The Centre for Research Excellence in Women’s Health in Reproductive Life (CRE WHiRL) collaborated with esteemed organizations such as the American Society for Reproductive Medicine (ASRM), Endocrine Society, European Society of Endocrinology (ESE), and European Society of Human Reproduction and Embryology (ESHRE), while collaborating with other professional societies. Together, they have enhanced the 2018 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (PCOS). This updated guideline addresses a broader range of clinical questions, with the goal of ensuring that women with PCOS receive optimal, evidence-based care tailored to their needs, ultimately leading to improved health outcomes.

PCOS is a complex condition that can result in hormonal imbalances, irregular periods, elevated androgen levels, and cysts in the ovaries. The irregular menstrual cycles, often associated with a lack of ovulation, can pose challenges for women trying to conceive, making PCOS a leading cause of infertility. While PCOS is a chronic condition without a cure, symptoms can be managed through lifestyle modifications, medications, and fertility treatments. It is estimated that 8–13% of women of reproductive age are affected by PCOS, with up to 70% of cases going undiagnosed according to the World Health Organization (WHO).

The emphasis on these international guidelines underscores the shift from consensus-based to evidence-based diagnostic criteria, aimed at improving the accuracy of diagnosis and promoting consistency in care. Despite these advancements, challenges such as delayed diagnosis, unmet needs of individuals with PCOS, low quality of evidence, and persistent gaps between evidence and practice still persist.

As we approach the 5-year mark since the release of the previous PCOS guidelines, it is important to highlight key changes and takeaways. While this list does not encompass all changes, it serves to provide a glimpse into the updates. For a comprehensive list of new recommendations, please refer to the full text guidelines located below:

Now let’s dive into the details!

PCOS Guidelines Key Changes and Takeaways Comparing 2023 vs. 2018

The 2023 and 2018 guidelines for the assessment and management of Polycystic Ovary Syndrome (PCOS) have several key differences and updates. Here are some of the main changes:

Quality of Evidence and Research Gaps

The guidelines established in 2018 were formulated based on the best available evidence, which unfortunately was generally of low to very low quality. Within these guidelines were 31 evidence-based recommendations, 59 clinical consensus recommendations, and 76 clinical practice points. It was evident that there were numerous gaps in the evidence, prompting a call for further research in crucial areas such as long-term health outcomes and the efficacy of various treatments.

Fast forward to the updated guidelines of 2023, which have significantly expanded to encompass 254 recommendations and practice points. These updated guidelines continue to prioritize the integration of multidisciplinary and consumer perspectives, with the goal of more effectively bridging the gap between evidence and practice. Furthermore, the 2023 guidelines have made strides in addressing the deficiencies noted in the 2018 version by incorporating new research findings and pinpointing new priority areas for future research.

Patient-Centered Care

The 2018 guideline underscored the significance of patient education and emphasized shared decision-making, as well as individualized care. Building upon this foundation, the 2023 guidelines have further emphasized patient-centered care by integrating extensive consumer engagement into the guideline development process. This approach involves enhancing education and awareness for healthcare professionals and empowering women with PCOS to take an active role in their own care. By incorporating patient and consumer preferences at all stages of guideline development, they strive to ensure that care is truly centered around the needs and preferences of the individual patient.

Diagnostic Criteria and Assessment

The shift in the 2018 guidelines from consensus-based to evidence-based diagnostic criteria has significantly improved the accuracy of diagnosing Polycystic Ovary Syndrome (PCOS). The guidelines now highlight the importance of utilizing the Rotterdam criteria for diagnosis, which requires the presence of two out of three key features:

1. Oligo/Anovulation:

  • Oligoovulation: Refers to infrequent or irregular ovulation, with women experiencing fewer than eight menstrual cycles per year.
  • Anovulation: The absence of ovulation, leading to irregular or absent menstrual periods and often causing infertility.

2. Hyperandrogenism:

  • Hyperandrogenism is characterized by an excess of male hormones like testosterone in the body, resulting in symptoms such as hirsutism, acne, and irregular menstrual cycles. This is a defining feature of PCOS.

3. Polycystic Ovaries on Ultrasound:

  • Polycystic Ovaries on Ultrasound refers to the appearance of the ovaries when viewed through ultrasound. The ovaries typically exhibit multiple small follicles, often described as a “string of pearls,” and may appear enlarged. This ultrasound finding is crucial in diagnosing PCOS.

The 2023 guideline has further refined the diagnostic criteria, emphasizing the importance of timely and accurate diagnosis to minimize delays and enhance patient outcomes. While still utilizing the Rotterdam criteria, the updated guideline places a stronger emphasis on individualized diagnosis, taking into account personal characteristics, preferences, culture, and values.

Overall, these advancements in diagnostic criteria and assessment for PCOS aim to improve the precision of diagnosis and ultimately enhance patient care and outcomes.

Management and Treatment Strategies

The 2018 guidelines outlined a variety of pharmacological and non-pharmacological treatments for Polycystic Ovary Syndrome (PCOS), including lifestyle interventions, combined oral contraceptives, metformin, and anti-androgen agents.

  • First-line treatments, the guidelines emphasized the importance of lifestyle modifications, such as diet and exercise, for managing PCOS symptoms effectively.
  • Combined oral contraceptives (COCs) were recommended for managing menstrual irregularities and hyperandrogenism. 
  • Metformin was suggested primarily for women with PCOS who have insulin resistance, particularly those with a high body mass index (BMI) or those who do not respond well to lifestyle changes. 
  • Anti-Androgens: Medications like spironolactone were also recommended for managing hirsutism and acne, often in combination with COCs.

Moving forward to the 2023 guidelines, there has been an expansion on management strategies, with more detailed recommendations on lifestyle interventions, mental health support, and newer pharmacological treatments.

  • Metformin has been expanded beyond just those with insulin resistance, now recommended more broadly for managing metabolic aspects of PCOS, including weight management and improving menstrual regularity. 
  • Newer pharmacological options, such as inositol supplements, have also been introduced, showing promise in improving insulin sensitivity and ovulatory function.
  • Individualized treatment plans were emphasized in the 2023 guidelines, taking into account the patient’s specific symptoms, preferences, and comorbidities. This includes a more tailored approach to using COCs and anti-androgens.
  • Mental health issues associated with PCOS are highlighted in the 2023 guidelines, recommending the use of antidepressants and other psychotropic medications when necessary.

Thank you for joining us for our Guidelines Spotlight on the Assessment and Management of Polycystic Ovary Syndrome. The ever-evolving guidelines are designed to enhance both physical and mental health outcomes for women with this condition worldwide. We welcome your thoughts and feedback. Stay tuned for our next spotlight!

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