PCOS: Where are we today?

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Basil C Tarlatzis, MD, PhD: “I am Professor Basil Tarlatzis from the University of Thessaloniki. We are at the ESHRE 2003 meeting in Madrid, where we organised a special session to present the outcome of our consensus meeting on PCOS that was recently held in Rotterdam. 

This meeting was organised in collaboration with Professor Bart Fauser from the University of Rotterdam, and was aiming to bring together experts and specialists in the field of PCOS in order to try to reach a consensus on the diagnostic criteria, the nomenclature, and the long-term health risks of PCOS. So I would like now to turn the microphone to Professor Fauser and ask him to provide the background knowledge and all the outcomes of our discussions on the diagnosis and nomenclature of PCOS.”

Bart CJM Fauser, MD, PhD: “We organised this meeting together and I think it took us about two years of preparation. It was quite a challenging endeavour because in many areas of medicine there is no complete consensus, but here there was almost a complete absence of consensus. Here the separation line was the ocean. The US really had different views compared to Europe. The only consensus, which was available was in 1990 NIH consensus, but it was heavily dominated by the Americans and really not accepted in the rest of the world. 

The primary focus there was the ultrasound appearance of polycystic ovaries, and whether that should be part of the diagnosis, yes or no. This was not included in the 1990 consensus, and when you look at the literature it has become extremely confusing because everyone uses their own inclusion criteria – that’s probably one of the main reasons why there is so much disagreement. 

So, interestingly enough, almost everyone we invited came. It was a closed workshop type of meeting with about 40 people, really key people in this area. Lots of discussion, obviously, but eventually it seemed pretty clear where we wanted to go and what seemed feasible and acceptable for everyone. Certainly, without going into details here, thereafter it’s quite interesting. So we had this session today for a predominantly European audience, and two weeks ago they had a similar session in the US for a predominantly US audience. 

It’s clear where the controversy is because if we compare the questions and comments in Europe versus the US, they were completely the opposite. So yes, there is work that needs to be done, and there are differences that need to be bridged, and hopefully this consensus statement, which we plan to publish soon, is going to help in that respect. We really hope it’s going to be published into two major fertility journals. And we really hope this is going to help also for the future that the journals adopt those criteria, and that they basically ask for all the papers published in those journals that they include these guidelines and criteria.”

Basil C Tarlatzis, MD, PhD: “Nowadays it is practically impossible to compare the findings of the different studies because everybody is using his own criteria; therefore, I think the main goal of this meeting was to reach commonly agreed criteria. 

Even if not all of us would agree on all the criteria, it would be important to accept the minimum ones to use them and specify them in all our protocols, so that the reader can compare the studies, and to be able to reach some conclusion. Moreover, I think it is pretty evident that this syndrome has great variability. It has different phenotypes, therefore, it is important to be as inclusive as possible – at least that was the prevailing philosophy in the meeting which will enable us to find out the exact roots, possibly the genetic basis for the different phenotypes. Otherwise, if we mix the phenotypes it is impossible to reach to the aetiology of the problem.”

Bart CJM Fauser, MD, PhD: “Yes and I think two things are worth adding here. Number two, because that’s what they are all asking now obviously, how about therapy? So purposely we did not start with therapy, because that’s probably the most difficult part. We used a step-by-step approach, so first on the diagnosis and nomenclature. And hopefully thereafter we will be able to make some steps, because there is also certainly a lot of controversy in that area. 

There’s one other issue, which I think is really very important, and now hopefully is gaining interest amongst gynaecologists – that usually we see the patients as fertility doctors because they are infertile, and we try to treat them to get pregnant. But the awareness is growing that getting them pregnant hasn’t really solved all the problems. There are many, many other health issues, which are very, very relevant – especially cardiovascular disease, type 2 diabetes, and possibly various gynaecological cancers. 

So for us it’s not done when we’ve got them pregnant, and then let’s even forget about the pregnancy complications, but there are many long-term health risks. And with being overweight becoming more prevalent every year also in Europe, it’s quite likely that PCOS and all the related problems will increase every year. It’s already quite a prevalent syndrome so we can expect it to increase.”

Basil C Tarlatzis, MD, PhD: “It is interesting, that at least on this part, there was no major disagreement. On the long-term health risks, the consensus could be easily reached because we all agreed that it is indeed a predisposition for some serious health problems. Of course it is important to note that for the cardiovascular risk there is no solid data indicating that these patients do indeed suffer more from cardiovascular diseases, but they have all the risk factors that predispose for the occurrence of these diseases. And now it is a challenging job to try to identify whether indeed they have more occurrences of these diseases. This is one of the goals of the meeting – to stimulate our colleagues to embark on these kinds of studies concerning the identification: which patients are at high risk, and for which of the long-term health problems?”

Bart CJM Fauser, MD, PhD: “And indeed can preventative measures, either medication or lifestyle changes, etc. – can they really help to reduce risk?”

Basil C Tarlatzis, MD, PhD: “Because there we can do something.”

Bart CJM Fauser, MD, PhD: “From a women’s health perspective, I think it is evident for everyone this is one of the major problems.”

Basil C Tarlatzis, MD, PhD: “Absolutely.”

Bart CJM Fauser, MD, PhD: “So it’s not just ovulation induction, which is an important issue in these women, but many other issues.”

Basil C Tarlatzis, MD, PhD: “The good news is that there we have some possibilities to intervene. For example, it has been shown that diet and exercise, that means lifestyle changes, can indeed help. It is not the absolute solution, but at least it can help. Some studies have shown that even a reduction of 5% of the body mass index can lead to an improvement in menstruation, ovulation and reduction of the risks. 

On top of that, we have some other medications that could perhaps, in addition to these lifestyle changes, reduce the risk. But of course this needs to be further assessed – whether indeed they should be used, how long should the woman take the medication, and so on. So there are a lot of studies that need to be done, and the meeting’s aim was to stimulate the initiation of these studies in order to be able to come to a conclusion soon, hopefully.”