Leading Minds: accelerating the delivery of care in Polycystic Ovary Syndrome

The inaugural International Guideline on Polycystic Ovary Syndrome – or PCOS – was published in June 2018 and, for the first time, provides consistent evidence-based care for women with PCOS in order to improve their quality of life.

Dr Michael Costello from IVFAustralia (a member of Virtus Health) is a global authority on improving treatment and outcomes for women diagnosed with PCOS. Researching the condition extensively since 2003, Dr Costello’s work has met both national and international acclaim. This ultimately led him to be invited by the Centre of Research Excellence in PCOS (CRE-PCOS) to chair the fertility section of the international guideline published in 2018.

Dr Costello writes about the guideline and what it means for women suffering from PCOS.

The challenge

As the most common endocrine condition affecting reproductive aged women, PCOS affects between 12 and 18 per cent of women in Australia.

Studies of women with PCOS have shown that obtaining a timely diagnosis is challenging for patients, and many experience delays with multiple doctors involved. It was also found that when women were given a diagnosis there was inadequate information given and a lack of satisfaction with their care, especially in areas such as emotional wellbeing, lifestyle and prevention.

There is also the potential of over-diagnosis because of how common polycystic ovaries are in young women and adolescents. All this research highlighted that access to timely and accurate information needs significant improvement.

Past guidelines have not followed rigorous development processes and they have not involved diverse health professionals, nor have they engaged women affected by PCOS. Furthermore, guidelines are traditionally country specific, and many are now out of date. In this context, PCOS was a clear priority for updated, consistent and co-developed guidelines, translational resources, and health professional and consumer support.

The Guideline

The international guideline is designed to address the needs of health professionals in providing better and more timely care to improve outcomes for women with PCOS, as well as enabling women to be more informed and involved in their treatment.

Taking three years to complete, we (the authors of the guideline) sought to answer 60 clinical questions across five main priority areas in PCOS: diagnosis and screening, lifestyle, emotional wellbeing, treatment for non-fertility problems and fertility treatment.

The guideline wasn’t just a group of experts sitting around a table saying ‘this is what we think is important’, but rather we gathered insight through surveys and focus groups, involving over 3,000 health professionals and consumers with PCOS from around the world. We asked them what they believed were the most important questions in PCOS that needed answers and using those perspectives, we developed the 60 clinical questions that were addressed in the guideline.

Since completing the international guideline, we have proposed that our methodology could be used as best practice for developing and implementing guidelines for other women’s health issues, such as endometriosis.

The results

We established 166 recommendations and practice points with the aim to accelerate the delivery of consistent evidence-based care across both Australia and internationally. Since being released, the guideline has been published in various formats in a number of medical journals around the world.

As well as demonstrating what we know, the guideline has also demonstrated what we don’t know. What our work has highlighted is that, overall, the quality of evidence in PCOS is generally low to moderate, meaning we require much more research into this important condition.

In terms of some significant findings, the combined oral contraceptive pillis considered the first-line treatment for symptoms of PCOS such as irregular periods, excessive hair growth and acne. In terms of fertility and directly as a result of our guideline, letrozole is now the preferred first-line pharmacological treatment for ovulation induction in PCOS.

Bringing it to life

It’s all very well and good to go through all of this work to produce a guideline, but we now need to implement our recommendations. I am on the translational committee for the guideline and it all starts with education of both health professionals and consumers.

We educate health professionals through presentations at scientific meetings and conferences – something we have already started to do, presenting the guidelines at three major conferences in reproductive medicine; The European Society of Human Reproduction and Embryology (ESHRE), the American Society of Reproductive Medicine (ASRM), and the Fertility Society of Australia (FSA).

There are five clinical algorithms for doctors to follow and guide them to how best to treat PCOS. For Australian GPs, there was a publication of the guideline in the Medical Journal of Australia (MJA) on 1 October 2018 including a specific GP tool with a PCOS primary care plan.

In addition, there was also information for consumers included in the MJA article for GPs to give to their patients such as the single-page patient resources for each of the five priority areas we focused on in the international guideline. There is also a PCOS app, the first evidence-based app, which patients can download. All of these educational tools are freely available on the internet and all the information within them are consistent with the recommendations from the international guideline.

About Dr Michael Costello

An Obstetrician and Gynaecologist, Dr Michael Costello completed his sub-speciality training in Infertility and Reproductive Endocrinology and is one of the leading authorities on Polycystic Ovarian Syndrome (PCOS) both nationally and internationally. Since 2003, Dr Costello’s research into PCOS has met national and international acclaim which ultimately led him to be invited to author the first Australian guideline in PCOS published in 2011 and updated in 2015.

In 2016, Dr Costello was awarded a doctorate in medical science from the University of NSW in Sydney. This degree is awarded for making an original and meritorious contribution to medicine, commanding Dr Costello’s national and international recognition as an authority in the research area of disorders of female reproduction. Subsequently, Dr Costello chaired the fertility section of the international guideline in PCOS in 2018.

As well as being a fertility specialist at IVFAustralia, Dr Costello also has affiliations as a clinical academic at the Royal Hospital for Women and with the University of NSW in Sydney.