Putting PCOS in order

Published 09 July 2018

ESHRE was a collaborator in new international guidelines for PCOS. Roy Homburg, a former co-ordinator of ESHRE's SIG Reproductive Endocrinology and veteran of the Rotterdam consensus of 2003, takes a look.

One of the highlights of ESHRE 2018 was release of the international evidence-based guidelines for the assessment and management of PCOS. This monumental effort by Helena Teede and myriad international experts was rightly praised by an audience appreciative of the fact that the basis of the guidelines was thoroughly researched and evidence-based. No more "experience-based" evidence or transatlantic chasms of disagreement; here was the nitty-gritty, following a strict process of appraisal and engagement of professional societies (including ESHRE), multidisciplinary experts, consumer organisations and women with PCOS.

A welcome start was the endorsement and grounding of the Rotterdam PCOS diagnostic criteria for adults including a recommendation that, if both oligo-anovulation and hyperandrogenism were present, then an ultrasound examination was not needed. If an ultrasound is necessary, then 20 small follicles in one ovary are now required for a diagnosis. In adolescents, ultrasound is not recommended for diagnostic purposes, AMH concentrations are thought to be not yet adequate as a diagnostic criterion, and the measurement of insulin resistance is not recommended.

Once diagnosed, management is recommended according to the presenting symptoms, whether reproductive, metabolic or psychological, and is dealt with in an equally impressive and incisive manner. Particular emphasis is placed on counteracting excess weight, which is responsible for exaggerating the symptoms of this very prevalent syndrome. Combined low-dose oral contraceptives are recommended treatment for menstrual irregularity, metformin for management of metabolic features and letrozole has won the battle for the first-line treatment of PCOS-associated infertility.

Ever since the first real description of PCOS by Stein and Leventhal in 1935, this syndrome has been a source of intense investigation and debate. This international evidence-based guideline brings it all together in a manner which will be greatly appreciated by clinicians and researchers alike and will undoubtedly be widely quoted and serve as a solid foundation for further progress in the management of this fascinating, very prevalent syndrome. All credit is due to Helen Teede and her co-workers for putting evidence-based order in place for PCOS.