NEWS & VIEWS

PCOM is perhaps the most controversial

PCOS of the PCOS diagnostic criteria and is based
on the unilateral or bilateral presence of >12

Refining diagnostic features follicles with a diameter of 2–9 mm and/or an

ovarian volume >10 ml (REF. 6). However, as
ultrasonography technology has advanced,
in PCOS to optimize health follicles are more easily detected than with
previous equipment, and the prevalence of

outcomes PCOM in the population is now between

20% in adults and 84% in adolescents with
current PCOM criteria, including many
Jacqueline A. Boyle and Helena J. Teede without PCOS4. Consequently, the Androgen
Excess and PCOS Society (AE–PCOS) task
Polycystic ovary syndrome (PCOS) is associated with adverse metabolic and force reviewed the evidence and published
reproductive outcomes and guidelines recommend early diagnosis, recommendations in 2014 that aimed to
refine PCOM criteria and improve the accu-
screening and management. However, new stricter definitions of the racy of diagnosis of PCOS4.
diagnostic features of polycystic ovaries on ultrasonography might in fact The task force recommended that PCOM
exclude some women from a diagnosis of PCOS who could benefit from be defined as >25 follicles per ovary with
preventive management. a diameter between 2 mm and 10 mm.
However, this definition was contingent on
Refers to Quinn, M. M. et al. Raising threshold for diagnosis of polycystic ovary syndrome excludes population of the use of new ultrasonography technology
patients with metabolic risk. Fert. Steril. http://dx.doi.org/10.1016/j.fertnstert.2016.06.026 (2016) (with a transducer frequency >8 MHz). The
task force recognized that this technology is
not always available and ovarian volume of
Polycystic ovary syndrome (PCOS) is the (from 2003) defines PCOS as two of three >10 ml could be substituted as an alternative
most common endocrine disorder in women criteria: oligo-ovulation or anovulation; for PCOM, which recognizes the limitations
of reproductive age and affects between 10% polycystic ovarian morphology (PCOM) in specificity and sensitivity compared with
and 21% of women depending on the diag- on ultrasonography; and hyperandrogen- follicle number per ovary 4. However, no
nostic criteria used and population assessed1,2. ism with the exclusion of other aetiologies6. investigators have reported on the adop-
The condition has many short-term and Under the Rotterdam criteria, four diagnos- tion of these AE–PCOS recommendations
long-term complications, including repro- tic reproductive phenotypes are included or described their practicality in clinical
ductive (such as, amenorrhoea, anovulation, (A–D; TABLE 1), phenotypes C and D are new care. Interestingly, the AE–PCOS task force
hirsutism, infertility and pregnancy compli- additions to the definition. The Rotterdam also reports that women with ‘mild’ PCOS
cations), metabolic (diabetes mellitus, dys- criteria are now internationally accepted, ­( hyperandrogenism plus PCOM (pheno-
lipidaemia and cardiovascular risk factors) and the focus of research has moved to type C) or oligo-ovulation or anovulation
and psychological (depression, anxiety, body refining each of the individual diagnostic plus PCOM (phenotype D)) would probably
image and quality of life) disorders2. In a new features. However, as each feature of PCOS have similar management and, therefore,
study by Quinn and colleagues3, some of the represents a continuum, diagnostic thresh- ultra­sonography might not impact on clin-
diagnostic challenges of PCOS were addressed olds are arbitrary and women with PCOS ical care4. Given these considerations and
in light of the latest international recommen- cannot be clearly differentiated from the the persisting need to still disseminate
dations to refine specific diagnostic features4. normal population. Given these consider- and implement the AE–PCOS recommenda-
This study again highlights the need for a ations, concerns of over­diagnosis have also tions, their clinical ­relevance and impact are
definitive diagnostic test in PCOS and for been raised. difficult to judge.
longitudinal cohort studies to understand
the natural history of complications of the
Table 1 | Reproductive phenotypes in PCOS
condition and how they relate to diagnostic
reproductive phenotypes. Phenotype Hyperandrogenism PCOM Oligo-ovulation or anovulation
In clinical practice, PCOS is under- A + + +
recognised, diagnosis is often delayed and B + – +
women report unsatisfactory diagnosis expe-
rience and inadequate education5. A key con- C + + –
tributor to these issues is the controversy over D – + +
diagnostic criteria. The Rotterdam consensus PCOM, polycystic ovarian morphology; PCOS, polycystic ovary syndrome.

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NEWS & VIEWS

Quinn and colleagues investigated the clin-
ical application of these new PCOM criteria
and characterized the reproductive and met-
abolic phenotypes of a cohort of women with
PCOS (n = 259) from a research database com-
pared with controls from the Ovarian Aging
study (n = 1,100)3. Their aim was to assess
metabolic differences between three groups:
controls; women who no longer meet diag-
nostic criteria using the 2014 AE–PCOM rec-
ommendations (excluded); and those who still
meet diagnostic criteria using revised PCOM
recommendations (revised). They report that
women in the revised group had a more severe
phenotype with worse features across ovula-
tion, hyperandrogenism, waist‑to‑hip ratio
and fasting insulin than those in the excluded
group. However, significant differences per-
sisted between the excluded PCOS and con-
trols across antral follicle count, cholesterol
levels, fasting insulin and insulin resistance
as defined by HOMA, demonstrating that the
excluded PCOS group still exhibited metabolic
derangement5.
The strengths of the study by Quinn and
colleagues include the prospective nature of
the study; however, the study is limited by the
inclusion of women who had only ceased the
combined hormonal contraceptive pill 1 month
before, which potentially affects oligo-ovula-
tion or anovulation history and hirsutism. A
disparity was also present in representation of
multi-ethnic women between the study groups.
Additionally, the ultrasonography equipment
using 4–8 Mhz did not comply with the AE–
PCOS recommendation, which might limit
ultrasonography quality in the assessment of
follicle number.
Overall, the clinical relevance of the debate
over stricter PCOS diagnostic features is
dependent on the benefits of a diagnosis, espe-
cially for women with mild PCOS. Ultimately,
the determination of benefits requires detailed,
high-quality, longitudinal cohort studies
across the PCOS phenotypes and diverse eth-
nicities. Given the challenges with ultrasound,
indications are an important consideration.
Ultrasound is not recommended for diagnosis
in adolescents2,7 and is not required in pheno-
types with hyperandrogenism and ovulatory
disturbance. We suggest that based on phe-
notype prevalence the most clinically relevant
scenario where ultrasound is indicated for
diagnosis is in ovulatory disturbance without
hyperandrogenism. Until then, considerations
include that PCOS is underpinned by insulin
resistance in most women, independent of, yet
exacerbated by, increased BMI8. Weight gain
has increased prevalence in women with PCOS
and the increased BMI then drives increased
prevalence and severity of PCOS9.
Of potential relevance in the debate about
diagnostic criteria is the ‘coming-of-age’ of
PCOS in terms of genome-wide association
studies (GWAS)10. Data from GWAS have
provided significant insight into PCOS aeti-
ology and been remarkably consistent across
original NIH criteria, Rotterdam criteria and
self-reported PCOS. Indeed, the GWAS find-
ings have emphasized greater homogeneity
in PCOS than previously thought and have
arguably ‘narrowed the gap’ between different
phenotypes.
Ultimately, we seek a definitive and spe-
cific diagnostic test for PCOS and accompa-
nying longitudinal cohort studies to document
the natural history of the condition. Advances
in anti-Mullerian hormone tests might
improve diagnosis and in the future genetic
and epigenetic tests could prove to be useful.
However, until such time, the clinical implica-
tions of recommended changes in individual
PCOS diagnostic features need to be inves-
tigated. Given the unclear clinical implica-
tions and implementation challenges of new
PCOM recommendations outside advanced
centres, we suggest that considerations of
indications for ultrasound in clinical diag-
nosis and application of a broader PCOM
definition aligned with the Rotterdam criteria
might be the most pragmatic approach at the
present time. This approach is also consist-
ent with current genome studies suggesting
more limited hetero­geneity in PCOS than
originally perceived across diagnostic criteria.
This approach offers the opportunity for early
metabolic screening with lifestyle intervention,
timely diagnosis and management of related
metabolic disorders and improved family ini-
tiation and optimization of reproductive out-
comes in women with PCOS. In this context,
we encourage further research with documen-
tation of ovarian morphology, phenotypes and
natural history in this common condition.
Jacqueline A. Boyle and Helena J. Teede are at the
Monash Centre of Health Research and
Implementation, Monash University and Monash
Health, Locked Bag 29, Clayton, Victoria 3168,
Australia.
jacqueline.boyle@monash.edu;
helena.teede@monash.edu
doi:10.1038/nrendo.2016.157
Published online 16 Sep 2016
1. March, W. A. et al. The prevalence of polycystic ovary
syndrome in a community sample assessed under
contrasting diagnostic criteria. Hum. Reprod. 25,
544–551 (2010).
2. Teede, H. J. et al. Assessment and management of
polycystic ovary syndrome: summary of an evidence-
based guideline. Med. J. Aust. 195, S65–S112
(2011).
3. Quinn, M. M. et al. Raising threshold for diagnosis of
polycystic ovary syndrome excludes population of
patients with metabolic risk. Fertil. Steril. http://dx.
doi.org/10.1016/j.fertnstert.2016.06.026 (2016).
4. Dewailly, D. et al. Definition and significance of
polycystic ovarian morphology: a task force report
from the Androgen Excess and Polycystic Ovary
Syndrome Society. Hum. Reprod. Update 20,
334–352 (2014).
5. Gibson-Helm, M. E., Lucas, I. M., Boyle, J. A. &
Teede, H. J. Women’s experiences of polycystic ovary
syndrome diagnosis. Fam. Pract. 31, 545–549
(2014).
6. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus
Workshop Group. Revised 2003 consensus on
diagnostic criteria and long-term health risks related
to polycystic ovary syndrome. Fertil. Steril. 81, 19–25
(2004).
7. Kristensen, S. L. et al. A very large proportion of
young Danish women have polycystic ovaries: is a
revision of the Rotterdam criteria needed? Hum.
Reprod. 25, 3117–3122 (2010).
8. Stepto, N. K. et al. Women with polycystic ovary
syndrome have intrinsic insulin resistance on
euglycaemic-hyperinsulaemic clamp. Hum. Reprod.
28, 777–784 (2013).
9. Teede, H. J. et al. Longitudinal weight gain in women
identified with polycystic ovary syndrome: results of an
observational study in young women. Obesity (Silver
Spring) 21, 1526–1532 (2013).
10. Hayes, M. G. et al. Genome-wide association of
polycystic ovary syndrome implicates alterations in
gonadotropin secretion in European ancestry
populations. Nat. Commun. 6, 7502 (2015).
Competing interests
The authors declare no competing interests

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