My thoughts on the 2023 International Evidence Based Guidelines on the Assessment and Management of PCOS.
September is PCOS Awareness month and this year the long-awaited update to the PCOS guidelines was released just in time for us to educate ourselves and our colleagues and friends. It is a lengthy document, full of robust recommendations and highlights the need for further research in PCOS.
The first big change comes in the form of a modification to the diagnostic criteria for PCOS. The Rotterdam Criteria is still considered the gold standard. Using this criteria in adults, 2 out of 3 criteria must be met in order for a diagnosis of PCOS to be made. They are: 1) the presence of irregular menstrual cycles and ovulation dysfunction,2) clinical or biochemical hyperandrogenism and 3) polycystic ovarian morphology by ultrasound OR an elevated Anti-Mullerian Hormone or AMH level.
The addition to the use of AMH as an alternative to ultrasound in adults is the new addition to the criteria. AMH is a hormone produced by the cells that surround the egg containing “cysts” of the ovaries called follicles. When there are an abundance of follicles, more AMH is secreted and can be tested in the blood. What is great about this, if a person meets only one of the first two criteria, they can have a blood test instead of a potentially uncomfortable pelvic ultrasound. This can help people get a more timely diagnosis and can save money.
The second major change comes in the form of a mindset shift around weight stigma. The group reviewed all the scientific literature related to weight stigma in people with PCOS.
“Overall, systematic review findings are consistent with other populations, showing that weight stigma is pervasive, detrimental to mental health, profoundly affected by societal attitudes toward weight, and perpetrated in everyday settings by family members in the home and health and medical professionals in healthcare settings.” For people in larger bodies, this is not a surprise as their experiences are consistent with these research findings.
The group recommends that “healthcare professionals should be aware of weight-inclusive practices which promote acceptance of and respect for body size diversity and focus on improvement of health behaviors and health outcomes for people of all sizes.” Making health behaviors the goals is the approach I take with all my patients with PCOS, even if weight loss is a health goal of theirs. Encouraging “non-scale victories” that highlight improvements in health parameters that are not weight is another approach in weight-inclusive care.
The guidelines give extensive recommendations to address the knowledge gaps that exist in the public and amongst healthcare professionals and discuss at length the psychological impacts of PCOS and the long term health risks associated with PCOS. The use of gender-neutral language is encouraged. There are specific recommendations given for medical management of non-fertility symptoms of PCOS and also specific guidelines for treating PCOS associated infertility.
I hope these new guidelines have the intended impact, to achieve more timely diagnosis for people with PCOS, and a shift towards comprehensive care of PCOS as a chronic disease. The challenge will be in disseminating these guidelines worldwide, and adjusting current healthcare systems to accomplish these goals, especially here in the United States.