The 2023 guidelines for diagnosing PCOS: What OB-GYNs need to know

The new international evidence-based medical guidelines for the diagnosis of polycystic ovary syndrome (PCOS) aim to facilitate the timely and accurate detection of this common hormonal disorder. In this article, we break down the main takeaways from the 2023 diagnostic guidelines to assist OB-GYNs in the assessment of this disease.

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Why PCOS is important to diagnose early

Early detection is important for several reasons. First, timely diagnosis of PCOS can enable early interventions for acne, hirsutism, menstrual irregularity, and depression, which can greatly impact a woman’s quality of life. Women can also be counseled on future fertility and treatment options to help them build their family. 

Additionally, given that weight gain is a common symptom of PCOS, early diagnosis and lifestyle changes can help women manage their weight to prevent obesity and related metabolic complications. Because PCOS is associated with an increased risk of impaired glucose tolerance, type 2 diabetes, insulin resistance, hypertension, cardiovascular disease, and endometrial cancer, early diagnosis and care can make a significant impact on a patient’s long-term health. 

What are the main takeaways from the 2023 guidelines for PCOS?

There are five notable outcomes from the 2023 guidelines for the assessment and management of PCOS that OB-GYNs should be aware of. 

Refinement of individual diagnostic criteria and inclusion of anti-Mullerian hormone (AMH) to assess polycystic ovaries

PCOS can be diagnosed if two of the following are present:

• Clinical or biochemical hyperandrogenemia
• Irregular menstrual cycles and ovulatory dysfunction
• Polycystic-appearing ovarian morphology 

Due to the heterogeneity of ultrasound assessment in PCOS, anti-Mullerian hormone can now be used to determine if the ovaries are polycystic in adults. AMH levels are significantly higher in women with PCOS. 

Greater recognition of the broader health impacts of PCOS

PCOS has diverse features that should be screened and managed in women with this disorder. These include:

• Psychological features – anxiety, depression, eating disorders
• Sleep features – sleep disorders, sleep apnea
• Dermatologic features – hirsutism, acanthosis nigricans, acne
• Reproductive features – irregular menstrual cycles, infertility, endometrial cancer, adverse pregnancy outcomes
• Metabolic features – insulin resistance, metabolic syndrome, type 2 diabetes
• Cardiovascular factors – increased risk for cardiovascular disease

Need for more education across healthcare professionals and patients, along with further research into PCOS

Due to high dissatisfaction with PCOS diagnosis and care, the new guidelines emphasize the importance of greater awareness and evidence-based informational resources for both women and healthcare professionals alike with regards to this condition. 

Education, empowerment, and shared decision-making are crucial to help prevent complications, enhance the care experience, and improve health outcomes for women globally with PCOS. 

Increased emphasis on overall well-being and quality of life

Because depression and anxiety are significantly higher among this patient population, with impacts on eating habits and body image, psychological assessment and therapy if necessary should be included in PCOS care to enhance mental health and overall well-being. 

Healthcare professionals are encouraged to support healthy lifestyle habits among women with PCOS, to help them prevent weight gain and manage weight. There is no one specific diet exercise regimen recommended over others for patients, so this should be considered on an individual basis. Would also recommend limiting exposure to plastics, especially phthalates in personal care products and food containers as these chemicals have been associated with PCOS. 

Finally, the guidelines address the stigma associated with excess weight, and recommend healthcare professionals to exercise care and seek permission before weighing women. 

Recommendations for infertility management

Letrozole is the first-line pharmacological infertility treatment option, either with clomiphene alone or combined with metformin. Gonadotropins or ovarian surgery are recommended as a second-line therapy for infertility. As a third option, women with PCOS and anovulatory infertility could be offered IVF with in vitro maturation, when other ovulation induction methods have been unsuccessful.

PCOS symptoms and biomarkers for diagnosis according to the 2023 guidelines

Biochemical and clinical hyperandrogenism

Biochemical hyperandrogenism is diagnosed with elevated levels of total or free testosterone. Calculated free testosterone, free androgen index, or bioavailable testosterone can also be used to diagnose biochemical hyperandrogenism. 

If levels of total or free testosterone levels aren’t elevated, other biomarkers (ANSD and DHEAS) can be used as a test for PCOS.

Clinically, hyperandrogensim manifests as hirsuitism, acne and female pattern hair loss (which was previously called androgenic alopecia). The Modified Ferriman–Gallwey (MFG) scoring system is the gold standard for quantifying hair growth, and involves scoring hair growth at nine sites. The most recent guideline recommends a threshold of ≥4 to 6, which may vary depending on ethnicity of the patient.

Healthcare professionals can assess female pattern hair loss using the Ludwig visual scale, but due to variability in hair loss and acne, these are not reliable diagnostic markers for PCOS.

Irregular cycles and ovulatory dysfunction

Disruptions in the menstrual cycle in patients with PCOS is generally characterized by oligo-amenorrhea, which cyles lasting over 35 days or fewer than 8 cycles per year. If a patient presents with a regular menstrual cycle, polymenorrhea, or an unclear menstrual pattern, while other symptoms strongly suggest PCOS, serum progesterone or luteinizing hormone can be tested to assess the possibility of ovulatory dysfunction.

Polycystic ovarian morphology (PCOM)

The follicle number per ovary (FNPO) measured with transvaginal ultrasound is, according to the guidelines, the most effective ultrasound marker to detect polycystic ovaries in adults. PCOM is defined as ≥20 follicles in at least one ovary and/or an ovarian volume (OV) ≥ 10ml. Ultrasound is not recommended to diagnose PCOM in adolescents due to the lack of definitive diagnostic criteria. 

In adults, serum AMH can be used to diagnose PCOM in accordance with the diagnostic algorithm. However, it’s important to note that in patients with irregular menstrual cycles and hyperandrogenism, measuring AMH is not necessary to diagnose PCOS. AMH should also not be used as a singular test for diagnosing PCOS. 

When measuring AMH, it’s important for healthcare professionals and laboratories to be aware of the following factors:

• Age: Serum AMH typically peaks at the age of 24-26
• Body mass index (BMI): An elevated body mass index (BMI) is associated with lower AMH
• Hormonal contraception: Hormonal contraception reduces serum AMH levels. A couple of months after stopping hormonal contraception, this effect is no longer evident.

The link between PCOS and infertility

PCOS is one of the main causes of female infertility. Due to an imbalance of other important female hormones – namely FSH and LH – eggs cannot mature properly and get released from the ovaries and instead become stuck to the ovaries. Additionally, excess androgen hormones can impact ovulation by disrupting the menstrual cycle or causing a luteal phase defect. 

Factors that often delay PCOS diagnosis

Several factors contribute to the often delayed diagnosis of PCOS. First, some symptoms of PCOS, such as irregular periods, acne, and weight gain, can be attributed to other conditions or simply considered a natural phenomenon. Lack of awareness of this condition or embarrassment surrounding the symptoms may also prevent some women from seeking medical care. 

Therefore, it’s essential for healthcare professionals to be up to date on the latest diagnostic criteria for PCOS and guidelines for effective management of this condition to ensure timely detection and care. This can help manage symptoms and potential complications of PCOS and improve fertility outcomes.

• Teede H et al.: “International Evidence-based Guideline for the assessment and management of polycystic ovary syndrome 2023.” Monash University.  
• Teede HJ et al.: “Recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome.” Eur J Endocrinol. 2023;189(2):G43–G64.
• Christ JP and Cedars MI. “Current Guidelines for Diagnosing PCOS.” Diagnostics (Basel). 2023;13(6):1113. 
• Kurapati, K and S: PCOS Early Detection System. Harvard University. Accessed 22 January 2024. 
• Gibson-Helm M et al.: “Delayed Diagnosis and a Lack of Information Associated With Dissatisfaction in Women With Polycystic Ovary Syndrome.” J Clin Endocrinol Metab. 2017;102(2):604–612.