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Polycystic Ovarian Syndrome – New International Guidelines

Since Polycystic Ovarian Syndrome can have many variable and subtle signs & symptoms, some physicians may miss the diagnosis, especially in young women not trying for pregnancy. In other situations, PCOS can be over-diagnosed in adolescents and young women. PCOS is the leading cause of infertility in women.

PCOS Symptoms

PCOS symptoms may include:

  • Oligo-amenorrhea (irregular or absent periods)
  • Oligo-anovulation (infrequent or no ovulation)
  • Infertility
  • Hirsutism (excessive hair growth) of face, chest or abdomen; Acne; Scalp Hair loss
  • Weight gain/ Obesity
  • Increased anxiety, depression and reduced quality of life

Ovulatory Dysfunction

No single test can definitively diagnose PCOS. Ovulatory dysfunction is a key feature of PCOS with irregular menstrual cycles due to the ovulatory dysfunction, as reflected in the Rotterdam criteria for diagnosing PCOS. However, ovulatory dysfunction can occur even with regular cycles. In addition, irregular cycles and ovulatory dysfunction are also often seen during pubertal and menopausal ‘transitions’ due to normal reproductive physiology, so defining what is ‘abnormal’ during these stages remains difficult and variable. It is most controversial regarding diagnostic criteria during the pubertal/adolescent stages. This is just one of the issues that led to the new international PCOS guidelines for proper diagnosis.

Rotterdam PCOS Diagnostic Criteria

Many reproductive endocrine experts still agree that in order to diagnose PCOS, one must first rule out other endocrine conditions, such as thyroid and adrenal diseases. Most still rely on the Rotterdam criteria that a woman must have 2 out of 3 of the following diagnostic criteria:

  • History of irregular or absent menstrual cycles and/or no ovulation since puberty
  • Hirsutism clinically and/or high biochemical blood levels of male hormones (Androgens)
  • Ultrasound (US) morphologic ‘evidence’ of polycystic ovaries (see below)

New International PCOS Guidelines

Monash University’s Professor Helena Teede is the director of the National NHMRC Centre for Research Excellence in PCOS and led the International Evidence-Based Guideline on Assessment and Management of PCOS (2018) across 37 medical societies and consumer groups from 71 countries.

“The aim of this international evidence-based guideline is to integrate the best available evidence with multidisciplinary expertise and consumer preferences to provide health professionals, consumers and policy makers with transparent evidence-based guidance on timely diagnosis, accurate assessment and optimal treatment of PCOS.”

Monash University’s Professor Helena Teede is the director of the National NHMRC Centre for Research Excellence in PCOS and led the International Evidence-Based Guideline on Assessment and Management of PCOS (2018) across 37 medical societies and consumer groups from 71 countries.

The new PCOS guideline still endorses the Rotterdam diagnostic criteria, but in adults only and recommends tighter criteria requiring both hyperandrogenism and irregular cycles.

Ultrasound (US) diagnostic features have been revised to limit overlap with women without PCOS to improve diagnostic accuracy. Polycystic ovarian morphology (PCOM) was incorporated into the diagnosis of PCOS in 2003 in the Rotterdam criteria. The original definition of PCOM in the Rotterdam criteria is 12 or more follicles measuring 2 – 9mm throughout the entire ovary or an ovarian volume ≥ 10 cm.

Several factors mandated revision of this diagnostic US criteria, including advances in ultrasound technology (greater resolution), inadequate initial evidence, variable US tech skill levels, and natural physiologic changes that occur in antral follicle count during the pubertal and menopausal transitions (up to 70% of adolescents have PCOM based on original Rotterdam criteria).

Due to these variable normal ovarian physiologic changes, ultrasound is no longer indicated in adolescents. (Ultrasound is not recommended for a PCOS diagnosis in those within 8 years of menarche).

The new PCOM guidelines endorse use of endovaginal ultrasound transducers and the threshold for PCOM should be a follicle number per ovary (FNPO) of ≥ 20 on either ovary, and/or an ovarian volume ≥ 10ml. (no corpora lutea, dominant follicles, or cysts are present). There is insufficient evidenced-based data to suggest use of other US criteria, such as peripheral distribution of ovarian follicles (pearl necklace).

Exclusion of thyroid and adrenal diseases remains an important part of the PCOS guideline criteria.

The new PCOS guidelines were recently published in three international journals: Clinical Endocrinology, Human Reproduction and Fertility and Sterility and is an incredible example of international collaboration.

Lifestyle and Nutrition

Many women with PCOS suffer from obesity. Obese women are also particularly susceptible to diabetes and insulin resistance. Women with PCOS and/or obesity often have irregular menstrual cycles and infertility because they usually don’t ovulate. Researchers have determined that most women with PCOS and/or obesity have “insulin resistance” in which the body does not handle insulin properly. Women with insulin resistance may have normal blood glucose levels, but since their cells are resistant to insulin, they over compensate by producing even higher levels of insulin in order to keep their blood glucose levels normal.

The resulting higher insulin levels lead to more fat storage (obesity) and abnormal ovarian androgens (increased male hormones), thus interfering with ovulation. Insulin resistance ultimately can produce all the symptoms of PCOS…anovulation, infertility, obesity, and hirsutism.

When women with PCOS are able to correct the insulin resistance with proper low carbohydrate diet, exercise, vitamins (Myo-Inositol) and/or insulin-sensitizing drugs, such as metformin, normal ovarian function (ovulation and normal female hormone production) often returns. Use of metformin, Myo-Inositol, regular exercise and/or weight loss of 5-10% of body weight can each independently lead to occasional spontaneous pregnancies, as well as dramatically improve pregnancy rates with all fertility treatments, including IVF.

Medical Health Concerns

In addition to infertility problems, women with PCOS are at risk for several other health concerns, including:

  • Obesity
  • Impaired glucose tolerance & Insulin resistance
  • Diabetes
  • Cardiovascular disease
  • Obstructive sleep apnea
  • Endometrial hyperplasia & endometrial cancer at a relatively young age