I. Diagnosis of polycystic ovary syndrome
Diagnosis in adult patients
1. We suggest that the diagnosis of polycystic ovary syndrome (PCOS) requires two of the following three conditions (androgen excess, ovulatory dysfunction, or polycystic ovarian changes (PCO)) and exclusion of all conditions with similar clinical presentation to PCOS. These include: thyroid disease, hyperprolactinemia, and atypical congenital adrenocortical hyperplasia (primary 21-hydroxylase deficiency due to serum 17-hydroxyprogesterone (17-OHP)). In some women presenting with amenorrhea and severe manifestations, we recommend a more extensive workup to rule out other causes.
Diagnosis in adolescent patients
2. We recommend that in adolescent PCOS, the diagnosis should be based on clinical and/or biochemical hyperandrogenic manifestations and persistent sparse menstruation, with the exclusion of other disorders. Since anovulation and morphological changes in PCO can be natural stages in the process of sexual maturation, both are not considered as a basis for the diagnosis of pubertal PCOS.
Diagnosis of perimenopausal and menopausal patients
3. Although there are no diagnostic criteria for perimenopausal and menopausal PCOS patients, we suggest that persistent sporadic menstruation and hyperandrogenism from the onset of reproductive age should be used as diagnostic criteria. PCO changes on ultrasound may be additional diagnostic evidence, but are not usually present in menopausal women.
II. Related disease manifestations and evaluation
Skin manifestations
1. We recommend that PCOS-related skin manifestations should be documented during physical examination, including: hirsutism (note: this guideline still recommends the use of the Ferriman Gallwey score to assess the degree of hirsutism), acne, baldness, acanthosis nigricans, and skin nodules.
Infertility
2. Patients with PCOS are at increased risk of ovulatory arrest; if ovulatory arrest is not present, the risk of infertility cannot be determined. We recommend that patients with PCOS who are interested in having children be screened for ovulatory status by giving a menstrual history. Ovulatory arrest may also be present in a subset of patients with PCOS who have normal menstrual cycles. Mid-luteal progesterone levels should be added in these patients.
3. In patients with PCOS, both partners should be screened for other causes of infertility other than ovulatory disturbances.
Obstetric complications
4. Because of the increased risk of obstetric complications (including gestational diabetes, preterm delivery and preeclampsia) in patients with combined obesity, we recommend that such patients be screened prenatally for body mass index (BMI), blood pressure and oral glucose tolerance.
Embryonic origin
5. The evidence regarding the embryonic origin of PCOS remains controversial. We do not recommend specific prophylactic measures for PCOS in the offspring of PCOS patients.
Endometrial cancer
6. Endometrial cancer shares many of the same risk factors as PCOS, including obesity, hyperinsulinemia, diabetes mellitus, and abnormal vaginal bleeding. However. We oppose routine ultrasound screening for endometrial thickness in patients with PCOS.
Obesity
7. Increased body fat, especially abdominal fat, is associated with hyperandrogenemia and increased metabolic risk. We therefore recommend that all patients with PCOS who present with increased body fat (both adolescent and adult patients) undergo screening targeting BMI and waist circumference.
Depression
8. We recommend that patients with PCOS undergo history taking to determine the presence of depression and anxiety. If present, promptly refer and/or treat.
Sleep disordered breathing/obstructive sleep apnea (OSA)
9. For overweight/obese patients with PCOS (both adolescent and adult patients), we recommend clarifying the presence of OSA-related symptoms. If present, the use of polysomnography is recommended to clarify the diagnosis. Once OSA is diagnosed, patients should be referred to the relevant specialty for treatment.
Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH)
10. We recommend that patients with PCOS be evaluated for risk of NAFLD and NASH, but oppose routine screening.
Type 2 diabetes mellitus (T2DM)
11. For adolescent and adult patients with PCOS, we recommend screening using an oral glucose tolerance test (OGTT, fasting and 2-hour glucose levels at 75 g oral glucose load) due to their increased risk of abnormal glucose tolerance (IGT) and T2DM. If patients are unable or unwilling to perform OGTT, glycated hemoglobin (HgbA1c) measurement can be performed as an alternative. Thereafter, the test will be repeated every 3 to 5 years. The frequency of review is increased if the patient has comorbid abdominal obesity, substantial weight gain, and/or symptoms of diabetes.
Cardiovascular risk
12. For adolescent and adult patients with PCOS, we recommend routine screening if the following risk factors are combined: family history of early-onset cardiovascular disease, smoking, IGT/T2DM, hypertension, dyslipidemia, OSA, and obesity (especially abdominal obesity).
III. Treatment
Hormonal contraceptives (HCs): indications and screening
1. We recommend that HCs (e.g., oral contraceptives, patch, or vaginal ring) should be used as the first choice of treatment for PCOS with menstrual abnormalities and hirsutism/acne to help address these problems simultaneously.
2. We recommend screening for contraindications to HC using established criteria, including hypertension exceeding 160/100 mmHg; diabetes mellitus of more than 20 years duration; presence of neuropathy, retinopathy, or renal disease; and smoking more than 15 cigarettes per day. For adult patients with PCOS, we do not recommend a particular HC formulation.
The role of exercise in lifestyle interventions
3. We recommend treating overweight and obesity in patients with PCOS by increasing exercise. Although there are no large randomized clinical trials on increasing exercise for PCOS, increasing exercise and diet control can help with weight loss, cardiovascular risk factor reduction, and diabetes risk reduction in the general population.
The role of weight loss in lifestyle interventions
4. In adolescent and adult patients with PCOS who are overweight and obese, we recommend weight loss starting with a calorie-intensive diet (without evidence of a more optimal dietary pattern). Fertility disorders and metabolic disorders can be improved in these patients. In contrast, there is insufficient evidence for weight loss as a treatment option for PCOS in patients with normal weight.
The use of metformin
5, We oppose the use of metformin as the drug of choice for skin lesions, prevention of obstetric complications, or obesity.
Metformin is recommended for PCOS patients with combined T2DM or IGT who have not improved with lifestyle modification.
6. For patients with PCOS combined with menstrual irregularities who are unable to use or tolerate HCs, we recommend metformin as a second-line treatment option.
Treatment of infertility
7. For patients with PCOS combined with anovulatory infertility, we recommend clomiphene citrate or other similar estrogen-modulating drugs (e.g. letrozole) as the first choice.
8. For patients with PCOS undergoing in vitro fertilization (IVF), we recommend the use of metformin as an adjunctive treatment for infertility in order to prevent ovarian hyperstimulation (OHSS).
The use of other drugs
9. In patients with PCOS, we oppose the use of insulin sensitizers (such as inositol, which does not benefit) or thiazolidinediones (for safety reasons).
10. We oppose the use of statins for the treatment of hyperandrogenemia and cessation of ovulation in patients with PCOS until further studies are available to clarify the risk-benefit ratio. However, we recommend the use of statins for patients who meet the indications for statin therapy.
Treatment of adolescent patients
For adolescent patients with PCOS, we recommend HCs if treatment is aimed at addressing acne, hirsutism or cessation of ovulation, or if contraceptive intent is present, and we recommend lifestyle interventions aimed at weight loss (including caloric intake restriction diet and exercise) if combined with overweight/obesity. If treatment is directed at IGT/metabolic syndrome, metformin may be used. there are no clear criteria for the course of HCs and metformin.
12. For premenarcheal girls presenting with clinical and biochemical hyperandrogenemia who have advanced pubertal development (e.g., breast development ≥ Tanner IV stage), we recommend HCs as the first choice.