The polycystic ovary syndrome: a position statement from the European Society of Endocrinology

Conway, Gerard; Dewailly, Didier; Diamanti-Kandarakis, Evanthia; Escobar-Morreale, Héctor F; Franks, Stephen; Gambineri, Alessandra; Kelestimur, Fahrettin; Macut, Djuro; Micic, Dragan; Pasquali, Renato; Pfeifer, Marija; Pignatelli, Duarte; Pugeat, Michel; Yildiz, Bulent O

doi:10.1530/eje-14-0253

Cited by 676Ovarian function and disordersDiabetes, Cardiovascular Risks, and LipoproteinsEndometriosis Research and Treatment

The polycystic ovary syndrome: a position statement from the European Society of Endocrinology

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Conway, Gerard, Dewailly, Didier, Diamanti-Kandarakis, Evanthia, Escobar-Morreale, Héctor F, Franks, Stephen, Gambineri, Alessandra, Kelestimur, Fahrettin, Macut, Djuro +6 more·2014·European Journal of Endocrinology

DOI 10.1530/eje-14-0253

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Abstract

Polycystic ovary syndrome (PCOS) is the most common ovarian disorder associated with androgen excess in women, which justifies the growing interest of endocrinologists. Great efforts have been made in the last 2 decades to define the syndrome. The presence of three different definitions for the diagnosis of PCOS reflects the phenotypic heterogeneity of the syndrome. Major criteria are required for the diagnosis, which in turn identifies different phenotypes according to the combination of different criteria. In addition, the relevant impact of metabolic issues, specifically insulin resistance and obesity, on the pathogenesis of PCOS, and the susceptibility to develop earlier than expected glucose intolerance states, including type 2 diabetes, has supported the notion that these aspects should be considered when defining the PCOS phenotype and planning potential therapeutic strategies in an affected subject. This paper offers a critical endocrine and European perspective on the debate on the definition of PCOS and summarises all major aspects related to aetiological factors, including early life events, potentially involved in the development of the disorder. Diagnostic tools of PCOS are also discussed, with emphasis on the laboratory evaluation of androgens and other potential biomarkers of ovarian and metabolic dysfunctions. We have also paid specific attention to the role of obesity, sleep disorders and neuropsychological aspects of PCOS and on the relevant pathogenetic aspects of cardiovascular risk factors. In addition, we have discussed how to target treatment choices based according to the phenotype and individual patient's needs. Finally, we have suggested potential areas of translational and clinical research for the future with specific emphasis on hormonal and metabolic aspects of PCOS.

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Women with PCOS are often obese, develop IR and are at risk of developing T2D.
“Women with PCOS are often obese, develop IR and are at risk of developing T2D [187, 188].”
From Role of sex hormone-binding globulin in the free hormone hypothesis and the relevance of free testosterone in androgen physiology (2022) · cites this paper as [187]
In the diagnostic workup of PCOS, androgen excess is usually assessed by measurement of total T.
“In the diagnostic workup of PCOS, androgen excess is usually assessed by measurement of total T [187].”
From Role of sex hormone-binding globulin in the free hormone hypothesis and the relevance of free testosterone in androgen physiology (2022) · cites this paper as [187]
Chromatography-mass spectrometry has become the gold standard for measurement of sex steroids.
“Hence, acquisition of total T results in women should be done by chromatography-mass spectrometry, which has become the gold standard for measurement of sex steroids [39, 187].”
From Role of sex hormone-binding globulin in the free hormone hypothesis and the relevance of free testosterone in androgen physiology (2022) · cites this paper as [187]
In contrast to total T, free T seems to be a better marker to determine hyperandrogenemia in women with PCOS, provided that accurate and high quality methodology is used for measured or calculated free T.
“In contrast to total T, free T seems to be a better marker to determine hyperandrogenemia in women with PCOS [187], provided that accurate and high quality methodology is used for measured or calculated free T [193, 194].”
From Role of sex hormone-binding globulin in the free hormone hypothesis and the relevance of free testosterone in androgen physiology (2022) · cites this paper as [187]
Systemic upregulation of 5α-reductase activity in women with PCOS is associated with metabolic dysfunction.
“which is associated with metabolic dysfunction (Conway et al., 2014, O'Reilly et al., 2014b).”
From Intracrine androgen biosynthesis, metabolism and action revisited (2018) · cites this paper as Conway et al., 2014

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The role of low-grade inflammation in the polycystic ovary syndrome
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Association between the Current Use of Low-Dose Oral Contraceptives and Cardiovascular Arterial Disease: A Meta-Analysis
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Fetal Programming of Polycystic Ovary Syndrome by Androgen Excess: Evidence from Experimental, Clinical, and Genetic Association Studies
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Effect of clomifene citrate plus metformin and clomifene citrate plus placebo on induction of ovulation in women with newly diagnosed polycystic ovary syndrome: randomised double blind clinical trial
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Hyperandrogenemia Predicts Metabolic Phenotype in Polycystic Ovary Syndrome: The Utility of Serum Androstenedione
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Comparison of single and combined treatment with exenatide and metformin on menstrual cyclicity in overweight women with polycystic ovary syndrome
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Increased Prevalence of Obstructive Sleep Apnea Syndrome in Obese Women with Polycystic Ovary Syndrome<sup>1</sup>
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Exercise therapy in polycystic ovary syndrome: a systematic review
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Vitamin D deficiency is common and associated with metabolic risk factors in patients with polycystic ovary syndrome
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Altered Vascular Function in Young Women with Polycystic Ovary Syndrome
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Toward Excellence in Testosterone Testing: A Consensus Statement
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Characteristics and metabolic effects of estrogen and progestins contained in oral contraceptive pills
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Cardiovascular Disease and Risk Factors in PCOS Women of Postmenopausal Age: A 21-Year Controlled Follow-up Study
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Increased Risk for Abnormal Depression Scores in Women With Polycystic Ovary Syndrome
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Placental steroidogenesis in pregnant women with polycystic ovary syndrome
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Treatment with Flutamide, Metformin, and Their Combination Added to a Hypocaloric Diet in Overweight-Obese Women with Polycystic Ovary Syndrome: A Randomized, 12-Month, Placebo-Controlled Study
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Is polycystic ovary syndrome associated with high sympathetic nerve activity and size at birth?
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“Moreover, hyperinsulinaemia exerts a direct hypertrophic effect on the vascular endothelium and the vascular smooth muscle cells and in concert with insulin resistance stimulates endothelin-1 (ET1) production, thus exaggerating endothelial dysfunction (174).”
Comparison of Spironolactone, Flutamide, and Finasteride Efficacy in the Treatment of Hirsutism: A Randomized, Double Blind, Placebo-Controlled Trial1
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Quality of life and psychological morbidity in women with polycystic ovary syndrome: body mass index, age and the provision of patient information are significant modifiers
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A More Atherogenic Serum Lipoprotein Profile Is Present in Women with Polycystic Ovary Syndrome: A Case-Control Study
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The Polycystic Ovary Post-Rotterdam: A Common, Age-Dependent Finding in Ovulatory Women without Metabolic Significance
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Insulin-sensitising drugs versus the combined oral contraceptive pill for hirsutism, acne and risk of diabetes, cardiovascular disease, and endometrial cancer in polycystic ovary syndrome
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Referral Bias in Defining the Phenotype and Prevalence of Obesity in Polycystic Ovary Syndrome
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Effects of Exercise on Insulin Resistance and Body Composition in Overweight and Obese Women with and without Polycystic Ovary Syndrome
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Testosterone Increases Lipolysis and the Number of β-Adrenoceptors in Male Rat Adipocytes*
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Inappropriate Gonadotropin Secretion in Polycystic Ovary Syndrome: Influence of Adiposity 1
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Predictors of Endothelial Dysfunction in Young Women with Polycystic Ovary Syndrome
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Age-Specific Reference Ranges for Serum Testosterone and Androstenedione Concentrations in Women Measured by Liquid Chromatography-Tandem Mass Spectrometry
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The genetics of the polycystic ovary syndrome
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Lifestyle Modification Programs in Polycystic Ovary Syndrome: Systematic Review and Meta-Analysis
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Using an electrocautery strategy or recombinant follicle stimulating hormone to induce ovulation in polycystic ovary syndrome: randomised controlled trial
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Androgen Receptor Gene CAG Repeat Polymorphism in the Development of Ovarian Hyperandrogenism
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Short-term combined treatment with liraglutide and metformin leads to significant weight loss in obese women with polycystic ovary syndrome and previous poor response to metformin
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Carotid artery intima-media thickness in polycystic ovary syndrome: a systematic review and meta-analysis
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“A recent systematic review of the studies has conﬁrmed that C-IMT was thicker in women with PCOS in comparison with controls (204).”
Identification of Virilizing Adrenal Tumors in Hirsute Women
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Differential Gene Expression Profile in Omental Adipose Tissue in Women with Polycystic Ovary Syndrome
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Increased serum advanced glycation end‐products is a distinct finding in lean women with polycystic ovary syndrome (PCOS)
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Polycystic Ovary Syndrome
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Lipids and lipoprotein subfractions in women with PCOS: relationship to metabolic and endocrine parameters
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Comparison of Spironolactone, Flutamide, and Finasteride Efficacy in the Treatment of Hirsutism: A Randomized, Double Blind, Placebo-Controlled Trial
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Depression, anxiety and cardiometabolic risk in polycystic ovary syndrome
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Antiandrogens for the Treatment of Hirsutism: A Systematic Review and Metaanalyses of Randomized Controlled Trials
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The Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire (PCOSQ): a validation
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Maternal insulin resistance causes oxidative stress and mitochondrial dysfunction in mouse oocytes
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Drospirenone for the Treatment of Hirsute Women with Polycystic Ovary Syndrome: A Clinical, Endocrinological, Metabolic Pilot Study
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Reconciling the Definitions of Polycystic Ovary Syndrome: The Ovarian Follicle Number and Serum Anti-Müllerian Hormone Concentrations Aggregate with the Markers of Hyperandrogenism
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The relationship of serum anti-Mullerian hormone with polycystic ovarian morphology and polycystic ovary syndrome: a prospective cohort study
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Altered Cortisol Metabolism in Polycystic Ovary Syndrome: Insulin Enhances 5α-Reduction But Not the Elevated Adrenal Steroid Production Rates
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Low serum testosterone assayed by liquid chromatography-tandem mass spectrometry. Comparison with five immunoassay techniques
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Failure of mathematical indices to accurately assess insulin resistance in lean, overweight, or obese women with polycystic ovary syndrome
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Lifecycle of polycystic ovary syndrome (PCOS): from in utero to menopause
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Randomized, double‐blind clinical evaluation of the efficacy and safety of topical eflornithine HCl 13.9% cream in the treatment of women with facial hair
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Disturbed stress responses in women with polycystic ovary syndrome
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Inappropriate Gonadotropin Secretion in Polycystic Ovary Syndrome: Influence of Adiposity
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The phenotype of polycystic ovary syndrome ameliorates with aging
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Determinants of emotional distress in women with polycystic ovary syndrome
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Evaluation of Adverse Outcome in Young Women with Polycystic Ovary Syndrome<i>Versus</i>Matched, Reference Controls: A Retrospective, Observational Study
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Renaming PCOS—A Two-State Solution
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Adipose Tissue Dysfunction in Polycystic Ovary Syndrome
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Psychological implications of infertility in women with polycystic ovary syndrome
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Treatment of Obstructive Sleep Apnea Improves Cardiometabolic Function in Young Obese Women with Polycystic Ovary Syndrome
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Are There Any Sensitive and Specific Sex Steroid Markers for Polycystic Ovary Syndrome?
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Vitamin D Regulates Anti-Mullerian Hormone Expression in Granulosa Cells of the Hen1
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Risk of venous thromboembolism in women with polycystic ovary syndrome: a population-based matched cohort analysis
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The role of vitamin D in metabolic disturbances in polycystic ovary syndrome: a systematic review
Krul-Poel, Y. H. M., Snackey, C., Louwers, Y. V., Lips, P. T. A. M., Lambalk, C. B., Laven, J. S. E., & Şimşek, S. (2013) · European Journal of Endocrinology · doi:10.1530/eje-13-0617 · Cited by 124 · see citing works
Prediction of the individual follicle-stimulating hormone threshold for gonadotropin induction of ovulation in normogonadotropic anovulatory infertility: an approach to increase safety and efficiency
Imani, B., Eijkemans, M. J. C., Faessen, G. H., Bouchard, P., Giudice, L. C., & Fauser, B. C. J. M. (2002) · Fertility and Sterility · doi:10.1016/s0015-0282(01)02928-4 · Cited by 123 · see citing works
Sex Hormone–Binding Globulin, but Not Testosterone, Is Associated Prospectively and Independently With Incident Metabolic Syndrome in Men
Bhasin, S., Jasjua, G. K., Pencina, M. J., D’Agostino, R. B., Coviello, A. D., Vasan, R. S., & Travison, T. G. (2011) · Diabetes Care · doi:10.2337/dc11-0888 · Cited by 120 · see citing works
Polycystic ovarian syndrome: marked differences between endocrinologists and gynaecologists in diagnosis and management
Cussons, A. J., Stuckey, B. G. A., Walsh, J. P., Burke, V., & Norman, R. J. (2005) · Clinical Endocrinology · doi:10.1111/j.1365-2265.2004.02208.x · Cited by 119 · see citing works
Mitochondrial Complex I Impairment in Leukocytes from Polycystic Ovary Syndrome Patients with Insulin Resistance
Víctor, V. M., Rocha, M., Bañuls, C., Sánchez-Serrano, M., Solá, E., Gomez, M., & Hernández‐Mijares, A. (2009) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2009-0466 · Cited by 119 · see citing works
Effects of Gastric Bypass Surgery on Female Reproductive Function
Legro, R. S., Dodson, W. C., Gnatuk, C. L., Estes, S. J., Kunselman, A. R., Meadows, J. W., Kesner, J. S., Krieg, E. F., Rogers, A. M., Haluck, R. S., et al. (2012) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2012-2205 · Cited by 119 · see citing works
Ontogeny of the ovary in polycystic ovary syndrome
Dumesic, D. A., & Richards, J. S. (2013) · Fertility and Sterility · doi:10.1016/j.fertnstert.2013.02.011 · Cited by 118 · see citing works
Women living with facial hair: the psychological and behavioral burden
Lipton, M. G., Sherr, L., Elford, J., Rustin, M. H. A., & Clayton, W. J. (2006) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2006.01.016 · Cited by 118 · see citing works
Consensus on infertility treatment related to polycystic ovary syndrome.
Hong, K. (2008) · Human Reproduction · doi:10.1093/humrep/dem426 · Cited by 117 · see citing works
Metformin treatment of polycystic ovary syndrome improves health-related quality-of-life, emotional distress and sexuality
Hahn, S., Benson, S., Elsenbruch, S., Pleger, K., Tan, S., Mann, K., Schedlowski, M., van Halteren, W. B., Kimmig, R., & Janssen, O. E. (2006) · Human Reproduction · doi:10.1093/humrep/del069 · Cited by 115 · see citing works
Androgen suppressive effect of GnRH agonist in ovarian hyperthecosis and virilizing turnours*
Pascale, M., PUGEAT, M. M., Roberts, M., ROUSSET, H., Déchaud, H., Dutrieux-Berger, N., & TOURNIAIRE, J. (1994) · Clinical Endocrinology · doi:10.1111/j.1365-2265.1994.tb01820.x · Cited by 115 · see citing works
Self-citation
Polycystic ovary syndrome in Mexican-Americans: prevalence and association with the severity of insulin resistance
Goodarzi, M. O., Quiñones, M. J., Azziz, R., Rotter, J. I., Hsueh, W. A., & Yang, H. (2005) · Fertility and Sterility · doi:10.1016/j.fertnstert.2005.03.051 · Cited by 112 · see citing works
Proteomic analysis of human omental adipose tissue in the polycystic ovary syndrome using two-dimensional difference gel electrophoresis and mass spectrometry
Cortón, M., Botella-Carretero, J. I., López, J. A., Camafeita, E., Millán, J. L. S., Escobar-Morreale, H. F., & Peral, B. (2007) · Human Reproduction · doi:10.1093/humrep/dem380 · Cited by 112 · see citing works
Self-citation
Impact of obstructive sleep apnea on insulin resistance and glucose tolerance in women with polycystic ovary syndrome
Tasali, E., Van Cauter, E., Hoffman, L., & Ehrmann, D. A. (2008) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2008-0925 · Cited by 111 · see citing works
Laser and photoepilation for unwanted hair growth
Hædersdal, M., & Gøtzsche, P. C. (2006) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd004684.pub2 · Cited by 110 · see citing works
Increased 5α-Reductase Activity and Adrenocortical Drive in Women with Polycystic Ovary Syndrome
Vassiliadi, D. A., Barber, T. M., Hughes, B. A., McCarthy, M. I., Wass, J. A. H., Franks, S., Nightingale, P., Tomlinson, J. W., Arlt, W., & Stewart, P. M. (2009) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2009-0837 · Cited by 110 · see citing works
Self-citation
Improved Efficacy of Low-Dose Spironolactone and Metformin Combination Than Either Drug Alone in the Management of Women With Polycystic Ovary Syndrome (PCOS): A Six-Month, Open-Label Randomized Study
Ganie, M. A., Khurana, M. L., Nisar, S., Shah, P. A., Shah, Z. A., Kulshreshtha, B., Gupta, N., Zargar, M. A., Wani, T. A., Mudasir, S., et al. (2013) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2013-1040 · Cited by 109 · see citing works
Menstrual irregularity and cardiovascular mortality.
Wang, E., Cirillo, P. M., Vittinghoff, E., Bibbins-Domingo, K., Cohn, B., & Cedars, M. (2011) · Journal of Clinical Endocrinology and Metabolism · doi:10.1210/jc.2010-1709 · Cited by 109 · see citing works
Polycystic ovary syndrome, oral contraceptives and metabolic issues: new perspectives and a unifying hypothesis
Nader, S., & Diamanti-Kandarakis, E. (2007) · Human Reproduction · doi:10.1093/humrep/del407 · Cited by 109 · see citing works
Self-citation
Metabolic Heterogeneity in Polycystic Ovary Syndrome Is Determined by Obesity: Plasma Metabolomic Approach Using GC-MS
Escobar-Morreale, H. F., Samino, S., Insenser, M. R., Vinaixa, M., Luque‐Ramírez, M., Lasunción, M. A., & Correig, X. (2012) · Clinical Chemistry · doi:10.1373/clinchem.2011.176396 · Cited by 109 · see citing works
Self-citation
Low-dose flutamide-metformin therapy for hyperinsulinemic hyperandrogenism in non-obese adolescents and women
Ibáñez, L., & de Zegher, F. (2006) · Human Reproduction Update · doi:10.1093/humupd/dmi054 · Cited by 109 · see citing works
Adipose tissue expandability and the early origins of PCOS
de Zegher, F., López‐Bermejo, A., & Ibáñez, L. (2009) · Trends in Endocrinology and Metabolism · doi:10.1016/j.tem.2009.06.003 · Cited by 108 · see citing works
Hyperandrogenism in Women with Polycystic Ovary Syndrome Persists after Menopause
Markopoulos, M. C., Rizos, D., Valsamakis, G., Deligeoroglou, E., Grigoriou, O., Chrousos, G. P., Creatsas, G. K., & Mastorakos, G. P. (2010) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2010-0130 · Cited by 107 · see citing works
Comparative study of the therapeutic effects of oral contraceptive pills containing desogestrel, cyproterone acetate, and drospirenone in patients with polycystic ovary syndrome
Bhattacharya, S. M., & Jha, A. (2012) · Fertility and Sterility · doi:10.1016/j.fertnstert.2012.06.035 · Cited by 105 · see citing works
Oxidised low-density lipoprotein concentration – early marker of an altered lipid metabolism in young women with PCOS
Μacut, D., Damjanovic, S. S., Panidis, D., Spanos, N., Glišić, B., Petakov, M. S., Rousso, D., Kourtis, A., Bjekić, J., & Milic, N. M. (2006) · European Journal of Endocrinology · doi:10.1530/eje.1.02187 · Cited by 104 · see citing works
Accumulation of dietary glycotoxins in the reproductive system of normal female rats
Diamanti‐Kandarakis, E., Piperi, C., Korkolopoulou, P. A., Kandaraki, E., Levidou, G., Papalois, A. E., Patsouris, E., & Papavassiliou, A. G. (2007) · Journal of Molecular Medicine · doi:10.1007/s00109-007-0246-6 · Cited by 104 · see citing works
Self-citation
Psychological well-being and sexarche in women with polycystic ovary syndrome
de Niet, J. E., de Koning, C. M., Pastoor, H., Duivenvoorden, H. J., Valkenburg, O., Ramakers, M. J., Passchier, J., de Klerk, C., & Laven, J. S. E. (2010) · Human Reproduction · doi:10.1093/humrep/deq068 · Cited by 103 · see citing works
Impact of dietary modification of advanced glycation end products (AGEs) on the hormonal and metabolic profile of women with polycystic ovary syndrome (PCOS)
Tantalaki, E., Piperi, C., Livadas, S., Κόλλιας, Α., Adamopoulos, C., Koulouri, A., Christakou, C. D., & Diamanti‐Kandarakis, E. (2014) · HORMONES · doi:10.1007/bf03401321 · Cited by 101 · see citing works
Self-citation
Intraobserver and interobserver reliability of automated antral follicle counts made using three‐dimensional ultrasound and SonoAVC
Deb, S., Jayaprakasan, K., Campbell, B. K., Clewes, J. S., Johnson, I. R., & Raine‐Fenning, N. (2009) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.6310 · Cited by 101 · see citing works
Vitamin D receptor gene expression in human pituitary gland
Pérez-Fernández, R., Alonso‐Sampedro, M., Segura, C., Munoz, I., García‐Caballero, T., & Diéguez, C. (1996) · Life Sciences · doi:10.1016/s0024-3205(96)00586-3 · Cited by 97 · see citing works
Comparison of Ethinyl-Estradiol Plus Cyproterone AcetateVersusMetformin Effects on Classic Metabolic Cardiovascular Risk Factors in Women with the Polycystic Ovary Syndrome
Luque‐Ramírez, M., Álvarez‐Blasco, F., Botella-Carretero, J. I., Martínez‐Bermejo, E., Lasunción, M. A., & Escobar-Morreale, H. F. (2007) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2007-0282 · Cited by 96 · see citing works
Self-citation
Aromatase inhibitors for PCOS: a systematic review and meta-analysis
Misso, M. L., Wong, J. L. A., Teede, H. J., Hart, R. J., Rombauts, L. J. F., Melder, A., Norman, R. J., & Costello, M. (2012) · Human Reproduction Update · doi:10.1093/humupd/dms003 · Cited by 96 · see citing works
Infertility in Polycystic Ovary Syndrome: Focus on Low-Dose Gonadotropin Treatment
Gorry, A., White, D. M., & Franks, S. (2006) · Endocrine · doi:10.1385/endo:30:1:27 · Cited by 95 · see citing works
Self-citation
The oligomenorrhoic phenotypes of polycystic ovary syndrome are characterized by a high visceral adiposity index: a likely condition of cardiometabolic risk
Amato, M. C., Verghi, M., Galluzzo, A., & Giordano, C. S. D. S. (2011) · Human Reproduction · doi:10.1093/humrep/der088 · Cited by 95 · see citing works
Heterogeneity in the responsiveness to long-term lifestyle intervention and predictability in obese women with polycystic ovary syndrome
Pasquali, R., Gambineri, A., Cavazza, C., Gasparini, D. I., Ciampaglia, W., Cognigni, G. E., & Pagotto, U. (2010) · European Journal of Endocrinology · doi:10.1530/eje-10-0692 · Cited by 95 · see citing works
Self-citation
Evaluation and management of adolescent amenorrhea
Deligeoroglou, E., Athanasopoulos, N., Tsimaris, P., Dimopoulos, K., Vrachnis, N., & Creatsas, G. C. (2010) · Annals of the New York Academy of Sciences · doi:10.1111/j.1749-6632.2010.05669.x · Cited by 95 · see citing works
Peripubertal Vitamin D3 Deficiency Delays Puberty and Disrupts the Estrous Cycle in Adult Female Mice1
Dicken, C. L., Israel, D. D., Davis, J. B., Sun, Y., Shu, J., Hardin, J., & Neal-Perry, G. S. (2012) · Biology of Reproduction · doi:10.1095/biolreprod.111.096511 · Cited by 92 · see citing works
Induction of ovulation with clomiphene citrate in women with polycystic ovary syndrome: the difference between responders and nonresponders
POLSON, D. W., Kiddy, D. S., Mason, H. D., & Franks, S. (1989) · Fertility and Sterility · doi:10.1016/s0015-0282(16)60423-5 · Cited by 92 · see citing works
Self-citation
Diagnosis of hyperandrogenism: Biochemical criteria
Stanczyk, F. Z. (2006) · Best Practice & Research Clinical Endocrinology & Metabolism · doi:10.1016/j.beem.2006.03.007 · Cited by 90 · see citing works
Predictors of Pregnancy in Women with Polycystic Ovary Syndrome
Rausch, M., Legro, R. S., Barnhart, H. X., Schlaff, W. D., Carr, B. R., Diamond, M. P., Carson, S. A., Steinkampf, M. P., McGovern, P. G., Cataldo, N. A., et al. (2009) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2009-0545 · Cited by 90 · see citing works
Premature pubarche, ovarian hyperandrogenism, hyperinsulinism and the polycystic ovary syndrome: From a complex constellation to a simple sequence of prenatal onset
Ibáñez, L., de Zegher, F., & Potau, N. (1998) · Journal of Endocrinological Investigation · doi:10.1007/bf03350781 · Cited by 88 · see citing works
Level of Anxiety, Depression, Self‐Esteem, Social Anxiety, and Quality of Life among the Women with Polycystic Ovary Syndrome
Açmaz, G., Albayrak, E., Açmaz, B., Başer, M., Soyak, M., Zararsız, G., & İpekMüderris, İ. (2013) · The Scientific World JOURNAL · doi:10.1155/2013/851815 · Cited by 88 · see citing works
Polycystic ovaries at ultrasound: normal variant or silent polycystic ovary syndrome?
Catteau-Jonard, S., Bancquart, J., Poncelet, É., Lefebvre‐Maunoury, C., Robin, G., & Dewailly, D. (2012) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.11202 · Cited by 86 · see citing works
Self-citation
Vitamin D3 receptor is expressed in the endometrium of cycling mice throughout the estrous cycle
Zarnani, A., Shahbazi, M., Salek-Moghaddam, A., Zareie, M., Tavakoli, M., Ghasemi, J., Rezania, S., Moravej, A., Torkabadi, E., Rabbani, H., et al. (2009) · Fertility and Sterility · doi:10.1016/j.fertnstert.2009.09.045 · Cited by 86 · see citing works
Quantitative analysis of antral follicle number and size: a comparison of two‐dimensional and automated three‐dimensional ultrasound techniques
Deb, S., Campbell, B. K., Clewes, J. S., & Raine‐Fenning, N. J. (2009) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.7505 · Cited by 86 · see citing works
Phenotypes and Enviromental Factors: Their Influence in PCOS
Diamanti‐Kandarakis, E., Christakou, C. D., & Marinakis, E. (2012) · Current Pharmaceutical Design · doi:10.2174/138161212799040457 · Cited by 86 · see citing works
Self-citation
Psychological parameters in the reproductive phenotypes of polycystic ovary syndrome
Moran, L., Deeks, A. A., Gibson‐Helm, M. E., & Teede, H. J. (2012) · Human Reproduction · doi:10.1093/humrep/des114 · Cited by 86 · see citing works
High-Molecular-Weight Adiponectin Is Selectively Reduced in Women with Polycystic Ovary Syndrome Independent of Body Mass Index and Severity of Insulin Resistance
O’Connor, A. S., Phelan, N., Tun, T. K., Boran, G. P., Gibney, J., & Roche, H. M. (2010) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2009-1557 · Cited by 83 · see citing works
The impact of intensified exercise training on insulin resistance and fitness in overweight and obese women with and without polycystic ovary syndrome
Harrison, C. L., Stepto, N. K., Hutchison, S. K., & Teede, H. J. (2012) · Clinical Endocrinology · doi:10.1111/j.1365-2265.2011.04160.x · Cited by 80 · see citing works
Prevalence of metabolic syndrome in women with polycystic ovary syndrome
Panidis, D., Μacut, D., Τζιόμαλος, Κ., Papadakis, E. P., Mikhailidis, K., Kandaraki, E., Tsourdi, E. A., Tantanasis, T., Mavromatidis, G., & Katsikis, I. (2012) · Clinical Endocrinology · doi:10.1111/cen.12008 · Cited by 79 · see citing works
Effect of an oral contraceptive on emotional distress, anxiety and depression of women with polycystic ovary syndrome: a prospective study
Çınar, N., Harmanci, A., Demir, B., & Yıldız, B. O. (2012) · Human Reproduction · doi:10.1093/humrep/des113 · Cited by 79 · see citing works
In women with polycystic ovary syndrome and obesity, loss of intra-abdominal fat is associated with resumption of ovulation
Kuchenbecker, W. K. H., Groen, H., van Asselt, S. J., Bolster, J. H. T., Zwerver, J., Slart, R. H. J., vd Jagt, E. J., Muller Kobold, A. C., Wolffenbuttel, B. H. R., Land, J. A., et al. (2011) · Human Reproduction · doi:10.1093/humrep/der229 · Cited by 76 · see citing works

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The Diagnosis of Polycystic Ovary Syndrome during Adolescence
Witchel, S. F., Oberfield, S., Rosenfield, R. L., Codner, E., Bonny, A., Ibáñez, L., Pena, A., Horikawa, R., Gomez-Lobo, V., Joel, D., et al. (2015) · Hormone Research in Paediatrics · doi:10.1159/000375530 · Cited by 3,113 · see citing works
Polycystic Ovary Syndrome: Definition, Aetiology, Diagnosis and Treatment
Escobar-Morreale, H. F. (2018) · Nature Reviews Endocrinology · doi:10.1038/nrendo.2018.24 · Cited by 2,083 · see citing works
Self-citation
Polycystic ovary syndrome
Azziz, R., Carmina, E., Chen, Z., Dunaif, A., Laven, J. S. E., Legro, R. S., Lizneva, D., Natterson-Horowtiz, B., Teede, H. J., & Yildiz, B. O. (2016) · Nature Reviews Disease Primers · doi:10.1038/nrdp.2016.57 · Cited by 2,005 · see citing works
Recommendations from the international evidence‐based guideline for the assessment and management of polycystic ovary syndrome
Teede, H. J., Misso, M. L., Costello, M. F., Dokras, A., Laven, J., Moran, L., Piltonen, T., Norman, R. J., & the International PCOS Network (2018) · Clinical Endocrinology · doi:10.1111/cen.13795 · Cited by 1,823 · see citing works
Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome
Teede, H. J., Misso, M. L., Costello, M. F., Dokras, A., Laven, J., Moran, L., Piltonen, T., Norman, R. J., International PCOS Network, Andersen, M., et al. (2018) · Human Reproduction · doi:10.1093/humrep/dey256 · Cited by 1,593 · see citing works
Self-citation
Recommendations from the International Evidence-Based Guideline for the Assessment and Management of Polycystic Ovary Syndrome
Teede, H. J., Misso, M. L., Costello, M. F., Dokras, A., Laven, J., Moran, L., Piltonen, T., Norman, R. J., Andersen, M., Azziz, R., et al. (2018) · Fertility and Sterility · doi:10.1016/j.fertnstert.2018.05.004 · Cited by 1,325 · see citing works
Self-citation
Using human genetics to understand the disease impacts of testosterone in men and women
The Endometrial Cancer Association Consortium, Ruth, K. S., Day, F. R., Tyrrell, J., Thompson, D. J., Wood, A. R., Mahajan, A., Beaumont, R. N., Wittemans, L., Martin, S., et al. (2020) · Nature Medicine · doi:10.1038/s41591-020-0751-5 · Cited by 720 · see citing works
The management of anovulatory infertility in women with polycystic ovary syndrome: An analysis of the evidence to support the development of global who guidance
Balen, A. H., Morley, L. C., Misso, M., Franks, S., Legro, R. S., Wijeyaratne, C. N., Stener-Victorin, E., Fauser, B. C. J. M., Norman, R. J., & Teede, H. (2016) · Human Reproduction Update · doi:10.1093/humupd/dmw025 · Cited by 705 · see citing works
Self-citation
Polycystic Ovary Syndrome
McCartney, C. R., & Marshall, J. C. (2016) · New England Journal of Medicine · doi:10.1056/nejmcp1514916 · Cited by 619 · see citing works
Polycystic ovarian syndrome (PCOS): Long-term metabolic consequences
Anagnostis, P. G., Tarlatzis, B. C., & Kauffman, R. P. (2017) · Metabolism · doi:10.1016/j.metabol.2017.09.016 · Cited by 429 · see citing works
A brief insight into the etiology, genetics, and immunology of polycystic ovarian syndrome (PCOS)
Siddiqui, S., Mateen, S., Ahmad, R., & Moin, S. (2022) · Journal of Assisted Reproduction and Genetics · doi:10.1007/s10815-022-02625-7 · Cited by 385 · see citing works
Very-Low-Calorie Ketogenic Diet (VLCKD) in the Management of Metabolic Diseases: Systematic Review and Consensus Statement from the Italian Society of Endocrinology (SIE)
Caprio, M., Infante, M., Moriconi, E., Armani, A., Fabbri, A., Mantovani, G., Mariani, S., Lubrano, C., Poggiogalle, E., Migliaccio, S., et al. (2019) · Journal of Endocrinological Investigation · doi:10.1007/s40618-019-01061-2 · Cited by 283 · see citing works
Self-citation
Complications and challenges associated with polycystic ovary syndrome: current perspectives
Palomba, S., Santagni, S., Falbo, A., & La Sala, G. B. (2015) · International Journal of Women's Health · doi:10.2147/ijwh.s70314 · Cited by 287 · see citing works
Androgen Excess- Polycystic Ovary Syndrome Society: position statement on depression, anxiety, quality of life, and eating disorders in polycystic ovary syndrome
Dokras, A., Stener-Victorin, E., Yildiz, B. O., Li, R., Ottey, S., Shah, D., Epperson, N., & Teede, H. (2018) · Fertility and Sterility · doi:10.1016/j.fertnstert.2018.01.038 · Cited by 285 · see citing works
Association of Insulin Resistance and Elevated Androgen Levels with Polycystic Ovarian Syndrome (PCOS): A Review of Literature
Xu, Y., & Qiao, J. (2022) · Journal of Healthcare Engineering · doi:10.1155/2022/9240569 · Cited by 310 · see citing works
Association of metabolic and inflammatory markers with polycystic ovarian syndrome (PCOS): an update
Gnanadass, S. A., Prabhu, Y. D., & Gopalakrishnan, A. V. (2021) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-020-05951-2 · Cited by 299 · see citing works
11-Oxygenated C19 steroids are the predominant androgens in polycystic ovary syndrome
O’Reilly, M. W., Kempegowda, P., Jenkinson, C., Taylor, A. E., Quanson, J. L., Storbeck, K.-H., & Arlt, W. (2017) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/jc.2016-3285 · Cited by 267 · see citing works
Insulin and the polycystic ovary syndrome
Μacut, D., Bjekić-Macut, J., Rahelić, D., & Doknić, M. (2017) · Diabetes Research and Clinical Practice · doi:10.1016/j.diabres.2017.06.011 · Cited by 264 · see citing works
Polycystic Ovary Syndrome
(2022) · Cambridge University Press eBooks · doi:10.1017/9781108989831 · Cited by 254 · see citing works
Dihydrotestosterone: Biochemistry, Physiology, and Clinical Implications of Elevated Blood Levels
Swerdloff, R. S., Dudley, R. E., Page, S. T., Wang, C., & Salameh, W. A. (2017) · Endocrine Reviews · doi:10.1210/er.2016-1067 · Cited by 247 · see citing works
Nonalcoholic fatty liver disease in women with polycystic ovary syndrome
Paschou, S. Α., Pοlyzos, S. A., Anagnostis, P. G., Goulis, D. G., Kanaka‐Gantenbein, C., Lambrinoudaki, I. V., Georgopoulos, N. A., & Vryonidou, A. (2019) · Endocrine · doi:10.1007/s12020-019-02085-7 · Cited by 231 · see citing works
Diagnosis, treatment and prevention of pediatric obesity: consensus position statement of the Italian Society for Pediatric Endocrinology and Diabetology and the Italian Society of Pediatrics
Valerio, G., Maffeis, C., Saggese, G., Ambruzzi, M. A., Balsamo, A., Bellone, S., Bergamini, M., Bernasconi, S., Bona, G., Calcaterra, V., et al. (2018) · The Italian Journal of Pediatrics/Italian journal of pediatrics · doi:10.1186/s13052-018-0525-6 · Cited by 228 · see citing works
11-Oxygenated androgens in health and disease
Turcu, A. F., Rege, J., Auchus, R. J., & Rainey, W. E. (2020) · Nature Reviews Endocrinology · doi:10.1038/s41574-020-0336-x · Cited by 217 · see citing works
Gaps in knowledge among physicians regarding diagnostic criteria and management of polycystic ovary syndrome
Dokras, A., Saini, S., Gibson-Helm, M., Schulkin, J., Cooney, L., & Teede, H. (2017) · Fertility and Sterility · doi:10.1016/j.fertnstert.2017.04.011 · Cited by 218 · see citing works
Intracrine androgen biosynthesis, metabolism and action revisited
Schiffer, L., Arlt, W., & Storbeck, K.-H. (2018) · Molecular and Cellular Endocrinology · doi:10.1016/j.mce.2017.08.016 · Cited by 217 · see citing works
“Abnormal levels of SHBG and mutations altering the affinity for its ligands are associatedwith androgen excess and a PCOS phenotype, but have also been implicated in the pathogenesis of cancer and metabolic dysfunction (Hammond, 2016; Hogeveen et al., 2002).”
Influential
Follicle Stimulating Hormone (LH: FSH) Ratio in Polycystic Ovary Syndrome (PCOS) - Obese vs. Non- Obese Women
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Conway, G. S., Dewailly, D., Diamanti‐Kandarakis, E., Franks, S., Gambineri, A., Keleştimur, F., Μacut, D., Micić, D., Pasquali, R., Pfeifer, M., et al. (2014) · Cited by 3 · see citing works
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Polycystic ovarian syndrome: clinical and biological diagnosis
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Polycystic ovary syndrome: reviewing diagnosis and management of metabolic disturbances
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Authors: Conway, G., Dewailly, D., Diamanti-Kandarakis, E., Escobar-Morreale, H. F., Franks, S., Gambineri, A., Kelestimur, F., Macut, D., Micic, D., Pasquali, R., Pfeifer, M., Pignatelli, D., Pugeat, M., & Yildiz, B. O.
Affiliations: University College Hospital (GB)
National and Kapodistrian University of Athens (GR)
Universidad Complutense de Madrid (ES)
ORCID: Conway, Gerard
Dewailly, Didier
Escobar-Morreale, Héctor F
Gambineri, Alessandra
Pignatelli, Duarte
Venue: European Journal of Endocrinology
Publisher: Oxford University Press (OUP)
Published: 2014-10
Volume: 171
Issue: 4
Pages: P1-P29
ISSN: 0804-4643 (ISSN-L)
1479-683X
DOI: 10.1530/eje-14-0253
OpenAlex: W1963543729
Semantic Scholar: 518b85a010c577bc0434b3172e959aaf7980d719
Cited by: 676
References: 288
Citations by year: 2026: 24 · 2025: 26 · 2024: 45 · 2023: 73 · 2022: 77 · 2021: 68 · 2020: 58 · 2019: 69 · 2018: 84 · 2017: 53 · 2016: 48 · 2015: 43 · 2014: 6 · 2012: 1
FWCI: 60.60
Type: journal article
Language: en
Open access: green
hdl.handle.net
Licence: other-oa
Locations: European Journal of Endocrinology (publishedVersion)
PubMed (publishedVersion)
HAL (submittedVersion)
Archivio istituzionale della ricerca (Alma Mater Studiorum Università di Bologna) (submittedVersion)
UCL Discovery (University College London) (submittedVersion)
Hacettepe University Institutional Repository (hacettepe.edu.tr) (submittedVersion, other-oa)
Topics: Health Sciences › Medicine › Reproductive Medicine › Ovarian function and disorders
Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
Keywords: polycystic ovary syndrome, PCOS diagnostic criteria, PCOS phenotypes, hyperandrogenism, insulin resistance, obesity, type 2 diabetes, impaired glucose tolerance, early life events, PCOS pathogenesis, biomarkers, sleep disorders, neuropsychological aspects, cardiovascular risk factors, treatment targeting
MeSH terms: Androgens, Body Composition, Cardiovascular Diseases, Concept Formation, Female, Glucose, Humans, Hypoglycemic Agents, Infertility, Female, Insulin Resistance, Obesity, Ovary, Phenotype, Polycystic Ovary Syndrome, Quality of Life, Gonadal Steroid Hormones, Testosterone, Ultrasonography, Lipid Peroxidation, Biomarkers, Glucose Intolerance, Risk Reduction Behavior, Bariatric Surgery

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The polycystic ovary syndrome: a position statement from the European Society of Endocrinology

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