Are expanding disease definitions unnecessarily labelling women with polycystic ovary syndrome?

Ethnicity and the Prevalence of Polycystic Ovary Syndrome: The Eastern Siberia PCOS Epidemiology and Phenotype Study

CONTEXT

Previous studies have shown that the prevalence of polycystic ovary syndrome (PCOS) may vary according to race/ethnicity, although a few studies have assessed women of different ethnicities who live in similar geographic and socioeconomic conditions.

OBJECTIVE

To determine the prevalence of PCOS in an unselected multiethnic population of premenopausal women.

DESIGN

A multicenter prospective cross-sectional study.

SETTINGS

The main regional employers of Irkutsk Region and the Buryat Republic, Russia.

PARTICIPANTS

During 2016-2019, 1398 premenopausal women underwent a history and physical exam, pelvic ultrasound, and testing during a mandatory annual employment-related health assessment.

MAIN OUTCOME MEASURES

PCOS prevalence, overall and by ethnicity in a large medically unbiased population, including Caucasian (White), Mongolic or Asian (Buryat), and mixed ethnicity individuals living in similar geographic and socioeconomic conditions for centuries.

RESULTS

PCOS was diagnosed in 165/1134 (14.5%) women who had a complete evaluation for PCOS. Based on the probabilities for PCOS by clinical presentation observed in the cohort of women who had a complete evaluation, we also estimated the weight-adjusted prevalence of PCOS in 264 women with an incomplete evaluation: 46.2 or 17.5%. Consequently, the total prevalence of PCOS in the population was 15.1%, higher among Caucasians and women of mixed ethnicity compared to Asians (16.0% and 21.8% vs 10.8%, Pz < .05).

CONCLUSION

We observed a 15.1% prevalence of PCOS in our medically unbiased population of premenopausal women. In this population of Siberian premenopausal women of Caucasian, Asian, and mixed ethnicity living in similar geographic and socioeconomic conditions, the prevalence was higher in Caucasian or mixed than Asian women. These data highlight the need to assess carefully ethnic-dependent differences in the frequency and clinical manifestation of PCOS.

Prevalence and accurate diagnosis of polycystic ovary syndrome in adolescents across world regions: a systematic review and meta-analysis

OBJECTIVES

To examine the global prevalence of polycystic ovary syndrome (PCOS) among adolescents across world regions, comparing the 2003 Rotterdam consensus criteria with the current International Evidence-based PCOS Guideline criteria which omits polycystic ovarian morphology (PCOM).

DESIGN

Systematic review and meta-analysis, Prospero CRD42022372029.

METHODS

OVID MEDLINE, All EBM, PsycInfo, EMBASE, and CINAHL were searched from 1990 to November 2023 for studies assessing the prevalence of PCOS in unselected adolescent populations.

RESULTS

Overall, 15 708 articles were identified. After removal of duplicates, 11 868 titles and abstracts and 445 full texts were assessed. Of these, 24 articles reporting on 23 studies from five world regions were included. In meta-analysis of 20 studies (n = 14 010 adolescents), global prevalence was 9.8% (95% CI 7.2, 12.3) according to original Rotterdam criteria, and 6.3% (95% CI 3.9, 8.8) according to International Evidence-based Guideline criteria. Global PCOS prevalence based on self-report was 9.8% (95% CI 5.5, 14.1). Grouped by WHO region, prevalence ranged from 2.9% (95% CI 2.0, 3.9) in the Western Pacific region to 11.4% (95% CI 7.1, 15.7) in the South-East Asia region according to guideline criteria.

CONCLUSION

This paramount global meta-analysis on adolescent PCOS diagnosis directly informed the 2023 International PCOS Guideline. Guideline criteria generated a global PCOS prevalence of 6.3%, compared with 9.8% on Rotterdam criteria (including PCOM). Excluding PCOM, which overlaps with normal pubertal transition, is expected to deter over-diagnosis. To avoid under-diagnosis, the Guideline recommends identifying those with either irregular cycles or hyperandrogenism as being "at risk"; this group should undergo longitudinal serial evaluations until adulthood.

Healthcare professionals' perspectives on the challenges with managing polycystic ovary syndrome: A systematic review and meta-synthesis

OBJECTIVE

To provide an overview of healthcare professionals' experience of PCOS management and identify the relevant facilitators and barriers.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane CENTRAL database from the earliest available date to April 2023. Qualitative and mixed methods studies that described healthcare professionals' experiences of PCOS management were included.

RESULTS

A total of 74 findings were extracted from the 8 included studies, which were categorized into facilitators and barriers. The barriers were meta-aggregated into four themes: the weakness of clinical evidence; women's low adherence to PCOS management; various obstacles that healthcare professionals face, and the influence of social environment and culture. The facilitators were meta-aggregated into three themes: chronic disease healthcare plan, communication techniques and healthcare professionals' ability and awareness.

CONCLUSION

The findings of this study have the potential to improve the care provided to women with PCOS. However, it is important for national health professionals and policy markers to consider the cultural context of their own country when implementing these findings.

PRACTICAL IMPLICATIONS

This study illustrated several challenges in managing the heterogeneous condition of PCOS and provide insights for the development of medical policies and future research directions.

Evidence for overdiagnosis in noncancer conditions was assessed: a metaepidemiological study using the 'Fair Umpire' framework

OBJECTIVES

To evaluate the strength of the evidence for, and the extent of, overdiagnosis in noncancer conditions.

STUDY DESIGN AND SETTING

We systematically searched for studies investigating overdiagnosis in noncancer conditions. Using the 'Fair Umpire' framework to assess the evidence that cases diagnosed by one diagnostic strategy but not by another may be overdiagnosed, two reviewers independently identified whether a Fair Umpire-a disease-specific clinical outcome, a test result or risk factor that can determine whether an additional case does or does not have disease-was present. Disease-specific clinical outcomes provide the strongest evidence for overdiagnosis, follow-up or concurrent tests provide weaker evidence, and risk factors provide only weak evidence. Studies without a Fair Umpire provide the weakest evidence of overdiagnosis.

RESULTS

Of 132 studies, 47 (36%) did not include a Fair Umpire to adjudicate additional diagnoses. When present, the most common Umpire was a single test or risk factor (32% of studies), with disease-specific clinical outcome Umpires used in only 21% of studies. Estimates of overdiagnosis included 43-45% of screen-detected acute abdominal aneurysms, 54% of cases of acute kidney injury, and 77% of cases of oligohydramnios in pregnancy.

CONCLUSION

Much of the current evidence for overdiagnosis in noncancer conditions is weak. Application of the framework can guide development of robust studies to detect and estimate overdiagnosis in noncancer conditions, ultimately informing evidence-based policies to reduce it.

Incidence, prevalence, and trends in polycystic ovary syndrome diagnosis: a United States population-based study from 2006 to 2019

BACKGROUND

Polycystic ovary syndrome is the most common endocrine disorder in women of reproductive age, yet US incidence estimates do not exist, and prevalence estimates vary widely.

OBJECTIVE

A population-based US study estimated the incidence, prevalence, and trends of polycystic ovary syndrome by age, race and ethnicity, and diagnosing provider type.

STUDY DESIGN

A retrospective cohort study of patients enrolled in Kaiser Permanente Washington from 2006 to 2019 was conducted. All members identified as female, aged 16 to 40 years with at least 3 years of enrollment and at least 1 healthcare encounter during that time, were eligible for inclusion. Individuals were excluded if they had a history of oophorectomy or hysterectomy. Polycystic ovary syndrome cases were identified using the International Classification of Diseases diagnosis codes (International Classification of Diseases, Ninth Revision, 256.4 or International Classification of Diseases, Tenth Revision, E28.2). Individuals with a polycystic ovary syndrome diagnosis before study entry were excluded from incidence rate estimations. The incidence rates were adjusted by age using direct standardization to the 2010 US census data. Temporal trends in incidence were assessed using weighted linear regression (overall) and Poisson regression (by age, race and ethnicity, and provider type). Prevalent cases were defined as patients with a polycystic ovary syndrome diagnosis at any time before the end of 2019. Medical record review of 700 incident cases diagnosed in 2011-2019 was performed to validate incident cases identified by International Classification of Diseases codes using the Rotterdam criteria.

RESULTS

Among 177,527 eligible patients who contributed 586,470 person-years, 2491 incident polycystic ovary syndrome cases were identified. The mean age at diagnosis was 26.9 years, and the mean body mass index was 31.6 kg/m2. Overall incidence was 42.5 per 10,000 person-years; the rates were similar over time but increased in individuals aged 16 to 20 years from 31.0 to 51.9 per 10,000 person-years (P=.01) and decreased among those aged 26 to 30 years from 82.8 to 45.0 per 10,000 person-years (P=.02). A small decreasing temporal trend in incidence rates was only observed among non-Hispanic White individuals (P=.01). The incidence rates by diagnosing provider type varied little over time. Among the 58,241 patients who contributed person-time in 2019, 3036 (5.2%) had a polycystic ovary syndrome International Classification of Diseases diagnosis code; the prevalence was the highest among the Hawaiian and Pacific Islander group (7.6%) followed by Native American and Hispanic groups. Medical record review classified 60% as definite or probable incident, 14% as possible incident, and 17% as prevalent polycystic ovary syndrome. The overall positive predictive value of polycystic ovary syndrome International Classification of Diseases diagnosis code for identifying definite, probable, or possible incident polycystic ovary syndrome was 76% (95% confidence interval, 72%-79%).

CONCLUSION

Among a cohort of nonselected females in the United States, we observed stable rates of incident polycystic ovary syndrome diagnoses over time. The incidence of polycystic ovary syndrome was 4- to 5-fold greater than reported for the United Kingdom. The prevalence of polycystic ovary syndrome (5.2%) was almost double before the published US estimates (2.9%) based on the International Classification of Diseases codes. Race and ethnicity and provider type did not seem to have a major impact on temporal rates. Incident diagnoses increased over time in younger and decreased in older age groups, perhaps related to shifting practice patterns with greater awareness among practitioners of the impact of polycystic ovary syndrome on long-term health outcomes and improved prevention efforts. Moreover, increasing obesity rates may be a factor driving the earlier ages at diagnosis.

Too Much, Too Mild, Too Early: Diagnosing the Excessive Expansion of Diagnoses

Tremendous scientific and technological advances have vastly improved diagnostics. At the same time, false alarms, overdiagnosis, medicalization, and overdetection have emerged as pervasive challenges undermining the quality of healthcare and sustainable clinical practice. Despite much attention, there is no clarity on the classification and handling of excessive diagnoses. This article identifies three basic types of excessive diagnosing: too much, too mild, and too early. Correspondingly, it suggests three ways to reduce excess and advance high value care: we must stop diagnosing new phenomena, mild conditions, and early signs that do not give pain, dysfunction, and suffering.

A novel methodological framework was described for detecting and quantifying overdiagnosis

OBJECTIVES

Methods to quantify overdiagnosis of screen detected cancer have been developed, but methods for quantifying overdiagnosis of non-cancer conditions (whether symptomatic or asymptomatic) have been lacking. We aimed to develop a methodological framework for quantifying overdiagnosis that may be used for asymptomatic or symptomatic conditions, and used Gestational Diabetes Mellitus as an example of how it may be applied.

STUDY DESIGN AND SETTING

We identify two earlier definitions for overdiagnosis, a narrower prognosis-based definition, and a wider utility-based definition. Building on the central importance of the concepts of prognostic information and clinical utility of a diagnosis, we consider the following questions: within a target population, do people found to have a disease using one diagnostic strategy but found not to have the disease using another diagnostic strategy (so called 'additional diagnoses'), have an increased risk of adverse clinical outcomes without treatment (prognosis evidence), and/or a decreased risk of adverse outcomes with treatment (utility evidence)?

RESULTS

Using Causal Directed Acyclic Graphs and Fair Umpires, we illuminate the relationships between diagnostics strategies and the frequency of overdiagnosis. We then use the example of Gestational Diabetes Mellitus to demonstrate how the Fair Umpire framework may be applied to estimate overdiagnosis.

CONCLUSION

Our framework may be used to quantify overdiagnosis in non-cancer conditions (and in cancer conditions), as well as to guide further studies on this topic.

The challenges with managing polycystic ovary syndrome: A qualitative study of women's and clinicians' experiences

OBJECTIVE

To explore clinicians' and women's views and experiences with managing polycystic ovary syndrome (PCOS).

METHODS

Semi-structured interviews with 36 clinicians and 26 women with PCOS. Clinicians were recruited through advertising via relevant professional organisations, snowballing and contacting clinics across Australia. Women with PCOS were recruited through social media advertising. Transcribed audio-recordings were analysed thematically using Framework analysis.

RESULTS

Findings across women with PCOS and clinician interviews were organised into three themes. Both women and clinicians experienced 1) challenges with managing PCOS, often stemming from the disparate and wide spectrum of presentations, issues with current treatment options (including limited evidence) and the long-term nature of management. Both spoke about 2) online information about PCOS and alternative treatments, including lack of relevant information and widespread misinformation. 3) Follow-up and continuity of care, where we found notable differences between women's and clinicians' expectations.

CONCLUSIONS

This is the first study to explore both clinicians' and women's experiences with managing PCOS, illustrating several challenges in managing this heterogeneous condition.

PRACTICE IMPLICATIONS

Clarifying and addressing patient expectations, providing personalised counselling and information according to PCOS phenotype and a multidisciplinary approach may reduce uncertainty and improve patient-centred care.

Consequences of a Diagnostic Label: A Systematic Scoping Review and Thematic Framework

Objectives: To develop a thematic framework for the range of consequences arising from a diagnostic label from an individual, family/caregiver, healthcare professional, and community perspective. Design: Systematic scoping review of qualitative studies. Search Strategy: We searched PubMed, Embase, PsycINFO, Cochrane, and CINAHL for primary studies and syntheses of primary studies that explore the consequences of labelling non-cancer diagnoses. Reference lists of included studies were screened, and forward citation searches undertaken. Study Selection: We included peer reviewed publications describing the perceived consequences for individuals labelled with a non-cancer diagnostic label from four perspectives: that of the individual, their family/caregiver, healthcare professional and/or community members. We excluded studies using hypothetical scenarios. Data Extraction and Synthesis: Data extraction used a three-staged process: one third was used to develop a preliminary framework, the next third for framework validation, and the final third coded if thematic saturation was not achieved. Author themes and supporting quotes were extracted, and analysed from the perspective of individual, family/caregiver, healthcare professional, or community member. Results: After deduplication, searches identified 7,379 unique articles. Following screening, 146 articles, consisting of 128 primary studies and 18 reviews, were included. The developed framework consisted of five overarching themes relevant to the four perspectives: psychosocial impact (e.g., positive/negative psychological impact, social- and self-identity, stigma), support (e.g., increased, decreased, relationship changes, professional interactions), future planning (e.g., action and uncertainty), behaviour (e.g., beneficial or detrimental modifications), and treatment expectations (e.g., positive/negative experiences). Perspectives of individuals were most frequently reported. Conclusions: This review developed and validated a framework of five domains of consequences following diagnostic labelling. Further research is required to test the external validity and acceptability of the framework for individuals and their family/caregiver, healthcare professionals, and community.

Impact of diagnostic labels and causal explanations for weight gain on diet intentions, cognitions and emotions: An experimental online study

Disease labels and causal explanations for certain symptoms or conditions have been found to have both positive and negative outcomes. For example, a diagnosis of polycystic ovary syndrome could conceivably motivate a person to engage in weight management, which is the recommended first line treatment. Furthermore, doctors may feel more comfortable discussing weight when linked to a medical condition. However, such a diagnosis may elicit feelings of increased anxiety, perceived severity and reduced sense of control. Mixed findings are also evident for impacts of genetic explanations on psychosocial outcomes and behaviours. Using hypothetical scenarios presented in an online survey, participants were asked to imagine that they were visiting their general practitioner due to experiencing weight gain, irregular periods, and more pimples than usual. Participants were randomised to receive different diagnostic labels ('polycystic ovary syndrome', 'weight' or no label/description) and causal explanations (genetic or environmental) for their symptoms. Primary outcomes assessed included intention to eat a healthier diet and perceived personal control of weight (average score on scale 1-7 across 3 items). Secondary outcomes included weight stigma, blameworthiness, worry, perceived severity, self-esteem, belief diet will reduce risks and menu item choice. Participants were 545 females aged 18-45 years (mean = 33 years), living in Australia, recruited through a national online recruitment panel. The sample was overweight on average (BMI = 26.5). Participants reporting a PCOS diagnosis were excluded from analyses. We found no main effects of the label or explanation on intention to eat healthier or perceived personal control of weight. For secondary outcomes, those given the genetic explanation reported higher weight stigma (range 1-7; MD = 0.27, 95%CI: 0.011,0.522), greater worry (range 1-7; MD = 0.27, 95%CI: 0.037,0.496), lower self-esteem (range 10-40; MD = 1.26, 95%CI: 0.28 to 2.24) and perceived their weight as more severe (range 1-7; MD = 0.28; 95%CI: 0.05,0.52) than those given the environmental explanation, averaged over disease label given. These findings further highlight the deleterious effects of genetic explanations on psychosocial outcomes and reinforce the need for caution when communicating the aetiology of weight-related health issues.

Diagnosis delayed: health profile differences between women with undiagnosed polycystic ovary syndrome and those with a clinical diagnosis by age 35 years

STUDY QUESTION

Are reproductive, metabolic or psychological health profiles of women with clinically diagnosed polycystic ovary syndrome (PCOS) different from those with undiagnosed PCOS?

SUMMARY ANSWER

Obtaining a clinical diagnosis of PCOS is strongly linked to the experience of fertility problems, but not clinical depression or poor metabolic health, although these were highly prevalent in women with PCOS irrespective of when they were diagnosed.

WHAT IS KNOWN ALREADY

PCOS is an endocrine disorder that is relative common, but heterogeneous in presentation. This may impact on the pathways to diagnosis and timely treatment.

STUDY DESIGN, SIZE, DURATION

A cross-sectional analysis of a community-based cohort of 974 women, established retrospectively when women were around 30 years of age.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In this cohort of women born in Adelaide, South Australia, half of women who met the Rotterdam criteria for PCOS were previously undiagnosed. We compared women with prior clinical diagnosis of PCOS, those diagnosed through participation in this research, and the remainder in the cohort. Sociodemographic characteristics, reproductive, metabolic and psychological health, including medical conditions and medications were considered. Logistic regression was undertaken to identify independent predictors of prior clinical diagnosis.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 56 women with a prior clinical diagnosis of PCOS (5.7%) and a further 64 (6.6%) were undiagnosed until study entry. The great majority of women with a prior diagnosis of PCOS reported having had problems with periods (95%) and excess body hair (63%). Corresponding proportions for women undiagnosed until study participation were slightly lower (81% and 45%, respectively). Although the proportion of women attempting or achieving pregnancy was similar across all groups, those with a prior diagnosis of PCOS were four times more likely to have reported difficulties becoming pregnant than those undiagnosed (odds ratio = 4.05, 95% CI 1.74-9.45) and frequently sought medical assistance. Metabolic problems were higher in both PCOS groups compared to women without PCOS. In both PCOS groups, the prevalence of clinical depression was 50% higher than in those with no PCOS (P = 0.021).

LIMITATIONS, REASONS FOR CAUTION

The number of women who were diagnosed with PCOS both prior to and during the study limited statistical power available to detect modest differences between the PCOS groups. Some women in the group classified as not having PCOS may have remained undiagnosed, but any bias from this source would contribute to more conservative findings.

WIDER IMPLICATIONS OF THE FINDINGS

Findings reinforce the need for early detection of PCOS symptoms from adolescence, ensuring timely diagnosis and appropriate health care. The high prevalence of depression among clinically diagnosed and undiagnosed women with PCOS suggests this is a feature of the condition and supports recent recommendations in the international PCOS guidelines to screen all women with PCOS for depression and anxiety.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a project grant (2017) from the National Health and Medical Research Council of Australia (NHMRC) Centre for Research Excellence in Polycystic Ovary Syndrome (Grant ID APP1078444). R.C.F. and J.C.A. were supported by Robinson Research Institute Lloyd Cox Career Development Fellowships (2018). Establishment of the cohort was funded by an NHMRC Strategic Award No. 465455, a Career Development Award in Population Health (No. 349548) and the Australian Research Council (Future Fellowship FT100101018) awarded to M.J.D. All authors declared no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Médicalisation et autonomie des femmes affectées par le syndrome des ovaires polykystiques

Le syndrome des ovaires polykystiques (SOPK) est un trouble endocrinien répandu qui affecte environ 10% des femmes en âge de procréer. Bien qu’il soit principalement connu pour ses effets sur la fertilité, le SOPK est considéré comme un facteur de risque pouvant mener au diabète de type 2. Il est également associé à des conditions comme les cancers hormono-dépendants, les troubles psychiatriques ou encore les maladies cardio-vasculaires. La volonté de prévenir les conditions associées pourrait pousser à une plus grande médicalisation des femmes atteintes par le SOPK, notamment par d’éventuels dépistages. Cet article examine les facteurs potentiels pouvant contribuer à la médicalisation de ces femmes et la manière dont leur autonomie pourrait être affectée par ce phénomène. Entre autres, l’article met en évidence comment la médicalisation façonne des représentations collectives et individuelles par rapport aux notions de santé, de maladie et de traitement. Dans une perspective relationnelle de l’autonomie, il attire l’attention sur l’importance de reconnaitre comment la médicalisation influence ces représentations et l’impact potentiel que cela pourrait avoir sur les femmes. Encourager la démédicalisation du SOPK par une approche visant à soutenir la santé pousse à interroger ces représentations et fait partie des pistes de solution permettant de favoriser l’autonomie des femmes affectées par le SOPK. Il devient alors possible non seulement de contrôler la maladie, mais aussi de soutenir la santé, voire de faire les deux selon la situation individuelle.

How to Draw the Line Between Health and Disease? Start with Suffering

How can we draw the line between health and disease? This crucial question of demarcation has immense practical implications and has troubled scholars for ages. The question will be addressed in three steps. First, I will present an important contribution by Rogers and Walker who argue forcefully that no line can be drawn between health and disease. However, a closer analysis of their argument reveals that a line-drawing problem for disease-related features does not necessarily imply a line-drawing problem for disease as such. The second step analyzes some alternative approaches to drawing the line between health and disease. While these approaches do not provide full answers to the question, they indicate that the line-drawing question should not be dismissed too hastily. The third step investigates whether the line-drawing problem can find its solution in the concept of suffering. In particular, I investigate whether returning to the origin of medicine, with the primary and ultimate goal of reducing suffering, may provide sources of demarcation between health and disease. In fact, the reason why we pay attention to particular phenomena as characteristics of disease, consider certain processes to be relevant, and specific functions are classified as dys-functions, is that they are related to suffering. Accordingly, using suffering as a criterion of demarcation between health and disease may hinder a wide range of challenges with modern medicine, such as unwarranted expansion of disease, overdiagnosis, overtreatment, and medicalization.

Paeoniflorin attenuates DHEA-induced polycystic ovary syndrome via inactivation of TGF-β1/Smads signaling pathway in vivo

Polycystic ovarian syndrome (PCOS) is one of the most common reproductive endocrine disorders which are involved in complicated and unknown pathogenic mechanisms. Paeoniflorin (PAE) plays a significant anti-fibrotic role according to previous studies. The aim of the present study was to investigate the effect of PAE on ovarian fibrosis and its underlying mechanism in PCOS development. An animal model of PCOS was established by subcutaneous injection of 60mg/kg/d dehydroepiandrosterone (DHEA) for 35 consecutive days. Rats in PAE-L, PAE-M and PAE-H groups were administrated by gavage with PAE (20, 40, 80 mg/kg/d) for 4 weeks. Our results indicated that DHEA-induced PCOS rats showed similar phenotypes with PCOS patients. PAE could significantly block the DHEA-induced decline of ovary weight and organ coefficient, shorten the prolonged diestrus period, and regulate the irregular estrous cycle of PCOS rats. Moreover, PAE regulated reproductive hormone levels and improved ovarian fibrosis induced by DHEA. PAE treatment could also reduce the expression levels of TGF-β1 and Smad3, and increase the expression levels of Smad7 and MMP2. In conclusion, PAE significantly attenuated the ovarian fibrosis in PCOS, which could be mediated by TGF-β1/Smads signaling pathway. Herein, PAE can be used for the treatment of ovarian fibrosis in PCOS progression.

Characterizing the Clinical and Genetic Spectrum of Polycystic Ovary Syndrome in Electronic Health Records

CONTEXT

Polycystic ovary syndrome (PCOS) is one of the leading causes of infertility, yet current diagnostic criteria are ineffective at identifying patients whose symptoms reside outside strict diagnostic criteria. As a result, PCOS is underdiagnosed and its etiology is poorly understood.

OBJECTIVE

We aim to characterize the phenotypic spectrum of PCOS clinical features within and across racial and ethnic groups.

METHODS

We developed a strictly defined PCOS algorithm (PCOSkeyword-strict) using the International Classification of Diseases, ninth and tenth revisions and keywords mined from clinical notes in electronic health records (EHRs) data. We then systematically relaxed the inclusion criteria to evaluate the change in epidemiological and genetic associations resulting in 3 subsequent algorithms (PCOScoded-broad, PCOScoded-strict, and PCOSkeyword-broad). We evaluated the performance of each phenotyping approach and characterized prominent clinical features observed in racially and ethnically diverse PCOS patients.

RESULTS

The best performance came from the PCOScoded-strict algorithm, with a positive predictive value of 98%. Individuals classified as cases by this algorithm had significantly higher body mass index (BMI), insulin levels, free testosterone values, and genetic risk scores for PCOS, compared to controls. Median BMI was higher in African American females with PCOS compared to White and Hispanic females with PCOS.

CONCLUSIONS

PCOS symptoms are observed across a severity spectrum that parallels the continuous genetic liability to PCOS in the general population. Racial and ethnic group differences exist in PCOS symptomology and metabolic health across different phenotyping strategies.

Clinicians’ perspectives on diagnosing polycystic ovary syndrome in Australia: a qualitative study

STUDY QUESTION

What are clinicians’ views about the diagnosis of polycystic ovary syndrome (PCOS), and how do they handle any complexities and uncertainties in practice?

SUMMARY ANSWER

Clinicians have to navigate many areas of complexity and uncertainty regarding the diagnosis of PCOS, related to the diagnostic criteria, limitations in current evidence and misconceptions surrounding diagnosis, and expressed concern about the risk and consequences of both under- and overdiagnosis.

WHAT IS KNOWN ALREADY

PCOS is a complex, heterogeneous condition with many areas of uncertainty, raising concerns about both underdiagnosis and overdiagnosis. Quantitative studies with clinicians have found considerable variation in diagnostic criteria used and care provided, as well as a lack of awareness around the breadth of PCOS features and poor uptake of recommended screening for metabolic complications. Clinicians’ views about the uncertainties and complexities of diagnosing PCOS have not been explored.

STUDY DESIGN, SIZE, DURATION

Semi-structured telephone interviews were conducted with clinicians from September 2017 to July 2018 to explore their perceptions about the diagnosis of PCOS, including how they handle any complexities and uncertainties in practice.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A group of 36 clinicians (15 general practitioners, 10 gynaecologists and 11 endocrinologists) currently practicing in Australia, were recruited through advertising via professional organisations, contacting a random sample of endocrine and gynaecology teams across Australia and snowballing. Transcribed audio-recordings were analysed thematically using Framework analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Clinicians expressed a range of uncertainties and complexities regarding the diagnosis of PCOS, which were organised into three areas: (i) establishing diagnosis (e.g. lack of standardisation regarding diagnostic cut-offs, risk of misdiagnosis), (ii) factors influencing the diagnostic process (e.g. awareness of limitations in evidence and consideration of the benefits and harms) and (iii) strategies for handling challenges and uncertainties (e.g. using caution and communication of uncertainties). Clinicians also varied in their concerns regarding under- and overdiagnosis. Overall, most felt the diagnosis was beneficial for women provided that it was the correct diagnosis and time was taken to assess patient expectations and dispel misconceptions, particularly concerning fertility.

LIMITATIONS, REASONS FOR CAUTION

There is possible selection bias, as clinicians who are more knowledgeable about PCOS may have been more likely to participate. Clinicians’ views may also differ in other countries.

WIDER IMPLICATIONS OF THE FINDINGS

These findings underscore the vital need to first consider PCOS a diagnosis of exclusion and use caution before giving a diagnosis in order to reduce misdiagnosis, as suggested by clinicians in our study. Until there is greater standardisation of diagnostic criteria, more transparent conversations with women may help them understand the uncertainties surrounding the criteria and limitations in the evidence. Additionally, clinicians emphasised the importance of education and reassurance to minimise the potential harmful impact of the diagnosis and improve patient-centred outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the University of Sydney Lifespan Research Network and an NHMRC Program Grant (APP1113532). T.C. is supported by an Australian Government Research Training Program (RTP) Scholarship and a Sydney Medical School Foundation Scholarship, from the The University of Sydney, Australia. B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA and Guerbet. No further competing interests exist.

TRIAL REGISTRATION NUMBER

N/A

Impact of a diagnosis of polycystic ovary syndrome on diet, physical activity and contraceptive use in young women: findings from the Australian Longitudinal Study of Women’s Health

STUDY QUESTION

Do diet, physical activity and contraceptive use change after receiving a diagnosis of polycystic ovary syndrome (PCOS)?

SUMMARY ANSWER

Using longitudinal data 12 months apart, young women newly diagnosed with PCOS were more likely to stop using contraception but did not change their physical activity or vegetable intake.

WHAT IS KNOWN ALREADY

Diagnostic criteria for PCOS have widened to capture more women, despite limited evidence of the benefits and harms. Possible benefits of a PCOS diagnosis are that it may help women with family planning and motivate them to implement healthy lifestyle changes to reduce the reproductive, metabolic and cardiovascular risks associated with PCOS. However, there are no empirical studies investigating how women respond to a diagnosis of PCOS with respect to their health behaviour, and longitudinal population-based studies are lacking.

STUDY DESIGN, SIZE, DURATION

This is a longitudinal analysis of two waves of data collected 12 months apart from the cohort born 1989–1995 in the Australian Longitudinal Survey on Women’s Health, a population-based cohort study. Women in this cohort were first surveyed in 2012-2013, aged 18-23 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women who responded to the 2014 survey (aged 19–24, n = 11 344) and 2015 survey (aged 20–25, n = 8961) were included. Using logistic regression, multinomial logistic regression and linear regression, change in vegetable intake, physical activity and contraceptive use were compared for women newly diagnosed with PCOS to women not reporting a diagnosis of PCOS. Changes in psychological distress and BMI were also examined.

MAIN RESULTS AND THE ROLE OF CHANCE

Young women reporting a new diagnosis of PCOS were no more likely to increase their vegetable intake or physical activity than women not reporting a PCOS diagnosis. Women newly diagnosed with PCOS were 3.4 times more likely to stop using contraception during the 12-month study period than women without PCOS (14% versus 4%, 95% CI = 2.3 to 5.1, P &lt; 0.001). This difference remained significant after controlling for demographics, chronic conditions associated with PCOS, endometriosis, BMI and psychological distress (P &lt; 0.001).

LIMITATIONS, REASONS FOR CAUTION

All data was self-reported including PCOS diagnosis, assessment of diet quality was limited to vegetable intake only. The exact timing of diagnosis within the 12-month period and whether the women intended to conceive are unknown. The number of women reporting a new diagnosis of PCOS was also relatively small.

WIDER IMPLICATIONS OF THE FINDINGS

These findings suggest that a diagnosis of PCOS may not produce short-term benefits by way of improving health behaviour. The observed reduction in contraception use suggests some women may be at increased risk of unplanned pregnancies, highlighting the importance of counselling about contraceptive needs. Both potential benefits and harms must be considered when determining the appropriateness of a PCOS diagnosis.

STUDY FUNDING/COMPETING interest(s)

The Australian Longitudinal Study on Women’s Health is funded by the Australian Government Department of Health. BWM reports consultancy for ObsEva, Merck, Merck KGaA and Guerbet. No further competing interests exist.

TRIAL REGISTRATION NUMBER

N/A

The benefits and harms of receiving a polycystic ovary syndrome diagnosis: a qualitative study of women's experiences

STUDY QUESTION

What are the benefits and harms of receiving a polycystic ovary syndrome (PCOS) diagnosis in a community sample of women, including impact on psychosocial wellbeing, lifestyle choices and behaviour?

SUMMARY ANSWER

Although some women benefit considerably from the diagnosis, such as through increased awareness and reassurance, women with minimal symptoms may experience more harm than benefit, including long-lasting anxiety and altered life plans.

WHAT IS KNOWN ALREADY

Disease labels can validate symptoms and play a vital role in understanding and coping with illness; however, they can also cause harm by evoking illness schemas about severity and permanence. Regarding PCOS, the diagnostic criteria have expanded over time to include women with milder phenotypes (such as those without signs of androgen excess). This has occurred despite limited investigation of the benefits and harms of the diagnosis and has increased the number of women diagnosed.

STUDY DESIGN SIZE DURATION

Semi-structured interviews were conducted face-to-face or by telephone with 26 participants from April-July 2018 to explore women's experiences with the diagnosis, including the benefits and harms of receiving the diagnosis and the impact on their life.

PARTICIPANTS/MATERIALS SETTING METHODS

In total, 26 women in the community self-reporting a diagnosis of PCOS (reporting mild to severe symptoms) made by a medical doctor, aged 18-45 years and living in Australia were recruited through social media. Data were analysed thematically using Framework analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

The study identified a range of both positive and negative effects of a PCOS diagnosis in the immediate, short and long-term, which were influenced by symptom severity, expectations and experience. For women with previously unexplained and bothersome symptoms, it was a relief to receive a diagnosis, and this resulted in an increased understanding about the importance of a healthy lifestyle. By contrast, women with milder symptoms often reported feeling shocked and overwhelmed by the diagnosis, consequently experiencing anxiety about the associated long-term risks. The majority of women, regardless of symptom severity, experienced prolonged worry and anxiety about infertility, resulting for some in risk taking with contraception, unintended pregnancies, pressure to conceive early or altered life plans. With time, many women developed positive coping strategies and perceived the diagnosis to be valuable, including those who felt they had experienced minimal benefit or even harm.

LIMITATIONS REASONS FOR CAUTION

PCOS diagnosis was self-reported and the sample was highly educated.

WIDER IMPLICATIONS OF THE FINDINGS

Fear of infertility was salient for many women, underscoring the need for accurate information, counselling and reassurance of fertility potential. Given the risk of significant consequences, health professionals should use a tailored approach to PCOS diagnosis to increase the benefits of appropriate and timely diagnosis for women affected by significant symptoms, while reducing the harms of unnecessarily labelling healthy women for whom the benefits of a diagnosis are small.

STUDY FUNDING/COMPETING INTERESTS

The study was funded by the University of Sydney Lifespan Research Network and an NHMRC Program Grant (APP1113532). B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA and Guerbet. No further competing interests exist.

TRIAL REGISTRATION NUMBER

N/A.

Endocrine characteristics, body mass index and metabolic syndrome in women with polycystic ovary syndrome

RESEARCH QUESTION

The study aimed to evaluate the associations of endocrine and ultrasound characteristics with metabolic syndrome in women with polycystic ovary syndrome (PCOS), and whether these associations were modified by body mass index (BMI).

DESIGN

The study was a secondary analysis of baseline data from a randomized controlled trial of induction of ovulation in women with PCOS.

RESULTS

Among 947 Chinese women with PCOS, 153 (16.2%) were diagnosed with metabolic syndrome. The prevalence of metabolic syndrome in women with normal (<24 kg/m²) and high (≥24 kg/m²) BMI was 3.6% and 30.5%, respectively. In all women, a high free androgen index (FAI ≥5%) was positively associated with metabolic syndrome (adjusted odds ratio [OR] 2.06, 95% confidence interval [CI] 1.11-3.82). High FAI was positively associated with metabolic syndrome among women with high BMI (adjusted OR 3.37, 95% CI 1.78-6.37), but the association was not significant in women with normal BMI (adjusted OR 1.27, 95% CI 0.34-4.70). The presence of polycystic ovary morphology was negatively associated with metabolic syndrome (adjusted OR 0.52, 95% CI 0.26-1.03) in all women (normal BMI adjusted OR 0.42, 95% CI 0.11-1.67; high BMI adjusted OR 0.54, 95% CI 0.23-1.28). LH, sex hormone-binding globulin (SHBG) and anti-Müllerian hormone (AMH) were negatively associated with metabolic syndrome. The associations of FAI, SHBG and AMH in relation to metabolic syndrome were significantly modified by BMI.

CONCLUSION(S)

The associations of endocrine characteristic with metabolic syndrome were modified by BMI in women with PCOS. Women with PCOS and normal BMI did not have an increased risk of metabolic syndrome.

Laparoscopic Sleeve Gastrectomy Outcomes in Patients with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common disease among the bariatric population. However, there are limited data regarding the impact of laparoscopic sleeve gastrectomy (SG) on these patients. The study was conducted at University Hospital, United States. The purpose of this study was to examine per cent excess body weight loss (%EWL) and diabetes control in patients who have PCOS compared with those without PCOS. A total of 550 female patients underwent SG between December 2011 and October 2016. Retrospective analysis was completed to include follow-up data at 1, 3, 6, and 12 months and yearly after that. Outcomes measured were %EWL and hemoglobin A1c (HgbA1c). The mean and median follow-up for the entire cohort was 21 and 15 months, respectively. Seventy-eight per cent of patients completed at least 12 months of follow-up for %EWL, although only 21 per cent had similar follow-up for HgbA1c. PCOS patients had similar age (36.3 vs 36.2 years, P = 0.90), preoperative BMI (47.2 vs 47.2, P = 0.99), preoperative HgbA1c (6% vs 5.8%, P = 0.31), conversion rate to gastric bypass, and other associated comorbidities compared with non-PCOS comparisons. There was no difference in %EWL at 12-month (49.7% vs 53.1%, P = 0.53) or 24-month (43% vs 49.8%, P = 0.46) postoperative intervals. There was no difference in absolute change of HgbA1c at 12 months (-0.47% vs -0.67%, P = 0.39). SG has equivalent short-term results in %EWL and reduction in HgbA1c for patients who have PCOS and those who do not.

Functional hypothalamic amenorrhea: case presentations and overview of literature

Functional hypothalamic amenorrhea is a form of chronic anovulation not due to identifiable organic causes with adverse health consequences. A thorough history is paramount in the identification of women with this disorder as it is usually associated with lifestyle factors such as stress, weight loss, and excessive exercise. In this paper, recently published clinical guidelines are reviewed and a series of cases is presented that highlights diagnostic and therapeutic challenges encountered.

Geographical Prevalence of Polycystic Ovary Syndrome as Determined by Region and Race/Ethnicity

Polycystic ovarian syndrome (PCOS) is thought to be the most common endocrine disorder found in women. Common symptoms include irregular menstrual cycle, polycystic ovaries, and hirsutism, as well as an increased risk for a multitude of conditions, including insulin resistance, dyslipidemia and infertility. The prevalence of polycystic ovarian syndrome is generally thought to be between 3% and 10% but it is widely unknown for specific subpopulations based on geographical location and race/ethnicity. Based on the high degree of variability and inconsistencies between the different diagnostic criteria, there is a unique challenge that exists when determining the prevalence of this syndrome. There are a large percentage of individuals that remain undiagnosed even after visiting multiple health care providers. Most studies conducted across the world are limited by small sample size, selection bias, and lack of comparability across studies. There have been very few studies that have examined the prevalence of polycystic ovary syndrome across the United States. Based on the National Institutes of Health (NIH)’s diagnostic criteria, there is a similar prevalence of PCOS documented across the United States, the United Kingdom, Spain, Greece, Australia, and Mexico. Other studies have shown some differences between geographical location and race. The existing data is not conclusive enough to determine whether or not there is any significant differences in the prevalence of PCOS across geographical location, racial or ethnic groups. This review will seek to determine the prevalence of polycystic ovarian syndrome based on geographical location and race/ethnicity.

Explaining variations in test ordering in primary care: protocol for a realist review

INTRODUCTION

Studies have demonstrated the existence of significant variation in test-ordering patterns in both primary and secondary care, for a wide variety of tests and across many health systems. Inconsistent practice could be explained by differing degrees of underuse and overuse of tests for diagnosis or monitoring. Underuse of appropriate tests may result in delayed or missed diagnoses; overuse may be an early step that can trigger a cascade of unnecessary intervention, as well as being a source of harm in itself.

METHODS AND ANALYSIS

This realist review will seek to improve our understanding of how and why variation in laboratory test ordering comes about. A realist review is a theory-driven systematic review informed by a realist philosophy of science, seeking to produce useful theory that explains observed outcomes, in terms of relationships between important contexts and generative mechanisms.An initial explanatory theory will be developed in consultation with a stakeholder group and this 'programme theory' will be tested and refined against available secondary evidence, gathered via an iterative and purposive search process. This data will be analysed and synthesised according to realist principles, to produce a refined 'programme theory', explaining the contexts in which primary care doctors fail to order 'necessary' tests and/or order 'unnecessary' tests, and the mechanisms underlying these decisions.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. A complete and transparent report will be produced in line with the RAMESES standards. The theory developed will be used to inform recommendations for the development of interventions designed to minimise 'inappropriate' testing. Our dissemination strategy will be informed by our stakeholders. A variety of outputs will be tailored to ensure relevance to policy-makers, primary care and pathology practitioners, and patients.

PROSPERO REGISTRATION NUMBER

CRD42018091986.