Anovulation Guidelines

Updated: Jan 06, 2023
  • Author: Armando E Hernandez-Rey, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
  • Print

Guidelines Summary

Polycystic Ovarian Syndrome Clinical Practice Guidelines (2018)

Clinical practice guidelines for polycystic ovarian syndrome were released in 2018, by the Australian National Health and Medical Research Council, European Society of Human Reproduction and Embryology, and American Society for Reproductive Medicine. [12] Highlights of these guidelines follow.

When irregular menstrual cycles are present, a diagnosis of polycystic ovarian syndrome (PCOS) should be considered.

Ovulatory dysfunction can still occur with regular cycles; if anovulation needs to be confirmed, serum progesterone levels can be measured.

Calculated free testosterone, free androgen index, or calculated bioavailable testosterone should be used to assess biochemical hyperandrogenism in the diagnosis of PCOS.

High-quality assays such as liquid chromatography–mass spectrometry (LCMS) and extraction/chromatography immunoassays should be used for the most accurate assessment of total or free testosterone in PCOS.

Androstenedione and dehydroepiandrosterone sulfate (DHEAS) could be considered if total or free testosterone is not elevated.

Where androgen levels are markedly above laboratory reference ranges, other causes of biochemical hyperandrogenism need to be considered.

Ultrasound should not be used for the diagnosis of PCOS in those < 8 years after menarche, because of a high incidence of multifollicular ovaries.

Transvaginal ultrasound is preferred in the diagnosis of PCOS if the patient is sexually active and if the test is acceptable to the individual.

Weight, height, and waist circumference should be measured and BMI calculated.

All women with PCOS should be assessed for cardiovascular risk factors and CVD risk.

Overweight and obese women with PCOS should have a fasting lipid profile.

Glycemic status should be assessed in all women with PCOS. An oral glucose tolerance test (OGTT), fasting plasma glucose, or HbA1c should be performed to assess glycemic status. In high-risk women with PCOS, an OGTT is recommended.

In all women with PCOS, 75 g OGTT should be offered before conception. If performed after conception, OGTT should be offered at < 20 weeks' gestation and at 24-28 weeks' gestation.

In women with PCOS or a history of PCOS, there is a low threshold for investigating endometrial cancer with transvaginal ultrasound and/or endometrial biopsy. Women with PCOS have a twofold to sixfold increased risk of endometrial cancer.

Anxiety and depressive symptoms should be routinely screened.

Combined oral contraceptive pills (COCP) should be recommended to manage hyperandrogenism and/or irregular menstrual cycles.

Metformin should be considered if COCP and lifestyle changes alone are not successful. Metformin may be most beneficial in high-risk patients, including those with diabetes risk factors or impaired glucose tolerance.

Antiandrogens should only be considered to treat hirsutism if 6 months or more of COCP and cosmetic therapy have been unsuccessful.

The use of ovulation induction agents, including letrozole, metformin, and clomiphene citrate is off label in many countries. Where off-label use of ovulation induction agents is allowed, women need to be informed of the evidence, concerns, and side effects.

Pregnancy needs to be excluded before ovulation induction.

Unsuccessful, prolonged use of ovulation induction agents should be avoided because of poor success rates.

Letrozole should be considered the first-line pharmacologic agent for ovulation induction in women with PCOS.

Clomiphene citrate could be used alone in women with PCOS with anovulatory infertility and no other infertility factors.

Metformin could be used alone in women with PCOS for ovulation induction, but women should be informed of more effective agents.

Gonadotropins could be used as second-line agents in women with PCOS who have failed first-line oral ovulation induction therapy.

Laparoscopic ovarian surgery could be considered second-line therapy for ovulation induction for women with PCOS who are clomiphene citrate resistant with anovulatory infertility and no other infertility factors.

Women with PCOS and anovulatory infertility could be offered in vitro fertilization as a third-line therapy when other induction therapies have been unsuccessful.