364–79.
2.          The Academy Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee. Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian. J Acad Nutr Diet 2013;113(6):S17–28.
3.          Gibson-Helm M, Teede H, Dunaif A, Dokras A. Delayed diagnosis and a lack of information associated with dissatisfaction in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2017;102(2):604–12.
4.          Dokras A, Saini S, Gibson-Helm M, Schulkin J, Cooney L, Teede H. Gaps in knowledge among physicians regarding diagnostic criteria and management of polycystic ovary syndrome. Fertil Steril 2017;107(6):1380–6.
5.          Conway G, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale H, Franks S, Gambineri A, et al. European survey of diagnosis and management of the polycystic ovary syndrome: Results of the ESE PCOS Special Interest Group’s Questionnaire. Eur J Endocrinol 2014;171(4):489–98.
6.          Lin A, Dollahite J, Sobal J, Lujan M. Health-related knowledge, beliefs and self-efficacy in women with polycystic ovary syndrome. Hum Reprod 2018;33(1):91–100.
7.          Moran L, Pasquali R, Teede H, Hoeger K, Norman R. Treatment of obesity in polycystic ovary syndrome: a position statement of the Androgen Excess and Polycystic Ovary Syndrome Society. Fertil Steril 2009;92(6):1966–82.
8.          Moran L, Harrison C, Hutchison S, Stepto N, Strauss B, Teede H. Exercise decreases anti-mullerian hormone in anovulatory overweight women with polycystic ovary syndrome - a pilot study. Horm Metab Res 2011;43:977–9.
9.          Cooney L, Milman L, Hantsoo L, Kornfield S, Sammel M, Allison K, et al. Cognitive-behavioral therapy improves weight loss and quality of life in women with polycystic ovary syndrome: a pilot randomized clinical trial. Fertil Steril 2018;110(1):161-71.
10.       Dokras A, Stener-Victorin E, Yildiz B, Li R, Ottey S, Shah D, et al. Androgen Excess-Polycystic Ovary Syndrome Society: position statement on depression, anxiety, quality of life, and eating disorders in polycystic ovary syndrome. Fertil Steril 2018;109(5):888–99.
11.       Jeanes Y, Barr S, Smith K, Hart K. Dietary management of women with polycystic ovary syndrome in the United Kingdom: The role of dietitians. J Hum Nutr Diet 2009;22(6):551–8.
12.       Lin A, Bergomi E, Dollahite J, Sobal J, Hoeger K, Lujan M. Trust in physicians and medical experience beliefs differ between women with and without polycystic ovary syndrome. J Endocr Soc 2018;2(9):1001–9.
13.       Herman WH. The cost-effectiveness of diabetes prevention: results from the Diabetes Prevention Program and the Diabetes Prevention Program Outcomes Study. Clin Diabetes Endocrinol 2015;1(1):9.