AFJOG

REVIEW African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | Polycystic Ovary Syndrome: An update from the 2023 international guideline INTRODUCTION Polycystic ovary syndrome (PCOS) is the most common endocrinopathy that affects women of reproductive age. (1) In 1935, Stein and Leventhal described a series of women who had in common, features of hirsutism, menstrual disturbances and ovaries with numerous small cysts. (2) Various degrees of manifestation of the PCOS were described prior to this, with one of the earliest descriptions in 1721 by Vallisneri, an Italian scientist. (3) He described a case of a married infertile woman who was obese, and had 2 larger than normal ovaries, both smooth and shiny. (4) The criteria for diagnosis and specific treatment have evolved over time. Formal diagnostic criteria were first proposed at the National Institution of Health (NIH) sponsored conference on PCOS April 16-18, 1990. The consensus after a survey of meeting participants, by Zawadski and Dunaif, was that the major criteria for the diagnosis of PCOS “should include (in order of importance): 1) hyperandrogenism and/or hyperandrogenemia, 2) oligoovulation, (and the) 3) exclusion of other known disorders.” (5) The criteria were again reviewed at a conference in Rotterdam which was sponsored by both the European Society for Human Reproduction and Embryology and the American Society for Reproductive Medicine. PCOS was defined when at least two of the following three features were present: 1) oligo- and/or anovulation, 2) clinical and/or biochemical signs of hyperandrogenism, and 3) polycystic ovaries. Other androgen excess or related disorders should be excluded before the diagnosis could be made. (6, 7) In 2006, the Androgen Excess Society (AES) task force reviewed all available data at the time, to recommend an evidence-based definition for PCOS. The criteria they recommended were: 1) hyperandrogenism: hirsutism and/or hyperandrogenemia, 2) ovarian dysfunction: oligo- anovulation and/or polycystic ovaries and 3) exclusion of other androgen excess or related disorders. (5) Following the 2018 International evidence-based guideline for assessment, diagnosis and management of PCOS and the consensus-based Rotterdam Criteria the diagnostic criteria for the diagnosis of PCOS required two of (1) ovulatory dysfunction; (2) clinical or biochemical evidence of hyperandrogenism; (3) polycystic ovaries on ultrasound, and the exclusion of any other cause of the symptoms. (8) The 2023 guideline added elevated antimullerian hormone (AMH) levels to criteria 3. AMH levels only have a role in adults and the use of both ultrasound and AMH is not recommended in adolescents, due to the overlap with normal physiology. (9) This is currently the consensus criteria for diagnosis of PCOS. Criteria for diagnosis of PCOS in adolescents include 1) Oligo- or anovulation; and 2) Clinical and/or biochemical hyperandrogenism; and exclusion of other aetiologies. (Table 1) Figure 1 illustrates a simplifiedflowdiagramof symptoms and the steps to making a diagnosis of PCOS. Investigations are aimed at excluding the differential diagnoses for irregular periods and hyperandrogenism. A detailed flow diagram for the diagnosis and screening for PCOS is available for downloading in the International Evidence- based Guideline for the Assessment and Management of Polycystic Ovary Syndrome 2023. (algorithm1; (10) accessible at: monash.edu/medicine/mchri/pcos/ guideline https://doi.org/10.26180/24003834.v1) Adolescents who have features of PCOS but who do not fulfil the criteria, should be classified as being at ‘increased risk’ of PCOS. Reassessment should be done at or just before full reproductive maturity which is around 8 years post menarche. (9,10) The prevalence of PCOS is dependent on the population being studied and the diagnostic criteria used. Based on the Rotterdam criteria, it affects up to 11.5% (95% CI 10.39-13.15%) of adult women across world regions and ethnicities. (9) A timely diagnosis of PCOS, while avoiding overdiagnosis especially in adolescents, allows appropriate management of concomitant conditions. TABLE 1. Diagnostic Criteria: International Guideline Criteria 2023 Adults: 1. Oligo- or anovulation 2. Clinical and/or biochemical hyperandrogenism 3. Polycystic ovaries (FNPO* > 20 follicles per ovary) or AMH levels AND exclusion of other aetiologies *FNPO: Follicle number per ovary Adolescents: 1. Oligo- or anovulation AND 2. Clinical and/or biochemical hyperandrogenism AND exclusion of other aetiologies Figure 1: Algorithm for diagnosis of PCOS in adults and adolescents Fig. 1 Adapted from International guideline (10) accessible at: monash.edu/ medicine/mchri/pcos/ guideline https://doi.org/10.26180/24003834.v1 M Patel, 1 1 Reproductive Medicine Unit, Department of Obstetrics and Gynaecology, Groote Schuur Hospital/University of Cape Town CORRESPONDENCE: M Patel| Email: m.patel@uct.ac.za Polycystic Ovary Syndrome: An update from the 2023 international guideline African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | 06