A Summary on Polycystic Ovary Syndrome: Diagnostic Criteria, Prevalence, Clinical Manifestations, and Management According to the Latest International Guidelines

Adriana Catharina Helena Neven; Joop Laven; Helena J. Teede; Jacqueline A. Boyle

doi:10.1055/s-0038-1668085

Seminars in Reproductive Medicine, Table of Contents

Semin Reprod Med 2018; 36(01): 005-012
DOI: 10.1055/s-0038-1668085

Review Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

A Summary on Polycystic Ovary Syndrome: Diagnostic Criteria, Prevalence, Clinical Manifestations, and Management According to the Latest International Guidelines

Adriana Catharina Helena Neven

¹Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, The Netherlands

,

Joop Laven

¹Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, The Netherlands

,

Helena J. Teede

²Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia

,

Jacqueline A. Boyle

²Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia

³Monash Department of Obstetrics and Gynaecology, Monash Health, Clayton, Victoria, Australia

› Author Affiliations

Abstract

Polycystic ovary syndrome (PCOS) is a common hormonal condition with reproductive, metabolic, and psychological sequelae. The Rotterdam Criteria are now internationally accepted, with different phenotypes recognized with varying clinical presentations and risk profiles. The complexity of the disorder, and the impact on quality of life, requires timely diagnosis, screening for complications and management strategies. PCOS remains underdiagnosed and women experience significant delays to diagnosis. Effective dissemination of evidence-based management is therefore vital. In this review, we summarize key aspects of PCOS as a prelude to this issue of Seminars in Reproductive Medicine on PCOS which focuses on the development of the international evidence-based guideline on the assessment and management of PCOS and the related translation program. We cover diagnostic criteria, prevalence, phenotypes, reproductive, metabolic, and psychological factors of PCOS. We also cover management strategies including lifestyle interventions as well as treatment of nonreproductive outcomes and reproductive outcomes informed by the latest international evidence-based guidelines.

Keywords

PCOS update - PCOS diagnosis - PCOS treatment

Full Text

References

References
1 Bozdag G, Mumusoglu S, Zengin D, Karabulut E, Yildiz BO. The prevalence and phenotypic features of polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod 2016; 31 (12) 2841-2855
2 Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004; 81 (01) 19-25
3 Dumesic DA, Oberfield SE, Stener-Victorin E, Marshall JC, Laven JS, Legro RS. Scientific statement on the diagnostic criteria, epidemiology, pathophysiology, and molecular genetics of polycystic ovary syndrome. Endocr Rev 2015; 36 (05) 487-525
4 Moran LJ, Hutchison SK, Norman RJ, Teede HJ. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev 2011;16(2)
5 Teede HJ, Misso ML, Costello MF. , et al. Norman RJ on behalf of the International PCOS Network. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril 2018; In press
6 Hart R. Definitions, prevalence and symptoms of polycystic ovaries and polycystic ovary syndrome. In: Allahbadia G, Agrawal R. , eds. Polycystic Ovary Syndrome. 2nd ed. Kent, UK: Anshan, Ltd; 2007: 15-26
7 Balen AH, Conway GS, Kaltsas G. , et al. Polycystic ovary syndrome: the spectrum of the disorder in 1741 patients. Hum Reprod 1995; 10 (08) 2107-2111
8 Alexiou E, Hatziagelaki E, Pergialiotis V. , et al. Hyperandrogenemia in women with polycystic ovary syndrome: prevalence, characteristics and association with body mass index. Horm Mol Biol Clin Investig 2017; 29 (03) 105-111
9 Tena G, Moran C, Romero R, Moran S. Ovarian morphology and endocrine function in polycystic ovary syndrome. Arch Gynecol Obstet 2011; 284 (06) 1443-1448
10 Christodoulaki C, Trakakis E, Pergialiotis V. , et al. Dehydroepiandrosterone-sulfate, insulin resistance and ovarian volume estimation in patients with polycystic ovarian syndrome. J Family Reprod Health 2017; 11 (01) 24-29
11 Piouka A, Farmakiotis D, Katsikis I, Macut D, Gerou S, Panidis D. Anti-Mullerian hormone levels reflect severity of PCOS but are negatively influenced by obesity: relationship with increased luteinizing hormone levels. Am J Physiol Endocrinol Metab 2009; 296 (02) E238-E243
12 Alebić MS, Stojanović N, Duhamel A, Dewailly D. The phenotypic diversity in per-follicle anti-Müllerian hormone production in polycystic ovary syndrome. Hum Reprod 2015; 30 (08) 1927-1933
13 Pankhurst MW, Shorakae S, Rodgers RJ, Teede HJ, Moran LJ. Efficacy of predictive models for polycystic ovary syndrome using serum levels of two antimüllerian hormone isoforms (proAMH and AMH_N,C). Fertil Steril 2017; 108 (05) 851-857.e2
14 Spritzer PM. Polycystic ovary syndrome: reviewing diagnosis and management of metabolic disturbances. Arq Bras Endocrinol Metabol 2014; 58 (02) 182-187
15 Tripathy P, Sahu A, Sahu M, Nagy A. Metabolic risk assessment of Indian women with polycystic ovarian syndrome in relation to four Rotterdam criteria based phenotypes. Eur J Obstet Gynecol Reprod Biol 2018; 224: 60-65
16 Brassard M, AinMelk Y, Baillargeon JP. Basic infertility including polycystic ovary syndrome. Med Clin North Am 2008; 92 (05) 1163-1192 , xi
17 Joham AE, Teede HJ, Ranasinha S, Zoungas S, Boyle J. Prevalence of infertility and use of fertility treatment in women with polycystic ovary syndrome: data from a large community-based cohort study. J Womens Health (Larchmt) 2015; 24 (04) 299-307
18 Rees DA, Jenkins-Jones S, Morgan CL. Contemporary reproductive outcomes for patients with polycystic ovary syndrome: a retrospective observational study. J Clin Endocrinol Metab 2016; 101 (04) 1664-1672
19 Qin JZ, Pang LH, Li MJ, Fan XJ, Huang RD, Chen HY. Obstetric complications in women with polycystic ovary syndrome: a systematic review and meta-analysis. Reprod Biol Endocrinol 2013; 11 (11) 56
20 de Wilde MA, Lamain-de Ruiter M, Veltman-Verhulst SM. , et al. Increased rates of complications in singleton pregnancies of women previously diagnosed with polycystic ovary syndrome predominantly in the hyperandrogenic phenotype. Fertil Steril 2017; 108 (02) 333-340
21 Boomsma CM, Eijkemans MJ, Hughes EG, Visser GH, Fauser BC, Macklon NS. A meta-analysis of pregnancy outcomes in women with polycystic ovary syndrome. Hum Reprod Update 2006; 12 (06) 673-683
22 Barry JA, Azizia MM, Hardiman PJ. Risk of endometrial, ovarian and breast cancer in women with polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update 2014; 20 (05) 748-758
23 Gottschau M, Kjaer SK, Jensen A, Munk C, Mellemkjaer L. Risk of cancer among women with polycystic ovary syndrome: a Danish cohort study. Gynecol Oncol 2015; 136 (01) 99-103
24 Cassar S, Misso ML, Hopkins WG, Shaw CS, Teede HJ, Stepto NK. Insulin resistance in polycystic ovary syndrome: a systematic review and meta-analysis of euglycaemic-hyperinsulinaemic clamp studies. Hum Reprod 2016; 31 (11) 2619-2631
25 Legro RS, Kunselman AR, Dodson WC, Dunaif A. Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women. J Clin Endocrinol Metab 1999; 84 (01) 165-169
26 Gambineri A, Patton L, Altieri P. , et al. Polycystic ovary syndrome is a risk factor for type 2 diabetes: results from a long-term prospective study. Diabetes 2012; 61 (09) 2369-2374
27 Panidis D, Tziomalos K, Misichronis G. , et al. Insulin resistance and endocrine characteristics of the different phenotypes of polycystic ovary syndrome: a prospective study. Hum Reprod 2012; 27 (02) 541-549
28 Hong SH, Sung YA, Hong YS, Jeong K, Chung H, Lee H. Polycystic ovary morphology is associated with insulin resistance in women with polycystic ovary syndrome. Clin Endocrinol (Oxf) 2017; 87 (04) 375-380
29 Pinola P, Puukka K, Piltonen TT. , et al. Normo- and hyperandrogenic women with polycystic ovary syndrome exhibit an adverse metabolic profile through life. Fertil Steril 2017; 107 (03) 788-795.e2
30 Li S, Chu Q, Ma J. , et al. Discovery of novel lipid profiles in PCOS: do insulin and androgen oppositely regulate bioactive lipid production?. J Clin Endocrinol Metab 2017; 102 (03) 810-821
31 Kravariti M, Naka KK, Kalantaridou SN. , et al. Predictors of endothelial dysfunction in young women with polycystic ovary syndrome. J Clin Endocrinol Metab 2005; 90 (09) 5088-5095
32 Paradisi G, Steinberg HO, Hempfling A. , et al. Polycystic ovary syndrome is associated with endothelial dysfunction. Circulation 2001; 103 (10) 1410-1415
33 Christian RC, Dumesic DA, Behrenbeck T, Oberg AL, Sheedy II PF, Fitzpatrick LA. Prevalence and predictors of coronary artery calcification in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2003; 88 (06) 2562-2568
34 Talbott EO, Zborowski JV, Rager JR, Boudreaux MY, Edmundowicz DA, Guzick DS. Evidence for an association between metabolic cardiovascular syndrome and coronary and aortic calcification among women with polycystic ovary syndrome. J Clin Endocrinol Metab 2004; 89 (11) 5454-5461
35 Calderon-Margalit R, Siscovick D, Merkin SS. , et al. Prospective association of polycystic ovary syndrome with coronary artery calcification and carotid-intima-media thickness: the Coronary Artery Risk Development in Young Adults Women's study. Arterioscler Thromb Vasc Biol 2014; 34 (12) 2688-2694
36 Kahal H, Kyrou I, Tahrani AA, Randeva HS. Obstructive sleep apnoea and polycystic ovary syndrome: a comprehensive review of clinical interactions and underlying pathophysiology. Clin Endocrinol (Oxf) 2017; 87 (04) 313-319
37 Meun C, Franco OH, Dhana K. , et al. High androgens in postmenopausal women and the risk for atherosclerosis and cardiovascular disease: the Rotterdam study. J Clin Endocrinol Metab 2018; 103 (04) 1622-1630 . doi: 10.1210/jc.2017-02421
38 Barry JA, Kuczmierczyk AR, Hardiman PJ. Anxiety and depression in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod 2011; 26 (09) 2442-2451
39 Dokras A, Clifton S, Futterweit W, Wild R. Increased risk for abnormal depression scores in women with polycystic ovary syndrome: a systematic review and meta-analysis. Obstet Gynecol 2011; 117 (01) 145-152
40 Veltman-Verhulst SM, Boivin J, Eijkemans MJ, Fauser BJ. Emotional distress is a common risk in women with polycystic ovary syndrome: a systematic review and meta-analysis of 28 studies. Hum Reprod Update 2012; 18 (06) 638-651
41 Farrell K, Antoni MH. Insulin resistance, obesity, inflammation, and depression in polycystic ovary syndrome: biobehavioral mechanisms and interventions. Fertil Steril 2010; 94 (05) 1565-1574
42 Cooney LG, Lee I, Sammel MD, Dokras A. High prevalence of moderate and severe depressive and anxiety symptoms in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod 2017; 32 (05) 1075-1091
43 Bazarganipour F, Ziaei S, Montazeri A, Foroozanfard F, Kazemnejad A, Faghihzadeh S. Health-related quality of life in patients with polycystic ovary syndrome (PCOS): a model-based study of predictive factors. J Sex Med 2014; 11 (04) 1023-1032
44 Lim SS, Norman RJ, Davies MJ, Moran LJ. The effect of obesity on polycystic ovary syndrome: a systematic review and meta-analysis. Obes Rev 2013; 14 (02) 95-109
45 Teede H, Michelmore J, McCallister V, Norman R. Evidence- based guidelines in PCOS. 2011. Available at: www.nhmrc.gov.au/guidelines/publications/ext2 . Accessed July 17, 2018
46 Dokras A, Sarwer DB, Allison KC. , et al. Weight loss and lowering androgens predict improvements in health-related quality of life in women with PCOS. J Clin Endocrinol Metab 2016; 101 (08) 2966-2974
47 Legro RS, Dodson WC, Kunselman AR. , et al. Benefit of delayed fertility therapy with preconception weight loss over immediate therapy in obese women with PCOS. J Clin Endocrinol Metab 2016; 101 (07) 2658-2666
48 Orio F, Muscogiuri G, Giallauria F. , et al. Oral contraceptives versus physical exercise on cardiovascular and metabolic risk factors in women with polycystic ovary syndrome: a randomized controlled trial. Clin Endocrinol (Oxf) 2016; 85 (05) 764-771
49 Brennan L, Teede H, Skouteris H, Linardon J, Hill B, Moran L. Lifestyle and behavioral management of polycystic ovary syndrome. J Womens Health (Larchmt) 2017; 26 (08) 836-848
50 Helvaci N, Yildiz BO. Oral contraceptives in polycystic ovary syndrome. Minerva Endocrinol 2014; 39 (03) 175-187
51 Escobar-Morreale HF, Carmina E, Dewailly D. , et al. Epidemiology, diagnosis and management of hirsutism: a consensus statement by the Androgen Excess and Polycystic Ovary Syndrome Society. Hum Reprod Update 2012; 18 (02) 146-170
52 Amiri M, Kabir A, Nahidi F, Shekofteh M, Ramezani Tehrani F. Effects of combined oral contraceptives on the clinical and biochemical parameters of hyperandrogenism in patients with polycystic ovary syndrome: a systematic review and meta-analysis. Eur J Contracept Reprod Health Care 2018; 23 (01) 64-77
53 Cinar N, Harmanci A, Demir B, Yildiz BO. Effect of an oral contraceptive on emotional distress, anxiety and depression of women with polycystic ovary syndrome: a prospective study. Hum Reprod 2012; 27 (06) 1840-1845
54 Tay CT, Joham AE, Hiam DS. , et al. Pharmacological and surgical treatment of non-reproductive outcomes in polycystic ovary syndrome: an overview of systematic reviews. Clin Endocrinol (Oxf) 2018; . [Epub ahead of print]
55 Glintborg D, Altinok ML, Mumm H, Hermann AP, Ravn P, Andersen M. Body composition is improved during 12 months' treatment with metformin alone or combined with oral contraceptives compared with treatment with oral contraceptives in polycystic ovary syndrome. J Clin Endocrinol Metab 2014; 99 (07) 2584-2591
56 Elter K, Imir G, Durmusoglu F. Clinical, endocrine and metabolic effects of metformin added to ethinyl estradiol-cyproterone acetate in non-obese women with polycystic ovarian syndrome: a randomized controlled study. Hum Reprod 2002; 17 (07) 1729-1737
57 Velazquez EM, Mendoza S, Hamer T, Sosa F, Glueck CJ. Metformin therapy in polycystic ovary syndrome reduces hyperinsulinemia, insulin resistance, hyperandrogenemia, and systolic blood pressure, while facilitating normal menses and pregnancy. Metabolism 1994; 43 (05) 647-654
58 Diamanti-Kandarakis E, Christakou CD, Kandaraki E, Economou FN. Metformin: an old medication of new fashion: evolving new molecular mechanisms and clinical implications in polycystic ovary syndrome. Eur J Endocrinol 2010; 162 (02) 193-212
59 Yang PK, Hsu CY, Chen MJ. , et al. The efficacy of 24-month metformin for improving menses, hormones, and metabolic profiles in polycystic ovary syndrome. J Clin Endocrinol Metab 2018; 103 (03) 890-899
60 Naderpoor N, Shorakae S, de Courten B, Misso ML, Moran LJ, Teede HJ. Metformin and lifestyle modification in polycystic ovary syndrome: systematic review and meta-analysis. Hum Reprod Update 2015; 21 (05) 560-574
61 Patel R, Shah G. Effect of metformin on clinical, metabolic and endocrine outcomes in women with polycystic ovary syndrome: a meta-analysis of randomized controlled trials. Curr Med Res Opin 2017; 33 (09) 1545-1557
62 Morley LC, Tang T, Yasmin E, Norman RJ, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev 2017; 11 (11) CD003053
63 van Zuuren EJ, Fedorowicz Z, Carter B, Pandis N. Interventions for hirsutism (excluding laser and photoepilation therapy alone). Cochrane Database Syst Rev 2015; 28 (04) CD010334
64 Moretti C, Guccione L, Di Giacinto P. , et al. Combined oral contraception and bicalutamide in polycystic ovary syndrome and severe hirsutism: a double-blind randomized controlled trial. J Clin Endocrinol Metab 2018; 103 (03) 824-838
65 Skubleny D, Switzer NJ, Gill RS. , et al. The impact of bariatric surgery on polycystic ovary syndrome: a systematic review and meta-analysis. Obes Surg 2016; 26 (01) 169-176
66 Franik S, Eltrop SM, Kremer JAM, Kiesel L, Farquhar C. Aromatase inhibitors (letrozole) for subfertile women with polycystic ovary syndrome. Cochrane Database Syst Rev 2018; 5: CD010287
67 Kafy S, Tulandi T. New advances in ovulation induction. Current Opinion in Obstetrics & Gynecology 2007; 19: 248-252
68 Weiss NS, Nahuis M, Bayram N, Mol BW, Van der Veen F, van Wely M. Gonadotrophins for ovulation induction in women with polycystic ovarian syndrome. Cochrane Database Syst Rev 2015; 9 (09) CD010290
69 Bordewijk EM, Nahuis M, Costello MF. , et al. Metformin during ovulation induction with gonadotrophins followed by timed intercourse or intrauterine insemination for subfertility associated with polycystic ovary syndrome. Cochrane Database Syst Rev 2017; 1 (01) CD009090
70 Farquhar C, Brown J, Marjoribanks J. Laparoscopic drilling by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev 2012; (06) CD001122
71 Nahuis MJ, Oude Lohuis E, Kose N. , et al. Long-term follow-up of laparoscopic electrocautery of the ovaries versus ovulation induction with recombinant FSH in clomiphene citrate-resistant women with polycystic ovary syndrome: an economic evaluation. Hum Reprod 2012; 27 (12) 3577-3582
72 Balen AH, Morley LC, Misso M. , et al. The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance. Hum Reprod Update 2016; 22 (06) 687-708