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Polycystic ovary syndrome

Key sources
The following summarized guidelines for the evaluation and management of polycystic ovary syndrome are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023; 2018; 2017), the Endocrine Society (ES 2020; 2013), the American College of Obstetricians and Gynecologists (ACOG 2018), the American Society for Reproductive Medicine (ASRM 2017), the American College of Endocrinology (ACE/AACE 2016), the Androgen Excess and Polycystic Ovary Syndrome Society (AE-PCOS 2015), and the Royal College of Obstetricians and Gynaecologists (RCOG 2014).
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Guidelines

1.Screening and diagnosis

Diagnostic criteria: as per RCOG 2014 guidelines, diagnose PCOS according to the Rotterdam consensus criteria.
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  • Differential diagnosis

2.Diagnostic investigations

History and physical examination: screen for ovulatory status using menstrual history in all patients with PCOS seeking fertility. Recognize that some patients with PCOS and a eumenorrheic menstrual history may still experience anovulation, thus consider obtaining a midluteal serum progesterone level as an additional screening test.
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  • Screening for congenital adrenal hyperplasia

  • Screening for cardiac risk

  • Screening for diabetes

  • Screening for NAFLD

  • Screening for obstructive sleep apnea

  • Screening for depression/anxiety

  • Screening for endometrial cancer

3.Medical management

Hormonal contraceptives: as per ACOG 2018 guidelines, initiate combination low-dose hormonal contraceptives, frequently used for the long term, as primary treatment of menstrual disorders.
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  • Insulin sensitizers

  • Ovulation induction

  • Statin therapy

  • Weight loss medications

  • Management of hirsutism

4.Nonpharmacologic interventions

Lifestyle modifications
As per ACOG 2018 guidelines:
Advise exercising and dietary changes to reduce diabetes risk in patients with PCOS.
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Advise weight loss to improve pregnancy rates, decrease hirsutism, and improve glucose tolerance and lipid levels in patients with PCOS.
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5.Therapeutic procedures

Assisted reproductive technology: reserve IVF for patients with PCOS failed gonadotropin therapy or having other indications for IVF treatment.
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6.Surgical interventions

Laparoscopic surgery: as per SOGC 2023 guidelines, consider performing laparoscopic ovarian drilling in patients with PCOS resistant to oral agents if gonadotropins are not accessible.
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  • Bariatric surgery

7.Specific circumstances

Pregnant patients: as per RCOG 2014 guidelines, consider obtaining screening for gestational diabetes in patients diagnosed with PCOS before pregnancy. Obtain screening at 24-28 weeks of gestation and refer to a specialist obstetric diabetic service if abnormalities are detected.
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  • Adolescent patients (diagnosis)

  • Adolescent patients (hyperandrogenemia)

  • Adolescent patients (oligoanovulation)

  • Adolescent patients (insulin resistance)

  • Patients with diabetes

8.Patient education

General counseling: inform patients with PCOS of the possible long-term risks to health.
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9.Preventative measures

Prevention in offspring: insufficient evidence to recommend any specific intervention for the prevention of PCOS in offspring of patients with PCOS.
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