Delayed Diagnosis and a Lack of Information Associated With Dissatisfaction in Women With Polycystic Ovary Syndrome

Biomarkers to inform the management of polycystic ovary syndrome: A review of systematic reviews

INTRODUCTION

Polycystic ovarian syndrome (PCOS) is the commonest endocrine condition affecting reproductive age women. Many biomarkers may aid assessment and management, however evidence is limited on their utility in clinical practice. We conducted a review of systematic reviews to identify the most useful biomarkers in the clinical management of PCOS.

METHODS

We searched MEDLINE, EMBASE, CENTRAL and HTA until August 2023 for reviews evaluating biomarkers in PCOS women compared to healthy controls. Methodological quality was assessed using the AMSTAR2 tool. We reported pooled evidence for each biomarker with 95% confidence intervals from the most recent, up-to-date, and best quality review.

RESULTS

From 3360 citations, we included 75 systematic reviews (88 biomarkers, 191,792 women). Most reviews (50/75, 67%) were moderate quality, but reported high heterogeneity (66/75, 88%). We identified 63 abnormal biomarkers in women with PCOS versus healthy controls. Of these, 22 core biomarkers could help evaluate the multisystemic impact of PCOS and inform patient management and surveillance: dehydroepiandrosterone, prolactin, sex hormone-binding globulin, total and free testosterone, anti-Mullerian hormone, systolic and diastolic blood pressure, c-reactive protein, fibrinogen, oral glucose tolerance test, homoeostatic model assessment-insulin resistance index, fasting insulin, total cholesterol, triglycerides, lipoprotein(a), HDL, LDL, non-HDL-cholesterol, ferritin, iron, and 25-hydroxy-vitamin D.

CONCLUSION

We identified 22 core biomarkers assessing the multisystemic impact of PCOS and inform its clinical management. Future research is required to establish validated healthcare pathways.

The Value of Androgen Measures for Diagnosing Polycystic Ovary Syndrome (PCOS) in an Unselected Population

OBJECTIVE

Polycystic Ovary Syndrome (PCOS) is diagnosed by a combination of three features: hyperandrogenism (biochemical and/or clinical), ovulatory dysfunction, and polycystic ovarian morphology, usually detected by ultrasonography. Our study aimed to determine the need for androgen measurements by using hirsutism to establish hyperandrogenism for diagnosing PCOS in a medically unbiased population.

MATERIALS AND METHODS

We utilized a pre-existing cohort of unselected (medically unbiased) females aged 18-45 years. All underwent a history and physical, including a modified Ferriman-Gallwey (mFG) hirsutism score. Subjects were categorized clinically as eumenorrheic non-hirsute (CONTROLS), menstrual dysfunction only (OLIGO-ONLY), hirsutism only (HIRSUTE-ONLY), or menstrual dysfunction and hirsutism (OLIGO + HIRSUTE). All subjects underwent measurements of androgens using high-quality assays. CONTROLS established the upper normal limit for androgen levels. We defined PCOS using the NIH 1990 criteria.

RESULTS

Of 462 individuals with complete evaluations, 311 (67.3%) were CONTROLS, 71 (15.4%) were OLIGO-ONLY, 64 (13.9%) were HIRSUTE-ONLY, and 16 (3.5%) were OLIGO + HIRSUTE. Neither HIRSUTE-ONLY nor OLIGO-HIRSUTE women required androgen measures to demonstrate hyperandrogenism. Among OLIGO-ONLY, 19 (26.8%) demonstrated hyperandrogenemia without hirsutism, with White women significantly more likely than Black women to demonstrate this.

CONCLUSIONS

In our study of medically unbiased reproductive-aged women using the NIH 1990 criteria for PCOS, only 15.4% of women evaluated (those with menstrual dysfunction only) required androgen measurements. In these women only one-quarter demonstrated hyperandrogenemia. These data provide a strategy to minimize the need for androgen assays, including firstly categorizing subjects by clinical presentation and then assessing circulating androgens in the subgroup with menstrual dysfunction only.

Prevalence and accurate diagnosis of polycystic ovary syndrome in adolescents across world regions: a systematic review and meta-analysis

OBJECTIVES

To examine the global prevalence of polycystic ovary syndrome (PCOS) among adolescents across world regions, comparing the 2003 Rotterdam consensus criteria with the current International Evidence-based PCOS Guideline criteria which omits polycystic ovarian morphology (PCOM).

DESIGN

Systematic review and meta-analysis, Prospero CRD42022372029.

METHODS

OVID MEDLINE, All EBM, PsycInfo, EMBASE, and CINAHL were searched from 1990 to November 2023 for studies assessing the prevalence of PCOS in unselected adolescent populations.

RESULTS

Overall, 15 708 articles were identified. After removal of duplicates, 11 868 titles and abstracts and 445 full texts were assessed. Of these, 24 articles reporting on 23 studies from five world regions were included. In meta-analysis of 20 studies (n = 14 010 adolescents), global prevalence was 9.8% (95% CI 7.2, 12.3) according to original Rotterdam criteria, and 6.3% (95% CI 3.9, 8.8) according to International Evidence-based Guideline criteria. Global PCOS prevalence based on self-report was 9.8% (95% CI 5.5, 14.1). Grouped by WHO region, prevalence ranged from 2.9% (95% CI 2.0, 3.9) in the Western Pacific region to 11.4% (95% CI 7.1, 15.7) in the South-East Asia region according to guideline criteria.

CONCLUSION

This paramount global meta-analysis on adolescent PCOS diagnosis directly informed the 2023 International PCOS Guideline. Guideline criteria generated a global PCOS prevalence of 6.3%, compared with 9.8% on Rotterdam criteria (including PCOM). Excluding PCOM, which overlaps with normal pubertal transition, is expected to deter over-diagnosis. To avoid under-diagnosis, the Guideline recommends identifying those with either irregular cycles or hyperandrogenism as being "at risk"; this group should undergo longitudinal serial evaluations until adulthood.

How Frequently Is Ultrasound Required to Diagnose Polycystic Ovary Syndrome in a Clinical Population?

Background: Polycystic ovary syndrome (PCOS) is a common endocrine condition, affecting up to 20% of reproductive aged women worldwide. Polycystic ovarian morphology (PCOM) may be present, but is not required for diagnosis. Our study seeks to evaluate the utility of ultrasound in diagnosing or excluding PCOS by 2023 International Guidelines Criteria. Materials and Methods: Subjects were patients seen in a tertiary care referral clinic in whom other causes of hyperandrogenism (HA) were ruled out. All underwent complete history, physical, modified Ferriman Gallwey scoring, and serum androgen testing; followed by transvaginal ultrasound (TVUS) to assess ovarian morphology if indicated. PCOM was identified as antral follicle count ≥20 and/or ovarian volume >10 mL in at least one ovary. After clinical classification, PCOS was diagnosed by at least two of three: biochemical/clinical HA, ovulatory dysfunction (OD), and PCOM. Statistics were calculated using Fisher's exact test and chi-square. Results: In total, 454 subjects were included. 299 were classified as group A/B and did not require TVUS for diagnosis. Of 82 subjects with HA alone, 50 (61.0%) were classified as group C after demonstrating PCOM. Fifty-five subjects had OD alone, 37 (67.3%) of which were classified as group D based on PCOM. In total, 137/454, or 30.2% of subjects required TVUS for diagnosis or exclusion of PCOS. Conclusions: TVUS was necessary in less than one-third of subjects, primarily identifying PCOS groups C or D. Selective use of ovarian ultrasonography may reduce the costs and complexity of epidemiological and clinical studies for PCOS.

Available Treatments and Adjunctive Therapies for Polycystic Ovarian Syndrome (PCOS) Patients of Reproductive Age: A Scoping Review

Polycystic ovarian syndrome (PCOS) impacts the health of women worldwide. It is a condition consisting of dysfunctional cystic ovaries resulting in hormonal imbalance. Many women have symptoms such as infertility, increased production of androgens, and insulin resistance. Barriers to effective treatment of PCOS include issues such as delays in diagnosis and inconsistencies in treatment plans among physicians. Despite the current use of available medications to decrease symptomatology, women with PCOS continue to report a decreased quality of life. Using the electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and ScienceDirect, a scoping review was conducted on the globally available treatments for PCOS. After applying pre-determined inclusion criteria, 41 studies were included in this scoping review. The literature on the available treatments for PCOS revealed a wide range of therapeutics with evidence of reduction of symptoms and/or improvement in fertility status and pathological processes such as insulin resistance, hormone imbalance, obesity, inflammation, and infertility. Dozens of treatment options for PCOS have been identified, including new medications and modifications to existing treatment regimens. The hormonal drug Fezolinetant demonstrated effective suppression of hyperandrogenism. Drugs used to treat diabetes, such as Liraglutide, were found effective for weight loss. Green cardamom, cinnamon, and other supplements proved effective in treating metabolic dysfunction. Alternative approaches, such as osteopathic manipulative therapy and acupuncture, decreased sympathetic tone and androgen levels. This review provides a succinct overview of PCOS therapies that can be used by those with PCOS and their physicians everywhere. With a better understanding of their options, women with PCOS can become more involved in the decision-making process to improve their health. More research is needed on novel therapies that aim to reduce the primary pathogenesis of PCOS.

Lack of adequate counseling about pregnancy complications in patients with polycystic ovary syndrome: a cross-sectional survey study

Objective

To assess the counseling experiences of patients with polycystic ovary syndrome (PCOS) related to obstetric complications and preconception management of comorbidities.

Design

Cross-sectional survey study.

Setting

Not applicable.

Patients

Patients with PCOS with a history of or attempt at pregnancy.

Interventions

Not applicable.

Main Outcome Measures

Demographic characteristics, medical history, and counseling experiences.

Results

Of the 302 respondents, 72.9% had a previous pregnancy, with 66.8% reporting complications during pregnancy. Of the entire cohort, 52.7% received preconception counseling on PCOS-related obstetric complications, and 41.5% were satisfied with their counseling experience. Five percent were counseled on related postpartum complications, and 43.4% received counseling about prepregnancy weight management, with the minority satisfied with their counseling. Among the respondents with existing comorbidities including hypertension, diabetes, and anxiety or depression, the minority received counseling on their preconception management. Although there were no racial disparities in the overall counseling of pregnancy complications, more black patients were counseled about preeclampsia, cesarean section, and preterm birth than white patients. Of the patients who had a single provider managing their PCOS care, 78.6% who saw a reproductive endocrinologist, 53.2% who saw a general gynecologist, and 35.0% who saw a primary care physician reported receiving counseling on related pregnancy complications.

Conclusions

Despite the high prevalence of obstetric complications associated with PCOS, our study revealed inadequate patient counseling about both the antepartum and postpartum periods and preconception management of existing comorbidities. Our findings highlight the urgent need to increase provider education and patient awareness to optimize maternal and neonatal outcomes.

Assessment of the Validity and Quality of Polycystic Ovarian Syndrome (PCOS) Screening Tools Available for Women Globally: A Systematic Review

Background: This systematic review has the following aims: (1) to identify measurement tools used globally by healthcare providers to diagnose PCOS in women at elevated risk; (2) to assess the comprehensiveness of these tools regarding mental health and chronic pain; (3) to list strategies for validating, disseminating, and implementing these tools; and (4) to provide future recommendations for experts in healthcare settings. Methods: This review utilized the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and the Arksey and O'Malley York methodology. Studies were sourced from the PubMed, Embase, and Cochrane Library databases, with inclusion criteria focusing on peer-reviewed articles addressing PCOS diagnosis and associated comorbidities. Data extraction and analysis followed the Joanna Briggs Institute (JBI) recommendations. Results: A total of 63 studies met the inclusion criteria. Findings indicate that current screening tools for PCOS often lack comprehensive integration of mental health and chronic pain assessments. Tools like the PCOSQ and its updated version, PCOSQ-50, inadequately address pain-related symptoms, highlighting a gap in holistic patient evaluation. This review identified significant associations between PCOS and mental health disorders, including anxiety and depression, emphasizing the need for mental health screenings as part of PCOS management. Conclusions: There is a critical need for validated PCOS screening tools that encompass both physical and psychological aspects of the condition. Educating healthcare providers on the cultural and social determinants influencing PCOS can improve diagnosis and patient outcomes. Future research should focus on developing holistic screening tools and culturally relevant educational resources, aiming to enhance the overall quality of life for women with PCOS.

Genetic insights of blood lipid metabolites on polycystic ovary syndrome risk: a bidirectional two-sample Mendelian randomization study

Background

Pathologically, metabolic disorder plays a crucial role in polycystic ovarian syndrome (PCOS). However, there is no conclusive evidence lipid metabolite levels to PCOS risk.

Methods

In this study, genome-wide association study (GWAS) genetic data for 122 lipid metabolites were used to assign instrumental variables (IVs). PCOS GWAS were derived from a large-scale meta-analysis of 10,074 PCOS cases and 103,164 controls. An inverse variance weighted (IVW) analysis was the primary methodology used for Mendelian randomization (MR). For sensitivity analyses, Cochran Q test, MR-Egger intercept, MR-PRESSO, leave-one-out analysis,and Steiger test were performed. Furthermore, we conducted replication analysis, meta-analysis, and metabolic pathway analysis. Lastly, reverse MR analysis was used to determine whether the onset of PCOS affected lipid metabolites.

Results

This study detected the blood lipid metabolites and potential metabolic pathways that have a genetic association with PCOS onset. After IVW, sensitivity analyses, replication and meta-analysis, two pathogenic lipid metabolites of PCOS were finally identified: Hexadecanedioate (OR=1.85,95%CI=1.27-2.70, P=0.001) and Dihomo-linolenate (OR=2.45,95%CI=1.30-4.59, P=0.005). Besides, It was found that PCOS may be mediated by unsaturated fatty acid biosynthesis and primary bile acid biosynthesis metabolic pathways. Reverse MR analysis showed the causal association between PCOS and 2-tetradecenoyl carnitine at the genetic level (OR=1.025, 95% CI=1.003-1.048, P=0.026).

Conclusion

Genetic evidence suggests a causal relationship between hexadecanedioate and dihomo-linolenate and the risk of PCOS. These compounds could potentially serve as metabolic biomarkers for screening PCOS and selecting drug targets. The identification of these metabolic pathways is valuable in guiding the exploration of the pathological mechanisms of PCOS, although further studies are necessary for confirmation.

Systematic review and meta-analysis of birth outcomes in women with polycystic ovary syndrome

It is unclear whether polycystic ovary syndrome (PCOS) is an independent risk factor for adverse birth outcomes in the offspring of affected women. Here, we investigate the association of PCOS with birth outcomes in the offspring of women with PCOS overall and by potential confounders. This systematic review and meta-analysis included 73 studies and 92,881 offspring of women with and without PCOS from inception until 13th July 2022. We report that mothers with PCOS are younger and have higher body mass index (BMI) around conception and have greater gestational weight gain. The odds of preterm birth, fetal growth restriction and low birth weight are higher and mean birthweight is lower in PCOS of which a lower mean birthweight and a higher small for gestational age are probably independent of BMI. This work informed the recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome, emphasizing that PCOS status should be captured at pregnancy to identify risk and improve birth outcomes in the offspring.

The Menstrual Health Manager (MHM): A Resource to Reduce Discrepancies Between Science and Practice in Sport and Exercise

Inadequate research on female health and performance; the complexity of the research; low menstrual health literacy of athletes, coaches, and support staff; and ethical and cultural sensitivities are all recognized as barriers to effective health monitoring for females in sports. Frameworks have been developed for academics to follow to help improve the quality of female-specific research. However, a similar resource that enables correct terminology, and use of health monitoring techniques has not been provided for sporting organizations, coaches, support staff or athletes. Therefore, this critical commentary presents a new resource, the Menstrual Health Manager. This resource may be used to determine the level of menstrual health monitoring detail that may be used by organisations, coaches or athletes, and specifies what reproductive health details the data will provide. This resource aims to provide organizations and coaches with a means of understanding the data that inform their decisions for female athletes. Utilization of this resource may aid in the consistent use of terminology and methods for female-specific health monitoring in both sports and research.

Effects of weight loss intervention on anxiety, depression and quality of life in women with severe obesity and polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in women that is associated with an increased risk of anxiety and depression and with a lower health-related quality of life (HRQoL). PCOS is closely associated with obesity, which per se can lead to symptoms of anxiety and depression and lower HRQoL. The first-line treatment for PCOS is weight loss through lifestyle intervention, which has been shown to improve all symptoms of the syndrome. The aim of this study was to investigate symptoms of anxiety and depression and HRQoL in women with severe obesity (BMI ≥ 35) with and without PCOS, and to evaluate the effect of a one-year structured weight loss intervention. A total of 246 women with severe obesity (PCOS n = 63, non-PCOS n = 183) were included. The comprehensive psychopathological rating scale self-rating scale for affective symptoms (CPRS-S-A) and the short form-36 (SF-36) were used to assess symptoms of anxiety and depression and HRQoL. In total 72 women of the 246 women with severe obesity completed a one-year weight loss programme and were followed up and compared with baseline data. In women with severe obesity, there were no differences in symptoms of anxiety and depression and HRQoL between women with and without PCOS at baseline. Clinically relevant anxiety symptoms were present in 71.3% (PCOS) and 65.6% (non-PCOS), and depression symptoms were present in 56.4% (PCOS) and 52.2% (non-PCOS). Significant weight loss improved physical HRQoL in all women, but reduced symptoms of anxiety and depression only in women without PCOS. There were no differences when comparing the changes between the groups. Women with severe obesity are severely affected by symptoms of anxiety and depression, independent of PCOS. Weight loss improved symptoms of anxiety and depression in women without PCOS, but there were no differences between groups in change from baseline to follow-up.Trial registration number: Clinical trial.gov: NCT01319162, March 18, 2011. Date of registration and enrolment of the first subject September 2011.

Productivity loss due to polycystic ovary syndrome and its relationship to race, mental health and healthcare delivery indices

Objective

To study the impact of polycystic ovary syndrome (PCOS) on work-related impairments and explore relationships with race, mental health, and healthcare delivery indices.

Design

A cross-sectional internet-based survey.

Setting

North American women with PCOS between August 2022 and October 2022.

Patients

Individuals with a self-reported diagnosis of PCOS.

Interventions

Not applicable.

Main Outcome Measures

The primary outcome was missed work because of PCOS. The secondary outcomes included leave from work, impacts on the quality of work, and feelings of being held back at work because of PCOS.

Results

Of 1,105 respondents, 1,058 reported having PCOS diagnosed by a physician. Of this group, 50.4% reported missing work because of PCOS, 72% felt that PCOS impacted the quality of their work, and 51.5% felt held back at work by PCOS. Multivariate analyses revealed that missing work because of PCOS was independently associated with black race, lack of insurance, requiring multiple doctors for a PCOS diagnosis, needing ≥3 doctors for current care, decreased satisfaction with care, and symptoms of anxiety and depression.

Conclusions

Polycystic ovary syndrome significantly impacts employment-related productivity. Factors such as race, mental health, and healthcare delivery appear to play a crucial role in the extent of this impact.

The role of meditation and mindfulness in the management of polycystic ovary syndrome: a scoping review

Polycystic Ovary Syndrome (PCOS) presents multifaceted challenges affecting women's reproductive, metabolic, and psychological systems, consequently impacting their psychological and emotional well-being. The utilization of meditation and mindfulness interventions (MMIs) is found to be increasing for the management of PCOS. This scoping review systematically explored the current literature to identify the type and application of MMIs for PCOS management. A systematic search of literature was conducted using CINAHL, PsycINFO, Scopus, MEDLINE, and PubMed databases for identifying studies conducted on the usage of MMIs in women diagnosed with PCOS, irrespective of age. The comprehensive search identified 14 trials (comprising 17 citations) meeting inclusion criteria, involving 723 participants across various age groups. Among these, nine were randomized controlled trials (RCTs), while the remaining comprised non-RCTs. Several types of MMIs, including Rajayoga of Brahmakumaris, Yoga Nidra, OM cyclic meditation, unspecified forms of meditation, mindfulness-based stress reduction programs, mindful yoga, and mindfulness-based activities, were used. Outcomes were predominantly assessed in psychological domains (n=11), followed by anthropometric (n=9), quality of life (n=7), and metabolic metrics (n=7). The review findings suggest the integration of meditation with conventional treatment modalities. Preliminary data indicate that MMIs have the potential to improve psychosocial well-being and quality of life among PCOS-affected women. However, adequately powered studies with extended follow-up periods are required to investigate the mechanisms and therapeutic efficacy of MMIs, particularly concerning reproductive outcomes and weight management. Furthermore, diligent monitoring and reporting of adverse events and adherence are essential for a comprehensive understanding of MMI utilization in PCOS management.

Unmet clinical needs in women with polycystic ovary syndrome in regard to mental health: a cross-sectional study

PURPOSE

Polycystic ovary syndrome (PCOS) management has hardly been standardized until recent years. Despite the existence of a detailed, evidence-based guideline published by the European Society of Human Reproduction and Embryology (ESHRE), it remains unclear to what extent healthcare providers adhere to this guideline. Our aim is to evaluate the gynaecological medical care provided in women with PCOS, particularly in terms of mental health, from the patients' perspective.

METHODS

For this cross-sectional online cohort study in women with PCOS, we designed a standardized, non-validated questionnaire covering aesthetic aspects, metabolism, menstrual cycle, reproduction, mental health, and prevention of chronic non-communicable diseases.

RESULTS

Among 1879 participants, various mental health aspects were reported: body image (n = 1879), eating patterns/habits (n = 1878), and emotional well-being (n = 1874). Although nearly all women (99.7%) reported complaints on at least one session of mental health, consultation rates were low (body image 9.7%, eating patterns/habits 16.6%, emotional well-being 4.4%). Mean satisfaction with counselling on the different domains varied from moderate to fairly satisfying, with scores of 56.0 points (SD 31.7), 53.5 points (SD 32.0), and 63.7 points (SD 30.2), respectively. More complaints were associated with lower satisfaction. The overall satisfaction with the management provided by the healthcare practitioner (HCP) was low, averaging 36.5 points (SD 29.7). Consequently, most women wished for more counselling (58.9%).

CONCLUSION

Women affected by PCOS are not properly managed according to ESHRE guideline in regard to mental health issues. Overall consultation rates and corresponding satisfaction with management were poor, highlighting the need for significant improvements in healthcare provision.

"Can Anyone Tell Me…". Online Health Communities in Diabetes Self-Management in Poland and Italy

This paper contributes to the debate about the role of Online Health Communities (OHCs) in the healthcare system by concentrating on the kind of information sought and shared by their members. The paper focuses on OHCs for diabetes and discusses the main findings of a qualitative study conducted in Italy and Poland. The Uses and Gratifications approach informed the study, while content analysis was used to perform the analysis. The findings show that OHCs' role goes beyond information and emotional support, which relies on expertise by experience. Indeed, the lack of basic knowledge constituting the essential diabetes literacy for self-management was partially compensated by peer exchange in the OHCs. This raises at least two problems: quality and reliability of the information shared online, and consequences in terms of the equity that a healthcare system provides.

Polycystic ovary syndrome

Despite affecting ~11-13% of women globally, polycystic ovary syndrome (PCOS) is a substantially understudied condition. PCOS, possibly extending to men's health, imposes a considerable health and economic burden worldwide. Diagnosis in adults follows the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome, requiring two out of three criteria - clinical or biochemical hyperandrogenism, ovulatory dysfunction, and/or specific ovarian morphological characteristics or elevated anti-Müllerian hormone. However, diagnosing adolescents omits ovarian morphology and anti-Müllerian hormone considerations. PCOS, marked by insulin resistance and hyperandrogenism, strongly contributes to early-onset type 2 diabetes, with increased odds for cardiovascular diseases. Reproduction-related implications include irregular menstrual cycles, anovulatory infertility, heightened risks of pregnancy complications and endometrial cancer. Beyond physiological manifestations, PCOS is associated with anxiety, depression, eating disorders, psychosexual dysfunction and negative body image, collectively contributing to diminished health-related quality of life in patients. Despite its high prevalence persisting into menopause, diagnosing PCOS often involves extended timelines and multiple health-care visits. Treatment remains ad hoc owing to limited understanding of underlying mechanisms, highlighting the need for research delineating the aetiology and pathophysiology of the syndrome. Identifying factors contributing to PCOS will pave the way for personalized medicine approaches. Additionally, exploring novel biomarkers, refining diagnostic criteria and advancing treatment modalities will be crucial in enhancing the precision and efficacy of interventions that will positively impact the lives of patients.

Primary care clinicians' perspectives on interacting with patients with gynaecological conditions: a systematic review

BACKGROUND

Studies have found that women with gynaecological conditions and symptoms do not feel listened to by primary care clinicians (PCCs). Less understood is whether PCCs perceive that there are challenges around listening to and interacting with this patient group.

AIM

To understand PCCs' perspectives on the challenges of listening to and interacting with women patients with gynaecological conditions and symptoms.

DESIGN & SETTING

Systematic review of English-language studies.

METHOD

We searched ASSIA (Applied Social Sciences Index and Abstracts), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, HMIC (Healthcare Management Information Consortium), and MEDLINE from inception to July 2023. We also conducted forward and backward citation searches of included studies. Identified records were screened independently by two reviewers. Data extraction was undertaken by one reviewer and checked by a second. Quality appraisal used the Wallace checklist. 'Best-fit' framework synthesis was used to synthesise findings around themes that explored the challenges of patient-clinician interaction.

RESULTS

We identified 25 relevant articles. Perceived challenges associated with listening to and interacting with patients with gynaecological conditions and symptoms were identified at four 'levels': individual clinician level factors; structural and organisational factors; community and external factors; and factors related to gynaecological conditions. Interpretive analysis identified specific challenges relating to sociocultural factors affecting the consultation experience; the need for further education, training, or guidance for clinicians; factors affecting referral decisions; and factors related to service structure and organisation.

CONCLUSION

PCCs acknowledge that empathy, respect, and attentive listening are important when interacting with women patients with gynaecological conditions and symptoms. However, these ideals are impeded by several factors.

Total weight loss rather than preoperative body mass index correlates with remission of irregular menstruation after sleeve gastrectomy in patients with polycystic ovary syndrome

Introduction

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting reproductive-aged women. Some retrospective studies with small sample sizes have reported that bariatric metabolic surgery is effective in remission of irregular menstruation in patients with PCOS and obesity. However, the correlation between preoperative body mass index (BMI), postoperative weight loss, and remission of irregular menstruation in patients with obesity and PCOS after sleeve gastrectomy (SG) is lack of consensus.

Methods

We enrolled 229 participants with obesity and PCOS who underwent SG. All patients were followed up for one year after surgery. Remission of irregular menstruation was defined as a spontaneous consecutive six-month menstrual cycle in one year. Subgroup analysis was conducted using tertiles of preoperative BMI and postoperative total weight loss (TWL)% to determine their correlation with the remission of irregular menstruation after SG.

Results

79.03% (181/229) patients achieved remission of irregular menstruation one year after SG with a TWL% of 33.25 ± 0.46%. No significant difference was detected in the remission rate among the subgroups with different BMI (P=0.908). TWL% was correlated with the remission of irregular menstruation (OR 1.78, 95% CI 1.18-2.69, P<0.05).

Conclusions

SG had a significant effect on the remission of irregular menstruation in patients with obesity and PCOS. Preoperative BMI did not emerge as a decisive factor correlated with remission; instead, TWL% showed potential as a key factor.

Women's use of online health and social media resources to make sense of their polycystic ovary syndrome (PCOS) diagnosis: a qualitative study

BACKGROUND

With the growing availability of online health resources and the widespread use of social media to better understand health conditions, people are increasingly making sense of and managing their health conditions using resources beyond their health professionals and personal networks. However, where the condition is complex and poorly understood, this can involve extensive "patient work" to locate, interpret and test the information available. The overall purpose of this study was to investigate how women with polycystic ovary syndrome (PCOS) across two healthcare systems engage with online health resources and social media to better understand this complex and poorly understood lifelong endocrine disorder.

METHODS

A semi-structured interview study was conducted with women from the US ( N = 8 ) and UK ( N = 7 ) who had been diagnosed with PCOS within the previous five years. Transcribed data was analysed using a reflexive thematic analysis method.

RESULTS

We highlight the information needs and information-seeking strategies women use to make sense of how PCOS affects them, to gain emotional support, and to help them find an effective treatment. We also show how women with PCOS use online health and social media resources to compare themselves to women they view as "normal" and other women with PCOS, to find their sense of "normal for me" along a spectrum of this disorder.

CONCLUSION

We draw on previous models of sense-making and finding normal for other complex and sensitive health conditions to capture the nuances of making sense of PCOS. We also discuss implications for the design and use of social media to support people managing PCOS.

Understanding hirsutism in PCOS

INTRODUCTION

Hirsutism is a prevalent condition among women and represents a primary clinical feature of polycystic ovary syndrome (PCOS).

AREAS COVERED

Our study aims to address the principal challenges associated with this hyperandrogenic manifestation in PCOS women. Our narrative review based on the available indexed literature explored the complexities of establishing mFG cutoff values for various ethnic groups, investigated hirsutism during peri- and postmenopausal stages, and examined the role of oxyandrogens.

EXPERT OPINION

Hirsutism may have a negative impact on the quality of life and on the mental health, being associated with anxiety and depression. Future perspectives for its diagnosis include the use of artificial intelligence and the consideration of the distress caused by excessive hair growth.

Validation of an Anti-Müllerian Hormone Cutoff for Polycystic Ovarian Morphology in the Diagnosis of Polycystic Ovary Syndrome in the HARMONIA Study: Protocol for a Prospective, Noninterventional Study

BACKGROUND

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women and is diagnosed using the Rotterdam criteria, including diagnosis of polycystic ovarian morphology (PCOM) by transvaginal ultrasound (TVUS). Due to high cost, availability, and the impact of the operator and ultrasound equipment on the reliability of the antral follicle count (AFC) by TVUS, an unmet need exists for a diagnostic test to determine PCOM without TVUS. A strong positive correlation between elevated anti-Müllerian hormone (AMH) levels and AFCs has been demonstrated in women with PCOS. In addition, recent updates to the international evidence-based PCOS guidelines state that serum AMH can be used as an alternative to TVUS-determined AFC, in the diagnosis of PCOM. The retrospective APHRODITE study derived and validated an AMH cutoff of 3.2 ng/mL for the Elecsys AMH Plus or Elecsys AMH assays (Roche) to diagnose PCOM in patients with PCOS.

OBJECTIVE

This study aims to further validate, in an independent prospective cohort, the AMH cutoff (3.2 ng/mL) for PCOM determination, which was previously derived and validated in the APHRODITE study.

METHODS

This large, prospective, multicenter, population-based, noninterventional study will evaluate the previously established AMH cutoff for the determination of PCOM during the diagnosis of PCOS using the Elecsys AMH Plus immunoassay in an independent population. Participants were women born between July 1985 and December 1987 in Northern Finland; the study partially links to the Northern Finland Birth Cohort 1986. We assessed the enrolled women, determined with the 2023 PCOS Guidelines, for current PCOS status and divided them by phenotype if positive. Each participant had 1 study visit to collect serum samples, record clinical data, and undergo a gynecological examination including TVUS. All data were collected by highly trained midwives or trained gynecologists. Sensitivity, specificity, and agreement measures were used to validate the previously determined cutoff in the whole population and in subpopulations based on phenotype and relevant demographic or clinical factors. The minimum target sample size was approximately 1800 women, including approximately 10% with PCOS.

RESULTS

At the time of manuscript submission, participant recruitment had concluded, and 1803 women were enrolled into the study. Data collection is complete and biostatistical analysis is planned for 2023.

CONCLUSIONS

To limit variability, there were few TVUS operators and only 2 TVUS machines of the same type. Additionally, all women who were taking oral contraceptives were excluded from the primary analysis population. Selection bias was limited as this was a population-based study and participants were not seeking treatment for PCOS symptoms. Validating the AMH cutoff in a large, population-based study will provide further evidence on the utility of the Elecsys AMH Plus or Elecsys AMH assays in PCOM diagnosis as an alternative to TVUS. Measuring AMH for PCOM diagnosis could reduce delayed or missed diagnoses due to operator-dependent TVUS examinations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05527353; http://tinyurl.com/2f3ffbdz.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48854.

Increased Prevalence of Adverse Health Outcomes Across the Lifespan in Those Affected by Polycystic Ovary Syndrome: A Canadian Population Cohort

Background

Polycystic ovary syndrome (PCOS) is the most common metabolic-endocrine disorder impacting the health and quality of life of women over the lifespan. Evidence-based data on the scope of adverse health outcomes in those affected by PCOS is critical to improve healthcare and quality of life in this population. The aim of this study was to determine the prevalence of adverse health outcomes in those with PCOS compared to age-matched controls.

Methods

We conducted a retrospective observational case-control study in those diagnosed with PCOS and age-matched controls using the Alberta Health Services Health Analytics database and the International Classification of Diseases, for the period from 2002-2018 in Alberta, Canada.

Results

The cohort consisted of n = 16,531 exposed PCOS cases and n = 49,335 age-matched un-exposed controls. The prevalences of hypertension, renal disease, gastrointestinal disease, eating disorders, mental illness, depression-anxiety, rheumatoid arthritis, respiratory infections, and all malignancies were 20%-40% (P < 0.0001) higher in those with PCOS, compared to controls. The prevalence of obesity, dyslipidemia, nonalcoholic fatty liver disease, and type 2 diabetes was 2-3 fold higher in those with PCOS (P < 0.001). Cardiovascular, cerebrovascular, and peripheral vascular disease were 30%-50% higher, and they occurred 3-4 years earlier in those with PCOS (P < 0.0001); a 2-fold higher prevalence of dementia occurred in those with PCOS, compared to controls.

Conclusion

These findings provide evidence that PCOS is associated with a higher prevalence of morbidities over the lifespan, and the potential scope of the healthcare burden in women affected by PCOS.

Predicting polycystic ovary syndrome with machine learning algorithms from electronic health records

Introduction

Predictive models have been used to aid early diagnosis of PCOS, though existing models are based on small sample sizes and limited to fertility clinic populations. We built a predictive model using machine learning algorithms based on an outpatient population at risk for PCOS to predict risk and facilitate earlier diagnosis, particularly among those who meet diagnostic criteria but have not received a diagnosis.

Methods

This is a retrospective cohort study from a SafetyNet hospital's electronic health records (EHR) from 2003-2016. The study population included 30,601 women aged 18-45 years without concurrent endocrinopathy who had any visit to Boston Medical Center for primary care, obstetrics and gynecology, endocrinology, family medicine, or general internal medicine. Four prediction outcomes were assessed for PCOS. The first outcome was PCOS ICD-9 diagnosis with additional model outcomes of algorithm-defined PCOS. The latter was based on Rotterdam criteria and merging laboratory values, radiographic imaging, and ICD data from the EHR to define irregular menstruation, hyperandrogenism, and polycystic ovarian morphology on ultrasound.

Results

We developed predictive models using four machine learning methods: logistic regression, supported vector machine, gradient boosted trees, and random forests. Hormone values (follicle-stimulating hormone, luteinizing hormone, estradiol, and sex hormone binding globulin) were combined to create a multilayer perceptron score using a neural network classifier. Prediction of PCOS prior to clinical diagnosis in an out-of-sample test set of patients achieved an average AUC of 85%, 81%, 80%, and 82%, respectively in Models I, II, III and IV. Significant positive predictors of PCOS diagnosis across models included hormone levels and obesity; negative predictors included gravidity and positive bHCG.

Conclusion

Machine learning algorithms were used to predict PCOS based on a large at-risk population. This approach may guide early detection of PCOS within EHR-interfaced populations to facilitate counseling and interventions that may reduce long-term health consequences. Our model illustrates the potential benefits of an artificial intelligence-enabled provider assistance tool that can be integrated into the EHR to reduce delays in diagnosis. However, model validation in other hospital-based populations is necessary.

The Experience of Living With Polycystic Ovary Syndrome in the Military

INTRODUCTION

Polycystic ovary syndrome (PCOS) is the most prevalent reproductive endocrinopathy in women, ranging from 5% to 26% depending on diagnostic criteria applied. Common manifestations of PCOS include overweight and obesity, abnormal menstrual cycles, pelvic pain, increased facial and body hair, acne, and infertility. These abnormalities and associated complications have significant military operational and readiness implications. There is a large gap in research regarding active duty servicewomen (ADW) with PCOS. Therefore, the purpose of this study is to describe ADW's experience of living with PCOS and to describe the service-branch-specific differences among these women.

MATERIALS AND METHODS

Moderator's guide, audiotapes, transcripts, and field notes. This was a qualitative descriptive study using focus groups and individual interviews. The David Grant Medical Center Institutional Review Board at Travis AFB, CA, USA, approved the study protocol. Women with PCOS were recruited from U.S. Air Force, Army, and Navy locations. Data were analyzed using constant comparative content analysis.

RESULTS

Twenty-three servicewomen from 19 occupations across the Army, Navy, Air Force, and Marine Corps participated. Three overarching categories emerged: (1) challenges managing PCOS symptoms, (2) navigating the military health care system, and (3) navigating PCOS as a service member.

CONCLUSIONS

Servicewomen may have significant career consequences related to PCOS sequelae, such as overweight, obesity, uncontrolled menstrual cycle, and pain. Managing the myriad of symptoms can distract women while deployed, in austere conditions, or at their home stations. As one of the most common cardiometabolic, reproductive endocrinologic conditions in women, PCOS has not received the attention, awareness, education, or research necessary to sufficiently support ADW with this condition. It is imperative that evidence-based strategies are developed to inform relevant and high-quality care for these warfighters. Future qualitative studies are needed to further describe specific stressors and needs of ADW with PCOS. Future intervention studies are also needed to evaluate effective management options for ADW with PCOS.

Risk of cardiocerebrovascular diseases is increased in Korean women with polycystic ovary syndrome: a nationwide cohort study

To investigate the relationship between polycystic ovary syndrome (PCOS) and risk of cardiocerebrovascular disease in Korean women. This longitudinal cohort study using data from the Korean National Health Insurance Service included the women aged 15-44 years diagnosed with PCOS between 2002 and 2019, and the controls were matched 1:3 by age group, income, and region of residence. The endpoint outcomes of this study were the occurrence of ischemic heart disease, cerebrovascular diseases, and combined cardiocerebrovascular diseases in the PCOS and control groups. A stratified Cox proportional hazards regression analysis for matched data was performed to evaluate the relative hazard of events in the PCOS group compared to that in the control group. Among a total of 549,400 participants in the cohort, 137,416 women had a diagnosis of PCOS and 412,118 women did not have it. During a median follow-up of 54 months (interquartile range, 30-78 months), the incidence rates of all cardiovascular, ischemic heart, and cerebrovascular diseases were 6.6, 4.0, and 2.9, respectively, per 1000 person-years for women with PCOS, and 4.8, 2.8, and 2.3, respectively, per 1000 person-years for healthy control women. Women with PCOS had a higher hazard ratio of 1.224 (95% confidence interval, 1.18-1.27) of the composite cardiocerebrovascular diseases than those in the controls after propensity score matching for confounding variables, including body mass index, diabetes mellitus, hypertension, dyslipidemia, physical exercise level, alcohol consumption, current smoking, systolic and diastolic blood pressures, total cholesterol, and triglyceride levels. Hazard ratio for ischemic heart and cerebrovascular diseases was higher in women with PCOS than in the control group (hazard ratio, 1.254; 95% confidence interval, 1.20-1.31 and hazard ratio, 1.201; 95% confidence interval, 1.14-1.27, respectively). PCOS is associated with an increased risk of cardiocerebrovascular diseases in Korean women irrespective of their obesity. Counselling on the management of long-term risk of cardiovascular diseases should be offered to women with PCOS in East Asian countries where PCOS is characterized by a relatively low BMI.

Enhancing the accuracy of polycystic ovary syndrome diagnosis

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder, experienced by 1 in 10 women of childbearing age. Its aetiology is multifactorial and complex, and its clinical presentation is heterogeneous with menstrual irregularities, high levels of androgens and the presence of multiple follicles or cysts in the ovaries giving its name to the condition. In addition, PCOS has been linked to reproductive, cardiometabolic, dermatologic and psychological complications making it a significant public health concern.1 Diagnosing PCOS has always been a challenge with some women remaining undiagnosed hence potentially experiencing delays in their care.2 Therefore, optimising PCOS diagnosis accuracy is of crucial importance.

Polycystic ovary syndrome v.2023: Simplified diagnostic criteria for an East Asian phenotype

Introduction

Two decades after the Rotterdam 2003 consensus workshop, there have been considerable advances in elucidating the pathophysiology and epidemiology of polycystic ovary syndrome (PCOS). This has prompted the re-examination of the features that characterise this common condition. Current definitions have led to great heterogeneity in the prevalence of PCOS and have contributed to inconsistent treatment protocols and assessment of therapeutic outcomes. Diagnosis is further complicated by the lack of universal agreement on threshold cut-offs for ovarian dysfunction and ethnic differences in hirsutism; both of which are key features in the definitions that are commonly used currently. These challenges often result in dissatisfaction with medical care among PCOS patients and their physicians.

Method

Our factor analysis mathematically identified anti-Mullerian hormone (AMH), associated polycystic ovarian morphology (PCOM) and serum testosterone as the only significant cluster associated with menstrual cycle length variability.

Results and Conclusion

As such, we propose a simplified criteria wherein the presence of at least 2 of the 3 features below would be sufficient to define PCOS: (1) chronic oligo-ovulation or anovulation as indicated by oligomenorrhea (cycle lengths >35 days) or amenorrhea; (2) PCOM: raised AMH ≥37.0 pmol/L instead of transvaginal ultrasound assessment of ovaries; and (3) Androgen excess, or raised serum androgens above the laboratory reference for women. Further studies are required to examine whether the proposed criteria would reduce diagnostic confusion and improve care and outcomes, especially among patients of East Asian ethnicities.

Assessment of a Digital Symptom Checker Tool's Accuracy in Suggesting Reproductive Health Conditions: Clinical Vignettes Study

BACKGROUND

Reproductive health conditions such as endometriosis, uterine fibroids, and polycystic ovary syndrome (PCOS) affect a large proportion of women and people who menstruate worldwide. Prevalence estimates for these conditions range from 5% to 40% of women of reproductive age. Long diagnostic delays, up to 12 years, are common and contribute to health complications and increased health care costs. Symptom checker apps provide users with information and tools to better understand their symptoms and thus have the potential to reduce the time to diagnosis for reproductive health conditions.

OBJECTIVE

This study aimed to evaluate the agreement between clinicians and 3 symptom checkers (developed by Flo Health UK Limited) in assessing symptoms of endometriosis, uterine fibroids, and PCOS using vignettes. We also aimed to present a robust example of vignette case creation, review, and classification in the context of predeployment testing and validation of digital health symptom checker tools.

METHODS

Independent general practitioners were recruited to create clinical case vignettes of simulated users for the purpose of testing each condition symptom checker; vignettes created for each condition contained a mixture of condition-positive and condition-negative outcomes. A second panel of general practitioners then reviewed, approved, and modified (if necessary) each vignette. A third group of general practitioners reviewed each vignette case and designated a final classification. Vignettes were then entered into the symptom checkers by a fourth, different group of general practitioners. The outcomes of each symptom checker were then compared with the final classification of each vignette to produce accuracy metrics including percent agreement, sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

A total of 24 cases were created per condition. Overall, exact matches between the vignette general practitioner classification and the symptom checker outcome were 83% (n=20) for endometriosis, 83% (n=20) for uterine fibroids, and 88% (n=21) for PCOS. For each symptom checker, sensitivity was reported as 81.8% for endometriosis, 84.6% for uterine fibroids, and 100% for PCOS; specificity was reported as 84.6% for endometriosis, 81.8% for uterine fibroids, and 75% for PCOS; positive predictive value was reported as 81.8% for endometriosis, 84.6% for uterine fibroids, 80% for PCOS; and negative predictive value was reported as 84.6% for endometriosis, 81.8% for uterine fibroids, and 100% for PCOS.

CONCLUSIONS

The single-condition symptom checkers have high levels of agreement with general practitioner classification for endometriosis, uterine fibroids, and PCOS. Given long delays in diagnosis for many reproductive health conditions, which lead to increased medical costs and potential health complications for individuals and health care providers, innovative health apps and symptom checkers hold the potential to improve care pathways.

Challenges in diagnosis and health care in polycystic ovary syndrome in Canada: a patient view to improve health care

BACKGROUND

Polycystic Ovary Syndrome (PCOS) is the most common endocrine-metabolic disorder affecting health and quality of life of those affected across the lifespan. We currently have limited evidence-based data on the experience of those living with PCOS in the health care system including diagnosis, health concerns and disease management. The aim of this study was to assess the perceptions of health status, health care experience and disease management support in those affected by PCOS in Alberta, Canada.

METHODS

An online questionnaire was completed via REDCap by individuals self-reporting a diagnosis of PCOS. Question categories included demographics, symptoms of PCOS and time to confirm a diagnosis, follow-up care, health concerns, and information resources. Descriptive statistics were used and thematic analyses was applied to open-response questions.

RESULTS

Responses from 194 participants living in Canada (93% in Alberta) were included. The average age was 34 ± 8 years and BMI was 35 ± 9. Menstrual irregularity was identified in 84% of respondents as the first symptom noticed and the primary reason for seeking a medical consultation. A PCOS diagnosis occurred on average 4.3 years following awareness of first symptoms and required consultation with more than one primary care provider for 57% of respondents. Half (53%) of respondents reported not receiving a referral to specialists for follow-up care and 70% were not informed about long-term health morbidity such as diabetes or cardiovascular disease. Most respondents (82%) did their own research about PCOS using on-line sources, academic literature and advice from peer support. The participant themes from open questions for improving health care included more resources and support, increased and reliable information, better education and training for clinicians, timely diagnosis, prompt referrals to specialists, and generally more compassion and empathy to the challenges faced by those managing their disease.

CONCLUSION

Our findings highlight the health concerns and challenges in health care for those with PCOS. In Alberta, Canada we have identified major gaps in health care including a timely diagnosis, follow up care and supports, and multidisciplinary care. This evidence-based data can be used to inform development of pathways to improve the health care experience in those affected by PCOS.

Unmet Clinical Needs in Women with Aesthetic Manifestations of Polycystic Ovary Syndrome: A Cross-Sectional Study

Background: Polycystic ovary syndrome (PCOS) management has hardly been standardized until recent years. There is an accurate, evidence-based guideline published by the European Society of Human Reproduction and Embryology (ESHRE). However, it remains unclear to which extent, if at all, the guideline is followed by health care providers. The aim was to explore the subjectively perceived quality of gynecological medical care in women with PCOS suffering from aesthetic complaints. Materials and Methods: A nonvalidated questionnaire was constructed in a standardized manner covering the domains: aesthetic aspects, metabolism, menstrual cycle, reproduction, mental health, and prevention of chronic noncommunicable diseases. Results: A total of 1960 participants with aesthetic complaints, such as acne (66.2%), alopecia (43.9%), hirsutism (77.9%), or overweight/obesity (72.3%) were included. The percentage of women being counseled was low (acne 20.3%, alopecia 12.9%, hirsutism 17.5%, overweight/obesity 36.2%). Satisfaction with counseling was moderate (40.4-44.1 points). Many women tried at least one therapeutic method (75.9%), whereas only a few were counseled for therapy (acne 27.0%, alopecia 24.6%, hirsutism 24.0%, overweight/obesity 18.8%) with moderate satisfaction for hyperandrogenism (mean 55.1-59.5 points) and good satisfaction for overweight/obesity (mean 60.8 points). Overall satisfaction was rated with a mean of 30.5 points (standard deviation 27.1) on a scale from 0 to 100 and thus considered "not satisfied." Fewer complaints were significantly correlated with higher satisfaction. Most women wished for more counseling (80.8%), as well as more diagnostic (63.2%) and therapeutic options (70.2%). Conclusions: Women affected by PCOS are not properly managed according to the ESHRE guideline. Indeed, this guideline recommends comprehensive history and physical examination for clinical hyperandrogenism as well as holistic approaches in therapy, including education and counseling of patients. Still, overall consultation rates and satisfaction were poor.

Polycystic ovary syndrome: pathophysiology and therapeutic opportunities

Polycystic ovary syndrome is characterised by excessive levels of androgens and ovulatory dysfunction, and is a common endocrine disorder in women of reproductive age. Polycystic ovary syndrome arises as a result of polygenic susceptibility in combination with environmental influences that might include epigenetic alterations and in utero programming. In addition to the well recognised clinical manifestations of hyperandrogenism and ovulatory dysfunction, women with polycystic ovary syndrome have an increased risk of adverse mental health outcomes, pregnancy complications, and cardiometabolic disease. Unlicensed treatments have limited efficacy, mostly because drug development has been hampered by an incomplete understanding of the underlying pathophysiological processes. Advances in genetics, metabolomics, and adipocyte biology have improved our understanding of key changes in neuroendocrine, enteroendocrine, and steroidogenic pathways, including increased gonadotrophin releasing hormone pulsatility, androgen excess, insulin resistance, and changes in the gut microbiome. Many patients with polycystic ovary syndrome have high levels of 11-oxygenated androgens, with high androgenic potency, that might mediate metabolic risk. These advances have prompted the development of new treatments, including those that target the neurokinin-kisspeptin axis upstream of gonadotrophin releasing hormone, with the potential to lessen adverse clinical sequelae and improve patient outcomes.

Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome

STUDY QUESTION

What is the recommended assessment and management of those with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference?

SUMMARY ANSWER

International evidence-based guidelines address prioritized questions and outcomes and include 254 recommendations and practice points, to promote consistent, evidence-based care and improve the experience and health outcomes in PCOS.

WHAT IS KNOWN ALREADY

The 2018 International PCOS Guideline was independently evaluated as high quality and integrated multidisciplinary and consumer perspectives from six continents; it is now used in 196 countries and is widely cited. It was based on best available, but generally very low to low quality, evidence. It applied robust methodological processes and addressed shared priorities. The guideline transitioned from consensus based to evidence-based diagnostic criteria and enhanced accuracy of diagnosis, whilst promoting consistency of care. However, diagnosis is still delayed, the needs of those with PCOS are not being adequately met, evidence quality was low and evidence-practice gaps persist.

STUDY DESIGN, SIZE, DURATION

The 2023 International Evidence-based Guideline update reengaged the 2018 network across professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Extensive evidence synthesis was completed. Appraisal of Guidelines for Research and Evaluation-II (AGREEII)-compliant processes were followed. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength and diversity and inclusion were considered throughout.

PARTICIPANTS/ MATERIALS, SETTING, METHODS

This summary should be read in conjunction with the full Guideline for detailed participants and methods. Governance included a six-continent international advisory and management committee, five guideline development groups, and paediatric, consumer, and translation committees. Extensive consumer engagement and guideline experts informed the update scope and priorities. Engaged international society-nominated panels included paediatrics, endocrinology, gynaecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, obesity care, public health and other experts, alongside consumers, project management, evidence synthesis, statisticians and translation experts. Thirty-nine professional and consumer organizations covering 71 countries engaged in the process. Twenty meetings and five face-to-face forums over 12 months addressed 58 prioritized clinical questions involving 52 systematic and 3 narrative reviews. Evidence-based recommendations were developed and approved via consensus across five guideline panels, modified based on international feedback and peer review, independently reviewed for methodological rigour, and approved by the Australian Government National Health and Medical Research Council (NHMRC).

MAIN RESULTS AND THE ROLE OF CHANCE

The evidence in the assessment and management of PCOS has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report and analyses (∼6000 pages) underpins 77 evidence-based and 54 consensus recommendations, with 123 practice points. Key updates include: i) further refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone (AMH) levels as an alternative to ultrasound in adults only; ii) strengthening recognition of broader features of PCOS including metabolic risk factors, cardiovascular disease, sleep apnea, very high prevalence of psychological features, and high risk status for adverse outcomes during pregnancy; iii) emphasizing the poorly recognized, diverse burden of disease and the need for greater healthcare professional education, evidence-based patient information, improved models of care and shared decision making to improve patient experience, alongside greater research; iv) maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and v) emphasizing evidence-based medical therapy and cheaper and safer fertility management.

LIMITATIONS, REASONS FOR CAUTION

Overall, recommendations are strengthened and evidence is improved, but remain generally low to moderate quality. Significantly greater research is now needed in this neglected, yet common condition. Regional health system variation was considered and acknowledged, with a further process for guideline and translation resource adaptation provided.

WIDER IMPLICATIONS OF THE FINDINGS

The 2023 International Guideline for the Assessment and Management of PCOS provides clinicians and patients with clear advice on best practice, based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation programme supports the Guideline with an integrated evaluation program.

STUDY FUNDING/COMPETING INTEREST(S)

This effort was primarily funded by the Australian Government via the National Health Medical Research Council (NHMRC) (APP1171592), supported by a partnership with American Society for Reproductive Medicine, Endocrine Society, European Society for Human Reproduction and Embryology, and the Society for Endocrinology. The Commonwealth Government of Australia also supported Guideline translation through the Medical Research Future Fund (MRFCRI000266). HJT and AM are funded by NHMRC fellowships. JT is funded by a Royal Australasian College of Physicians (RACP) fellowship. Guideline development group members were volunteers. Travel expenses were covered by the sponsoring organizations. Disclosures of interest were strictly managed according to NHMRC policy and are available with the full guideline, technical evidence report, peer review and responses (www.monash.edu/medicine/mchri/pcos). Of named authors HJT, CTT, AD, LM, LR, JBoyle, AM have no conflicts of interest to declare. JL declares grant from Ferring and Merck; consulting fees from Ferring and Titus Health Care; speaker's fees from Ferring; unpaid consultancy for Ferring, Roche Diagnostics and Ansh Labs; and sits on advisory boards for Ferring, Roche Diagnostics, Ansh Labs, and Gedeon Richter. TP declares a grant from Roche; consulting fees from Gedeon Richter and Organon; speaker's fees from Gedeon Richter and Exeltis; travel support from Gedeon Richter and Exeltis; unpaid consultancy for Roche Diagnostics; and sits on advisory boards for Roche Diagnostics. MC declares travels support from Merck; and sits on an advisory board for Merck. JBoivin declares grants from Merck Serono Ltd.; consulting fees from Ferring B.V; speaker's fees from Ferring Arzneimittell GmbH; travel support from Organon; and sits on an advisory board for the Office of Health Economics. RJN has received speaker's fees from Merck and sits on an advisory board for Ferring. AJoham has received speaker's fees from Novo Nordisk and Boehringer Ingelheim. The guideline was peer reviewed by special interest groups across our 39 partner and collaborating organizations, was independently methodologically assessed against AGREEII criteria and was approved by all members of the guideline development groups and by the NHMRC.

Application of machine learning and artificial intelligence in the diagnosis and classification of polycystic ovarian syndrome: a systematic review

Introduction

Polycystic Ovarian Syndrome (PCOS) is the most common endocrinopathy in women of reproductive age and remains widely underdiagnosed leading to significant morbidity. Artificial intelligence (AI) and machine learning (ML) hold promise in improving diagnostics. Thus, we performed a systematic review of literature to identify the utility of AI/ML in the diagnosis or classification of PCOS.

Methods

We applied a search strategy using the following databases MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Web of Science, and the IEEE Xplore Digital Library using relevant keywords. Eligible studies were identified, and results were extracted for their synthesis from inception until January 1, 2022.

Results

135 studies were screened and ultimately, 31 studies were included in this study. Data sources used by the AI/ML interventions included clinical data, electronic health records, and genetic and proteomic data. Ten studies (32%) employed standardized criteria (NIH, Rotterdam, or Revised International PCOS classification), while 17 (55%) used clinical information with/without imaging. The most common AI techniques employed were support vector machine (42% studies), K-nearest neighbor (26%), and regression models (23%) were the commonest AI/ML. Receiver operating curves (ROC) were employed to compare AI/ML with clinical diagnosis. Area under the ROC ranged from 73% to 100% (n=7 studies), diagnostic accuracy from 89% to 100% (n=4 studies), sensitivity from 41% to 100% (n=10 studies), specificity from 75% to 100% (n=10 studies), positive predictive value (PPV) from 68% to 95% (n=4 studies), and negative predictive value (NPV) from 94% to 99% (n=2 studies).

Conclusion

Artificial intelligence and machine learning provide a high diagnostic and classification performance in detecting PCOS, thereby providing an avenue for early diagnosis of this disorder. However, AI-based studies should use standardized PCOS diagnostic criteria to enhance the clinical applicability of AI/ML in PCOS and improve adherence to methodological and reporting guidelines for maximum diagnostic utility.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022295287.

Concerns and expectations in women with polycystic ovary syndrome vary across age and ethnicity: findings from PCOS Pearls Study

Objective

To understand and explore the perceptions and opinions of women with polycystic ovary syndrome (PCOS) and further delineate the variations across age and ethnicity.

Design

Qualitative survey focussed on lived experiences of people with PCOS. Participants could share their views either as written text or as voice note audio recording(s) on WhatsApp. The data from the audio were transcribed verbatim. Responses were coded by two study members independently, using a thematic inductive method with NVivo 12. Two senior study members then reviewed these codes to identify common themes.

Subjects

Women with PCOS aged 18-60 years.

Results

43 of 45 participants had a formal diagnosis of PCOS, the remaining two had suspected PCOS which was under investigation. Four participants opted to share their views as voice note recordings. Poor mental health was the most reported (83.3% of participants), followed by dermatological (81.0%) and menstrual issues (76.2%). Participants were generally dissatisfied with the care they received (88.1%). A lengthy diagnostic journey was reported in 35.7% of cases. 52.6% felt less feminine, particularly regarding weight gain and infertility. As part of the recommendations by participants, it was emphasised that others with the condition should educate themselves and be proactive in their management. 46.3% reported that being more enlightened regarding their condition improved their health outcomes and enabled them to advocate for their own care. Women in their 20s expressed distress due to poor mental health, needing a longer time to get the diagnosis, and having weight and eating concerns. While women with PCOS in their 30s discussed their menstrual irregularities and fertility issues, those in their 40s expressed their concerns about the societal expectations of women when diagnosed with PCOS. The concerns varied across ethnicities as well.

Conclusion

PCOS has wide-ranging consequences for women living with the condition, with many dissatisfied with the clinical support they currently receive. The concerns and expectations vary across ages and ethnicities. Therefore, we propose involving women with PCOS to co-create clinical and educational resources informed by lived experiences to provide end-user-informed services.

Factors associated with self-report of polycystic ovary syndrome in the Coronary Artery Risk Development in Young Adults study (CARDIA)

BACKGROUND

Polycystic ovary syndrome (PCOS) is underdiagnosed, but factors associated with women's report of diagnosis are not well-understood, particularly social determinants of health. Therefore, in a population-based cohort, we compared the characteristics of women with self-reported PCOS vs. women who have unrecognized PCOS vs. women without PCOS.

METHODS

We performed a secondary data analysis of the Coronary Artery Risk Development in Young Adults (CARDIA) Study, a population-based, prospective cohort of Black and White women. Participants were women (n = 2028) who responded to the question, "Did a doctor or nurse ever tell you that you had polycystic ovarian syndrome or polycystic ovarian disease?" at the year 15 examination. Women who answered "yes" were defined as having self-reported PCOS. Women who answered "no or not sure" were defined as having unrecognized PCOS if they also had irregular menses and hyperandrogenemia between 20 and 30 years of age. Exposures of interest included social determinants of health, symptoms including irregular menses and hirsutism, and comorbid conditions.

RESULTS

Forty-three (2.1%) of women had self-reported PCOS, 135 (6.7%) had unrecognized PCOS, and 1850 (91%) women were without PCOS. In logistic regression models adjusting for age, race, and center, women with self-reported PCOS were more likely to have obesity (OR 1.83, 95% CI 1.22, 2.75) and diabetes (OR 2.37, 95% CI 1.05, 5.33) compared to women without PCOS. Women with unrecognized PCOS were more likely to have hypertension (OR 1.68, 95% CI 1.03, 2.74) and food insecurity (OR 1.94, 95% CI 1.25, 3.01) compared to women without PCOS.

CONCLUSIONS

Unrecognized PCOS is common. Self-report of PCOS is not associated with access to healthcare. Women who report PCOS are more often obese and comorbidities may contribute to recognition of PCOS.

Polycystic ovarian syndrome awareness among females in the UAE: a cross-sectional study

BACKGROUND

Polycystic Ovarian Syndrome (PCOS) is a common hormonal disorder affecting females of reproductive age. Clinical guidelines recommend following the diagnostic criteria of PCOS based on an appropriate assessment of the patient's clinical presentation. Sufficient awareness among the population will prompt females to seek medical attention when necessary. This study aimed to assess knowledge and awareness about PCOS among females above the age of 18 years in the United Arab Emirates (UAE) and to correlate the level of awareness with women's backgrounds, demographics, and education levels.

METHODS

This was a cross-sectional study conducted in early 2020. 430 females over the age of 18 years were conveniently selected and interviewed in the UAE using a 21-item questionnaire that assessed participants' awareness of PCOS as a term, its causes, symptoms, complications, treatment, and prevention. 414 entries were eligible for data analysis. IBM® SPSS® Statistics version 25 was used for data entry and analysis.

RESULTS

349 participants (84.3%) were familiar with the term PCOS. However, only 21.7% of them had sufficient awareness of the syndrome (95% CI = 17.77-25.71%). Being knowledgeable of PCOS was significantly associated with having a previous diagnosis (p = 0.002) and with studying or working in a medical field (p < 0.001). In addition, females who knew someone diagnosed with PCOS were 5 times more likely to be more aware compared to those who didn't (95% CI = 2.5-10.8; p < 0.001). Age, education level, and nationality showed no correlation with the level of awareness.

CONCLUSIONS

Overall, the level of PCOS awareness was insufficient in the study sample. Participants whose source of information was medical practitioners demonstrated more accurate knowledge. Accordingly, awareness of PCOS needs to be raised among females in the UAE, aiding early diagnosis and improving patient-oriented outcomes.

Risk of Gynecological Cancers in Women With Polycystic Ovary Syndrome and the Pathophysiology of Association

Polycystic ovary syndrome (PCOS) is an endocrine disorder increasingly affecting women in the reproductive age group. The women usually present with menstruation irregularities, hirsutism, weight gain, and acne. There has been ongoing research about the increased risk of gynecological cancers in women with polycystic ovary syndrome compared to those without it. This review aimed to understand the risk of gynecological cancers, endometrial, ovarian, and breast cancer in PCOS, and to study in detail the underlying mechanisms involved. We searched PubMed and Google Scholar databases for studies and selected 10 articles from a total of 19,388 relevant articles. We found an increased risk of endometrial cancer in women with PCOS whereas the risk of ovarian and breast cancer was not increased. A recent study has even reported a reduced risk of ovarian cancer in genetically predicted PCOS. In understanding various medical conditions possibly leading to cancer in these women we found that hyperandrogenism, hyperinsulinemia, unopposed estrogen action, chronic inflammation, and dyslipidemia were major contributors. There is a need for more large-scale cohort studies which will take into consideration other factors leading to cancers in women with PCOS, such as smoking, alcohol, and family history, to substantiate the significance of these associations further. The interventions used to treat PCOS might also affect the risk of cancer and require further probing. This review is an attempt to analyze the risk of cancers of the reproductive system in females with PCOS in coherence with understanding the mechanisms leading to the respective cancers.

Awareness of Lifestyle Modifications in the Management of Polycystic Ovarian Syndrome: A Hospital-Based Descriptive Cross-Sectional Study

OBJECTIVE

Polycystic ovarian syndrome (PCOS) is a prevalent endocrinological disorder in reproductive-age women. Due to varied presentations, it's often difficult to diagnose and manage women with PCOS. Management usually focuses on treating the symptoms and preventing long-term sequelae of the disease. This study was planned to assess the knowledge among reproductive-age women (15-44 years) regarding the risk factors, symptoms, complications, and management of PCOS.

MATERIAL AND METHODS

This is a hospital-based descriptive cross-sectional study. A pre-validated well-structured questionnaire which included basic demographic data, menstrual history, knowledge about PCOS symptoms, risk factors, complications, prevention, and treatment, was administered. Completed questionnaires were analyzed to calculate the knowledge score of the participants and its association with their education level and occupation was seen.

RESULTS

A total of 350 women participated but only 334 completed questionnaires were included for final evaluation. The mean age of the study population was 28.70±6.29 years. Around 9.3% of the participants were already diagnosed with PCOS. Most of the women (43.4%) had heard about PCOS. The source of information was doctors (26.6%), the internet (6.28%), teachers (5.6%), and friends (4.7%). Obesity (33.5%), unhealthy dietary habits (35%), and genetic predisposition (40.7%) were thought as risk factors for PCOS. Most of the participants were aware that subfertility (40.1%), abortions (34.4%), diabetes (28.7%), hypertension (31.7%), cardiovascular disease (33.5%), endometrial carcinoma (35.9%), and psychological disturbances (37.1%) are among the known PCOS related complications. Eating a healthy diet (37.1%) and weight reduction (41%) can help in the management of PCOS. Around 60.5% of women showed poor knowledge, 14.7% fair knowledge, and 24.9% good knowledge regarding PCOS. Education level and occupation status were found to be significantly related to the knowledge score (P≤0.001).

CONCLUSION

PCOS is a prevalent condition with varied presentations which significantly affects one's quality of life. Since there is no definitive treatment for PCOS the management generally aims at managing symptoms and reducing the risk of long-term complications. To reduce the burden of PCOS-related long-term complications behavioral changes in terms of regular exercise and healthy dietary habits need to be incorporated from childhood.

Cardiovascular disease risk in offspring of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder affecting women at reproductive age. PCOS diagnosis (Rotterdam criteria) is based on the presence of two out of three criteria; clinical and/or biochemical hyperandrogenism, oligo- or an-ovulation and polycystic ovaries. PCOS women suffer from a constellation of reproductive and metabolic abnormalities including obesity and insulin resistance. PCOS women also have increased blood pressure and increased risk of cardiovascular diseases (CVD). In-utero, offspring of PCOS women are exposed to altered maternal hormonal environment and maternal obesity (for most of PCOS women). Offspring of PCOS women could also be subject to genetic susceptibility, the transgenerational transmission of some of the PCOS traits or epigenetic changes. Offspring of PCOS women are commonly reported to have an abnormal birth weight, which is also a risk factor for developing CVD and hypertension later in life. Although studies have focused on the growth pattern, reproductive and metabolic health of children of PCOS women, very limited number of studies have addressed the risk of hypertension and CVD in those offspring particularly as they age. The current narrative review is designed to summarize the available literature (both human studies and experimental animal studies) and highlight the gaps in addressing hypertension and CVD risks in offspring of PCOS women or hyperandrogenemic female animal models.

A Global Survey of Ethnic Indian Women Living with Polycystic Ovary Syndrome: Co-Morbidities, Concerns, Diagnosis Experiences, Quality of Life, and Use of Treatment Methods

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrinopathy that is highly prevalent in women of Indian ethnicity. Clinical practice guidelines do not adequately consider ethnic-cultural differences in the diagnosing and care of women with PCOS. This study aimed to understand co-morbidities, key concerns, quality of life (QoL), and diagnosis experiences of ethnic Indian women living with PCOS.

METHODS

Global online survey of ethnic Indian women of reproductive age living with PCOS.

RESULTS

Respondents (n = 4409) had a mean age of 26.8 (SD 5.5) years and reported having a family history of type 2 diabetes (43%) and PCOS (18%). Most of them (64%) were diagnosed with one or more co-morbidities (anxiety/depression being the most common). Irregular periods, cysts on the ovaries, and excess unwanted facial hair growth were their three top concerns. On average, women experienced symptoms of PCOS at the age of 19.0 (SD 5.0) and were diagnosed at the age of 20.8 years (SD 4.8). We report a one-year delay in seeking medical help and a seven-month diagnostic delay, which were associated with poor satisfaction with the information provided related to PCOS and its treatment options (p < 0.01). Women living outside India reported difficulty losing weight as their most key concern; however, they had higher dissatisfaction with the information provided on diet (OR, 0.74; 95% CI, 0.6 to 0.8; p = 0.002), exercise (OR, 0.74; 95% CI, 0.6 to 0.9; p = 0.002) and behavioural advice (OR, 0.74; 95% CI, 0.6 to 0.9; p = 0.004) than women living in India. Most women reported poor QoL in weight and emotion domains.

CONCLUSIONS

Ethnic Indian women experience early onset of PCOS symptoms and delay in seeking professional help. Timely diagnosis, providing cultural-specific education related to lifestyle and weight management, and improving psycho-emotional support are key areas that should be addressed in clinical practice and future research.

The Disparity in the Management of Polycystic Ovary Syndrome between Obstetrician-Gynecologists in Different-Level Hospitals under the Hierarchical Medical System

Background

PCOS is a prevalent endocrine and metabolic disorder in women characterized by abnormal blood glucose, dyslipidemia, and abnormal mental health. To improve patient care, the goal of our study is to find out if there are differences in how PCOS patients are treated at different hospital levels within the hierarchical medical system.

Methods

Obstetricians and gynecologists from primary, secondary, and tertiary hospitals were the participants in the survey. The responses provided and collected were analyzed using various statistical techniques like the chi-square test, Fisher exact test, and logistic regression with multiple variables.

Results

The investigation examined 2298 survey replies (13.1% primary hospitals, 52.4% secondary hospitals, and 34.5% tertiary hospitals). As hospital grade increases, more participants inquire about a patient's history of unfavorable pregnancies concerning hormone evaluation; the better the hospital's grade, the greater the number of participants who would undergo AMH and androgen-related tests. The higher the hospital level, the more participants would pick the oral glucose tolerance test (OGTT) to determine insulin resistance, the BMI Asian criteria for defining obesity, and blood lipids. Participants in primary (odds ratio (OR) = 0.383, 95% confidence interval (CI) 0.282-0.520) and secondary (OR = 0.607, 95% confidence interval (CI) 0.481-0.765) hospitals were significantly less likely to select OGTT than those in tertiary hospitals. Comparatively, fewer primary hospitals chose to do lipid profiling than tertiary hospitals (OR 0.689, 95% CI 0.523-0.909). With the increase in hospital level, participants were more knowledgeable about the multiple efficacies and dose alternatives of metformin and selected letrozole and assisted reproduction more frequently.

Conclusion

Our study uncovered differences in the endocrine evaluation, metabolic screening, and management of PCOS patients across obstetrics and gynecology at various hospital levels. Simultaneously, it underlines the need to improve the hierarchical medical system and close the knowledge gap across hospitals.

Development and validation of a prediction model for depression in adolescents with polycystic ovary syndrome: A study protocol

Introduction

The high prevalence and severity of depression in adolescents with polycystic ovary syndrome (PCOS) is a critical health threat that must be taken seriously. The identification of high-risk groups for depression in adolescents with PCOS is essential to preventing its development and improving its prognosis. At present, the routine screening of depression in adolescents with PCOS is mainly performed using scales, and there is no early identification method for high-risk groups of PCOS depression in adolescents. It is necessary to use a warning model to identify high-risk groups for depression with PCOS in adolescents.

Methods and analysis

Model development and validation will be conducted using a retrospective study. The study will involve normal adolescent girls as the control group and adolescent PCOS patients as the experimental group. We will collect not only general factors such as individual susceptibility factors, biological factors, and psychosocial environmental factors of depression in adolescence, but will also examine the pathological factors, illness perception factors, diagnosis and treatment factors, and symptom-related factors of PCOS, as well as the outcome of depression. LASSO will be used to fit a multivariate warning model of depression risk. Data collected between January 2022 and August 2022 will be used to develop and validate the model internally, and data collected between September 2022 and December 2022 will be used for external validation. We will use the C-statistic to measure the model's discrimination, the calibration plot to measure the model's risk prediction ability for depression, and the nomogram to visualize the model.

Discussion

The ability to calculate the absolute risk of depression outcomes in adolescents with PCOS would enable early and accurate predictions of depression risk among adolescents with PCOS, and provide the basis for the formulation of depression prevention and control strategies, which have important theoretical and practical implications.

Trial registration number

[ChiCTR2100050123]; Pre-results.

Polycystic Ovary Syndrome: Insights from Preclinical Research

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age, affecting approximately 10%. PCOS is diagnosed by the presence of at least two of these three criteria: hyperandrogenemia, oligo- or anovulation, and polycystic ovaries. The most common type (80%) of PCOS includes hyperandrogenemia. PCOS is also characterized by obesity or overweight (in 80% of US women with PCOS), insulin resistance with elevated plasma insulin but not necessarily hyperglycemia, dyslipidemia, proteinuria, and elevated BP. Although elevated compared with age-matched controls, BP may not reach levels considered treatable according to the current clinical hypertension guidelines. However, it is well known that elevated BP, even modestly so, increases the risk of cardiovascular disease. We have developed a model of hyperandrogenemia in rodents that mimics the characteristics of PCOS in women, with increases in body weight, insulin resistance, dyslipidemia, andproteinuria and elevated BP. This review discusses potential mechanisms responsible for the elevated BP in the adult and aging PCOS rat model that may be extrapolated to women with PCOS.

The Reliability and Validity of the Malay Version of Polycystic Ovarian Syndrome Health-Related Quality of Life Questionnaire

The Polycystic Ovary Syndrome Questionnaire is a reliable instrument for measuring health-related quality of life. This study aimed to develop a Malay version of the Polycystic Ovary Syndrome Questionnaire and to evaluate the health-related impact of Malaysian women with polycystic ovary syndrome. The participants were women who were diagnosed with polycystic ovary syndrome using Rotterdam criteria in a gynecology clinic. Reliability was determined by internal consistency using Cronbach's coefficient alpha and test-retest reliability using an intra-class correlation coefficient. Validity was assessed through convergent and discriminant validity. Examining the correlation between similar content of the Malay version of the Polycystic Ovary Syndrome Questionnaire and the SF-36 assessed the convergent validity. The discriminant validity was assessed using the known group comparison. Cronbach's alpha coefficient was over 0.70 for the total scale and over 0.60 for each subscale. Known group comparison supported the discriminant validity. The Malay version of the Polycystic Ovary Syndrome Questionnaire differentiated between the subgroups of women who differed in polycystic ovary syndrome-specific symptoms. Convergent validity was consistent with the good positive correlation between related subscales of the two instruments. Polycystic ovary syndrome women in Malaysia scored the lowest for the weight (3.74) and infertility (3.41) domains, thereby indicating worse health status in these domains. Body hair (5.42) was the least troublesome for the local population. The Malay version of the Polycystic Ovary Syndrome Questionnaire is a reliable and valid tool for assessing the health-related quality of life among women in the local population. It can be used to objectively assess the quality of life among Malaysian women with polycystic ovary syndrome and evaluate their responsiveness to treatment modalities.

What can be done to improve polycystic ovary syndrome (PCOS) healthcare? Insights from semi-structured interviews with women in Canada

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common and perplexing condition affecting metabolic, reproductive, cardiovascular, and psychological health in women. Previous studies point to widespread dissatisfaction and frustration in women with the information and care they receive. Studies have found delays with the diagnosis of PCOS and gaps in knowledge in physicians regarding the diagnosis and management of PCOS. Little has been heard from women on what they think can be improved with PCOS care, especially in Canada. This qualitative study explores women's experiences navigating the healthcare system and their insights on what could be improved based on their lived experiences.

METHODS

Twenty-five participants were interviewed remotely over the phone by the first author between October and December 2018.Interviews were semi-structured and in-depth. Data were analyzed using thematic analysis and interpretive description methodology.

RESULTS

Twenty-five in-depth interviews conducted with participants across Canada (ages 18-63) revealed three overall areas in need of improvement. First, women emphasized a need for greater knowledge and awareness of PCOS in primary care physicians (PCPs) as well as the need for the medical community to prioritize women's health. Second, participants advocated for greater PCOS awareness and de-stigmatization in the general community and in women and girls, and any individuals with female reproductive systems. Third, participants brought up several needed resources, such as the need for more PCOS research to be funded and undertaken, more PCOS specialists and experts to be available, credible doctor-provided information (e.g., pamphlets, websites), and age-specific support groups and mental health supports to be available. Participants were generally unaware of existing PCOS organizations and brought up the need for established PCOS organizations to aid in the training and retraining of doctors and local awareness-building in communities.

CONCLUSIONS

Participants believed that PCPs in Canada needed to be well-versed on how to diagnose and manage PCOS to prevent delays in diagnosis and provide easier access to care. Further, greater awareness and de-stigmatization in the general community are needed so women can identify symptoms early and have access to support from those around them. Overall, PCOS may be an overlooked and under-prioritized condition, both in the Canadian healthcare system and general community.

Mental Health and PCOS Information-Sharing: Interviews with Health Care Providers in a Low-Income Urban Community

Polycystic ovary syndrome (PCOS) is a female metabolic-endocrine disorder typically characterized by menstrual dysfunction, hyperandrogenism, and/or polycystic ovaries. While comorbidity with poor mental health is often observed, it is less understood if women of color are given information on PCOS, mental health, or both by healthcare providers. This paper examines the information-sharing practices of healthcare providers serving a low-income, predominantly Latino/Hispanic municipality in Southeast Los Angeles, CA. Of 65 providers identified across 27 clinics in the service area, four participated in one-on-one semi-structured interviews. Four themes relating to PCOS and mental health information were identified using content analysis. Results suggest that information-sharing on PCOS is limited to symptomatic patients and varies by provider specialization. Poor mental health as a side effect of PCOS is not elaborated on during patient-provider interactions within the explored service area. Implications and directions for further research are discussed, including mixed methods approaches for contextual information on PCOS among women of color and recommendations for improving communication among healthcare providers.

Diagnosis and management of polycystic ovary syndrome: Perspectives of clinicians in Singapore

INTRODUCTION

To harmonise the diagnostic processes of polycystic ovary syndrome (PCOS) and enable clinicians to provide better patient care, it is critical to understand the knowledge gaps in PCOS diagnosis. We evaluated how clinicians in endocrinology, family medicine, general practice and gynaecology diagnose PCOS.

METHODS

This cross-sectional survey involved 208 clinicians from specific subspecialties across various healthcare settings in Singapore.

RESULTS

A total of 160 responses were included in the final analysis. Among all the diagnostic criteria, the Rotterdam 2003 criteria was most frequently used (66.3%). More than half of the gynaecologists reported having a standardised workplace protocol while the majority from other specialties reported otherwise. A large percentage of respondents (60.5%) were unable to identify the correct PCOS clinical features, which is concerning. Only 8.8% of respondents used clinical and biochemical hyperandrogenism, menstrual disturbances and pelvic ultrasound to diagnose PCOS without performing unnecessary and incorrect investigations. Most clinicians recognised insulin resistance/type 2 diabetes mellitus and fertility problems as complications while only a few recognised psychological complications. Many clinicians (37.3%) sought standardisation of PCOS diagnosis and management guidelines for improvement in PCOS care and 81.9% of respondents would appreciate standardised educational materials.

CONCLUSION

This is the first study to the best of our knowledge that gives an insight into the diagnostic and management processes of PCOS among various healthcare institutions in Singapore. This study calls for greater harmonisation of diagnostic processes and holistic evidence-based management of patients with PCOS through standardised workplace protocols and patient education resources.

Machine-Aided Self-diagnostic Prediction Models for Polycystic Ovary Syndrome: Observational Study

Background

Artificial intelligence and digital health care have substantially advanced to improve and enhance medical diagnosis and treatment during the prolonged period of the COVID-19 global pandemic. In this study, we discuss the development of prediction models for the self-diagnosis of polycystic ovary syndrome (PCOS) using machine learning techniques.

Objective

We aim to develop self-diagnostic prediction models for PCOS in potential patients and clinical providers. For potential patients, the prediction is based only on noninvasive measures such as anthropomorphic measures, symptoms, age, and other lifestyle factors so that the proposed prediction tool can be conveniently used without any laboratory or ultrasound test results. For clinical providers who can access patients’ medical test results, prediction models using all predictor variables can be adopted to help health providers diagnose patients with PCOS. We compare both prediction models using various error metrics. We call the former model the patient model and the latter, the provider model throughout this paper.

Methods

In this retrospective study, a publicly available data set of 541 women’s health information collected from 10 different hospitals in Kerala, India, including PCOS status, was acquired and used for analysis. We adopted the CatBoost method for classification, K-fold cross-validation for estimating the performance of models, and SHAP (Shapley Additive Explanations) values to explain the importance of each variable. In our subgroup study, we used k-means clustering and Principal Component Analysis to split the data set into 2 distinct BMI subgroups and compared the prediction results as well as the feature importance between the 2 subgroups.

Results

We achieved 81% to 82.5% prediction accuracy of PCOS status without any invasive measures in the patient models and achieved 87.5% to 90.1% prediction accuracy using both noninvasive and invasive predictor variables in the provider models. Among noninvasive measures, variables including acanthosis nigricans, acne, hirsutism, irregular menstrual cycle, length of menstrual cycle, weight gain, fast food consumption, and age were more important in the models. In medical test results, the numbers of follicles in the right and left ovaries and anti-Müllerian hormone were ranked highly in feature importance. We also reported more detailed results in a subgroup study.

Conclusions

The proposed prediction models are ultimately expected to serve as a convenient digital platform with which users can acquire pre- or self-diagnosis and counsel for the risk of PCOS, with or without obtaining medical test results. It will enable women to conveniently access the platform at home without delay before they seek further medical care. Clinical providers can also use the proposed prediction tool to help diagnose PCOS in women.

"I felt like she didn't take me seriously": a multi-methods study examining patient satisfaction and experiences with polycystic ovary syndrome (PCOS) in Canada

Background

Polycystic ovary syndrome (PCOS) is a common and complex condition affecting metabolic, reproductive, cardiovascular, and psychological health in women. Previous studies point to widespread dissatisfaction and delays with the diagnosis of PCOS and a lack of information provision by doctors, with few studies on Canadian populations. This multi-methods study explored the perceptions and experiences of PCOS diagnosis in Canada using an online-distributed survey and follow-up, in-depth, semi-structured phone interviews.

Methods

The online questionnaire was completed by 296 women aged 18–60 with a self-reported diagnosis of PCOS. The survey measured time to diagnosis, number of doctors seen, and information provided. Descriptive statistics, Chi-square tests, Fisher’s exact tests, and Spearman’s rank correlations were used to analyze the sample characteristics and correlations between the demographic factors and the outcome measures. Twenty-five follow-up interviews were held over the phone and analyzed using thematic analysis and interpretive description methodology.

Results

Survey respondents were dissatisfied with the information provided about PCOS (66%), lifestyle management (34%), and medical therapy (38%) at the time of diagnosis. Approximately 34% of respondents waited for more than 2 years and 41% saw 3 or more doctors before attaining diagnosis. Many did not receive any information about lifestyle management (42%) or medical therapy (28%). Interview participants encountered doctors who lacked sufficient knowledge on PCOS to diagnose, chronically dismissed concerns, and did not provide necessary medical information about the condition. Women described benefitting from self-advocation to receive the care they needed from doctors, and self-educating about PCOS using materials they could find online. Younger interview participants whose symptoms began in adolescence would often not understand the significance of symptoms until much later in life, contributing to delayed diagnoses.

Conclusions

Greater education on PCOS for physicians, particularly in primary care, is needed to prevent delayed diagnoses and ensure that patients are provided with reliable medical information about their condition. Greater awareness of PCOS may be necessary for the general population to help women identify symptoms, especially for adolescents and their parental figures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01630-3.

[Clinical guidelines «Polycystic Ovary Syndrome»]

Polycystic ovary syndrome (PCOS) is a polygenic endocrine disorder caused by both genetic and epigenetic factors. Depending on the period of a woman's life, the clinical picture, diagnosis, and treatment tactics of the disease are different. PCOS has a complex of reproductive, metabolic and psychological characteristics. The target audience of these clinical recommendations are obstetrician-gynecologists, endocrinologists, general practitioners, general practitioners. In these clinical guidelines, all information is ranked according to the level of persuasiveness of recommendations and the reliability of evidence, depending on the number and quality of studies on this issue.