Published: Oct 28, 2013

Image from MedPageToday.com

By Salynn Boyles, Contributing Writer, MedPage Today

Full Story:  http://www.medpagetoday.com/Endocrinology/GeneralEndocrinology/42519

Women with at least two of the three cardinal features of polycystic ovary syndrome (PCOS) should be considered to have the disorder, according to clinical practice guidelines released by the Endocrine Society.

The new guidelines endorse the Rotterdam criteria for diagnosing PCOS, which identifies excess androgen production, ovulatory dysfunction, and polycystic ovaries as the key diagnostic features of the disorder in adult women.

An independent panel convened by the National Institutes of Health (NIH) also endorsed the diagnostic classification system in a report published in January.

A goal of the newly released clinical practice guidelines was to simplify diagnosis and treatment recommendations for PCOS, which affects about 5 million women in the U.S. and is a leading cause of infertility, according to the Endocrine Society guidelines released online Friday and scheduled for publication in the December issue of the Journal of Clinical Endocrinology & Metabolism.

Several unrelated conditions — such as thyroid disease, nonclassical congenital adrenal hyperplasia, and hyperprolactinemia — can mimic PCOS, and the ovarian cysts which give PCOS its name are not seen in all patients.

Because of this, the NIH panel also concluded that the name PCOS causes confusion and should be changed.

“The name PCOS is a distraction that impedes progress,” panel member Robert A. Rizza, MD, of the Mayo Clinic, Rochester, Minnesota, noted in a written press statement. “It is time to assign a name that reflects the complex interactions that characterize the syndrome.”

The Endocrine Society task force concluded that the diagnosis and treatment of PCOS remains a significant challenge in young girls and menopausal women.

Task force chairman Richard S. Legro, MD, of Penn State University College of Medicine in Hershey, Pa., told MedPage Today that research designed to better understand the disorder in adolescents is a priority. One problem, he said, is that common symptoms of PCOS in young women, such as irregular periods, acne, and mild elevations in androgen levels, are also common in puberty.

“We tried to identify gray areas in this report and probably the grayest area out there is what to do with adolescents with PCOS who are presumably at a phase in life when aggressive treatment may have the greatest benefits,” he said. “The message is that we shouldn’t just sit around and twiddle our thumbs. We felt that the full range of treatments should be available to adolescents and should not be restricted based on age.”

In perimenopausal and menopausal women, the task force suggested that a presumptive diagnosis of PCOS can be based upon a history of oligomenorrhea and hyperandrogenism.

Other panel recommendations included:

• Women with PCOS seeking fertility should be asked about their menstrual history, and causes of infertility other than anovulation should be screened for in couples where the woman has PCOS.
• Because women with PCOS are at increased risk for pregnancy complications such as gestational diabetes, preterm delivery and pre-eclampsia, the task force recommended pre-conceptual assessment of body mass index, blood pressure, and oral glucose tolerance.
• The panel recommended against routine ultrasound screening for endometrial thickness, even though women with PCOS typically have risk factors associated with the development of endometrial cancer.

With regard to treatment, the panel recommended:

• Hormonal contraceptives as the first-line treatment for the management of menstrual abnormalities and hirsutism/acne in women who are not seeking fertility.
• Treatment with clomiphene citrate (or comparable estrogen modulators such as letrozole) as first-line therapy for anovulatory infertility in women with PCOS, with metformin used as an adjuvant therapy to prevent ovarian hyperstimulation syndrome in PCOS patients undergoing in vitro fertilization.
• Against the use of insulin sensitizers, such as inositols or thiazolidinediones.
• That metformin not be used as a first-line treatment for cutaneous manifestations, prevention of pregnancy complications, or obesity.

Legro said there is strong evidence that hormonal contraceptives are both effective and safe for the treatment for the PCOS, but he added that metformin may be overprescribed.