Clinical Practice Guidelines on the Diagnosis and Management of Polycystic Ovary Syndrome

Key points

• The review included 13 polycystic ovary syndrome (PCOS) guidelines, 5 national and 8 international, published between 2007 and 2018, and assessed them with the AGREE II tool.
• Screening for and managing metabolic disease was the most covered domain (12/13, 92%), followed by cardiovascular risk assessment (10/13, 77%); mental health (8/13, 62%) and diagnosis in adolescents (7/13, 54%) were the least covered.
• Most guidelines described their scope and purpose well (12/13, 92%), but stakeholder involvement and applicability to practice were adequate in only 2 (15%).
• Recommendations were inconsistent on diagnosis in adolescents, lifestyle interventions, hirsutism and acne, reducing the risk of ovarian hyperstimulation syndrome, metabolic and cardiovascular screening, and mental health screening tools.
• Lifestyle treatment was the most widely recommended first-line intervention.

Overview

This systematic review found that clinical practice guidelines on PCOS vary considerably in scope and methodological quality, which may hinder the translation of evidence into practice. The authors searched MEDLINE, EMBASE and CENTRAL until December 2020, screened 575 titles and abstracts, assessed 26 articles in full and mapped the recommendations of the 13 included guidelines across prespecified disease domains.

Guideline quality

The median number of recommendations per guideline was 26 (range 6-90). Only 2 guidelines used an established consensus method such as Delphi, 7 used a clear evidence grading system and 2 provided implementation tools. Clarity of presentation was high in 9 of 13 (69%), and there was no meaningful correlation between quality and year of publication (r = -0.02).

Diagnosis

For adults, 7 guidelines supported the Rotterdam criteria or a modification, but only 1 clearly defined polycystic ovarian morphology. All relevant guidelines supported total or free testosterone or the free androgen index to diagnose hyperandrogenemia, with variation on androstenedione and dehydroepiandrosterone sulphate. Anti-Müllerian hormone was considered useful in 1 guideline but not recommended by the international PCOS guideline. In adolescents, all relevant guidelines advised against polycystic ovarian morphology as an independent ultrasound criterion and against anti-Müllerian hormone.

Treatment

Nine guidelines recommended lifestyle treatment as first line, mostly combining a calorie-restricted diet, exercise and behavioural interventions; 4 set a weight loss target of 5% to 10%, and 3 recommended 150 min/week of exercise. Six recommended hormonal contraceptives as first-line treatment for menstrual irregularity in adults. Three recommended photoepilation and topical eflornithine as first line for hirsutism and acne, whereas the Endocrine Society guideline favoured hormonal contraceptives in adolescents. For infertility, lifestyle treatment for 3 to 6 months was considered first line, and 3 guidelines recommended letrozole as the primary agent for ovulation induction, unlike the older Thessaloniki ESHRE/ASRM guideline, which recommended clomiphene citrate.

Screening

The oral glucose tolerance test was considered the gold standard for glucose intolerance and type 2 diabetes, with suggested intervals ranging from annually to every 5 years and haemoglobin A1c as a substitute. Weight and blood pressure were to be checked at each visit (at least every 6 to 12 months) and lipids every 2 years. Seven guidelines supported routine mental health assessment, but only the international guideline named specific tools. Routine endometrial cancer screening was not recommended in 3 guidelines.

Frequently asked questions

Which diagnostic criteria do most guidelines use in adults?

Seven of the 13 guidelines supported the Rotterdam criteria or a modification of them.

Is anti-Müllerian hormone recommended for diagnosing PCOS?

Guidelines disagree in adults: 1 considered it useful, while the international PCOS guideline did not recommend it. All relevant guidelines advised against it in adolescents.

What is the usual first-line treatment?

Lifestyle treatment, recommended as first line by 9 guidelines in adolescents and adult women.

Source

Al Wattar BH, Fisher M, Bevington L, Talaulikar V, Davies M, Conway G, et al. Clinical Practice Guidelines on the Diagnosis and Management of Polycystic Ovary Syndrome: A Systematic Review and Quality Assessment Study. J Clin Endocrinol Metab 2021;106(8):2436-2446. doi:10.1210/clinem/dgab232. Open access under CC BY 4.0. This summary was prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.