**4. Conventional management and limitations**

**3. Diagnosis**

94 Debatable Topics in PCOS Patients

**3.1. History taking**

PCOS [13, 37–40].

**3.2. Clinical manifestations**

**3.3. Other diagnostic methods**

There are several diagnostic criteria for PCOS such as NIH 1990/2012, ESHRE/ASRM 2003 (Rotterdam), or AE-PCOS 2006. Diagnosis of PCOS should take into consideration the history,

Menstrual abnormality such as oligo-anovulation (OA) is usually noted [32]. According to the Rotterdam criteria, OA is defined as less than eight episodes of menses a year or cycle lengths of more than 35 days [5]. A stricter definition, such as less than eight menstruations and/or two cycles of less than 22 or more than 42 days per year, the prevalence of OA drops to 14% and OA becomes highly predictive of PCOS [33, 34]. Although 30% of women with PCOS will have normal menses [2, 35], 85–90% of women with OA have PCOS, while 30–40% of women with amenorrhea have PCOS [2, 36]. After the age of 40, women with PCOS often have more regular menstrual cycles while women over 30 who develop OA are less likely to have PCOS [32].

Weight gain and central obesity are common presentations in PCOS and usually come before the onset of anovulatory cycles [14]. In the United States, the prevalence of obesity in girls aged 12–19 years in 2007–2008 was 17%, compared with 50–80% among adolescent girls with

Clinical manifestations are acne, hirsutism, and androgenic alopecia . Some patients appear with only one or two manifestations, while a few patients have all the three [2]. Sixty percent

The BMI, blood pressure, waist circumference (WC), and hip circumference should be measured at the initial visit. Fasting lipid profile, sugar and glycohemoglobin, or a 2-hour oral glucose tolerance test (OGTT) should be performed if PCOS is suspected at the initial visit. Trans-vaginal ultrasound is indicated rather than trans-abdominal ultrasound if the patient has one of either irregular menstruation or HA. The Rotterdam PCOM criteria, considered to have sufficient specificity and sensitivity to define PCOM, requires the presence of ≥12 follicles

both ovaries [32, 41–42]. In 2014, the AE-PCOS guidelines suggested using follicle number per ovary (FNPO) ≥25 for the definition of PCOM when using newer technology that allows maximal resolution of ovarian follicles (such as a transducer frequency of more than 8 MHz) [41, 43].

Serum hormone examination, such as serum androgens, should be performed on women with clinical appearance of PCOS. In addition, anti-Müllerian hormone (AMH) in women is generated by granulosa cells, and preantral and antral follicles, and its major function seems to be limited to inhibit the development of the initial stage of follicular maturation [44]. Serum

) in a single ovary or

of patients with PCOS have hirsutism and 15–25% patients have acne [6].

measuring 2–9 mm in diameter and/or increased ovarian volume (>10 cm3

clinical manifestations, ultrasound imaging results, and serum examination results.

Management of PCOS is limited to improve clinical manifestations, since the real etiology of the disorder is unclear [47]. While multiple cardiovascular risk factors such as obesity, dyslipidemia, hypertension, and DM are prevalent in PCOS, current therapeutic management of PCOS usually focuses firstly on the treatment of metabolic disturbances (anovulation, menstrual irregularity, and hirsutism) and secondly on the control of reproductive hormones or insulin levels [48]. Lifestyle modifications including increased exercise, dietary changes, and weight loss are appropriate first-line interventions for many women with PCOS [49]. Diet therapy for patients with PCOS includes the design of low-calorie diets to achieve weight loss or preserve a healthy weight, restrict the intake of simple sugars, and increase the consumption of foods with a low glycemic index and refined carbohydrates, a decrease in the consumption of trans and saturated fatty acids, and awareness of possible deficiencies such as omega-3, vitamin D, and chromium [50]. One systematic review and meta-analysis demonstrated that moderate physical activity mostly 12 or 24 weeks would improve ovulation, decreased IR (9–30%), and weight loss (4.5–10%) [51]. The AE-PCOS guidelines suggested a target of caloric, diet, and body weight control in PCOS women with more restrictions if dyslipidemia occurred [52–54]. The detailed information is listed in **Table 2** [52–54].


**Table 2.** Nutritional recommendations for PCOS women from the AE-PCOS society.


improved insulin sensitivity [57]. Metformin could reduce body weight, improve menstrual pattern, and decrease LH, oestradiol levels, androgens, and AMH levels [57]. **Table 3** lists the

Complementary Therapy with Traditional Chinese Medicine for Polycystic Ovarian Syndrome

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Bariatric surgery is used for weight reduction in patients with morbid obesity. One systematic review showed that bariatric surgery can improve postoperative conception rates, hirsutism, menstrual irregularities, and hormonal abnormalities in women with PCOS [68]. Another systematic review and meta-analysis about bariatric surgery demonstrated that the incidence of PCOS preoperatively was 45.6%, which significantly decreased to 6.8 and 7.1% at the 1 year follow-up and study endpoint, respectively [69]. Moreover, it also demonstrated nearly a 50% improvement in menstrual irregularity and a 30% improvement in hirsutism [69]. There is still a lack of evidence for the improvement in fertility after bariatric surgery [68, 69]. One report revealed the tendency of increasing infant mortality in the bariatric group and bariatric surgery may have its own unique risk-benefit ratio with regards to pregnancy results [70].

Traditional Chinese medicine formulas and herbs have been used to manage the health problems of women for hundreds of years. Classically, Chinese medicine prescription is composed of many herbs to treat a specific disease. According to the principles of TCM syndrome patterns for PCOS, one study showed that Shen deficiency with blood-stasis syndrome was the most frequent pattern noted in these patients, followed by Pi-deficiency with phlegmdampness syndrome, Pi-Shenyang-deficiency syndrome, and Shen-yin deficiency syndrome [71]. Another study demonstrated that TCM syndrome patterns presented in patients with PCOS were mostly amalgamative, of which Shen deficiency and Gan stagnancy are the basic syndromes [72]. One earlier study revealed that elevated levels of testosterone correlated more with the TCM syndrome pattern of Shen-Yi deficiency compared to other patterns [73]. Interestingly, there is one study that describes the correlation between TCM syndrome patterns of PCOS and ovulation induction effects [74]. The effects of clomiphene on patients with phlegm-dampness accumulation syndrome and Shen-yin deficiency syndrome were poorer than in patients with Shen-yang deficiency syndrome and Gan-stagnancy transformed heat syndrome, which suggested the degree of reproduction endocrine dysfunction or the metabolism disturbance of the former two syndrome patterns were more severe than the latter two

Jia-Wei-Xiao-Yao-San, also called Dan-Zhi-Xiao-Yao-San, consists of Moutan Radicis Cortex, Radix Paeoniae Rubra, Bupleuri Radix, Angelicae Sinensis Radix, Poria, Glycyrrhizae Radix, Atractylodes Ovatae Rhizoma, Zingiberis Rhizoma Recens, and Menthae Herba. According

medical treatment agents and limitations for PCOS [58–67].

**5. Traditional Chinese medicine**

syndrome patterns [74].

*5.1.1. Jia-Wei-Xiao-Yao-San*

**5.1. Chinese herbal formulas for PCOS**

**Table 3.** Current medical agents and limitations for PCOS.

Unfortunately, lifestyle interventions are associated with low adherence and sustainability, and engagement, compliance, and sustainability remain challenging [55]. Medical treatment of PCOS is indicated if lifestyle modifications are a failure or unsuitable. Medical treatments include clomiphene citrate, metformin, oral contraceptives (OCPs), anti-androgen, steroids, and statins. One-year randomized clinical trial (RCT) showed that combined oral contraceptives plus spironolactone can decrease hirsutism score, androgens, and DHEA levels with fewer menstrual dysfunction [56]. Another randomized, controlled crossover study demonstrated that both metformin and myoinositol significantly reduced the insulin response to OGTT and improved insulin sensitivity [57]. Metformin could reduce body weight, improve menstrual pattern, and decrease LH, oestradiol levels, androgens, and AMH levels [57]. **Table 3** lists the medical treatment agents and limitations for PCOS [58–67].

Bariatric surgery is used for weight reduction in patients with morbid obesity. One systematic review showed that bariatric surgery can improve postoperative conception rates, hirsutism, menstrual irregularities, and hormonal abnormalities in women with PCOS [68]. Another systematic review and meta-analysis about bariatric surgery demonstrated that the incidence of PCOS preoperatively was 45.6%, which significantly decreased to 6.8 and 7.1% at the 1 year follow-up and study endpoint, respectively [69]. Moreover, it also demonstrated nearly a 50% improvement in menstrual irregularity and a 30% improvement in hirsutism [69]. There is still a lack of evidence for the improvement in fertility after bariatric surgery [68, 69]. One report revealed the tendency of increasing infant mortality in the bariatric group and bariatric surgery may have its own unique risk-benefit ratio with regards to pregnancy results [70].
