Assessment and Management

of Women with Polycystic Ovary

39
Syndrome (PCOS)

Rhonda Garad, Soulmaz Shorakae,
and Helena Teede

Contents
39.1   Introduction   756
39.2   Epidemiology   756
39.3   Pathophysiology   756
39.4   Diagnostic Criteria (Rotterdam Criteria)   756
39.4.1  PCOS and Obesity   757
39.4.2  Clinical Features   759
39.4.3  Reproductive Features   759
39.4.4  Metabolic Features   759
39.4.5  Psychological Features   759
39.5   Diagnosis and Investigations   760
39.6   Presentation of PCOS at Different Life Stages   760
39.6.1  Young Women (<20 Years)   760
39.6.2  Adult Women (Reproductive Years)   760
39.6.3  Peri/menopausal Women   760
39.7   Patient-Centred Care Model   760
39.7.1  Key Patient Messages Once Diagnosis Established   761
39.8   Management of Hyperandrogenism   761

R. Garad (*)
Knowledge Translation in Polycystic Ovary
Syndrome (PCOS), Monash Centre for Health
Research and Implementation (MCHRI), School of
Public Health and Preventive Medicine, Monash
University, Clayton, VIC, Australia
e-mail: rhonda.garad@monash.edu
S. Shorakae
Monash Centre for Health Research and
Implementation (MCHRI), School of Public Health
and Preventative Medicine, Monash University,
Clayton, VIC, Australia
e-mail: soulmaz.shorakae@monash.edu
H. Teede
Monash Centre for Health Research and
Implementation (MCHRI), Monash Partners,
Clayton, VIC, Australia
e-mail: helena.teede@monash.edu

© Springer Nature Switzerland AG 2019 753

S. Llahana et al. (eds.), Advanced Practice in Endocrinology Nursing,
https://doi.org/10.1007/978-3-319-99817-6_39
754 R. Garad et al.

39.9   Management of Reproductive Features   761

39.9.1  Therapeutic Benefits of Metformin in PCOS   762
39.9.2  Preconception and Early Pregnancy Care   762
39.10   Early Screening and Management of Metabolic Complications   762
39.10.1  Metabolic Risk Management in PCOS (Next Section Will
Be Put in Table Format)   763
39.11   Conclusions   768
39.12   Online Resources   768
References   768

Abstract isfaction with diagnosis experiences, poor

Polycystic ovary syndrome (PCOS) is a com-
plex, common endocrine condition affecting
reproductive aged women with a reported
prevalence of between 8 and 13%, depending
on the diagnostic criteria and the population
studied. Diagnosis, based on Rotterdam crite-
ria, commonly requires two of the three fol-
lowing features: oligo/amenorrhoea, polycystic
ovaries on ultrasound, biochemical/or clinical
hyperandrogenism, with exclusion of other
aetiologies. Nurses are ideally situated to pro-
vide evidence-based care and education within
an interdisciplinary model to optimise the
health outcomes of women with PCOS.
PCOS affects health and well-being over
the lifespan. The presentation of PCOS can be
heterogeneous with reproductive (hyperan-
drogenism, anovulation, and subfertility),
metabolic (dyslipidaemia, type 2 diabetes, and
CVD risk factors), and psychological features
(depression, anxiety, and poor self-esteem).
Women with PCOS are also predisposed to
weight gain, which in turn increases PCOS
prevalence and exacerbates its severity. PCOS
is underpinned by intrinsic insulin resistance.
Obesity exacerbates insulin resistance, and
lifestyle modification alleviates this feature.
Despite the high prevalence of PCOS many
women with PCOS remain undiagnosed, clin-
ical practice is inconsistent, psychological
issues are neglected, and there is little focus
on lifestyle modification and chronic disease
prevention with most services targeting fertil-
ity and offering costly assisted reproductive
technology. In addition, women report dissat-
quality information, and inadequate support.
Given the multi-system dimensions of
PCOS and duration of impact over the lifes-
pan, PCOS places a large financial burden on
health systems with affected women also suf-
fering the social costs of stigmatisation and
isolation, largely due to non-conformity with
societal expectations relating to femininity
and fecundity. In addition, due to the diversity
of PCOS health impacts, affected women
may be marginalised within the health system
and often fall between the gaps in a special-
ity-focused health care system, with knowl-
edge gaps among practitioners and,
inconsistency in care delivered. In the pri-
mary care sector, health practitioners report
feeling confused and ill equipped to manage
PCOS, listing PCOS as the highest priority
for education in women’s health. With women
feeling isolated, disempowered, and under-
serviced, PCOS places a personal burden on
affected women and their significant others,
and highlights the lack of systemic, evidence-
based responsiveness to their needs. This
chapter provides an overview of PCOS for
endocrine nurses who can play a c­ ritical role
in providing evidence-based, person-­centred
care, within an interdisciplinary, biopsycho-
social model of care.
Keywords
Polycystic ovary syndrome · Metabolic
syndrome · Subfertility · Hyperandrogenism
Menstrual irregularity · Emotional well-being
Lifestyle management
39  Assessment and Management of Women with Polycystic Ovary Syndrome (PCOS)
Abbreviations
AMH Anti-Müllerian hormone
BMI Body mass index
FAI Free androgen index
FSH Follicle stimulating hormone
GnRH Gonadotropin-releasing hormone
LH Luteinising hormone
OGTT Oral glucose tolerance test
PCOS Polycystic ovary syndrome
SHBG Sex hormone binding globulin
T Testosterone
Key Terms
• Body image: is the way a person may feel,
think, and view their body including their
appearance.
• Disordered eating: refers to eating and
weight-­related symptoms and can include
behavioural, cognitive, and emotional factors.
• Emotional well-being: a broad subjective
concept encompassing; feelings, behaviour,
relationships, goals, and personal strengths.
Well-being may manifest differently due to
sociocultural and individual factors.
• Hirsutism: excessive hair growth (face,
stomach).
• HRQoL: Health-Related Quality of Life is a
multidimensional (physical, psychological,
social) and subjective concept related to a
variety of patient outcomes.
• Hyperandrogenism: is characterised by
excessive production and/or secretion of
androgens.
• Metabolic syndrome: is a clustering of risk
factors such as excess abdominal weight, lipid
abnormalities, hypertension, and elevated glu-
cose levels that are underpinned by the patho-
physiological causes of insulin resistance
associated with central adiposity.
• Psychosexual dysfunction: encompasses
sexual problems or difficulties that have a psy-
chological basis.
755
Key Points
• PCOS is a highly prevalent, complex,
heterogeneous condition with reproduc-
tive, metabolic, and psychological
features.
• It is under-recognised with up to 70% of
affected women undiagnosed. This lack
of recognition leads to significant delays
in diagnosis and inconsistent manage-
ment practices with affected women
reporting unsatisfactory diagnosis expe-
riences and inadequate support and
information provision.
• Emotional well-being and increased
metabolic risks are often under-­
recognised in PCOS and ethnic differ-
ences are often poorly appreciated.
• Subfertility is a prevalent feature of
PCOS with approximately 75% of
PCOS-related subfertility due to anovu-
lation, yet with simple medical assis-
tance the majority of women with PCOS
can attain desired family size.
• Insulin resistance is a cardinal feature in
PCOS, affecting 75% of lean women
and 95% of obese women, contributing
to an increased risk of impaired glucose
metabolism and chronic diseases such as
diabetes, obesity, and CVD risk factors.
• There is a bi-directional relationship
between PCOS and obesity. Weight loss
is a highly effective way to reduce the
severity of PCOS symptoms and reduce
long-term health risks. Healthy lifestyle
(diet, exercise, and reduction of harmful
behaviours such as smoking) is the first-
line treatment for symptom management
and prevention of chronic diseases.
• A holistic, person-centred approach
within a biopsychosocial model of care is
recommended, with a primary focus on a
healthy lifestyle, emotional well-being,
and prevention of chronic diseases.
756
39.1 Introduction
Polycystic ovary syndrome (PCOS) is the most
common endocrinopathy affecting reproductive
aged women (Yilmaz et al. 2018). It is a preva-
lent, complex condition with a heterogeneous
range of reproductive, metabolic, and
­psychological symptoms. The condition is undi-
agnosed in up to 70% of affected women and key
features such as a psychological burden and met-
abolic risks are under-recognised. Women with
PCOS report dissatisfaction with diagnosis expe-
riences, poor quality information, and inconsis-
tent management practices. To achieve optimal
health outcomes for women with PCOS a holis-
tic, person-centred approach implemented within
a biopsychosocial model of care is
recommended.
39.2 Epidemiology
PCOS is increasingly recognised as a condition
affecting women across the lifespan with hyper-
androgenic symptoms (acne, hirsutism) most evi-
dent in adolescents and increased metabolic risks
(diabetes, central obesity, and CVD risk factors)
more prominent later in life. The prevalence of
PCOS ranges from 8 to 13% depending on the
criteria used to diagnose the condition (March
et al. 2010; Boyle et al. 2012; Yildiz et al. 2012).
Women at higher risk of developing PCOS
include those who are overweight, and those with
a family history of PCOS or type 2 diabetes
(T2DM).
39.3 Pathophysiology
The pathophysiology of PCOS is not fully under-
stood despite the identification of a genetic predis-
position (Fig.  39.1). Studies have shown women
with a positive family history for PCOS are at
increased risk of developing the condition, with up
to 80% heritability (Kahsar-Miller and Azziz
1998). Hyperandrogenism and insulin resistance,
caused by both genetic and environmental factors,
are the key hormonal features underpinning the
R. Garad et al.
pathophysiology of PCOS (Teede et  al. 2011).
Insulin resistance is present in up to 85% of women
with PCOS, including lean and obese women
(Stepto et al. 2013) and hyperandrogenism is pres-
ent in 60–80% (Teede et  al. 2011). In addition,
alterations in hormonal signalling is evident with
increased gonadotropin releasing hormone
(GnRH) and luteinising hormone (LH) pulse fre-
quency and increased LH to follicular stimulating
hormone (FSH) ratio, resulting in impaired follic-
ular development and increased ovarian androgen
production. Also, hyperinsulinaemia, through the
gonadotropic action of insulin on follicular cells,
further exacerbates these hormonal derangements
(Azziz et al. 2016).
Note: The current name—polycystic ovary
syndrome—is increasingly recognised as redun-
dant with moves afoot to rename the condition to
more accurately reflect the underpinning
pathophysiology.
39.4 Diagnostic Criteria
(Rotterdam Criteria)
PCOS is diagnosed based on excess androgens
(clinical or biochemical hyperandrogenism),
menstrual irregularity (secondary to ovulatory
dysfunction), and polycystic ovarian morphology
(PCOM) on ultrasound.
The Rotterdam diagnostic criteria (Fig. 39.2)
highlights the refined diagnostic criteria in ado-
lescents, which require both hyperandrogenism
and irregular cycles, with ultrasound now not rec-
ommended for diagnosis within 8 years of men-
arche, owing to overlap with normal reproductive
physiology.
Patient Quote 1
“When I found out that what was happen-
ing to me had a name and was fairly com-
mon I was greatly relieved. Up to that
point, I thought I was I going crazy. When I
asked my doctor she just it was nothing to
worry about and just stop eating so much. I
felt very isolated”.
39  Assessment and Management of Women with Polycystic Ovary Syndrome (PCOS) 757

Genetics Lifestyle

Hormonal changes
Obesity exacerbates hormonal changes

↑ Androgens ↑ Insulin

Ovarian follicles Diabetes

Anovulation Metabolic
↑ Oestrogen syndrome

Hirsutism Menstrual disturbances Cardiovascular

Acne Sub fertility risk

Psychosocial issues: body image, self esteem, depression, anxiety

Fig. 39.1  The aetiological, hormonal, and clinical features of polycystic ovary syndrome (Teede et al. 2011)

step 1: Irregular cycles + clinical hyperandrogenism

(exclude other causes)* = diagnosis

step 2: If no clinical hyperandrogenism

Test for biochemical hyperandrogenism (exclude other causes)* = diagnosis

step 3: If ONLY irregular cycles OR hyperandrogenism

Adolescents ultrasound is not indicdated = consider at risk of PCOS and reassess later
Adults - request ultrasound for PCOM, if positive (exclude other causes)* = diagnosis
* Exclusion of other causes requires TSH, Prolactin levels, FSH and if clinical status indicates other causes need to be excluded
(e.g. CAH, Cushings, adrenal tumours etc)
Hypogonadotrophic hypogonadism, generally due to low body fat or intensive exercise, should also be excluded
clinically and with LH and FSH levels.

Fig. 39.2  The refined Rotterdam diagnostic criteria

39.4.1  PCOS and Obesity increased hunger signalling and/or the impact of

There is a strong bi-directional relationship
between PCOS and obesity. Whilst PCOS occurs
independently of obesity, there is an increased
prevalence of obesity in women with PCOS. In
turn, there is an increased prevalence of PCOS as
BMI increases, with obesity exacerbating meta-
bolic, reproductive, and psychological features
of PCOS (Teede et  al. 2013; Lim et  al. 2013).
Studies have shown that women with PCOS
have a higher calorie intake and a more seden-
tary lifestyle than women without PCOS (Moran
et al. 2013). Further research is required into the
biopsychosocial drivers of obesity such as
emotional well-being on lifestyle habits.
Mechanistically, insulin resistance and hyperan-
drogenism are both exacerbated by obesity with
adipose tissue producing pro-inflammatory sig-
nals mediating insulin resistance and hyperan-
drogenism. Moreover, decreased production of
sex hormone binding globulin (SHBG) associ-
ated with obesity and insulin resistance results in
increased levels of free circulating androgens
and hyperandrogenism. Whilst a higher body
mass index (BMI) is a common feature in women
with PCOS, there is a need for vigilance in order
not to miss the diagnosis of PCOS in lean
women.
758 R. Garad et al.

Upper lip

1 2 3 4

Chin
1 2 3 4

Chest

1 2 3 4

Abdomen

1 2 3 4

Pelvis

1 2 3 4

Upper arms

1 2 3 4

Thighs

1 2 3 4

Upper back

1 2 3 4

Lower back

1 2 3 4

Fig. 39.3 Hirsutism scoring scale of Ferriman and
Gallwey. Figure used with permission from Ehrmann DA
(2017) Hirsutism, Chapter 17. In: Jameson JL (Eds)
Harrison’s Endocrinology, 4th Edition, McGraw Hill
Education, New  York, pages 226–231 (Figure  17-1).
Permission also obtained from original source: Hatch, R.,
Rosenfield, R.  L., Kim, M.  H. & Tredway, D. 1981.
Hirsutism: implications, aetiology, and management. Am
J Obstet Gynecol, 140, 815–30
39  Assessment and Management of Women with Polycystic Ovary Syndrome (PCOS) 759

39.4.2  Clinical Features
Women with PCOS may present with a constella-
tion of symptoms that can vary according to the age
at presentation. Reproductive symptoms may dom-
inate in younger women whilst metabolic features
become of great concern later in life. Clinical fea-
tures can be categorised under the three domains:
reproductive, metabolic, and psychological.
39.4.3  Reproductive Features
ing a high-risk pregnancy and have more frequent
assessment of weight gain, blood pressure, and
glucose tolerance during pregnancy.
There is also an association between PCOS
and endometrial cancer as these women share
many of the risk factors including obesity, hyper-
insulinaemia, T2DM, and anovulation with unop-
posed uterine oestrogen exposure. However,
routine ultrasound screening for endometrial
thickness is not recommended unless risk factors
(prolonged amenorrhoea or oligomenorrhoea) or
symptoms are present.

These include hyperandrogenism and oligomenor-

rhoea, subfertility, and pregnancy complications. 39.4.4  Metabolic Features
Biochemical (identified by increased free androgen
levels) or clinical hyperandrogenism (identified by Insulin resistance is a cardinal feature in PCOS,
hirsutism using the Ferriman-­Gallwey (mFG) scor- affecting 75% of lean women and 95% of obese
ing tool (Fig.  39.3) [Hirsutism assessment tool - women (Stepto et al. 2013). PCOS is associated
Ferriman-Gallwey (mFG)] scoring tool http://www. with an increased risk of developing impaired
hirsutism.com/hirsutism-biology/ferriman-gall- glucose tolerance, pre-diabetes, GDM, and
wey-score.shtml), and to a lesser extent acne and T2DM.  It is noteworthy that these metabolic
scalp alopecia is one of the key diagnostic and clini- abnormalities occur at a younger age and are
cal features of PCOS. Menstrual irregularity (cycle increased independent of body weight, but are
length greater than 35 days or less than 21 days or further exacerbated by increased BMI.
fewer than eight cycles per year) and fertility issues Women with PCOS also have increased risk
are common reproductive manifestations of PCOS. factors for cardiovascular disease including
PCOS is the most common cause of oligo/ dyslipidaemia and obstructive sleep apnoea
anovulation and subfertility secondary to dysreg- (OSA). BMI is a key driver of dyslipidaemia,
ulated reproductive hormones and follicular which is characterised by higher triglycerides
development (Homburg 2004). Moreover, and lower high-density lipoprotein (LDL) cho-
women with PCOS were more likely to receive lesterol levels.
hormonal treatment for fertility assistance than
women without PCOS (Joham et  al. 2015).
Importantly, family size can reach desired goals, 39.4.5  Psychological Features
where ovulation induction is available.
Women with PCOS are also at increased risk PCOS is associated with higher rates of depres-
of pregnancy complications including pre-­ sion, anxiety, disordered eating, psychosexual
eclampsia, preterm delivery, and gestational dia- dysfunction, and low self-esteem (Teede et  al.
betes (GDM). These risks are mediated by 2011). Symptoms challenging feminine identity,
multiple factors (including genetic and environ- including obesity, acne, excess hair growth, and
mental factors, the metabolic and reproductive subfertility, are associated with a higher risk for
characteristics of PCOS), as well as higher rates anxiety and depression. However, studies have
of subfertility and use of assisted fertility shown this increased prevalence of psychological
­treatments. The aforementioned may act inde- symptoms in PCOS also exists independent of
pendently or in concert (Palomba et  al. 2015). obesity and reproductive abnormalities. Overall,
Obesity further exacerbates these risks. Therefore, quality of life is significantly reduced in women
women with PCOS should be recognised as hav- with PCOS (Barnard et al. 2007).
760
39.5 Diagnosis and Investigations
Nurses should have a high level of suspicion of
PCOS in women who present with menstrual
irregularity (2  years or more after menarche),
overweight or obesity, fertility issues, acne or hir-
sutism, pre-diabetes, gestational diabetes, or
early-onset T2DM. The Rotterdam criteria is the
most universally accepted diagnostic criteria
(Fig. 39.2).
In young women (<20 years) only 1 and 2 are
required due to the high prevalence of polycystic
ovarian morphology (PCOM) in this group.
39.6 P
 resentation of PCOS at
Different Life Stages
39.6.1  Young Women (<20 Years)
Two years after the onset of menarche, if young
women report irregular menstrual cycles (>35 or
<21 days) a diagnosis of PCOS should be consid-
ered. The value and optimal timing of assessment
and diagnosis of PCOS should be discussed, tak-
ing into account diagnostic challenges at this life
stage and psychosocial and cultural factors.
When commencing hormonal contraception in
adolescents, who have presented with 12 months
of irregular menstrual cycles (>35 or <21 days)
following onset of menarche, take a baseline
assessment of clinical and ­biochemical hyperan-
drogenism and cycle patterns before commence-
ment of hormonal contraception. If baseline
assessment is abnormal, potential increased risk
of PCOS could be discussed with the patient and
future reassessment planned (Need to cease oral
contraception for a period of 3 months to attain
an accurate assessment). Ultrasound is not rec-
ommended in this age group and not required if
hyperandrogenism (clinical or biochemical) and
irregular periods are present.
39.6.2  Adult Women (Reproductive
Years)
Irregular menstrual cycles (>35 days of <21 days) in
adult women clinically reflect ovulatory dysfunc-
R. Garad et al.
tion. However, ovulatory dysfunction can still occur
with regular cycles and luteal phase progesterone
levels can be measured to assess ovulation when
PCOS is clinically suspected and cycles are regular.
39.6.3  Peri/menopausal Women
Diagnosis at this life stage may be based on a his-
tory of oligomenorrhoea and hyperandrogenism
during the reproductive years. In addition, whilst
some aspects of PCOS improve at this life stage,
the risk of metabolic abnormalities may persist.
39.7 Patient-Centred Care Model
Women with PCOS report delayed diagnosis and
dissatisfaction with the care and information pro-
vided by health professionals. A patient focused,
multidisciplinary approach targeting both short-
and long-term reproductive, metabolic and psy-
chological features is required given the complexity
and chronicity of PCOS. A thorough clinical eval-
uation is necessary to explore all associated fea-
tures and to enable the tailoring of treatment for
each individual. Nurses need to actively engage
women in a partnership approach to their own
care. Ongoing management in primary care is the
mainstay of management. However, interdisciplin-
ary care is often required and referral to an obste-
trician/gynaecologist, endocrinologist,
psychologist, or a dermatologist maybe needed for
targeted medical therapy of reproductive, meta-
bolic, and psychological complications. In addi-
tion, the provision of high quality PCOS-specific
education and resources are vital to optimise
patient empowerment and self-management.
Patient Quote 2
“Once I received a proper diagnosis and
realised that this condition was well under-
stood and that there was a lot of help for me,
I feel to much better. It was the not knowing
why I had these symptoms and what I could
do that was so difficult. I know now that
there is a lot I can do to help myself”.
39  Assessment and Management of Women with Polycystic Ovary Syndrome (PCOS)
39.7.1  Key Patient Messages Once
Diagnosis Established
• PCOS is common.
• PCOS is a long-term condition.
• PCOS affects individuals differently and there-
fore treatment needs to be individualised.
• There are some long-term health risks.
• Lifestyle management improves all aspects of
PCOS.
• Treatment can reduce symptoms and risk of
complications.
• A great deal of support is available and educa-
tion is important.
• Continue the effort to reduce the risk of health
complications.
39.8 Management
of Hyperandrogenism
Hyperandrogenism is mainly manifested by
excessive hair growth and to some extent acne
and androgen-related alopecia. Whilst various
options are available for management of hir-
sutism, the choice of therapy depends on the
severity of the condition and its impact on
individual well-being, patient preference,
access and affordability of the treatment, and
potential side effects. Cosmetic therapy,
including laser therapy and electrolysis, are
considered first line in management of
hirsutism.
Combined oral contraceptive pills (COCPs)
are first-line management and are generally
effective but need 6–12 months to work. COCPs
or alternative forms of contraception can be used
with antiandrogens although the evidence for
these agents in limited.
Patient Quote 3
“For me the symptoms I struggle with the
most are my facial hair and my weight.
Also, I used to also have very severe acne
which was really tough but this was cleared
up by medication”.
761
39.9 Management
of Reproductive Features
Oligo/anovulation and menstrual irregularity is
best managed by combined oral contraceptive
pills in women who do not seek fertility. COCPs
are effective in reducing ovarian androgen pro-
duction by supressing GnRH. Androgen produc-
tion is also inhibited by the progestins in these
pills, which impairs androgen receptor binding.
The oestrogen in COCPs increases production of
SHBG which in turn reduces availability of free
androgens. Combined oral contraceptive pills
also provide progestins which protect the
endometrium.
Age, BMI, metabolic and thromboembolism
risk factors as well as history of smoking need to
be considered when prescribing COCPs. Whilst
COCPs are effective in resuming cycle regularity,
providing contraception and controlling hirsut-
ism, they may have a negative influence on
venous, thromboembolic and metabolic risk fac-
tors including dyslipidaemia and insulin resis-
tance. Therefore, a low dose COCP is preferred
and evidence does not support one preparation
over another.
Intermittent progestin every 3 months can be
considered as an alternative to induce a with-
drawal bleed and protect the endometrium from
hyperplasia in women with oligo/amenorrhoea
who do not wish to take the COCP, or if there is a
contraindication to their use. In women with oli-
gomenorrhoea, routine ultrasound screening for
endometrial thickness is not recommended unless
risk factors are present; these may include obe-
sity, older age, and amenorrhoea.
Fertility declines as women get older and
with obesity. Therefore, early family planning,
when possible, and weight management should
be initiated to preserve and optimise fertility.
Lifestyle intervention is first-line treatment and
increases spontaneous pregnancy. Early inter-
vention is required to prevent weight gain and
to engage women in intensive lifestyle pro-
grammes with regular exercise and caloric
restriction to achieve a BMI of less than 30 kg/
m2. Achieving optimal body weight is benefi-
cial for regulation of menstrual cycles, ovula-
tion, and spontaneous pregnancy and for
762
prevention of potential pregnancy complica-
tions and should be initiated at the primary care
level (Clark et  al. 1998). First-line therapies
include pharmacological ovulation induction
with aromatase inhibitors, clomiphene citrate,
metformin, gonadotropins, and surgical options
such as laparoscopic ovarian drilling could be
considered second line when appropriate.
Third-line IVF is not often required in isolated
PCOS.  Early specialist referral for consider-
ation of assisted reproductive techniques is
warranted once infertility is established
(12  months of failure to conceive). Referral
should be initiated earlier in older women if
infertility is suspected (6  months of failure to
conceive).
39.9.1  Therapeutic Benefits
of Metformin in PCOS
The role of metformin is now clearer. Metformin
is not first-line treatment. In the general popula-
tion with impaired glucose tolerance, metformin
prevents diabetes and is known to be effective in
the prevention of weight gain and restoration of
menstrual cyclicity and ovulation in women with
PCOS.  The addition of metformin to structured
lifestyle programmes may improve BMI, yet it is
not recommended as a substitute for diet and
exercise (Teede et al. 2011; Legro et al. 2013). In
PCOS, it reduces BMI (a high priority endpoint
for women) and has positive effects on ovulation
and metabolic features.
Metformin does not have the same adverse
metabolic or homeostatic effects of COCPs;
however it does not provide contraception. It
also causes mild, self-limiting gastrointestinal
side effects. Metformin is not as effective as
COCPs in managing symptoms of clinical
hyperandrogenism. In women resistant to clo-
miphene, the addition of metformin to clomi-
phene citrate increases live birth rates when
compared with clomiphene alone or laparo-
scopic ovarian drilling. Metformin was also
effective in preventing ovarian hyperstimula-
tion syndrome in women with PCOS undergo-
ing IVF treatment.
R. Garad et al.
Metformin is a low cost and readily available
medication, its use to prevent weight gain,
impaired glucose tolerance and T2DM in PCOS
is primarily in those whose lifestyle programmes
alone are ineffective. It also could be considered
to alleviate menstrual irregularity in women who
do not desire contraception or have contraindica-
tions to the use of COCPs and to assist reproduc-
tion in women who are resistant to ovulation
induction with clomiphene.
39.9.2  Preconception and Early
Pregnancy Care
There is an increased risk of pregnancy compli-
cations in women with PCOS. Preconception and
early antenatal lifestyle intervention, assessment
of BMI, blood pressure, and OGTT are recom-
mended in all women with PCOS to reduce the
risk of developing GDM, pregnancy-induced
hypertension, and pre-eclampsia (Legro et  al.
2013; Boomsma et al. 2006).
39.10 Early Screening
and Management
of Metabolic Complications
According to both national and international
guidelines, all women with PCOS should undergo
regular screening for early detection of metabolic
complications including IGT, T2DM, and other
cardiovascular risk factors including dyslipidae-
mia and hypertension (Teede et al. 2011).
Current guidelines recommend screening all
women with PCOS for glucose intolerance using
a 2-h oral glucose tolerance test (OGTT).
Health professionals and women with PCOS
should be aware that, regardless of age, the prev-
alence of gestational diabetes, impaired glucose
tolerance, and type 2 diabetes (fivefold in Asia,
fourfold in the Americas, and threefold in
Europe) are significantly increased in PCOS,
with risk independent of, yet exacerbated by
obesity. Glycaemic status should be assessed at
baseline in all women with PCOS.  Thereafter,
assessment should be every 1–3  years, influ-
39  Assessment and Management of Women with Polycystic Ovary Syndrome (PCOS)
enced by the presence of other diabetes risk fac-
tors. An oral glucose tolerance test (OGTT)
should be performed at baseline in high risk
women with PCOS (including a BMI >25 or in
Asian >23  kg/m2, history of impaired fasting
glucose, impaired glucose tolerance or gesta-
tional diabetes, family history of type 2 diabetes,
hypertension or high risk ethnicity). Fasting
plasma glucose or HbA1c may be substituted in
women with PCOS with no other diabetes risk
factors; however, these may be less ideal for
detecting impaired glucose tolerance, as a key
predictor for diabetes. An OGTT should be
offered in all women with PCOS who are plan-
ning pregnancy or seeking fertility treatment
preconception, and if negative at <20 weeks ges-
tation and at 28 weeks gestation, given their high
risk of hyperglycaemia and the associated
comorbidities in pregnancy.
Measurement of fasting insulin levels is not
appropriate clinically as the commercially avail-
able assays are not adequately sensitive and accu-
rate; therefore, results are potentially misleading
and hard to interpret. Measurement of fasting
glucose alone is also not recommended as this is
not adequately sensitive for detection of impaired
glucose tolerance and diabetes in PCOS.  The
mechanism underpinning insulin resistance in
PCOS mainly affects the skeletal muscle and adi-
pose tissue rather than the liver. Therefore,
women with PCOS are more likely to demon-
strate postprandial dys/hyperglycaemia rather
than abnormal fasting glucose levels. Frequency
of screening for glucose intolerance varies
according to each individual’s risk profile. These
risk factors include age, ethnicity, parental his-
tory of diabetes, history of high glucose levels,
smoking, use of COCPS or antihypertensive
medications, physical inactivity, and waist cir-
cumference greater than 80 cm.
Screen and assess all women with PCOS for
risk factors for cardiovascular disease at diagno-
sis. This includes screening for overweight and
obesity, dyslipidaemia, hypertension, and taking
a history for smoking. Frequency of re-screening
is still under discussion; however, current guide-
lines recommend subsequent assessments based
on each individual’s overall risk profile, age, and
763
family history of cardiovascular disease (Teede
et al. 2011; Legro et al. 2013).
39.10.1  Metabolic Risk Management
in PCOS (Next Section Will
Be Put in Table Format)
• Encourage smoking cessation.
• Check BP once a year if BMI is less than
25 kg/m2 and at every visit if BMI is equal to
or greater than 25 kg/m2.
• Measure fasting lipids at diagnosis and moni-
tor based on additional obesity and cardiovas-
cular risk factors.
• OGTT at baseline in all women with PCOS,
then assess every 1–3 years, influenced by the
presence of other diabetes risk factors. OGTT
should be performed at baseline in high risk
women with PCOS (including a BMI >25 or
in Asian >23 kg/m2, history of impaired fast-
ing glucose, impaired glucose tolerance or
gestational diabetes, family history of type 2
diabetes, hypertension or high risk ethnicity).
• Screen all women for impaired glucose toler-
ance or diabetes preconception and early in
pregnancy and all women at 24–28 weeks.
39.10.1.1 Weight Management
• Offer regular monitoring for weight changes
and excess weight, in consultation with and
where acceptable to the individual woman.
Monitoring could be at each visit or at a mini-
mum 6–12 monthly, with frequency planned
and agreed between the health professional
and the individual.
• Target prevention of weight gain for all and
achieving at least 5–10% weight loss if over-
weight. Note: education alone and unachiev-
able goals are generally unsuccessful.
• Key message: 5–10% weight loss will greatly
assist in symptom control.
• Encourage simple behaviour change—priori-
tisation of healthy lifestyle, family support,
lifestyle and exercise planning, setting of
small achievable goals.
• Consider referral if appropriate to: dietitian
(tailored dietary advice, education, behav-
764
ioural change support), exercise physiologist
(exercise motivation, education), psychologist
(motivational interviewing, behaviour man-
agement techniques, emotional health, and
motivation), and/or group support (diet and
exercise programme).
39.10.1.2 Management
of Psychological Features
Given the psychological burden associated with
PCOS, the assessment and monitoring of psycho-
logical well-being is essential for making life-
style changes, to promote ongoing engagement
with management strategies and to improve qual-
ity of life. PCOS guidelines recommend emo-
tional health screening using evidence-based
screening tools.
It is important to note that treatment of factors
such as hirsutism and excess body weight, which
can negatively affect quality of life, can be as
important as conventional treatments (cognitive
­ least 6 months before making changes in dose
behavioural
­ therapy, psychotherapy, and
pharmacotherapy) available for management of
­ • COCPs are first line. If ineffective after
mood disorders (Teede et al. 2011). It is equally criti-
cal to empathise the role lifestyle can play is improv-
ing emotional well-being (Thomson et al. 2010).
39.10.1.3 E  motional Health Simple
Screening Tools
If the answers to any of the questions in any of the
domains are positive, further exploration of that
domain should be considered. Moreover, proper
management of the problem including consider-
ation of a mental health care plan and referral to a
mental health professional is required.
In addition to the above questions, health pro-
fessionals should capture and consider women’s
perceptions of their symptoms, impact on their
quality of life, and personal priorities for care to
improve patient outcomes.
Additional recommended tools:
• Modified Polycystic Ovary Syndrome
Questionnaire (MPCOSQ)
• The female sexual function index Female
Sexual Function Index (FSFI)
• The Arizona sexual experience scale Arizona
Sexual Experience Scale (ASEX Summary of
treatment strategies in PCOS
R. Garad et al.
39.10.1.4 Oligo/amenorrhoea
• Lifestyle changes (5–10% weight loss through
structured exercise and calorie restriction).
• COCPs (low oestrogen doses, i.e. 20 micro-
grams may have less impact side effects and
second-generation progestins are associated
with lower risk of thromboembolism).
• Cyclic progestins to induce withdrawal bleed if
COCPs not desired or contraindicated (i.e.
10 mg medroxyprogesterone acetate 10–14 days
every 2–3 months if no cycle in interim).
• Metformin improves menstrual cyclicity and
ovulation.
39.10.1.5 Hirsutism
• Cosmetic therapy (laser or electrolysis) is con-
sidered first line.
• Consider pharmacotherapy if cosmetic ther-
apy is ineffective, inaccessible, or unafford-
able. Each medication should be tried for at
or introducing a new medication.
6–9  months, an antiandrogen can be added
(i.e. spironolactone or cyproterone acetate).
• Monotherapy with antiandrogens should not be
considered in premenopausal women as they
increase irregular vaginal bleeding and have
adverse foetal outcomes should pregnancy occur.
• Ensure adequate contraception when prescrib-
ing antiandrogens.
39.10.1.6 Infertility
• Advise early family planning and initiation
where possible.
• Emphasise prevention of weight gain prior to
conception.
• Encourage weight loss if overweight. Lifestyle
changes (5–10% weight loss through struc-
tured exercise and calorie restriction). If a sig-
nificant weight loss occurs, consider a period
of 3–6  months of weight stability prior to
conception.
• Smoking cessation.
• Folate supplementation.
• Specialist referral for consideration of assisted
reproductive techniques is essential in women
who fail to conceive after 12 months and ear-
lier in women over 35 years.
39  Assessment and Management of Women with Polycystic Ovary Syndrome (PCOS)
• Ovulation induction techniques include phar-
macotherapy with letrozole, clomiphene
citrate  ±  metformin, gonadotropins, or
­laparoscopic ovarian drilling. IVF is uncom-
monly needed in isolated PCOS.
39.10.1.7 Weight Management
and Cardiometabolic Risk
Reduction
• Encourage cessation of smoking.
• Prevention of weight gain through ongoing
attention to lifestyle and weight
monitoring.
• Note: no specific diet is recommended as ideal
in PCPS and generally healthy principles
apply.
• Encourage reduction of sedentary behaviour
and increase in physical activity.
• If overweight or obese, encourage 5–10%
weight loss through structured exercise and
calorie restriction.
• Metformin aids prevention of weight gain,
assists lifestyle induced weight loss, and pre-
vents diabetes onset.
39.10.1.8 Psychological Symptoms
• Screen women using the emotional health
simple screening tool (Box 39.1)
• Address factors which can negatively affect
quality of life
• Consider a mental health care plan and
referral to psychologist/psychiatrist when
needed
Box 39.1 Emotional Health Simple Screening
Tool
Depression and/or anxiety
1. During the last month, have you often
been bothered by feeling down,
depressed, or hopeless?
2. During the last month, have you often
been bothered by having little interest or
pleasure in doing things?
765
3. During the last month, have you been
bothered by feeling excessively worried
or concerned?
Negative body image
1. Do you worry a lot about the way you look
and wish you could think about it less?
2. On a typical day, do you spend more
than 1  h per day worrying about your
appearance? (More than 1  h a day is
considered excessive). If positive what
are your specific concerns and how does
it affect your life?
3. Does it make it hard to do your work or
be with your friends and family?
Disordered eating and eating disorders
1. Do you worry you have lost control over
your eating?
2. Do you ever feel disgusted, depressed,
or guilty about eating?
3. Have you tried fasting or skipping meals
in an attempt to lose weight?
4. Have you tried vomiting, laxatives, or
diuretics in an attempt to lose weight?
5. Have you had significant (i.e. >5–7%),
recurrent fluctuation in body weight?
Psychosexual dysfunction
1. During the last few months, have you
often been bothered by problems with
your sex life such as reduced satisfac-
tion, diminished desire, pain, or any
other problems?
2. Do you feel that polycystic ovary syn-
drome affects your sex life?
3. (If relevant) Do sexual problems affect
your current relationship and/or have
sexual problems affected your past
relationships?
Copyright Monash University
Considering the high prevalence of depression
and anxiety in PCOS appropriate screening and a
timely referral to psychologist/psychiatrist is
important.
766 R. Garad et al.

39.10.1.9 Use of Metformin Investigations

When indicated, metformin can be started at a –– testosterone 2.0 (0.1–1.7), SHBG 15 (18–
low dose (500 mg daily) to enhance GI tolerance 136), FAI 13% (0.7–10.9)
with dosage titrated (by 500 mg every 2–4 weeks –– TSH, prolactin, FSH, LH, hCG—normal
as tolerated) to a maximum dose of 1500– –– transvaginal ultrasound: multiple follicles
2000 mg daily. consistent with PCOM
Metformin may also be used –– OGTT normal, mild dyslipidaemia—normal
total cholesterol and LDL-C, low HDL-C
• To prevent weight gain, IGT, and T2DM in
PCOS where lifestyle programmes fail Diagnosis and Treatment
• To improve menstrual irregularity in women –– Fei chooses to start a COCP for regulation of
who do not desire or have contraindications to her periods, considers laser therapy for
the use of COCPs hirsutism
• To assist reproduction in women who are –– sees a dietician, attends regular aerobic exercise
resistant to ovulation induction with clomi- sessions at the local gym to achieve weight loss
phene alone
Sequela
Four years later—presents to emergency depart-
Case Studies
ment with vaginal bleeding and abdominal
Scenario 1: Fei
pain
26 year old, Chinese woman
–– pregnant and referred for an ultrasound, a
live pregnancy at 8 weeks
History
–– bleeding stopped, Fei reassured pregnancy
–– menarche at age 14 with irregular cycles
still viable
(45–60 days).
–– strong family history of T2DM and CVD on On Examination
father’s side –– weight is 73 kg, BMI 26, normotensive
–– stopped taking COCP about 6 months ago to
Presenting Symptoms get pregnant
–– amenorrhoea (last 4 months)—Fei concerned –– referred for early OGTT to screen for gesta-
about this tional diabetes—fasting glucose 5.1, 2 hourly
–– weight gain (7  kg over the past 2  years)— glucose 9
struggling to lose
Critical Thinking Questions: Scenario 1
Lifestyle 1. How could the nursing process be used to pri-
–– currently sexually active (uses condoms) oritise Fei’s care?
–– sedentary lifestyle, little time for exercise 2. What would your key lifestyle messages to
Fei be?
Examination 3. What other health professionals may form

–– Not cushingoid part of Fei’s care team?
–– normotensive
–– BMI 28 Scenario 2: Katie
–– central adiposity, waist circumference 29 year old, caucasian woman
89 cm
History
On Further Questioning – – menarche at age 13, irregular menstruation
–– excessive facial hair growth, requires regular until she started taking a COCP at age 15
waxing – – no regular medication
–– self-rating of 11 on the modified Ferriman-­ –– works fulltime
Gallwey scoring system –– does not smoke, drinks alcohol occasionally
39  Assessment and Management of Women with Polycystic Ovary Syndrome (PCOS) 767

Presenting Symptoms Sequela

–– presents to GP with 12  months irregular returns to GP after 3/12—lost 4 kg
menstruation cycles shorter and lipid profile normalised
–– cycle lengths 50–70 days advised to continue active lifestyle for 6/12
–– stopped COCP last year—planning to if not conceived, further examination, ovulation
conceive induction considered
–– no success after 6/12 will refer to reproductive/infertility specialist
after 12 months of trying to conceive
On Further Questioning after a further 2 kg weight loss—Katie conceives,
–– disappointed with weight gain of 8  kg over although she develops gestational diabetes.
9 year
–– believes weight gain is disproportionate as
very active Critical Thinking Questions: Scenario 2
1. What would your key lifestyle messages to
Katie be to optimise her fertility?
Examination 2. What percentage of body weight reduction has
–– normotensive been shown to improve PCOS symptoms?
–– BMI 29 3. How does excess weight impact the symp-
–– central adiposity, waist circumference 89 cm toms of PCOS?
–– no physical features suggestive of secondary
causes of weight gain Scenario 3: Anju
–– modified Ferriman-Gallwey scores 5, reports 33 year old, South-east Asian woman
waxing face frequently
–– normal testosterone, low SHBG, elevated FAI Presenting Symptoms
–– thyroid function, 17-OH progesterone, and –– presents to GP with irregular menstruation
prolactin levels—normal <4 cycles per year
–– menarche at age 14, COCP until 30
On Further Screening –– not planning to conceive—uses condoms
–– mildly elevated LDL, low HDL
–– OGTT normal, no signs or symptoms sugges- Examination
tive of OSA –– Normotensive, BMI 29, central adiposity
–– waist circumference 86 cm, no features of sec-
Emotional well-being—using simple screen- ondary causes of obesity
ing tool Katie found to be concerned about –– modified Ferriman-Gallwey score 4, however
weight gain but not distressed about body image. reports laser therapy
–– normal testosterone, low SHBG, and elevated
–– mood, energy levels, and social FAI
relationships—good –– transvaginal ultrasound—unilateral PCOM
–– elevated LDL, low HDL
Diagnosis and Treatment –– OGTT–IGT
–– diagnosed with PCOS (Rotterdam) –– no signs and symptoms of OSA
–– advised to commence lifestyle changes, aim –– thyroid function, 17-O progesterone, prolactin
weight loss of 5–10% of body weight levels—normal
–– referred to a dietitian, calorie-restricted diet,
and exercise programme (dramatic weight Diagnosis and Treatment
loss to be avoided) –– diagnosis of PCOS (three Rotterdam criteria)
–– Medroxyprogesterone acetate prescribed to –– lifestyle programmes with personal trainer 6/12
induce a withdrawal bleed as Katie does not –– lost 2 kg (reports being stressed about not los-
want to commence COCPs ing weight due to effects on fertility)
–– will continue waxing (can’t afford laser therapy) –– failed to lose weight on diet and exercise alone
768
Started metformin 500 mg daily—dose gradu-
ally titrated to 2000 mg (for IGT and weight gain
prevention)
–– referred to psychologist—anxiety
Sequela
–– visits GP after 3/12, lost 3 kg
–– cycles returned
–– reports psychologist helpful—learnt behav-
ioural techniques to overcome anxiety
–– advised to plan family (risk of age-related
infertility)
–– starts folate, conceives naturally after 3/12
–– advised to cease metformin
–– referred for early screening for gestational
diabetes
–– advised to aim for optimal gestational weight
gain to reduce risk of complications in
pregnancy
Critical Thinking Questions: Scenario 3
1. Which of Anju’s presenting symptoms may
lead you to suspect a diagnosis of PCOS?
2. What are the pathological processes that lead
to irregular menstrual cycles in PCOS?
3. How can lifestyle changes improve the regu-
larity of menstrual cycles?
39.11 Conclusions
PCOS is a complex, prevalent, life-long endo-
crine condition with long-term metabolic, repro-
ductive, and psychological features. It is
independent of, yet exacerbated by, obesity.
Many women remain undiagnosed because of the
heterogeneity of clinical presentation. Affected
women report diagnostic delays (>2  years)
(Gibson-Helm et al. 2017), inconsistent practices
and inadequate health practitioner knowledge
(Dokras et al. 2017), poor diagnostic experiences
(Gibson-Helm et al. 2017), and inadequate health
system responsiveness leading to additional costs
(Jason 2011; Azziz et al. 2005).
Therefore, awareness of this condition and its
features is important for nurses who positively
contribute to early and accurate diagnosis, raising
PCOS-related health literacy and being a critical
member of an interdisciplinary care team. This
R. Garad et al.
will avoid missing the diagnosis and assist with
appropriate screening of all women with PCOS
for the presence of potential metabolic, psycho-
logical, and reproductive manifestations. Nurses
can play a critical role in delivering evidence-­
based, holistic care through the provision of tar-
geted education, and preventative and therapeutic
strategies within a biopsychosocial model of care.
39.12 Online Resources
• Web resources for the eBook—This chapter
is based on; The international evidenced-based
guideline for the assessment and management
of polycystic ovary syndrome (https://www.
monash.edu/medicine/sphpm/mchri/pcos/
guideline)
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