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1
NoTypeRecommendationGradeQuality
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1PPAll diagnostic assessments are recommended for use in accordance with the diagnostic algorithm (Algorithm 1).
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1.1Irregular cycles and ovulatory dysfunction
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1.1.1CRIrregular menstrual cycles are defined as: Normal in the first year post menarche as part of the pubertal transition. 1 to < 3 years post menarche: < 21 or > 45 days. 3 years post menarche to perimenopause: < 21 or > 35 days or < 8 cycles per year. 1 year post menarche > 90 days for any one cycle. Primary amenorrhea by age 15 or > 3 years post thelarche (breast development). When irregular menstrual cycles are present a diagnosis of PCOS should be considered and assessed according to these PCOS Guidelines.4
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1.1.2PPThe mean age of menarche may differ across populations.
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1.1.3PPIn adolescents with irregular menstrual cycles, the value and optimal timing of assessment and diagnosis of PCOS should be discussed with the patient and their parent/s or guardian/s, considering diagnostic challenges at this life stage and psychosocial and cultural factors.
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1.1.4PPFor adolescents who have features of PCOS, but do not meet diagnostic criteria, an "increased risk" could be considered and reassessment advised at or before full reproductive maturity, 8 years post menarche. This includes those with PCOS features before combined oral contraceptive pill (COCP) commencement, those with persisting features and those with significant weight gain in adolescence.
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1.1.5PPOvulatory dysfunction can still occur with regular cycles and if anovulation needs to be confirmed serum progesterone levels can be measured.
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1.2Biochemical hyperandrogenism
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1.2.1EBRHealthcare professionals should use total and free testosterone to assess biochemical hyperandrogenism in the diagnosis of PCOS; free testosterone can be estimated by the calculated free androgen index.41
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1.2.2EBRIf testosterone or free testosterone is not elevated, healthcare professionals could consider measuring androstenedione and dehydroepiandrosterone sulfate (DHEAS), noting their poorer specificity and greater age associated decrease in DHEAS.31
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1.2.3EBRLaboratories should use validated, highly accurate tandem mass spectrometry (LC-MS/MS) assays for measuring total testosterone and if needed, for androstenedione and DHEAS. Free testosterone should be assessed by calculation, equilibrium dialysis or ammonium sulfate precipitation.42
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1.2.4EBRLaboratories should use LC-MS/MS assays over direct immunoassays (e.g., radiometric, enzyme-linked, etc.) for assessing total or free testosterone, which have limited accuracy and demonstrate poor sensitivity and precision for diagnosing hyperandrogenism in PCOS.42
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1.2.5PPFor the detection of hyperandrogenism in PCOS, the assessment of biochemical hyperandrogenism is of greatest value in patients with minimal or no clinical signs of hyperandrogenism (i.e., hirsutism).
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1.2.6PPIt is very difficult to reliably assess for biochemical hyperandrogenism in women on the combined oral contraceptive pill (COCP) as the pill increases sex hormone-binding globulin and reduces gonadotrophin-dependent androgen production. If already on the COCP, and assessment of biochemical androgens is imperative, the pill should be withdrawn for a minimum of three months and contraception should be managed otherwise during this time.
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1.2.7PPRepeated androgen measures for the ongoing assessment of PCOS in adults have a limited role.
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1.2.8PPIn most adolescents, androgen levels reach adult ranges at 12-15 years of age
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1.2.9PPIf androgen levels are markedly above laboratory reference ranges, causes of hyperandrogenaemia other than PCOS, including ovarian and adrenal neoplastic growths, congenital adrenal hyperplasia, Cushing's syndrome, ovarian hyperthecosis (after menopause), iatrogenic causes, and syndromes of severe insulin resistance, should be considered. However, some androgen-secreting neoplasms are associated with only mild to moderate increases in androgen levels. The clinical history of time of onset and/or rapid progression of symptoms is critical in assessing for an androgen-secreting tumour.
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1.2.10PPReference ranges for different methods and laboratories vary widely, and are often based on an arbitrary percentile or variances of the mean from a population that has not been fully characterized and is highly likely to include women with PCOS. Normal values should be determined either by the range of values in a well characterized healthy control population or by cluster analysis of general population values.
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1.2.11PPLaboratories involved in androgen measurements in females should consider: Determining laboratory normal values by either the range of values in a well characterized healthy control population or by cluster analysis of the values of a large general population. Applying the most accurate methods where available. Using extraction/chromatography immunoassays as an alternative to mass spectrometry only where adequate expertise is available. Future improvements may arise from measurement of 11-oxygenated androgens, and from establishing cut-off levels or thresholds based on large-scale validation in populations of different ages and ethnicities.
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1.3Clinical hyperandrogenism
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1.3.1EBRThe presence of hirsutism alone should be considered predictive of biochemical hyperandrogenism and PCOS in adults.31
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1.3.2EBRHealthcare professionals could recognize that female pattern hair loss and acne in isolation (without hirsutism) are relatively weak predictors of biochemical hyperandrogenism.31
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1.3.3CRA comprehensive history and physical examination should be completed for symptoms and signs of clinical hyperandrogenism, including acne, female pattern hair loss and hirsutism in adults, and severe acne and hirsutism in adolescents.4
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1.3.4CRHealthcare professionals should be aware of the potential negative psychosocial impact of clinical hyperandrogenism and should consider the reporting of unwanted excess hair growth and/or female pattern hair loss as being important, regardless of apparent clinical severity.3
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1.3.5CRA modified Ferriman Gallwey score (mFG) of 4 – 6 should be used to detect hirsutism, depending on ethnicity, acknowledging that self-treatment is common and can limit clinical assessment.4
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1.3.6CRHealthcare professionals should consider that the severity of hirsutism may vary by ethnicity but the prevalence of hirsutism appears similar across ethnicities.3
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1.3.7PPHealthcare professionals should: Be aware that standardized visual scales are preferred when assessing hirsutism, such as the mFG scale in combination with a photographic atlas. Consider the Ludwig or Olsen visual scales for assessing female pattern hair loss. Note that there are no universally accepted visual instruments for assessing the presence of acne. Recognize that women commonly treat clinical hyperandrogenism cosmetically, diminishing their apparent clinical severity. Appreciate that self-assessment of unwanted excess hair growth, and possibly acne and female pattern hair loss, has a high degree of validity and merits close evaluation, even if overt clinical signs of hyperandrogenism are not readily evident on examination. Note that only terminal hairs need to be considered in defining hirsutism, and these can reach >5 mm if untreated, vary in shape and texture, and are generally pigmented. Note that new-onset severe or worsening hyperandrogenism, including hirsutism, requires further investigation to rule out androgen-secreting tumours and ovarian hyperthecosis. Monitor clinical signs of hyperandrogenism, including hirsutism, acne and female pattern hair loss, for improvement or treatment adjustment during therapy.
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1.4Ultrasound and polycystic ovarian morphology
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1.4.1EBRFollicle number per ovary (FNPO) should be considered the most effective ultrasound marker to detect polycystic ovarian morphology (PCOM) in adults.42
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1.4.2EBRFollicle number per ovary (FNPO), follicle number per cross-section (FNPS) and ovarian volume (OV) should be considered accurate ultrasound markers for PCOM in adults.42
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1.4.3CRPCOM criteria should be based on follicle excess (FNPO, FNPS) and/or ovarian enlargement.4
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1.4.4CRFollicle number per ovary (FNPO) ≥ 20 in at least one ovary should be considered the threshold for PCOM in adults.4
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1.4.5CROvarian volume (OV) ≥ 10ml or follicle number per section (FNPS) ≥ 10 in at least one ovary in adults should be considered the threshold for PCOM if using older technology or image quality is insufficient to allow for an accurate assessment of follicle counts throughout the entire ovary.4
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1.4.6PPThere are no definitive criteria to define polycystic ovary morphology (PCOM) on ultrasound in adolescents, hence it is not recommended in adolescents.
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1.4.7PPWhen an ultrasound is indicated, if acceptable to the individual, the transvaginal approach is the most accurate for the diagnosis of PCOM.
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1.4.8PPTransabdominal ultrasound should primarily report ovarian volume (OV) with a threshold of ≥ 10 ml or follicle number per section (FNPS) ≥ 10 in either ovary in adults given the difficulty of assessing follicle counts throughout the entire ovary with this approach.
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1.4.9PPIn patients with irregular menstrual cycles and hyperandrogenism, an ovarian ultrasound is not necessary for PCOS diagnosis.
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1.4.10PPThresholds for PCOM should be revised regularly with advancing ultrasound technology, and age-specific cut-off values for PCOM should be defined.
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1.4.11PPThere is a need for training in careful and meticulous follicle counting per ovary and clear standardized protocols are recommended for PCOM reporting on ultrasound including at a minimum: Last menstrual period (or stage of cycle). Transducer bandwidth frequency. Approach/route assessed. Total number of 2 – 9 mm follicles per ovary. Measurements in three dimensions (in cm) or volume of each ovary. Other ovarian features and/or pathology including ovarian cysts, corpus lutea, dominant follicles (≥10 mm) (which should not be included in ovarian volume calculations). Reliance on the contralateral ovary FNPO for diagnosis of PCOM, where a dominant follicle is noted. Uterine features and/or pathology including endometrial thickness and pattern.
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1.5Anti-Müllerian Hormone in the diagnosis of PCOS
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1.5.1EBRSerum anti-Müllerian hormone (AMH) could be used for defining PCOM in adults.33
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1.5.2EBRSerum AMH should only be used in accordance with the diagnostic algorithm, noting that in patients with irregular menstrual cycles and hyperandrogenism, an AMH level is not necessary for PCOS diagnosis.43
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1.5.3EBRWe recommend that serum AMH should not be used as a single test for the diagnosis of PCOS.43
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1.5.4EBRSerum AMH should not yet be used in adolescents.43
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1.5.5PPEither serum AMH or ultrasound may be used to define PCOM; however, both tests should not be performed to limit overdiagnosis.
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1.5.6PPLaboratories and healthcare professionals need to be aware of factors that influence AMH in the general population including: Age: Serum AMH generally peaks between the ages of 20-25 years in the general population. Body mass index (BMI): Serum AMH is lower in those with higher BMI in the general population. Hormonal contraception and ovarian surgery: Serum AMH may be suppressed by current or recent COCP use. Menstrual cycle day: Serum AMH may vary across the menstrual cycle.
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1.5.7PPLaboratories involved in AMH measurements in females should use population and assay specific cut-offs.
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1.6Ethnic variation
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1.6.1EBRHealthcare professionals should be aware of the high prevalence of PCOS in all ethnicities and across world regions, ranging from 10-13% globally using the Rotterdam criteria.42
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1.6.2EBRHealthcare professionals should be aware that PCOS prevalence is broadly similar across world regions, but may be higher in South East Asian and Eastern Mediterranean regions.42
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1.6.3PPHealthcare professionals should be aware that the presentation of PCOS may vary across ethnic groups.
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1.7Menopause life stage
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1.7.1CRA diagnosis of PCOS could be considered as enduring / lifelong.3
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1.7.2CRHealthcare professionals could consider that both clinical and biochemical hyperandrogenism persist in the postmenopause for women with PCOS.3
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1.7.3CRPCOS diagnosis could be considered postmenopause if there is a past diagnosis, or a long-term history of oligo-amenorrhoea with hyperandrogenism and/or PCOM, during the earlier reproductive years (age 20-40).3
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1.7.4CRFurther investigations should be considered to rule out androgen-secreting tumours and ovarian hyperthecosis in postmenopausal women presenting with new-onset, severe or worsening hyperandrogenism including hirsutism.3
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1.8Cardiovascular disease risk
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1.8.1EBRWomen with PCOS should be considered at increased risk of cardiovascular disease and potentially of cardiovascular mortality, acknowledging that the overall risk of cardiovascular disease in pre-menopausal women is low.31
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1.8.2EBRAll women with PCOS should be assessed for cardiovascular disease risk factors.41
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1.8.3CRAll women with PCOS, regardless of age and BMI, should have a lipid profile (cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol and triglyceride level) at diagnosis. Thereafter, frequency of measurement should be based on the presence of hyperlipidaemia and additional risk factors or global cardiovascular risk.4
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1.8.4CRAll women with PCOS should have blood pressure measured annually and when planning pregnancy or seeking fertility treatment, given the high risk of hypertensive disorders in pregnancy and the associated comorbidities.4
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1.8.5CRFunding bodies should recognize that PCOS is highly prevalent with multisystem effects including cardiometabolic disease and should diversify and increase research support accordingly.4
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1.8.6CRCardiovascular general population guidelines could consider the inclusion of PCOS as a cardiovascular risk factor.3
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1.8.7CRHealthcare professionals, women with PCOS and other stakeholders should all prioritize preventative strategies to reduce cardiovascular risk.4
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1.8.8PPConsideration should be given to the differences in cardiovascular risk factors, and cardiovascular disease, across ethnicities (see 1.6.1) and age, when determining frequency of risk assessment.
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1.9Impaired glucose tolerance and type 2 diabetes risk
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1.9.1EBRHealthcare professionals and women with PCOS should be aware that, regardless of age and BMI, women with PCOS have an increased risk of impaired fasting glucose, impaired glucose tolerance and type 2 diabetes.42
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1.9.2EBRGlycaemic status should be assessed at diagnosis in all adults and adolescents with PCOS.42
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1.9.3CRGlycaemic status should be reassessed every one to three years, based on additional individual risk factors for diabetes.4
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1.9.4CRHealthcare professionals, women with PCOS and other stakeholders should prioritize preventative strategies to reduce type 2 diabetes risk.4
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1.9.5CRFunding bodies should recognize that PCOS is highly prevalent, has significantly higher risk for diabetes, and should be funded accordingly.4
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1.9.6CRDiabetes general population guidelines should consider the inclusion of PCOS as an independent risk factor for diabetes.4
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1.9.7PPHealthcare professionals, adults and adolescents with PCOS and their first-degree relatives, should be aware of the increased risk of diabetes and the need for regular glycaemic assessment.
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1.9.8PPWomen with type 1 and type 2 diabetes have an increased risk of PCOS and screening should be considered in individuals with diabetes.
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1.9.9EBRHealthcare professionals and women with PCOS should recommend the 75-g oral glucose tolerance test (OGTT) as the most accurate test to assess glycaemic status in PCOS, regardless of BMI.41
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1.9.10EBRIf an OGTT cannot be performed, fasting plasma glucose and/or glycated haemoglobin (HbA1c) could be considered, noting significantly reduced accuracy.31
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1.9.11EBRAn OGTT should be considered in all women with PCOS and without pre-existing diabetes, when planning pregnancy or seeking fertility treatment, given the high risk of hyperglycaemia and the associated comorbidities in pregnancy. If not performed preconception, an OGTT could be offered at the first prenatal visit and all women with PCOS should be offered the test at 24-28 weeks gestation.31
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1.9.12PPInsulin resistance is a pathophysiological factor in PCOS, however, clinically available insulin assays are of limited clinical relevance and are not recommended in routine care (refer to 3.1.10).
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1.10Obstructive Sleep Apnea
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1.10.1EBRHealthcare professionals should be aware that women with PCOS have significantly higher prevalence of obstructive sleep apnea compared to women without PCOS, independent of BMI.43
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1.10.2EBRWomen with PCOS should be assessed for symptoms of obstructive sleep apnea (i.e., snoring in combination with waking unrefreshed from sleep, daytime sleepiness or fatigue) and if present, screen with validated tools or refer for assessment.43
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1.10.3PPSimple obstructive sleep apnea screening questionnaires (such as the Berlin questionnaire, validated in the general population) can assist in identifying obstructive sleep apnea in women with PCOS, noting that diagnosis requires a formal sleep study.
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1.10.4PPGoals of treatment should target obstructive sleep apnea related symptom burden.
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1.11Endometrial hyperplasia and cancer
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1.11.1EBRHealthcare professionals should be aware that premenopausal women with PCOS have markedly higher risk of developing endometrial hyperplasia and endometrial cancer.41
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1.11.2PPWomen with PCOS should be informed about the increased risk of endometrial hyperplasia and endometrial cancer, acknowledging that the overall chance of developing endometrial cancer is low, therefore routine screening is not recommended.
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1.11.3PPLong-standing untreated amenorrhea, higher weight, type 2 diabetes and persistent thickened endometrium are additional to PCOS as risk factors for endometrial hyperplasia and endometrial cancer.
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1.11.4PPWomen with PCOS should be informed of preventative strategies including weight management, cycle regulation and regular progestogen therapy.
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1.11.5PPWhen excessive endometrial thickness is detected, consideration of a biopsy with histological analysis and withdrawal bleed is indicated.
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1.12Risks in first degree relatives
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1.12.1EBRHealthcare professionals could consider that fathers and brothers of women with PCOS may have an increased prevalence of metabolic syndrome, type 2 diabetes, and hypertension.31
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1.12.2PPThe cardiometabolic risk in female first degree relatives of women with PCOS remains inconclusive.
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2Prevalence, screening and management of psychological features and models of care
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2.1Quality of Life
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2.1.1EBRHealthcare professionals and women should recognize the adverse impact of PCOS and/or PCOS features on quality of life in adults.42
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2.1.2PPWomen with PCOS should be asked about their perception of PCOS related-symptoms, impact on quality of life, key concerns, and priorities for management.
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2.2Depression and Anxiety
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2.2.1EBRHealthcare professionals should be aware of the high prevalence of moderate to severe depressive symptoms and depression in adults and adolescents with PCOS and should screen for depression in all adults and adolescents with PCOS, using regionally validated screening tools.44
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2.2.2EBRHealthcare professionals should be aware of the high prevalence of moderate to severe anxiety symptoms and anxiety disorders in adults and should screen for anxiety in all adults with PCOS, using regionally validated screening tools.44
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2.2.3CRIf moderate or severe depressive or anxiety symptoms are detected, practitioners should further assess, refer appropriately, or offer treatment.4
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2.2.4PPSeverity of symptoms and clinical diagnosis of depression or anxiety should guide management. The optimal interval for anxiety and depression screening is not known. A pragmatic approach could include screening at diagnosis with repeat screening based on clinical judgement, risk factors, comorbidities, and life events, including the perinatal period. Screening for mental health disorders comprises assessment of risk factors, symptoms, and risk of self-harm and suicidal intent.
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2.3Psychosexual function
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2.3.1CRHealthcare professionals could consider the multiple factors that can influence psychosexual function in PCOS including higher weight, hirsutism, mood disorders, infertility and PCOS medications.3
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2.3.2CRPermission to discuss psychosexual function should be sought noting that the diagnosis of psychosexual dysfunction requires both low psychosexual function combined with related distress.4
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2.4Body Image
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2.4.1EBRHealthcare professionals should be aware that features of PCOS can have a negative impact on body image.42
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2.5Eating disorders
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2.5.1EBREating disorders and disordered eating should be considered in PCOS, regardless of weight, especially in the context of weight management and lifestyle interventions (see sections 2.4 and 3.6).32
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2.5.2PPIf disordered eating or eating disorders are suspected, appropriately qualified practitioners should further assess via a full diagnostic interview. If an eating disorder or disordered eating is detected, appropriate management and support should be offered.
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2.6Information resources, models of care, cultural and linguistic considerations
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2.6.1Information needs
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2.6.1.1EBRTailored information, education and resources that are high-quality, culturally appropriate and inclusive should be provided to all with PCOS.43
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2.6.1.2EBRInformation, education and resources are a high priority for patients with PCOS and should be provided in a respectful and empathic manner.43
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2.6.1.3CREntities responsible for healthcare professional education should ensure that information and education on PCOS is systemically embedded at all levels of healthcare professional training to address knowledge gaps.4
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2.6.1.4PPThe diversity of the population should be considered when adapting practice paradigms. Healthcare professional education opportunities should be optimised at all stages of graduate and postgraduate training and continuing professional development and in practice support resources.
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2.6.1.5PPWomen should be counselled on the risk of misinformation and guided to evidence-based resources.
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2.6.2Models of care
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2.6.2.1CRModels of care should prioritize equitable access to evidence-based primary care with pathways for escalation to integrated specialist and multidisciplinary services as required.4
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2.6.2.2PPStrategies to deliver optimal models of care could include healthcare professional education, care pathways, virtual care, broader health professional engagement (e.g., nurse practitioners) and coordination tools.
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2.6.3Support to manage PCOS
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2.6.3.1CRPublic health actors should consider increasing societal awareness and education on PCOS to reduce stigma and marginalization.3
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2.6.3.2PPCulturally appropriate resources and education on PCOS across the life span for families of those with the condition should be considered.
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2.2.2EBRHealthcare professionals should be aware of the high prevalence of moderate to severe anxiety symptoms and anxiety disorders in adults and should screen for anxiety in all adults with PCOS, using regionally validated screening tools.44
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2.2.3CRIf moderate or severe depressive or anxiety symptoms are detected, practitioners should further assess, refer appropriately, or offer treatment.4
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2.2.4PPSeverity of symptoms and clinical diagnosis of depression or anxiety should guide management. The optimal interval for anxiety and depression screening is not known. A pragmatic approach could include screening at diagnosis with repeat screening based on clinical judgement, risk factors, comorbidities, and life events, including the perinatal period. Screening for mental health disorders comprises assessment of risk factors, symptoms, and risk of self-harm and suicidal intent.
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2.3Psychosexual function
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2.3.1CRHealthcare professionals could consider the multiple factors that can influence psychosexual function in PCOS including higher weight, hirsutism, mood disorders, infertility and PCOS medications.3
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2.3.2CRPermission to discuss psychosexual function should be sought noting that the diagnosis of psychosexual dysfunction requires both low psychosexual function combined with related distress.4
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2.4Body Image
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2.4.1EBRHealthcare professionals should be aware that features of PCOS can have a negative impact on body image.42
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2.5Eating disorders
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2.5.1EBREating disorders and disordered eating should be considered in PCOS, regardless of weight, especially in the context of weight management and lifestyle interventions (see sections 2.4 and 3.6).32
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2.5.2PPIf disordered eating or eating disorders are suspected, appropriately qualified practitioners should further assess via a full diagnostic interview. If an eating disorder or disordered eating is detected, appropriate management and support should be offered.
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2.6Information resources, models of care, cultural and linguistic considerations
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2.6.1Information needs
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2.6.1.1EBRTailored information, education and resources that are high-quality, culturally appropriate and inclusive should be provided to all with PCOS.43
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2.6.1.2EBRInformation, education and resources are a high priority for patients with PCOS and should be provided in a respectful and empathic manner.43
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2.6.1.3CREntities responsible for healthcare professional education should ensure that information and education on PCOS is systemically embedded at all levels of healthcare professional training to address knowledge gaps.4
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2.6.1.4PPThe diversity of the population should be considered when adapting practice paradigms. Healthcare professional education opportunities should be optimised at all stages of graduate and postgraduate training and continuing professional development and in practice support resources.
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2.6.1.5PPWomen should be counselled on the risk of misinformation and guided to evidence-based resources.
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2.6.2Models of care
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2.6.2.1CRModels of care should prioritize equitable access to evidence-based primary care with pathways for escalation to integrated specialist and multidisciplinary services as required.4
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2.6.2.2PPStrategies to deliver optimal models of care could include healthcare professional education, care pathways, virtual care, broader health professional engagement (e.g., nurse practitioners) and coordination tools.
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2.6.3Support to manage PCOS
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2.6.3.1CRPublic health actors should consider increasing societal awareness and education on PCOS to reduce stigma and marginalization.3
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2.6.3.2PPCulturally appropriate resources and education on PCOS across the life span for families of those with the condition should be considered.
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2.6.4Patient care
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2.6.4.1EBRHealthcare professionals should employ shared decision-making and support patient agency or ability to take independent actions to manage their health and care.43
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2.6.4.2EBRThe importance of being knowledgeable about PCOS, of applying evidence-based practices when sharing news on diagnosis, treatment, and health implications, and of ascertaining and focusing on patient priorities, should be recognized.43
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2.6.4.3CRHealthcare system leaders should enable system wide changes to support healthcare professional training, knowledge and practice in sharing news optimally, shared decision making and patient agency, including ensuring adequate consultation time and accessible resources.4
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2.6.4.4PPEvidence-based strategies for shared decision making and for sharing news (such as the SPIKES framework) are readily available and should be used to inform PCOS care. All healthcare professionals partnering with women with PCOS should be knowledgeable in sharing news, in shared decision-making, and in supporting patient self-management. Evidence-based strategies and resources can be used to support patient activation, which refers to modifiable knowledge, skills, ability, confidence, and willingness to self-manage one's own health and care.
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2.7Psychological therapy
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2.7.1CRWomen with PCOS diagnosed with depression, anxiety, and/or eating disorders should be offered psychological therapy guided by regional general population guidelines and the preference of the woman with PCOS.4
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2.7.2CRWomen with PCOS with disordered eating, body image distress, low self-esteem, problems with feminine identity, or psychosexual dysfunction should be offered evidence-based treatments (e.g., cognitive behaviour therapy) where appropriate.4
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2.8Antidepressant and anxiolytic treatment
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2.8.1CRPsychological therapy could be considered first-line management, and antidepressant medications considered in adults where mental health disorders are clearly documented and persistent, or if suicidal symptoms are present, based on general population guidelines.3
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2.8.2PPLifestyle intervention and other therapies (e.g., COCP, metformin, laser hair removal) that target PCOS features should be considered, given their potential to improve psychological symptoms. Where pharmacological treatment for anxiety and depression is offered in PCOS, healthcare professionals should apply caution: to avoid inappropriate treatment with antidepressants or anxiolytics; to limit use of agents that exacerbate PCOS symptoms, including weight gain. Healthcare professionals should be aware that not managing anxiety and depression may impact adherence to PCOS treatment / management.
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3Lifestyle management
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3.1Effectiveness of lifestyle interventions
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3.1.1EBRLifestyle intervention (exercise alone or multicomponent diet combined with exercise and behavioural strategies) should be recommended for all women with PCOS, for improving metabolic health including central adiposity and lipid profile.41
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3.1.2CRHealthy lifestyle behaviours encompassing healthy eating and/or physical activity should be recommended in all women with PCOS to optimize general health, quality of life, body composition and weight management (maintaining weight, preventing weight gain and/or modest weight loss).4
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3.1.3PPHealthcare professionals should be aware that lifestyle management is a core focus in PCOS management.
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3.1.4PPLifestyle management goals and priorities should be co-developed in partnership with women with PCOS, and value women's individualized preferences.
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3.1.5PPThere are benefits to a healthy lifestyle even in the absence of weight loss.
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3.1.6PPIn those with higher weight, weight management can be associated with significant clinical improvements and the following key points need to be considered including: A lifelong focus on prevention of further weight gain. If the goal is to achieve weight loss, a tailored energy deficit could be prescribed for women, considering individual energy requirements, body weight and physical activity levels. The value of improvement in central adiposity (e.g., waist circumference, waist-hip ratio) or metabolic health. The need for ongoing assessment and support.
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3.1.7PPHealthcare professionals should be aware of weight stigma when discussing lifestyle management with women with PCOS (see 3.6).
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3.1.8PPHealthy lifestyle and optimal weight management, in the context of structured, intensive, and ongoing clinical support, appears equally effective in PCOS as in the general population.
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3.1.9PPIn those who are not overweight, in the adolescent and at key life points, the focus should be on healthy lifestyle and the prevention of excess weight gain.
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3.1.10PPInsulin resistance is a pathophysiological factor in PCOS, however, clinically available insulin assays are of limited clinical relevance and should not be used in routine care (refer to 1.9.12).
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3.2Behavioural Strategies
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3.2.1CRLifestyle interventions could include behavioural strategies such as goal-setting, self-monitoring, problem solving, assertiveness training, reinforcing changes, and relapse prevention, to optimize weight management, healthy lifestyle and emotional wellbeing in women with PCOS.3
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3.2.2PPBehavioural support could include: goal-setting, problem solving, self-monitoring and reviewing, or SMART goals (Specific, Measurable, Achievable, Realistic and Timely).
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3.2.3PPComprehensive healthy behavioural or cognitive behavioural interventions could be considered to increase support, engagement, retention, adherence, and maintenance of healthy lifestyle and improve health outcomes in women with PCOS.
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3.3Dietary Intervention
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3.3.1EBRHealthcare professionals and women should consider that there is no evidence to support any one type of diet composition over another for anthropometric, metabolic, hormonal, reproductive or psychological outcomes.31
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3.3.2CRAny diet composition consistent with population guidelines for healthy eating will have health benefits and, within this, healthcare professionals should advise sustainable healthy eating tailored to individual preferences and goals.4
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3.3.3PPTailoring of dietary changes to food preferences, allowing for a flexible, individual and co-developed approach to achieving nutritional goals, and avoiding unduly restrictive and nutritionally unbalanced diets, are important, as per general population guidelines.
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3.3.4PPBarriers and facilitators to optimize engagement and adherence to dietary change should be discussed, including psychological factors, physical limitations, socioeconomic and sociocultural factors, as well as personal motivators for change. The value of broader family engagement should be considered. Referral to suitably trained allied healthcare professionals needs to be considered when women with PCOS need support with optimizing their diet.
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3.4Exercise Intervention
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3.4.1EBRHealthcare professionals and women could consider that there is a lack of evidence supporting any one type and intensity of exercise being better than another for anthropometric, metabolic, hormonal, reproductive or psychological outcomes.31
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3.4.2CRAny physical activity consistent with population guidelines will have health benefits and, within this, healthcare professionals should advise sustainable physical activity based on individual preferences and goals.4
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3.4.3CRHealthcare professionals should encourage and advise the following in concordance with general population physical activity guidelines: All adults should undertake physical activity as doing some physical activity is better than none. Adults should limit the amount of time spent being sedentary (e.g., sitting, screen time) as replacing sedentary time with physical activity of any intensity (including light intensity) provides health benefits. For the prevention of weight gain and maintenance of health, adults (18-64 years) should aim for a minimum of 150 to 300 minutes of moderate intensity activities or 75 to 150 minutes of vigorous intensity aerobic activity per week or an equivalent combination of both spread throughout the week, plus muscle strengthening activities (e.g., resistance/flexibility) on two non-consecutive days per week. For promotion of greater health benefits including modest weight-loss and prevention of weight-regain, adults (18-64 years) should aim for a minimum of 250 min/week of moderate intensity activities or 150 min/week of vigorous intensities or an equivalent combination of both, plus muscle strengthening activities (e.g., resistance/flexibility) ideally on two non-consecutive days per week. Adolescents should aim for at least 60 minutes of moderate- to vigorous-intensity physical activity per day, including activities that strengthen muscle and bone at least three times per week.4
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3.4.4PPPhysical activity is any bodily movement produced by skeletal muscles that requires energy expenditure. It includes leisure time physical activity, transportation (e.g., walking or cycling), occupational (i.e., work), household chores, playing games, sports or planned exercise, or activities in the context of daily, family and community activities.
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3.4.5PPAerobic activity is best performed in bouts of at least 10 minutes duration, aiming to achieve at least 30 minutes daily on most days.
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3.4.6PPBarriers and facilitators to optimize engagement and adherence to physical activity should be discussed, including psychological factors (e.g., body image concerns, fear of injury, fear of failure, mental health), personal safety concerns, environmental factors, physical limitations, socioeconomic factors, sociocultural factors, and personal motivators for change. The value of broader family engagement should be considered. Referral to suitably trained allied healthcare professionals needs to be considered for optimizing physical activity in women with PCOS.
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3.4.7PPSelf-monitoring, including with fitness tracking devices and technologies for step count and exercise intensity, could be considered as an adjunct to support and promote active lifestyles and minimize sedentary behaviours.
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3.5Factors affecting weight gain in PCOS
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3.5.1EBRHealthcare professionals and women with PCOS could consider that there is a lack of consistent evidence of physiological or behavioural lifestyle differences, related to weight, in women with PCOS compared to women without PCOS.31
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3.5.2PPWhilst the specific mechanisms are unclear, it is recognized that many women with PCOS will have underlying mechanisms that drive greater longitudinal weight gain and higher BMI which may: Underpin greater challenges with weight management. Highlight the importance of lifelong healthy lifestyle strategies and prevention of excess weight gain. Assist women with PCOS and healthcare professionals in forming realistic, tailored lifestyle goals.
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3.6Weight Stigma
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3.6.1EBRMany women with PCOS experience weight stigma in healthcare and other settings and the negative biopsychosocial impacts of this should be recognized.42
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3.6.2CRHealthcare professionals should be aware of their weight biases and the impact this has on their professional practice and on women with PCOS.4
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3.6.3CRHealth policy makers, managers and educators should promote awareness of weight stigma and invest in weight stigma education and minimization strategies.4
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3.6.4PPHealthcare professionals should be aware of weight-inclusive practices which promote acceptance of and respect for body size diversity and focus on improvement of health behaviours and health outcomes for people of all sizes. In PCOS this includes: Acknowledging that whilst higher weight is a risk factor for PCOS and its complications, it is only one indicator of health and broader factors should be assessed. Asking permission to discuss and measure weight and using strategies to minimize discomfort (e.g., blind weighing). Recognizing that the terms 'overweight' and 'obese/obesity' can be stigmatizing with suggested alternatives including 'higher weight'. If weighing, explaining how weight information will be used to inform risks, prevention and treatment and how not knowing may impact on recommendations. Ensuring appropriate equipment is available for women of all sizes. Offering options of weight-centric care (promoting intentional weight loss) or weight-inclusive care (promoting healthy lifestyle change without focusing on intentional weight loss) tailored to individual goals and preferences. Offering all women best practice assessment, treatment and support regardless of weight, acknowledging that weight may be a non-modifiable risk factor when using lifestyle modification alone.
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3.6.5PPIncreasing awareness of weight stigma among family members of women and adolescents with PCOS should be considered.
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4Management of non-fertility features
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4.1Pharmacology treatment principles in PCOS
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4.1.1PPShared decision making between the patient (and parent/s or guardian/s, if the patient is a child) and the healthcare professional is required.
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4.1.2PPAn individual’s characteristics, preferences and values must be elicited and considered when recommending any intervention alone or in combination.
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4.1.3PPUnderstanding how individual adults and adolescents value treatment outcomes is essential when prescribing medications.
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4.1.4PPMedical therapy is generally not approved for use specifically in PCOS and recommended use is therefore evidence-based, but off-label. Healthcare professionals need to inform adults, adolescents and their parents/s or guardian/s and discuss the evidence, possible concerns and side effects. Regulatory agencies should consider approval of evidence-based medications for use in PCOS.