Recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome
Authors: Teede Helena J , Tay Chau Thien , Laven Joop J E , Dokras Anuja , Moran Lisa J , Piltonen Terhi T , Costello Michael F , Boivin Jacky , Redman Leanne M , Boyle Jacqueline A , Norman Robert J , Mousa Aya , Joham Anju E ,   the International PCOS Network, Arlt Wiebke , Azziz Ricardo , Balen Adam , Bedson Lisa , Berry Lorna , Boivin Jacky , Boyle Jacqueline , Brennan Leah , Brown Wendy , Burgert Tania , Busby Maureen , Ee Carolyn , Garad Rhonda M , Gibson-Helm Melanie , Harrison Cheryce , Hart Roger , Hopkins Kim , Hirschberg Angelica Lindén , Ho Tuong , Hoeger Kathleen , Jordan Cailin , Legro Richard S , Li Rong , Lujan Marla , Ma Ronald , Mansfield Darren , Marsh Kate , Mocanu Edgar , Mol Ben , Mormon Rachel , Norman Robert , Oberfield Sharon , Patel Malika , Pattuwage Loyal , Peña Alexia , Redman Leanne , Rombauts Luk , Romualdi Daniela , Shah Duru , Spritzer Poli Mara , Stener-Victorin Elisabet , Tehrani Fahimeh Ramezani , Thangaratinam Shakila , Thondan Mala , Vanky Eszter , Wijeyaratne Chandrika , Witchel Selma , Yang Dongzi , Yildiz Bulent , Alesi Simon , Alur-Gupta Snigdha , Avery Jodie , Khomami Mahnaz Bahri , Benham Jamie , Bidstrup Hugh , Chua Su Jen , Cooney Laura , Coster Thisara , Ee Carolyn , Fitz Victoria , Flanagan Madeline , Forslund Maria , Jiskoot Geranne , Kazemi Maryam , Kempegowda Punith , Louwers Yvonne , Lujan Marla , Melin Johanna , Melson Eka , Mengistu Yitayeh Belsti , Naderpoor Negar , Neven Adriana , Pastoor Hester , Rocha Thais , Sabag Angelo , Subramanian Anuradhaa , Tan Katrina 
Published: August 2023

Abstract

Study question
What is the recommended assessment and management of those with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise, and consumer preference?

Summary answer
International evidence-based guidelines address prioritized questions and outcomes and include 254 recommendations and practice points, to promote consistent, evidence-based care and improve the experience and health outcomes in PCOS.

What is known already
The 2018 International PCOS Guideline was independently evaluated as high quality and integrated multidisciplinary and consumer perspectives from 6 continents; it is now used in 196 countries and is widely cited. It was based on best available, but generally very low- to low-quality, evidence. It applied robust methodological processes and addressed shared priorities. The guideline transitioned from consensus-based to evidence-based diagnostic criteria and enhanced accuracy of diagnosis, whilst promoting consistency of care. However, diagnosis is still delayed, the needs of those with PCOS are not being adequately met, the evidence quality was low, and evidence-practice gaps persist.

Study design, size, and duration
The 2023 International Evidence-based Guideline update re-engaged the 2018 network across professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Extensive evidence synthesis was completed. Appraisal of Guidelines for Research and Evaluation II (AGREEII)-compliant processes were followed. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation, and ultimately recommendation strength, and diversity and inclusion were considered throughout.

Participants/materials, setting, and methods
This summary should be read in conjunction with the full guideline for detailed participants and methods. Governance included a 6-continent international advisory and management committee, 5 guideline development groups, and paediatric, consumer, and translation committees. Extensive consumer engagement and guideline experts informed the update scope and priorities. Engaged international society-nominated panels included paediatrics, endocrinology, gynaecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, obesity care, public health, and other experts, alongside consumers, project management, evidence synthesis, statisticians, and translation experts. Thirty-nine professional and consumer organizations covering 71 countries engaged in the process. Twenty meetings and 5 face-to-face forums over 12 months addressed 58 prioritized clinical questions involving 52 systematic and 3 narrative reviews. Evidence-based recommendations were developed and approved via consensus across 5 guideline panels, modified based on international feedback and peer review, independently reviewed for methodological rigour, and approved by the Australian Government National Health and Medical Research Council.

Main results and the role of chance
The evidence in the assessment and management of PCOS has generally improved in the past 5 years but remains of low to moderate quality. The technical evidence report and analyses (∼6000 pages) underpin 77 evidence-based and 54 consensus recommendations, with 123 practice points. Key updates include the following: (1) further refinement of individual diagnostic criteria, a simplified diagnostic algorithm, and inclusion of anti-Müllerian hormone levels as an alternative to ultrasound in adults only; (2) strengthening recognition of broader features of PCOS including metabolic risk factors, cardiovascular disease, sleep apnoea, very high prevalence of psychological features, and high risk status for adverse outcomes during pregnancy; (3) emphasizing the poorly recognized, diverse burden of disease and the need for greater healthcare professional education, evidence-based patient information, improved models of care, and shared decision-making to improve patient experience, alongside greater research; (4) maintained emphasis on healthy lifestyle, emotional well-being, and quality of life, with awareness and consideration of weight stigma; and (5) emphasizing evidence-based medical therapy and cheaper and safer fertility management.

Limitations and reasons for caution
Overall, recommendations are strengthened and evidence is improved but remains generally low to moderate quality. Significantly greater research is now needed in this neglected, yet common condition. Regional health system variation was considered and acknowledged, with a further process for guideline and translation resource adaptation provided.

Wider implications of the findings
The 2023 International Guideline for the Assessment and Management of PCOS provides clinicians and patients with clear advice on best practice, based on the best available evidence, expert multidisciplinary input, and consumer preferences. Research recommendations have been generated, and a comprehensive multifaceted dissemination and translation programme supports the guideline with an integrated evaluation programme.