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Cited by 379Ovarian function and disordersGenetic and Kidney Cyst DiseasesEndometriosis Research and Treatment

Assessment and management of polycystic ovary syndrome: Summary of an evidence-based guideline

Teede, Helena J, Misso, Marie L, Deeks, Amanda A, Moran, Lisa J, Stuckey, Bronwyn G A, Wong, Jennifer L A, Norman, Robert J, Costello, Michael F +1 more·2011·Medical Journal of Australia
DOI 10.5694/mja11.10915
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Abstract

Helena J Teede, Marie L Misso, Amanda A Deeks, Lisa J Moran, Bronwyn G A Stuckey, Jennifer L A Wong, Robert J Norman and Michael F Costello on behalf of the Guideline Development Groups

AI snapshot

Written from the paper’s full text.

TL;DR

This summary presents an NHMRC-approved Australian evidence-based guideline for assessment and management of PCOS, covering diagnosis, cardiometabolic and emotional wellbeing, lifestyle, and infertility. It recommends lifestyle management as first-line therapy and highlights high prevalence, underdiagnosis, and poor-quality evidence in many areas.

Key findings

  • PCOS affects 12%–21% of Australian reproductive-age women; about 70% remain undiagnosed; among Indigenous Australian women, prevalence appears as high as 21% by Rotterdam criteria, and in one group 30.3% were obese and 7.0% had a normal BMI.
  • Diagnosis uses Rotterdam criteria requiring two of oligo- or anovulation, clinical and/or biochemical hyperandrogenism, and polycystic ovaries on ultrasound; calculated bioavailable testosterone, calculated free testosterone, or free androgen index should be first-line for biochemical hyperandrogenism (Grade C).
  • Cardiometabolic and psychological risks are elevated: women with PCOS have a 5–10-fold risk of progression from prediabetes to type 2 diabetes and a 4–7-fold risk of type 2 diabetes; depression prevalence is 28%–64% versus 7.1%–8.0% in the general population, and anxiety is 34%–57% versus 18%.
  • Lifestyle management (diet, exercise, and/or behavioural interventions) is first-line; 5%–10% weight loss improves features. One systematic review found lifestyle intervention outperformed minimal treatment for total testosterone (P=0.004), hirsutism by Ferriman-Gallwey score (P=0.04), weight (P<0.001), waist circumference (P=0.006), fasting insulin (P=0.002), OGTT insulin (P<0.001), and percent weight change (P<0.001).

Methods

  • The guideline was developed by an independent PCOS Australian Alliance under the Jean Hailes Foundation for Women’s Health, following NHMRC standards; four guideline development groups addressed 22 clinical questions, producing 38 recommendations graded A–D.
  • Evidence reviews searched multiple databases until November 2010; included studies were classified by NHMRC levels of evidence and appraised for risk of bias, with meta-analyses performed where appropriate.
  • Recommendations integrated best available evidence, clinical expertise, and consumer preferences; where evidence was insufficient, clinical consensus recommendations were developed. Public consultation ran for 30 days from 5 March 2011, and the guideline was approved by NHMRC in July 2011.

Limitations

  • The paper states that the complexity of PCOS meant not all aspects could be addressed; generally there is a paucity of evidence and available evidence is of poor quality; consensus recommendations were often informed by evidence in other similar conditions; no formal cost-effectiveness analysis was completed; the guideline is based on evidence up to November 2010; recommendations are limited by applicability and generalisability; and implementation may face cultural barriers.
  • The text makes evident that many recommendations are clinical consensus rather than evidence-based (e.g., interdisciplinary care, emotional wellbeing screening, bariatric surgery), and that evidence often comes from non-PCOS or predominantly Caucasian populations and may not generalise to Indigenous populations.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.5694/mja11.10915

Cites

238 of 238 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 277 cited sources checked · 0 supported · 0 flagged

  • Findingcitation
    § Clinical practice points

    The remaining two studies provided insufficient lower-quality evidence to support any differences between total testosterone, SHBG and androstenedione levels with respect to their value in PCOS diagnosis.

    “The remaining two studies provided insufficient lower-quality evidence to support any differences between total testosterone, SHBG and androstenedione levels with respect to their value in PCOS diagnosis. 60,62”
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  • Findingown data
    § Clinical practice point

    No PCOS-specific evidence was identified to answer the question of the most effective tool/method to assess disordered eating in women with PCOS.

    “We did not identify any PCOS-specific evidence to answer the question, so a clinical consensus recommendation has been made based on key relevant sources of evidencebased information for the general population and the clinical expertise of the multidisciplinary guideline development group. 37,39”
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  • Findingown data
    § Clinical practice point

    No PCOS-specific evidence was identified to answer the question of the most effective tool/method to assess psychosexual dysfunction in women with PCOS.

    “We did not identify any PCOS-specific evidence to answer the question; therefore, a clinical consensus recommendation was made based on key relevant sources of evidence-based information for the general population and the clinical expertise of the multidisciplinary guideline development group.”
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  • Findingcitation
    § Clinical practice points

    In the metformin group, two patients had adverse events.

    “Two patients had adverse events in the metformin group, 212”
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  • Findingown data
    § Clinical practice points

    There was little difference between lifestyle (diet) therapy and pharmacological therapy for fertility outcomes in women with PCOS and BMI >=25 kg/m2.

    “There was little difference between lifestyle (diet) therapy (with or without placebo) and pharmacological therapy (with or without lifestyle [diet] therapy) for fertility outcomes.”
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    Findingcitation
    § Section 7. Pharmacological management of infertility in PCOS (Figure 10) (Algorithms 4 and 5)

    Studies examining the reproductive effects of metformin in PCOS suggest benefits but are limited by study design.

    “Studies examining the reproductive effects of metformin in PCOS suggest benefits but are limited by study design. 223”
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    Findingcitation
    § Section 7. Pharmacological management of infertility in PCOS (Figure 10) (Algorithms 4 and 5)

    Metformin regimens in PCOS are not well standardised in research or clinical practice, with doses varying between 500 and 2550 mg per day and both standard and slow-release preparations available.

    “Metformin regimens in PCOS are not well standardised in research or clinical practice, with doses varying between 500 and 2550 mg per day and both standard and slowrelease preparations available. 209”
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    Findingcitation
    § Section 7. Pharmacological management of infertility in PCOS (Figure 10) (Algorithms 4 and 5)

    The rates of twin and triplet pregnancy with clomiphene citrate are 5%-7% and 0.3%, respectively.

    “The rates of twin and triplet pregnancy with clomiphene citrate are 5%-7% and 0.3%, respectively.”
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    Findingnone given
    § Clinical practice point

    Gonadotrophins appear to be as effective as laparoscopic ovarian surgery.

    “Gonadotrophins appear to be as effective as laparoscopic ovarian surgery”
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    Findingcitation
    § Research recommendation

    One high-quality RCT with low risk of bias found 10 days of letrozole better than 5 days for pregnancy rate per cycle (P=0.03), with no differences in ovulation rate per patient and miscarriage rate per pregnancy among women with CCR PCOS.

    “One high-quality RCT (level II) with low risk of bias found 10 days of letrozole better than 5 days for pregnancy rate per cycle ( P =0.03), with no differences in ovulation rate per patient and miscarriage rate per pregnancy among women with CCR PCOS. 246”
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    Findingnone given
    § Clinical practice point

    Mechanisms underpinning hormonal changes and resumption of ovulation after laparoscopic ovarian drilling remain poorly understood.

    “Mechanisms underpinning hormonal changes and resumption of ovulation remain poorly understood.”
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    Findingcitation
    § Clinical practice point

    One high-quality systematic review of RCTs with low risk of bias found no differences between laparoscopic ovarian surgery and gonadotrophins for live birth rate, pregnancy and ovulation rate per patient and miscarriage rate per pregnancy, but laparoscopic ovarian surgery had fewer multiple pregnancies.

    “One high-quality systematic review of RCTs (level I) with low risk of bias compared laparoscopic ovarian surgery to gonadotrophins with no differences for live birth rate, pregnancy and ovulation rate per patient and miscarriage rate per pregnancy, but laparoscopic ovarian surgery had fewer multiple pregnancies. 255”
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    Findingnone given
    § Clinical practice point

    The mechanisms of action, comparative effectiveness and long-term risks of laparoscopic ovarian surgery in infertile women with PCOS remain unclear.

    “The mechanisms of action, comparative effectiveness and the long-term risks of laparoscopic ovarian surgery in infertile women with PCOS still remain unclear”
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    Findingcitation
    § Research recommendation

    One high-quality RCT with low risk of bias found letrozole better than placebo for ovulation rates (P=0.006) but similar for pregnancy rate and live birth rate per patient in women with PCOS and CCR.

    “One high-quality RCT (level II) with a low risk of bias using letrozole versus placebo in PCOS with CCR, found letrozole better for ovulation rates ( P =0.006) but similar for pregnancy rate and live birth rate per patient. 243”
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    Findingcitation
    § Clinical practice point

    One high-quality RCT with low risk of bias found clomiphene citrate plus metformin was better than laparoscopic ovarian surgery for ovulation rate per cycle (P=0.02), but there was no difference for live birth rate, pregnancy rate per cycle and miscarriage rate per pregnancy.

    “One high-quality RCT (level II) with a low risk of bias found that clomiphene citrate plus metformin was better than laparoscopic ovarian surgery for ovulation rate per cycle ( P =0.02), but there was no difference for live birth rate, pregnancy rate per cycle and miscarriage rate per pregnancy. 256”
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    Findingnone given
    § Clinical practice point

    There is little research addressing the long-term complications of laparoscopic ovarian surgery.

    “There is little research addressing the long-term complications of laparoscopic ovarian surgery.”
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    Findingnone given
    § Clinical practice point

    Laparoscopic ovarian surgery, when compared with other second-line treatments, is equally effective as gonadotrophins, with fewer multiple pregnancies.

    “Laparoscopic ovarian surgery, when compared with other second-line treatments, is equally effective as gonadotrophins, with fewer multiple pregnancies.”
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  • May combine two claims.

    Findingcitation
    § Clinical practice points

    A recent meta-analysis of bariatric surgery in general populations reports weight loss of 38.5 kg or 56% excess weight loss and resolution of DM2 in 78% of patients with DM2.

    “A recent meta-analysis of bariatric surgery in general populations reports weight loss of 38.5 kg or 56% excess weight loss and resolution of DM2 in 78% of patients with DM2. 266”
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    Findingcitation
    § Clinical practice point

    There was insufficient evidence to support or refute the use of laparoscopic ovarian surgery over either metformin or clomiphene citrate alone, or clomiphene citrate plus metformin, for multiple pregnancies, and for adverse effects and QoL.

    “There was insufficient evidence to support or refute the use of laparoscopic ovarian surgery over either metformin or clomiphene citrate alone, or clomiphene citrate plus metformin, for multiple pregnancies, 257,260 and there was insufficient evidence to support or refute the use of laparoscopic ovarian surgery over any intervention for adverse effects and QoL.”
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    Findingnone given
    § Limitations of the guideline

    Generally in PCOS, there is a paucity of evidence and the evidence that is available is of poor quality.

    “Generally in PCOS, there is a paucity of evidence and the evidence that is available is of poor quality”
    Quote in the paperSubstantial claim

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    Premisecitation
    § Polycystic ovary syndrome: an introduction

    PCOS has potential for major metabolic consequences, including obesity and related type 2 diabetes mellitus (DM2) as well as cardiovascular disease (CVD).

    “PCOS has potential for major metabolic consequences, including obesity and related type 2 diabetes mellitus (DM2) as well as cardiovascular disease (CVD)”
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    Premisecitation
    § Polycystic ovary syndrome: an introduction

    PCOS is more common among women who are overweight or of Indigenous background.

    “being more common among those who are overweight or of Indigenous background.”
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    Premisecitation
    § Polycystic ovary syndrome: an introduction

    PCOS affects 12%-21% of Australian reproductive-age women.

    “Polycystic ovary syndrome (PCOS) has recently been shown to affect a striking 12%-21% of Australian reproductive-age women”
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    Premisecitation
    § Presentation

    Indigenous women appear to have a higher prevalence and severity of PCOS.

    “Indigenous women appear to have a higher prevalence and severity of PCOS.”
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    Premisecitation
    § Polycystic ovary syndrome: an introduction

    PCOS has significant mental health and psychological impact, impairing quality of life (QoL).

    “It also has significant mental health and psychological impact, impairing quality of life (QoL).”
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    Premisecitation
    § Presentation

    PCOS has significant and diverse implications, including reproductive (hyperandrogenism, hirsutism, anovulation, infertility), metabolic (insulin resistance [IR], impaired glucose tolerance, DM2, adverse cardiovascular risk profiles) and psychological features (increased anxiety and depression and worsened QoL).

    “PCOS has significant and diverse implications, including reproductive (hyperandrogenism, hirsutism, anovulation, infertility), metabolic (insulin resistance [IR], impaired glucose tolerance, DM2, adverse cardiovascular risk profiles) and psychological features (increased anxiety and depression and worsened QoL).”
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    Premisecitation
    § Presentation

    Fertility issues are most prominent among women in their 20s and 30s.

    “fertility issues most prominent among women in their 20s and 30s”
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    Premisecitation
    § Polycystic ovary syndrome: an introduction

    70% of Australian women with PCOS remain undiagnosed.

    “It is estimated that 70% of Australian women with PCOS remain undiagnosed”
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    Premisecitation
    § Diagnosis and investigations

    The role of ultrasound remains controversial for adolescents, among whom a polycystic appearance of the ovaries is very common, potentially leading to overdiagnosis.

    “The role of ultrasound remains controversial for adolescents, among whom a polycystic appearance of the ovaries is very common, potentially leading to overdiagnosis; 16”
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    Premisecitation
    § Clinical features

    Challenges to feminine identity and body image due to obesity, acne, excess hair, infertility and long-term health-related concerns compromise QoL and adversely affect mood and psychological wellbeing in women with PCOS.

    “challenges to feminine identity and body image due to obesity, acne, excess hair, infertility and long-term health-related concerns compromise QoL and adversely affect mood and psychological wellbeing.”
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    Premisecitation
    § Clinical features

    Women with PCOS present with psychological, reproductive and metabolic implications.

    “Women with PCOS present with psychological, 5,23 reproductive 24 and metabolic implications.”
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    Premisecitation
    § Clinical features

    Women with PCOS have a higher prevalence and greater severity of depression and anxiety, low self-esteem, negative body image, and psychosexual dysfunction.

    “With a higher prevalence and greater severity of depression and anxiety, low self-esteem, negative body image, and psychosexual dysfunction, 5,25”
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    Premisecitation
    § Diagnosis and investigations

    Diagnosis of PCOS is now largely based on the Rotterdam criteria, which require two of three key features: oligo- or anovulation, clinical and/or biochemical hyperandrogenism and polycystic ovaries on ultrasound.

    “Diagnosis of PCOS is now largely based on the Rotterdam criteria, 14 which are inclusive of the original National Institutes of Health (NIH) criteria 15 and require two of three key features: oligo- or anovulation, clinical and/or biochemical hyperandrogenism and polycystic ovaries on ultrasound (Figure 2).”
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    Interpretationnone given
    § Diagnosis and investigations

    PCOS phenotypes vary widely depending on life stage, genotype, ethnicity and environmental factors, including lifestyle and body weight.

    “PCOS phenotypes vary widely depending on life stage, genotype, ethnicity and environmental factors, including lifestyle and body weight.”
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    Premisecitation
    § Clinical features

    The adverse impact of obesity on fertility, exacerbated by delay in childbearing, is resulting in a significant social, health and economic burden in Australia.

    “Indeed, the adverse impact of obesity on fertility, exacerbated by delay in childbearing, is resulting in a significant social, health and economic burden in Australia. 35”
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    Interpretationreasoning
    § Clinical features

    Women with PCOS are a population at high risk of developing DM2 and CVD.

    “Women with PCOS are therefore a population at high risk of developing DM2 and CVD.”
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    Premisecitation
    § Clinical features

    Obesity has a specific impact on women's reproductive health, increasing the prevalence and severity of PCOS, infertility, pregnancy complications, gestational diabetes and fetal pregnancy complications, with substantial and escalating economic costs.

    “Obesity has a specific impact on women's reproductive health, increasing the prevalence and severity of PCOS, infertility, pregnancy complications, gestational diabetes and fetal pregnancy complications, with substantial and escalating economic costs. 33,34”
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    Premisecitation
    § Clinical features

    Women with PCOS have an increased prevalence of metabolic syndrome, which is associated with an increased risk for DM2 and CVD.

    “Women with PCOS also have an increased prevalence of metabolic syndrome (associated with an increased risk for DM2 and CVD), 28”
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    Premisecitation
    § Clinical features

    Women with PCOS have increased individual risk factors for CVD and clinical signs of atherosclerosis.

    “individual risk factors for CVD and clinical signs of atherosclerosis, 29,30”
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    Premisecitation
    § Clinical features

    Obesity is now the primary cause of chronic disease among Australian women, with adverse outcomes including DM2 and CVD.

    “Obesity is now the primary cause of chronic disease among Australian women, with adverse outcomes including DM2 and CVD. 31”
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    Premisecitation
    § Clinical features

    Cardiovascular risk factors are increased and CVD appears more prevalent among women with PCOS, despite inadequate long-term studies to appropriately address this question.

    “Cardiovascular risk factors are increased and CVD appears more prevalent among women with PCOS despite inadequate long-term studies to appropriately address this question. 22”
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    Premisecitation
    § Rationale and methods

    There are limited clinical guidelines and no evidence-based guidelines, either in Australia or internationally, for assessment or management of women with PCOS; rather, PCOS is briefly mentioned within guidelines for the management of obesity and DM2.

    “There are limited clinical guidelines and no evidence-based guidelines, either in Australia or internationally, for assessment or management of women with PCOS; rather, PCOS is briefly mentioned within guidelines for the management of obesity and DM2. 45,54”
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    Study design and conductnone given
    § Table 1. National Health and Medical Research Council grades for recommendations 56

    The recommendations in this guideline are strengthened by the use of rigorous methodology for evidence review and guideline development, including use of study designs least susceptible to bias, a-priori criteria for inclusion and appraisal of studies, extraction of study data, and meta-analysis where appropriate.

    “The recommendations in this guideline are strengthened by the use of rigorous methodology for evidence review and guideline development, including use of: study designs least susceptible to bias; a-priori criteria for inclusion and appraisal of studies; extraction of study data; and meta-analysis where appropriate.”
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    Premisecitation
    § Considerations for Indigenous women with PCOS

    The prevalence of PCOS among Indigenous Australian women appears to be as high as 21% by the Rotterdam criteria and the NIH criteria, and increases with rising BMI.

    “The prevalence of PCOS among Indigenous Australian women appears to be as high as 21% by the Rotterdam criteria 12 and the NIH criteria, 50 and increases with rising BMI. 12”
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    Premisecitation
    § Considerations for Indigenous women with PCOS

    Indigenous Australians are 1.2 times more likely to be overweight or obese than non-Indigenous Australians, and this disparity is greatest for women.

    “The National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) found that Indigenous Australians are 1.2 times more likely to be overweight or obese than non-Indigenous Australians, and this disparity is greatest for women. 51”
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    Study design and conductnone given
    § Table 1. National Health and Medical Research Council grades for recommendations 56

    Evidence reviews were conducted for each of the 22 identified clinical questions.

    “Evidence reviews were conducted for each of the 22 identified clinical questions.”
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    Study design and conductcitation
    § Table 1. National Health and Medical Research Council grades for recommendations 56

    Included studies were classified according to NHMRC levels of evidence and appraised using a-priori criteria according to study design, using a descriptive component approach to assign a risk of bias rating.

    “Included studies were classified according to the NHMRC levels of evidence 56 and appraised using a-priori criteria according to study design, using a descriptive component approach to assign a risk of bias rating. 57”
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    Interpretationreasoning
    § Cardiometabolic risk

    The risk of metabolic complications is already high among Indigenous women, independent of PCOS; therefore PCOS can amplify metabolic risk in these women.

    “The risk of metabolic complications is already high among Indigenous women, independent of PCOS; therefore, PCOS can amplify metabolic risk in these women.”
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    Study design and conductnone given
    § Table 1. National Health and Medical Research Council grades for recommendations 56

    Public and targeted consultation on the draft guideline was conducted for 30 days commencing 5 March 2011, in accordance with legislative requirements for approval of externally developed guidelines under Section 14A of the National Health and Medical Research Council Act 1992 (Cwlth).

    “Public and targeted consultation on the draft guideline was conducted for 30 days commencing 5 March 2011, in accordance with the legislative requirements for approval of externally developed guidelines under Section 14A of the National Health and Medical Research Council Act 1992 (Cwlth).”
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    Premisecitation
    § Considerations for Indigenous women with PCOS

    DM2 is the second-commonest cause of mortality and disability-adjusted life-years among Indigenous women.

    “DM2 is the second-commonest cause of mortality and disabilityadjusted life-years (DALY) among Indigenous women. 52”
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    Study design and conductcitation
    § Methodology

    This NHMRC-approved evidence-based guideline followed a rigorous, systematic process of development.

    “this NHMRC-approved evidence-based guideline followed a rigorous, systematic process of development, which is briefly outlined below and in detail in the full guideline. 8”
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    Premisecitation
    § Considerations for Indigenous women with PCOS

    In a group of Indigenous women with PCOS, 30.3% were obese and 7.0% had a normal BMI.

    “In a group of Indigenous women with PCOS, 30.3% were obese and 7.0% had a normal BMI. 12”
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    Study design and conductnone given
    § Table 1. National Health and Medical Research Council grades for recommendations 56

    Search strategies were developed according to a-priori selection criteria for each clinical question.

    “Search strategies were developed according to a-priori selection criteria for each clinical question.”
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    Premisenone given
    § Table 1. National Health and Medical Research Council grades for recommendations 56

    For many aspects of PCOS, there is little or no evidence or the evidence is of poor quality, with other potential biases resulting from different methods for diagnosis of PCOS and differing end points.

    “For many aspects of PCOS, there is little or no evidence or the evidence is of poor quality, with other potential biases resulting from different methods for diagnosis of PCOS and differing end points.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning
    § Table 1. National Health and Medical Research Council grades for recommendations 56

    The recommendations were formulated using a considered judgement process that took into account the amount and quality of available evidence as well as its generalisability and applicability to current practice in Australia.

    “The recommendations were formulated using a considered judgement process that took into account the amount and quality of available evidence as well as its generalisability and applicability to current practice in Australia.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Cardiometabolic risk

    The leading cause of burden of disease among Indigenous women in the NATSIHS was anxiety and depression, accounting for 10% of the burden.

    “The leading cause of burden of disease among Indigenous women in the NATSIHS was anxiety and depression, accounting for 10% of the burden. 51”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [51]

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation
    § Table 1. National Health and Medical Research Council grades for recommendations 56

    Data were extracted from included studies using a specially developed data extraction form, and meta-analyses were performed where appropriate.

    “data were extracted from included studies using a specially developed data extraction form, 57 and meta-analyses were performed where appropriate.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [57]

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation
    § Table 1. National Health and Medical Research Council grades for recommendations 56

    All aspects of the guideline were developed as outlined in the NHMRC standards and procedures for externally developed guidelines, and the guideline was approved by the NHMRC in July 2011.

    “All aspects of the guideline were developed as outlined in the NHMRC standards and procedures for externally developed guidelines, 55 and accordingly, the guideline was approved by the NHMRC in July 2011.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [55]

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  • May combine two claims.

    Premisecitation
    § Clinical practice points

    The optimal methodology for testosterone measurement on which to base calculated measurements is unclear; however, Davison and colleagues have described a highly sensitive direct manual radioimmunoassay in the Australian setting that more accurately measures total testosterone than other assays, and that provides reference values for androgens by age.

    “The optimal methodology for testosterone measurement on which to base calculated measurements is unclear; however, Davison and colleagues have described a highly sensitive direct manual radioimmunoassay in the Australian setting that more accurately measures total testosterone than other assays, and that provides reference values for androgens by age. 58”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [58] source

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  • May combine two claims.

    Premisecitation
    § Clinical practice point

    During the second year postmenarche, hormonal profiles are similar to control-group adult women during both phases of the menstrual cycle, although progesterone levels remain lower.

    “During the second year, hormonal profiles are similar to control-group adult women during both phases of the menstrual cycle, although progesterone levels remain lower. 63”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [63] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Clinical practice points

    For diagnosis of PCOS, calculated bioavailable and free testosterone were better than androstenedione, SHBG and total testosterone levels, and the FAI was better than androstenedione and SHBG levels.

    “For diagnosis of PCOS, calculated bioavailable and free testosterone were better than androstenedione, SHBG and total testosterone levels, and the FAI was better than androstenedione and SHBG levels. 61”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [61] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Clinical practice point

    The average adult menstrual cycle is 28 days, with a normal cycle range of 24 to 35 days.

    “The average adult menstrual cycle is 28 days, with a normal cycle range of 24 to 35 days. 64”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [64]

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation
    § Section 1. Challenges in diagnostic assessment of PCOS (Algorithm 1)

    PCOS is diagnosed based on at least two of: oligo- or anovulation, hyperandrogenism (clinical and/or biochemical) and polycystic ovaries on ultrasound, after exclusion (where relevant) of other conditions such as thyroid dysfunction, congenital adrenal hyperplasia, hyperprolactinaemia, androgen-secreting tumours and Cushing syndrome.

    “PCOS is diagnosed based on at least two of: oligo- or anovulation, hyperandrogenism (clinical and/or biochemical) and polycystic ovaries on ultrasound after exclusion (where relevant) of other conditions such as thyroid dysfunction, congenital adrenal hyperplasia, hyperprolactinaemia, androgen-secreting tumours and Cushing syndrome (Figure 2). 14”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning
    § Table 1. National Health and Medical Research Council grades for recommendations 56

    In approving the full version of the guideline, the NHMRC is satisfied that it is based on the systematic identification and synthesis of the best available scientific evidence and makes clear recommendations for health professionals practising in an Australian health care setting.

    “In approving the full version of the guideline, the NHMRC is satisfied that it is based on the systematic identification and synthesis of the best available scientific evidence and makes clear recommendations for health professionals practising in an Australian health care setting.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Supplement

    Between the ages of 2 and 9 years, the size and morphology of the ovaries are relatively stable, with the volume of each ovary being less than 2 cm3; from around 9 years of age onward, the ovaries undergo progressive increases in size.

    “Between the ages of 2 and 9 years, the size and morphology of the ovaries are relatively stable, with the volume of each ovary being less than 2 cm 3 ; however, from around 9 years of age onward, the ovaries undergo progressive increases in size. 70”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [70] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Clinical practice point

    Of girls who begin menses before 12 years, between 12 and 13 years, and after 13 years of age, 50% of cycles are ovulatory by 1 year, 3 years, and 4.5 years, respectively.

    “Of girls who begin menses at before 12 years of age, between 12 and 13 years, and after 13 years of age, 50% of cycles are ovulatory by 1 year, 3 years, and 4.5 years, respectively. 69”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [69] source

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  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning
    § Supplement

    Original NIH criteria based on ovulatory disturbance and hyperandrogenism may be the optimal way to diagnose PCOS in adolescents.

    “Original NIH criteria based on ovulatory disturbance and hyperandrogenism may be the optimal way to diagnose PCOS in adolescents.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Clinical practice point

    Elements of a successful collaboration include a willingness to collaborate, trust in each other, mutual respect and communication.

    “Elements of a successful collaboration include 'a willingness to collaborate, trust in each other, mutual respect and communication'. 74”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [74] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation
    § Clinical practice point

    Successful collaboration also relies on adequate systems and organisational supports.

    “Successful collaboration also relies on adequate systems and organisational supports. 75”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [75] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Supplement

    The number of large antral follicles and ovarian size reaches its maximum around the time of menarche.

    “The number of large antral follicles and ovarian size reaches its maximum around the time of menarche 71,72”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [71] source

      Not checked in the free run.

    • cites [72] source

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  • May combine two claims.

    Study design and conductcitation
    § Supplement

    One level III3 case-control study with moderate risk of bias was identified by our search to answer the question, and was deemed insufficient evidence on which to base a recommendation.

    “One level III3 case-control study with moderate risk of bias 73 was identified by our search to answer the question, and was deemed insufficient evidence on which to base a recommendation.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [73] source

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given
    § Supplement

    There is a high prevalence of polycystic ovaries among adolescents, and normal reference ranges for this age group have not been developed or validated.

    “There is a high prevalence of polycystic ovaries among adolescents, and normal reference ranges for this age group have not been developed or validated.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § Clinical practice point

    In PCOS, other novel CVD risk factors, premature cardiovascular dysfunction and subclinical CVD have been noted and are related to IR and obesity.

    “In PCOS, other novel CVD risk factors, premature cardiovascular dysfunction and subclinical CVD 29,30,83 have been noted and are related to IR and obesity. 84-89”
    Quote in the paperSubstantial claim0 of 9 sources checked
    • cites [29] source

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    • cites [30] source

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    • cites [83] source

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    • cites [84] source

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    • cites [85] source

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    • cites [86] source

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    • cites [87] source

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    • cites [88] source

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    • cites [89] source

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  • May combine two claims.

    Premisecitation
    § Clinical practice point

    Women with PCOS often have increased cardiovascular risk factors (hyperinsulinaemia, dyslipidaemia, hypertension) and increased prevalence of metabolic syndrome.

    “Women with PCOS often have increased cardiovascular risk factors (hyperinsulinaemia, dyslipidaemia, hypertension) and increased prevalence of metabolic syndrome 81”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [81] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Clinical practice point

    Women with PCOS have increased Finnish Diabetes Risk Scores as well as increased risk of gestational diabetes, prediabetes and DM2, independent of but exacerbated by obesity.

    “Women with PCOS have increased Finnish Diabetes Risk Scores as well as increased risk of gestational diabetes, 24 prediabetes and DM2 11,103 - independent of, but exacerbated by, obesity.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [24] source

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    • cites [11] source

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    • cites [103] source

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  • May combine two claims.

    Premisecitation
    § Clinical practice point

    Earlier-onset hyperglycaemia and rapid progression to DM2 is also reported in PCOS.

    “Earlier-onset hyperglycaemia and rapid progression to DM2 is also reported in PCOS. 104,105”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [104] source

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    • cites [105] source

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  • May combine two claims.

    Premisecitation
    § Clinical practice point

    IR is a key aetiological feature in PCOS, worsening the reproductive and metabolic features, type 2 diabetes and CVD risk.

    “IR is a key aetiological feature in PCOS, worsening the reproductive and metabolic features, type 2 diabetes and CVD risk. 30,99,100”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [30] source

      Not checked in the free run.

    • cites [99] source

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    • cites [100] source

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  • May combine two claims.

    Premisecitation
    § Clinical practice point

    Shaw and colleagues examined a subset of postmenopausal women from the Women's Ischemia Syndrome Evaluation study who had displayed clinical features consistent with PCOS and confirmed increased cardiovascular events and deaths.

    “In contrast, Shaw and colleagues examined a subset of postmen-pausal women from the Women's Ischemia Syndrome Evaluation study who had displayed clinical features consistent with PCOS and confirmed increased cardiovascular events and deaths. 22”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning
    § Clinical practice point

    We did not identify high-quality PCOS-specific evidence to answer the question, hence a clinical consensus recommendation was made based on clinical expertise, an international position statement on CVD risk assessment in PCOS and on national guidelines on absolute CVD risk assessment, management of obesity, lipids and hypertension for the general population.

    “We did not identify high-quality PCOS-specific evidence to answer the question, hence a clinical consensus recommendation was made based on clinical expertise, an international position statement on CVD risk assessment in PCOS 78 and on national guidelines on absolute CVD risk assessment, 46 management of obesity, 54 lipids 77,79 and hypertension 80 for the general population.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [78] source

      Not checked in the free run.

    • cites [46]

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    • cites [54]

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  • May combine two claims.

    Study design and conductcitation
    § Clinical practice point

    We identified one low-quality systematic review (level I) with high risk of bias; however, this was deemed insufficient evidence on which to base the recommendation.

    “We identified one low-quality systematic review (level I) with high risk of bias; 108 however, this was deemed insufficient evidence on which to base the recommendation.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [108] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Clinical practice point

    Body image is generally poor in women, yet negative body image is more prevalent among women with PCOS and affects thoughts and feelings about health and appearance, QoL, mood and physical fitness.

    “Body image is generally poor in women, yet negative body image is more prevalent among women with PCOS and affects thoughts and feelings about health and appearance, QoL, mood and physical fitness. 114,115”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [114] source

      Not checked in the free run.

    • cites [115]

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning
    § Clinical practice point

    Screening may uncover undiagnosed mood disorders with resource implications including increasing consultation duration.

    “Screening may uncover undiagnosed mood disorders with resource implications including increasing consultation duration.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: It is not usual practice to screen women with PCOS for depression and/or anxiety.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning
    § Clinical practice point

    The significantly increased risk of DM2 in PCOS represents a major health and economic burden.

    “The significantly increased risk of DM2 in PCOS represents a major health and economic burden.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Clinical practice point

    Prevalence of anxiety among women with PCOS ranges from 34% to 57%, again higher than in the general population (18%).

    “Prevalence of anxiety among women with PCOS ranges from 34% 113 to 57%; 5 again, higher than in the general population (18%). 111”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [113] source

      Not checked in the free run.

    • cites [5] source

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    • cites [111]

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning
    § Clinical practice point

    Assessment of depression and/or anxiety for women with PCOS is important, as recognition and treatment improves emotional wellbeing and QoL and is likely to improve effectiveness of lifestyle intervention in PCOS.

    “Assessment of depression and/or anxiety for women with PCOS is important, as recognition and treatment improves emotional wellbeing and QoL (Figure 6) and is likely to improve effectiveness of lifestyle intervention in PCOS.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Mood also adversely affects overall QoL.

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning
    § Clinical practice point

    The recommendation to screen all women with PCOS and to use an OGTT will result in earlier detection of prediabetes and DM2, and will present opportunities for prevention of DM2 and its complications, through effective lifestyle intervention.

    “The recommendation to screen all women with PCOS and to use an OGTT will result in earlier detection of prediabetes and DM2, and will present opportunities for prevention of DM2 and its complications, through effective lifestyle intervention, as outlined below.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Lifestyle therapy has been shown to prevent or delay progression to DM2.

  • May combine two claims.

    Premisecitation
    § Clinical practice point

    Previous studies have noted that fasting blood glucose level alone appears to lack sensitivity in screening for prediabetes or DM2 in PCOS, with national and international groups recommending screening all women with PCOS with an OGTT.

    “Previous studies have noted that fasting blood glucose level alone appears to lack sensitivity in screening for prediabetes or DM2 in PCOS, with national and international groups recommending screening all women with PCOS with an OGTT. 78,107”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [78] source

      Not checked in the free run.

    • cites [107] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Clinical practice point

    In PCOS, 62% had major depression and 41% anxiety disorders.

    “with high rates of associated mood disorders; 62% had major depression and 41% anxiety disorders.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [124] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given
    § Clinical practice point

    Improved screening practices will increase identification of disordered eating/eating disorders.

    “It is likely that improved screening practices will increase identification of disordered eating/eating disorders”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: It is not usual practice to screen women with PCOS for disordered eating.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Clinical practice point

    The prevalence of any eating disorder has been reported at 21% in PCOS.

    “The prevalence of any eating disorder has been reported at 21% in PCOS, 124”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [124] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Clinical practice point

    Australian research suggests that prevalence of diagnosable eating disorders is increasing.

    “Australian research suggests that prevalence of diagnosable eating disorders is increasing. 118”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [118] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Clinical practice point

    Women with PCOS report less sexual satisfaction and lower sexual self-worth than women without PCOS.

    “Women with PCOS also report less sexual satisfaction and lower sexual self-worth than women without PCOS”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [134]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Evidence-based recommendation

    Weight loss achieved through lifestyle management decreases abdominal fat, hyperandrogenism and IR and improves lipid profiles, ovulation, menstrual cyclicity, fertility, risk factors for DM2 and CVD and psychological health in women with PCOS who are overweight.

    “There is a large number of small, uncontrolled trials demonstrating that weight loss achieved through lifestyle management decreases abdominal fat, hyperandrogenism and IR and improves lipid profiles, ovulation, menstrual cyclicity, fertility, risk factors for DM2 and CVD and psychological health in women with PCOS who are overweight. 137-140”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [137] source

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    • cites [138] source

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    • cites [139] source

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    • cites [140] source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning
    § Evidence-based recommendation

    Lifestyle management is useful for targeting weight loss and prevention of weight gain, and is first-line treatment for a large proportion of women with PCOS.

    “Hence, lifestyle management is useful for targeting weight loss and prevention of weight gain, and is first-line treatment for a large proportion of women with PCOS.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning
    § Clinical practice point

    Overall, although exercise has benefits for women with PCOS who are overweight, the evidence is limited, inconsistent and of low quality.

    “Overall, although exercise has benefits for women with PCOS who are overweight, the evidence is limited, inconsistent and of low quality.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § Clinical practice points

    Pharmacological therapy including clomiphene citrate, metformin and gonadotrophins are available and effective in improving fertility in women with PCOS.

    “Pharmacological therapy i n cl u di ng clomiphene citrate, metformin and gonadotrophins are available and effective in improving fertility in women with PCOS. 208”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [208]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Clinical practice point

    There was no difference between aerobic exercise and aerobic-resistance exercise for percent of body fat, fat mass, fat-free mass, depression scores and PCOS-related QoL.

    “There was no difference between aerobic exercise and aerobic-resistance exercise for percent of body fat, fat mass, fat-free mass, depression scores and PCOS-related QoL. 140,192”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [140] source

      Not checked in the free run.

    • cites [192] source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data
    § Clinical practice point

    The multicentre RCT on gonadotrophins is only published in abstract form and was not included in the evidence review.

    “However, this study is only published in abstract form, informing the guideline development group but not included in the evidence review.”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Study design and conductreasoning
    § Clinical practice point

    The high-quality RCT on FSH versus clomiphene citrate had a small sample size and inadequate power, so it cannot inform a recommendation in isolation.

    “however, with small sample size and inadequate power, this cannot inform a recommendation in isolation.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning
    § Clinical practice points

    Given the similar efficacy of lifestyle and pharmacological therapy overall, the guideline development group deemed clear benefits in using lifestyle interventions over pharmacological interventions for first-line management of infertility among women with PCOS.

    “given the similar efficacy of lifestyle and pharmacological therapy overall, the guideline development group deemed clear benefits in using lifestyle interventions over pharmacological interventions for firstline management of infertility among women with PCOS.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationnone given
    § Evidence informing the recommendations.

    The evidence on metformin is generalisable to the patient population in terms of age and BMI and was completed in multiple countries, but may not be generalisable to Indigenous populations.

    “The evidence is generalisable to the patient population in terms of age and BMI and was completed in multiple countries; however, it may not be generalisable to Indigenous populations.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Section 7. Pharmacological management of infertility in PCOS (Figure 10) (Algorithms 4 and 5)

    Clomiphene citrate is a selective oestrogen receptor modulator with both oestrogenic and antioestrogenic properties.

    “Clomiphene citrate is a selective oestrogen receptor modulator with both oestrogenic and antioestrogenic properties. 216”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [216] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Section 7. Pharmacological management of infertility in PCOS (Figure 10) (Algorithms 4 and 5)

    Clomiphene citrate inhibits oestradiol receptors binding in the hypothalamus and pituitary, blocking negative feedback, which increases gonadotrophin-releasing hormone, FSH, and stimulates follicular growth and ovulation.

    “It inhibits oestradiol receptors binding in the hypothalamus and pituitary, blocking negative feedback. This hypothalamus release from negative inhibition increases gonadotrophinreleasing hormone, which in turn increases FSH and stimulates follicular growth and ovulation. 217”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [217] source

      Not checked in the free run.

  • The quote only partly states this claim.

    Study design and conductown data
    § Clinical practice point

    One systematic review and one RCT were identified by the search for gonadotrophins.

    “One systematic review and one RCT were identified by our search.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given
    § Clinical practice point

    The evidence on gonadotrophins is generalisable to patient populations in terms of age and BMI and applicability in Australia, but may not be relevant to Indigenous populations.

    “The evidence is generalisable to patient populations in terms of age and BMI and applicability in Australia, but may not be relevant to Indigenous populations.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Section 7. Pharmacological management of infertility in PCOS (Figure 10) (Algorithms 4 and 5)

    Metformin has been used extensively in DM2, is the most studied in PCOS, and has the most reassuring safety profile.

    “Metformin has been used extensively in DM2, is the most studied in PCOS, and has the most reassuring safety profile. 222”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [222] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Clinical practice point

    Gonadotrophins are often used as second-line therapy in anovulatory PCOS women with CCR; however, there is an increased risk of multiple pregnancy and ovarian hyperstimulation syndrome.

    “Gonadotrophins are often used as second-line therapy in anovulatory PCOS women with CCR; however, there is an increased risk of multiple pregnancy and ovarian hyperstimulation syndrome. 231”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [231]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Clinical practice point

    Laparoscopic ovarian 'drilling' was first described in 1984 with minor variations developed subsequently; all are characterised by an altered endocrine profile following surgery.

    “Laparoscopic ovarian 'drilling' was first described in 1984 254 with minor variations developed subsequently; all are characterised by an altered endocrine profile following surgery.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [254] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation
    § Research recommendation

    An abstract suggested higher risk of congenital cardiac and bone malformations in newborns with letrozole.

    “The potential for teratogenic effects of letrozole has been raised, with an abstract suggesting higher risk of congenital cardiac and bone malformations in newborns. 240”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [240] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Research recommendation

    Aromatase inhibitors theoretically avoid adverse effects of clomiphene citrate as they do not affect oestrogen receptors centrally or thin the endometrium.

    “These agents theoretically avoid adverse effects of clomiphene citrate, 238,239 as they do not affect oestrogen receptors centrally or thin the endometrium. 237”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [238] source

      Not checked in the free run.

    • cites [239] source

      Not checked in the free run.

    • cites [237] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Research recommendation

    Aromatase converts androgens to oestrogens, and aromatase inhibitors inhibit oestrogen biosynthesis, interfering with hypothalamus/pituitary feedback, increasing FSH and causing ovarian follicle stimulation.

    “Aromatase converts androgens to oestrogens, and aromatase inhibitors therefore inhibit oestrogen biosynthesis, interfering with hypothalamus/pituitary feedback, increasing FSH and causing ovarian follicle stimulation. 237”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [237] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Research recommendation

    Aromatase inhibitors were proposed as ovulation-inducing agents in 2001.

    “Aromatase inhibitors were proposed as ovulation-inducing agents in 2001. 236”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [236] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Clinical practice points

    Controversies include whether PCOS is considered an obesity-related condition and may reduce BMI cut-offs.

    “controversies, including whether PCOS is considered an obesity-related condition and may reduce BMI cut-offs, 271 need to be addressed. 270”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [271] source

      Not checked in the free run.

    • cites [270]

      Not checked in the free run.

  • May combine two claims.

    Premisenone given
    § Clinical practice points

    Bariatric surgery has significant complications, including malabsorptive states, psychological issues, poor nutritional status, and disordered eating.

    “Bariatric surgery has significant complications, including malabsorptive states, psychological issues, poor nutritional status, and disordered eating.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given
    § Clinical practice point

    The RCT included in the systematic review by Farquhar and colleagues conducted in New Zealand may also be generalisable to Indigenous populations.

    “The RCT 261 included in the systematic review by Farquhar and colleagues conducted in New Zealand 255 may also be generalisable to Indigenous populations.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [261] source

      Not checked in the free run.

    • cites [255]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Clinical practice points

    It has been suggested that women with a BMI >=35 kg/m2 after failed attempts at weight loss for more than 1 year may consider bariatric surgery; however, surgical studies are generally poorly designed.

    “It has been suggested that women with a BMI ⩾ 35kg/m 2 after failed attempts at weight loss for more than 1 year may consider bariatric surgery; however, surgical studies are generally poorly designed, 264”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [264] source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning
    § Clinical practice point

    The evidence on laparoscopic ovarian surgery was from multiple countries and may be generalisable to the patient population in terms of age and BMI.

    “The evidence was from multiple countries and may be generalisable to the patient population in terms of age and BMI.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Clinical practice points

    General international obesity guidelines recommended consideration of bariatric surgery with a BMI >=35 kg/m2 and one or more complications, after failure of a structured lifestyle intervention; surgery can be considered after unsuccessful lifestyle intervention with a BMI >=40 kg/m2 and can be first line with BMI >=50 kg/m2.

    “General international obesity guidelines 267 recommended consideration of bariatric surgery with a BMI ⩾ 35 kg/m 2 and one or more complications, which are expected to abate with weight reduction, after failure of a structured lifestyle intervention. Surgery can be considered after unsuccessful lifestyle intervention with a BMI ⩾ 40 kg/m 2 and can be first line with BMI ⩾ 50 kg/m 2 . 268”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [267]

      Not checked in the free run.

    • cites [268]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Clinical practice points

    The 2009 American College of Obstetrics and Gynecology clinical practice guidelines do not currently recommend bariatric surgery for fertility treatment.

    “the 2009 American College of Obstetrics and Gynecology clinical practice guidelines do not currently recommend bariatric surgery for fertility treatment. 265”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [265]

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Clinical practice points

    Nutritional impact in pregnancy after bariatric surgery is unclear, and although supplement use is widely recommended following bariatric surgery and for pregnant women, poor compliance is a problem.

    “Also, nutritional impact in pregnancy is unclear and although supplement use is widely recommended following bariatric surgery and for pregnant women, poor compliance is a problem. 269”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [269] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Limitations of the guideline

    A formal analysis of cost-effectiveness was not completed.

    “A formal analysis of cost-effectiveness was not completed.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § Limitations of the guideline

    The guideline is based on the best evidence available up to November 2010.

    “The guideline is based on the best evidence available up to November 2010.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation
    § Clinical practice points

    In general populations, bariatric surgery is recommended for individuals with a BMI >=35 kg/m2 and the presence of comorbid conditions that are expected to improve significantly with weight reduction.

    “In general populations, bariatric surgery is recommended for individuals with a BMI ⩾ 35 kg/m 2 and the presence of comorbid conditions that are expected to improve significantly with weight reduction. 267,270”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [267]

      Not checked in the free run.

    • cites [270]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given
    § Limitations of the guideline

    All recommendations are limited by their applicability and generalisability.

    “All recommendations are limited by their applicability and generalisability”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning
    § Clinical practice points

    We did not identify any PCOS-specific evidence to inform the bariatric surgery recommendation, and a clinical consensus recommendation was made using clinical expertise and existing evidence-based clinical guidelines for bariatric surgery in the general population.

    “We did not identify any PCOS-specific evidence to inform this recommendation and a c l i n i c a l c on se nsu s recommendation has been made using the clinical expertise of the multidisciplinary guideline development group, informed by existing evidence-based clinical guidelines for bariatric surgery in the general population.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning
    § Clinical practice points

    Therefore, it was concluded that general population evidence-based recommendations for bariatric surgery are applicable to this evidence review and patient population.

    “Therefore, it was concluded that general population evidence-based recommendations for bariatric surgery are applicable to this evidence review and patient population.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: PCOS is a comorbid condition that improves significantly with weight reduction and is strongly associated with other comorbidities including DM2 and increased CVD risk.
121 of 121

  • The paper relies on this without support.

    There is little focus on lifestyle and prevention in PCOS, with most services targeting infertility and costly assisted reproductive technology.

    “there is little focus on lifestyle and prevention, with most services targeting infertility and costly assisted reproductive technology.”

  • The paper relies on this without support.

    Lifestyle change and metformin improve insulin resistance in PCOS.

    “lifestyle change and metformin improve IR in PCOS”

  • The paper relies on this without support.

    Among other at-risk groups, lifestyle change and metformin dramatically reduce progression to diabetes.

    “among other at-risk groups these measures have been shown to dramatically reduce progression to diabetes”

  • The paper relies on this without support.

    The pathophysiology of PCOS remains unclear.

    “PCOS is an endocrine disorder, the pathophysiology of which remains unclear.”

  • The paper relies on this without support.

    Obesity affects psychological features of PCOS.

    “while obesity also affects psychological features of PCOS.”

  • The paper relies on this without support.

    Optimal approaches to screening and assessment of psychological functioning in PCOS are unknown and recognition is generally poor.

    “Optimal approaches to screening and assessment of psychological functioning in PCOS are unknown and recognition is generally poor”

  • The paper relies on this without support.

    Fertility is not necessarily impaired in all PCOS cases; some women conceive without medical intervention, depending on the severity of the condition.

    “A key point is that fertility is not necessarily impaired in all PCOS cases - some women conceive without medical intervention, depending on the severity of the condition.”

  • The paper relies on this without support.

    Obesity or excess weight is a major cause of chronic disease in Western countries.

    “Obesity or excess weight is a major cause of chronic disease in Western countries.”

  • The paper relies on this without support.

    Poor body image, sexual dysfunction, disordered eating and eating disorders are all more common among women with PCOS.

    “recognition of other aspects of emotional wellbeing, including poor body image, sexual dysfunction, disordered eating and eating disorders - all more common among women with PCOS - is important for improving QoL.”

  • The authors state this as an assumption.

    Insulin resistance and obesity have a putative aetiological role in PCOS.

    “Given the putative aetiological role of IR and obesity in PCOS, prevention of weight gain is important across the life span.”

  • The paper relies on this without support.

    Access to culturally appropriate care, services and programs is currently not optimal.

    “Access to culturally appropriate care, services and programs is currently not optimal.”

  • The paper relies on this without support.

    There is a lack of awareness of PCOS among consumers and health professionals.

    “there is a lack of awareness of PCOS among consumers and health professionals.”

  • The paper relies on this without support.

    There is no guidance on the assessment and management of PCOS among Indigenous women, nor any adaptation for the Australian context.

    “There is no guidance on the assessment and management of PCOS among Indigenous women, nor any adaptation for the Australian context.”

  • The paper relies on this without support.

    Optimal approaches to screening and assessment of emotional wellbeing among women with PCOS remain unclear.

    “Optimal approaches to screening and assessment of emotional wellbeing among women with PCOS remain unclear and are also addressed in this guideline (Section 4).”

  • The paper relies on this without support.

    Optimal methods for achieving weight loss and prevention of weight gain remain unclear.

    “Optimal methods for achieving weight loss and prevention of weight gain remain unclear and are a focus of this guideline (Section 5).”

  • The paper relies on this without support.

    Short-term diets rarely lead to permanent weight loss, and lifestyle change requires behavioural change.

    “Short-term diets rarely lead to permanent weight loss, and lifestyle change requires behavioural change.”

  • The paper relies on this without support.

    Little is known about the prevalence of eating disorders and disordered eating among Indigenous women.

    “Little is known about the prevalence of eating disorders and disordered eating among Indigenous women.”

  • The paper relies on this without support.

    Social and cultural factors influence emotional wellbeing, and the challenges facing many Indigenous women are likely to amplify the impact of PCOS on emotional wellbeing.

    “Social and cultural factors influence emotional wellbeing, and the challenges facing many Indigenous women are likely to amplify the impact of PCOS on emotional wellbeing.”

  • The paper relies on this without support.

    The role of ultrasound in the Indigenous setting is questionable due to limitations in care and access to ultrasound facilities and service provision in rural and remote locations.

    “the role of ultrasound in the Indigenous setting is questionable due to limitations in care and access to ultrasound facilities and service provision in rural and remote locations”

  • The paper relies on this without support.

    There may be cultural factors and potential issues around acceptability of bariatric surgery.

    “there may be cultural factors and potential issues around acceptability of bariatric surgery.”

  • The paper relies on this without support.

    Different laboratories currently use different methodologies for androgen measurement.

    “Because different laboratories currently use different methodologies, specific cut-off values to determine hyperandrogenism cannot be recommended”

  • The paper relies on this without support.

    Current practice in androgen measurement in PCOS is unclear.

    “Current practice in androgen measurement in PCOS is unclear, so the recommendation may require changes in usual care.”

  • The paper relies on this without support.

    The cost of a calculated testosterone test involves measurement of testosterone and SHBG levels, and this test is more expensive than a testosterone level alone.

    “There may be resource implications, as the cost of a calculated testosterone test involves measurement of testosterone and SHBG levels, and this test is more expensive than a testosterone level alone.”

  • The paper relies on this without support.

    In the first postmenarcheal year, around half of cycles are anovulatory.

    “In the first postmenarcheal year, around half of cycles are anovulatory.”

  • The paper relies on this without support.

    Weight and exercise influence the menstrual cycle of women in many ways.

    “Weight and exercise influence the menstrual cycle of women in many ways and should always be evaluated when assessing a women with menstrual disturbance.”

  • The paper relies on this without support.

    It is likely that current practice involves prescription of the oral contraceptive pill without diagnosis of PCOS in adolescents with irregular cycles.

    “It is likely that current practice involves prescription of the oral contraceptive pill without diagnosis of PCOS in adolescents with irregular cycles.”

  • The paper relies on this without support.

    Most women with PCOS do not adequately access the relevant health disciplines, and when they do it is usually via a GP referral to separate multidisciplinary health professionals, with limited communication and limited engagement and carriage of the care plan by the patient.

    “It appears that most women with PCOS do not adequately access these disciplines, and when they do it is usually via a GP referral to separate multidisciplinary health professionals, with communication between health professionals and limited engagement and carriage of the care plan by the patient with PCOS.”

  • The paper relies on this without support.

    A multidisciplinary approach has been credited with improvements in health-related behaviours, health parameters and general wellbeing.

    “A multidisciplinary approach has been credited with improvements in health-related behaviours, health parameters and general wellbeing.”

  • The paper relies on this without support.

    Limitations of the multidisciplinary care model include compartmentalisation of patient care and limited communication between health professionals.

    “However, limitations of the multidisciplinary care model include compartmentalisation of patient care and limited communication between health professionals.”

  • The paper relies on this without support.

    Current PCOS management involves one or more health professionals managing individual components of the syndrome.

    “Current PCOS management involves one or more health professionals managing individual components of the syndrome (Figure 4).”

  • The paper relies on this without support.

    Current Australian funding arrangements may hinder community-based interdisciplinary care.

    “Current Australian funding arrangements may hinder community-based interdisciplinary care.”

  • The paper relies on this without support.

    Medicare funding for allied health professionals is capped.

    “Medicare funding for allied health professionals is capped”

  • The paper relies on this without support.

    PCOS management often focuses on reproductive features and CVD risk is often not considered.

    “PCOS management often focuses on reproductive features and CVD risk is often not considered.”

  • The paper relies on this without support.

    Lifestyle therapy has been shown to prevent or delay progression to DM2.

    “Furthermore, lifestyle therapy has been shown to prevent or delay progression to DM2.”

  • The paper relies on this without support.

    Assessment of IR or measurement of serum insulin levels has no current role in clinically assessing for risk of DM2.

    “It is important to note that assessment of IR or measurement of serum insulin levels has no current role in clinically assessing for risk of DM2.”

  • The paper relies on this without support.

    OGTTs increase inconvenience for patients, which may affect compliance.

    “However, it is acknowledged that OGTTs increase inconvenience for patients, which may affect compliance.”

  • The paper relies on this without support.

    Contributing factors for mood disorders in PCOS remain controversial but include clinical symptoms of PCOS, excess weight, and the chronic and complex nature of PCOS.

    “Contributing factors remain controversial, but include clinical symptoms of PCOS, excess weight, and the chronic and complex nature of PCOS.”

  • The paper relies on this without support.

    Mood also adversely affects overall QoL.

    “Mood also adversely affects overall QoL.”

  • The paper relies on this without support.

    It is not usual practice to screen women with PCOS for depression and/or anxiety.

    “However, it is not usual practice to screen women with PCOS for depression and/or anxiety.”

  • The paper relies on this without support.

    Physical factors affecting appearance (excess weight and hirsutism), psychological factors (self-esteem) and sociocultural factors can influence body image.

    “Physical factors affecting appearance (excess weight and hirsutism), psychological (self-esteem) and sociocultural factors can influence body image.”

  • The paper relies on this without support.

    Body image is often not considered in PCOS.

    “However, body image is often not considered in PCOS; hence, this area was prioritised during the process of guideline development.”

  • The paper relies on this without support.

    It is not usual practice to screen women with PCOS for disordered eating.

    “It is not usual practice to screen women with PCOS for disordered eating.”

  • The paper relies on this without support.

    It is not usual practice to screen and assess women with PCOS for psychosexual dysfunction.

    “It is not usual practice to screen and assess women with PCOS for psychosexual dysfunction”

  • The paper relies on this without support.

    Current practice is unclear regarding face-to-face tailored dietary advice for women with PCOS.

    “Current practice is unclear.”

  • The paper relies on this without support.

    Most practitioners do not recommend specific dietary composition for women with PCOS.

    “Most practitioners do not recommend specific dietary composition”

  • The paper relies on this without support.

    Consumer-targeted marketing claims benefits for specific macronutrient composition in PCOS.

    “However, consumer-targeted marketing claims benefits for specific macronutrient composition in PCOS”

  • The paper relies on this without support.

    Morbid obesity (BMI >=35) increases risks during pregnancy.

    “Morbid obesity (body mass index ⩾ 35kg/m 2 ) increases risks during pregnancy”

  • The paper relies on this without support.

    Fertility rates are lower among women with a BMI >=30-32 kg/m2.

    “Fertility rates are lower among women with a BMI ⩾ 30-32 kg/m 2”

  • The paper relies on this without support.

    Lifestyle intervention benefits extend well beyond fertility and include DM2 prevention.

    “lifestyle intervention benefits extend well beyond fertility and include DM2 prevention.”

  • The paper relies on this without support.

    Studies with clomiphene citrate show ovulation rates of 60%-85% and pregnancy rates of 30%-50% after six ovulatory cycles.

    “Studies with clomiphene citrate show ovulation rates of 60%-85% and pregnancy rates of 30%50% after six ovulatory cycles.”

  • The paper relies on this without support.

    The discrepancy between ovulation rates and pregnancy rates with clomiphene citrate is attributed to anti-oestrogenic clomiphene citrate effects.

    “The discrepancy between ovulation rates and pregnancy rates has been attributed to anti-oestrogenic clomiphene citrate effects.”

  • The paper relies on this without support.

    IR leading to hyperinsulinaemia increases ovarian androgen biosynthesis and decreases SHBG synthesis, further increasing free androgens.

    “IR leading to hyperinsulinaemia increases ovarian androgen biosynthesis and decreased SHBG synthesis, further increasing free androgens.”

  • The paper relies on this without support.

    Excess androgens and insulin cause premature follicular atresia and anovulation.

    “Excess androgens and insulin cause premature follicular atresia and anovulation.”

  • The paper relies on this without support.

    Metformin may be associated with mild gastrointestinal adverse events.

    “Metformin may be associated with mild gastrointestinal adverse events”

  • The paper relies on this without support.

    Ovulation induction with gonadotrophins is expensive and requires regular monitoring, with risks of multiple pregnancy and ovarian hyperstimulation syndrome.

    “In contrast, ovulation induction with gonadotrophins is expensive and requires regular monitoring, with risks of multiple pregnancy and ovarian hyperstimulation syndrome.”

  • The paper relies on this without support.

    Weight loss improves fertility and addresses maternal and neonatal complications associated with obesity, potentially also increasing the safety and effectiveness of ovulation induction.

    “Weight loss improves fertility and addresses maternal and neonatal complications associated with obesity, potentially also increasing the safety and effectiveness of ovulation induction.”

  • The paper relies on this without support.

    Eating disorders are already relatively common among women with PCOS.

    “Eating disorders are already relatively common among women with PCOS.”

  • The paper relies on this without support.

    Among people with morbid obesity, lifestyle interventions have very limited efficacy.

    “Overall, among people with morbid obesity, lifestyle interventions have very limited efficacy”

  • The paper relies on this without support.

    Bariatric surgery has substantial efficacy for women who are severely obese, including in women with PCOS.

    “given the substantial efficacy of bariatric surgery for women who are severely obese, including in women with PCOS”

  • The paper relies on this without support.

    PCOS is a comorbid condition that improves significantly with weight reduction and is strongly associated with other comorbidities including DM2 and increased CVD risk.

    “PCOS is a comorbid condition that improves significantly with weight reduction and is strongly associated with other comorbidities including DM2 and increased CVD risk.”

  • The paper relies on this without support.

    Current practice is unclear, although few women with PCOS are likely to be having bariatric surgery.

    “Current practice is unclear, although few women with PCOS are likely to be having this surgery.”

  • The paper relies on this without support.

    Ethnic differences in obesity and complications are recognised and cut-off points for surgery may need to be adjusted for those at high risk.

    “Ethnic differences in obesity and complications are recognised and cut-off points for surgery may need to be adjusted for those at high risk.”

  • The paper relies on this without support.

    Polycystic ovary syndrome is a diagnosis of exclusion.

    “As polycystic ovary syndrome isa diagnosis of exclusion, other causes of irregular cycles (such as thyroid dysfunction or”

  • The paper relies on this without support.

    Achievable goals (5% to 0% loss of body weight in overweight women) yield significant clinical improvements.

    “Key messages should be reinforced with women with PCOS, including that achievable goals (5% to 0% loss of body weight in overweight women ield sinificant clinical improvements.”
64 of 64

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The most consistently observed androgenic abnormality in PCOS is elevated free testosterone or calculated free androgen index, which includes SHBG in the equation.

    “The most consistently observed androgenic abnormality in PCOS is elevated 'free testosterone' or calculated free androgen index, which includes SHBG in the equation (Teede et al., 2011).”

    From Insulin resistance in polycystic ovary syndrome: a systematic review and meta-analysis of euglycaemic–hyperinsulinaemic clamp studies (2016) · cites this paper as Teede et al., 2011

    The Clinical practice points say calculated free testosterone is a commonly measured marker and that the free androgen index is calculated from testosterone and SHBG. The evidence-based recommendation lists both as first-line tests for biochemical hyperandrogenism in PCOS. Neither passage establishes that their elevation is the most consistently observed androgenic abnormality. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Current guidelines indicate metformin in PCOS in some scenarios: to improve fertility, to manage menstrual irregularity when oral contraceptives cannot be used, and in co-existent prediabetes or type 2 diabetes when lifestyle modification fails.

    “Based on current guidelines, metformin is indicated in PCOS in some scenarios to improve fertility (Teede et al. , 2011; Legro et al. , 2013), for management of menstrual irregularity if women are unable to take OCPs, and in co-existent prediabetes or DM2, where lifestyle modification fails (Legro et al. , 2013).”

    From Metformin and lifestyle modification in polycystic ovary syndrome: systematic review and meta-analysis (2015) · cites this paper as Teede et al., 2011

  • Lifestyle management is first-line therapy in PCOS for preventing weight gain and for weight loss.

    “Lifestyle management is first line therapy in PCOS for prevention of weight gain and for weight loss (Teede et al. , 2011).”

    From Metformin and lifestyle modification in polycystic ovary syndrome: systematic review and meta-analysis (2015) · cites this paper as Teede et al., 2011

  • Comprehensive care for PCOS in a multidisciplinary setting is widely advocated.

    “Given these challenges, comprehensive care for PCOS in a multidisciplinary setting is widely advocated, but not received by most women (12, 22, 27).”

    From Delayed Diagnosis and a Lack of Information Associated With Dissatisfaction in Women With Polycystic Ovary Syndrome (2016) · cites this paper as [12]

  • Prevention of weight gain is recommended in PCOS position statements and guidelines.

    “Prevention of weight gain is recommended in PCOS position statements and guidelines (12, 29) and is more feasible at the individual level than weight loss (30).”

    From Delayed Diagnosis and a Lack of Information Associated With Dissatisfaction in Women With Polycystic Ovary Syndrome (2016) · cites this paper as [12]

Cites

11 retracted

Flagged first, then by citations

2 of the 240 references couldn’t be matched to a known paper.

Research works printed but not linked: 38

  1. 2011, Evidence‐based guideline for the assessment and management of polycystic ovary syndrome
  2. Boyle J, 2011, Polycystic ovary syndrome and associated metabolic features in Indigenous women in the Northern Territory [PhD thesis]
  3. Teede H, 2008, Check: Independent learning program for GPs. Polycystic ovary syndrome
  4. Zawadaki R, 1992, Current issues in endocrinology and metabolism: polycystic ovary syndrome, 377
  5. Women's Health Australia, 2005, The Australian Longitudinal Study on Women's Health. Australian women and their weight — a growing problem
  6. Australian Institute of Health and Welfare, 2006, Australia's health 2006: the tenth biannual health report of the Australian Institute of Health and Welfare
  7. American Psychiatric Association, 2000, Text revision
  8. Australian Medical Association, 2009, Body image and health — 2002. Revised 2009 [position statement]
  9. beyondblue, 2011, Clinical practice guidelines: depression in adolescents and young adults
  10. National Collaborating Centre for Mental Health, 2006, Obsessive–compulsive disorder: core interventions in the treatment of obsessive–compulsive disorder and body dysmorphic disorder
  11. National Institute for Clinical Excellence, 2004, Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders
  12. National Institute for Health and Clinical Excellence, 2009, Depression: the treatment and management of depression in adults
  13. National Institute for Health and Clinical Excellence, 2011, Management of generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: management in primary, secondary and community care
  14. National Health and Medical Research Council, 2001, National evidence based guidelines for the management of type 2 diabetes mellitus
  15. National Vascular Disease Prevention Alliance, 2009, Guidelines for the assessment of absolute cardiovascular disease risk
  16. Australian Bureau of Statistics, 2005, National and Torres Strait Islander health survey 2004–05
  17. National Health and Medical Research Council, 2004, Clinical practice guidelines for the management of overweight and obesity in adults
  18. National Health and Medical Research Council, 2007, NHMRC standards and procedures for externally developed guidelines
  19. National Health and Medical Research Council, 2009, NHMRC levels of evidence and grades for recommendations for developers of guidelines
  20. Southern Health Centre for Clinical Effectiveness, 2010, Critical appraisal templates
  21. National Heart Foundation of Australia; Cardiac Society of Australia and New Zealand, 2001, Lipid management guidelines 2001 — summary paper, Med J Aust, 175, S57
  22. National Blood Pressure and Vascular Disease Advisory Committee, 2010, Guide to management of hypertension 2008. Updated 2010
  23. Australian Bureau of Statistics, 2010, Causes of death
  24. World Health Organization, 2005, Preventing chronic diseases: a vital investment: WHO global report
  25. Geiss L, 1995, Diabetes in America, 233
  26. Colagiuri S, 2009, National evidence based guideline for case detection and diagnosis of type 2 diabetes
  27. Australian Bureau of Statistics, 2008, ABS National Survey of Mental Health Wellbeing: summary of results, 2007
  28. DeeksA Gibson‐HelmM TeedeH.Negative body image and lower self‐efficacy in women with polycystic ovary syndrome.Proceedings of the Australian Society for Behavioural Health and Medicine 8th Annual Scientific Conference; 2010; Feb 10‐12; Brisbane.
  29. American College of Sports Medicine; American Heart Association, 2007, Physical activity and public health guidelines
  30. Australian Government Department of Health and Ageing, 2010, National physical activity guidelines
  31. Physical Activity Guidelines Advisory Committee, 2008, Physical Activity Guidelines Advisory Committee report 2008
  32. World Health Organization, 2007, A guide for population‐based approaches to increasing levels of physical activity: implementation of the WHO global strategy on diet, physical activity and health
  33. Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2008, C‐Gyn 2: ovarian stimulation in infertility
  34. Macklon N, 2002, Ovulation induction [European practice in obstetrics and gynaecology series]
  35. HomburgR HendriksM KonigT et al.Clomifene or low dose FSH for the first line treatment of anovulatory PCOS: a prospective randomised multinational study (COFFI) [oral abstract O‐058].Conference of the European Society of Human Reproduction and Embryology; 2009; Amsterdam.
  36. American College of Obstetrics and Gynecology, 2009, Clinical management guidelines for obstetrician‐gynecologists
  37. National Institute for Health and Clinical Excellence, 2006, NICE clinical guideline 43
  38. Mechanick JI, 2009, American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient, Obesity (Silver Spring), 17, S1

Cited by

Sorted by citations

Related

Authors
Teede, H. J., Misso, M. L., Deeks, A. A., Moran, L. J., Stuckey, B. G. A., Wong, J. L. A., Norman, R. J., Costello, M. F., & Groups, O. B. O. T. G. D.
Affiliations
  • Jean Hailes (AU)
  • The University of Adelaide (AU)
  • The University of Western Australia (AU)
  • Department of Diabetes, Southern Health, Melbourne, VIC.
  • Royal Hospital for Women (AU)
Corresponding author
Teede, Helena J
ORCID
Venue
Medical Journal of Australia
Publisher
Wiley
Published
2011-09
Volume
195
Issue
S6
Pages
S65-112
ISSN
  • 0025-729X (ISSN-L)
  • 1326-5377
DOI
10.5694/mja11.10915
OpenAlex
W2054117560
Semantic Scholar
1afdab50cfe1ae8b3d69f93a21d9ec538b032a8b
Cited by
379
References
240
Citations by year
2026: 5 · 2025: 17 · 2024: 9 · 2023: 27 · 2022: 32 · 2021: 28 · 2020: 31 · 2019: 37 · 2018: 45 · 2017: 26 · 2016: 33 · 2015: 26 · 2014: 28 · 2013: 20 · 2012: 13
FWCI
22.51
Type
journal article
Language
en
Open access
closed
Licence
Locations
  • The Medical Journal of Australia (publishedVersion)
  • PubMed (publishedVersion)
  • Victoria University Research Repository (Victoria University) (submittedVersion)
  • Adelaide Research & Scholarship (AR&S) (University of Adelaide) (submittedVersion)
Topics
  • Health Sciences › Medicine › Reproductive Medicine › Ovarian function and disorders
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Genetic and Kidney Cyst Diseases
  • Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
Keywords
polycystic ovary syndrome, diagnosis, management, evidence-based care, infertility, hyperandrogenism, insulin resistance
MeSH terms
Anxiety, Australia, Depression, Female, Humans, Life Style, Obesity, Polycystic Ovary Syndrome, Quality of Life, Risk Factors, Body Mass Index, Risk Assessment, Evidence-Based Medicine, Overweight

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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