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This scoping review aims to identify and synthesise globally available literature that captures how gender and race/ethnicity interact to impact the career experiences and leadership attainment of racially and ethnically minoritised female health professionals. The review also seeks to identify key research priorities to consider when designing and implementing initiatives to support the career progression of racially and ethnically minoritised women in healthcare.

STUDY QUESTION: What is the recommended assessment and management of women with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertise and consumer preference? SUMMARY ANSWER: International evidence-based guidelines, including 166 recommendations and practice points, addressed prioritized questions to promote consistent, evidence-based care and improve the experience and health outcomes of women with PCOS. WHAT IS KNOWN ALREADY: Previous guidelines either lacked rigorous evidence-based processes, did not engage consumer and international multidisciplinary perspectives, or were outdated. Diagnosis of PCOS remains controversial, and assessment and management are inconsistent. The needs of women with PCOS are not being adequately met and evidence practice gaps persist. STUDY DESIGN, SIZE, DURATION: International evidence-based guideline development engaged professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. Appraisal of Guidelines for Research and Evaluation (AGREE) II-compliant processes were followed, with extensive evidence synthesis. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was applied across evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength. PARTICIPANTS/MATERIALS, SETTING, METHODS: Governance included a six continent international advisory and a project board, five guideline development groups, and consumer and translation committees. Extensive health professional and consumer engagement informed guideline scope and priorities. Engaged international society-nominated panels included pediatrics, endocrinology, gynecology, primary care, reproductive endocrinology, obstetrics, psychiatry, psychology, dietetics, exercise physiology, public health and other experts, alongside consumers, project management, evidence synthesis and translation experts. In total, 37 societies and organizations covering 71 countries engaged in the process. Twenty face-to-face meetings over 15 months addressed 60 prioritized clinical questions involving 40 systematic and 20 narrative reviews. Evidence-based recommendations were developed and approved via consensus voting within the five guideline panels, modified based on international feedback and peer review, with final recommendations approved across all panels. MAIN RESULTS AND THE ROLE OF CHANCE: The evidence in the assessment and management of PCOS is generally of low to moderate quality. The guideline provides 31 evidence based recommendations, 59 clinical consensus recommendations and 76 clinical practice points all related to assessment and management of PCOS. Key changes in this guideline include: (i) considerable refinement of individual diagnostic criteria with a focus on improving accuracy of diagnosis; (ii) reducing unnecessary testing; (iii) increasing focus on education, lifestyle modification, emotional wellbeing and quality of life; and (iv) emphasizing evidence based medical therapy and cheaper and safer fertility management. LIMITATIONS, REASONS FOR CAUTION: Overall evidence is generally low to moderate quality, requiring significantly greater research in this neglected, yet common condition, especially around refining specific diagnostic features in PCOS. Regional health system variation is acknowledged and a process for guideline and translation resource adaptation is provided. WIDER IMPLICATIONS OF THE FINDINGS: The international guideline for the assessment and management of PCOS provides clinicians with clear advice on best practice based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation program supports the guideline with an integrated evaluation program. STUDY FUNDING/COMPETING INTEREST(S): The guideline was primarily funded by the Australian National Health and Medical Research Council of Australia (NHMRC) supported by a partnership with ESHRE and the American Society for Reproductive Medicine. Guideline development group members did not receive payment. Travel expenses were covered by the sponsoring organizations. Disclosures of conflicts of interest were declared at the outset and updated throughout the guideline process, aligned with NHMRC guideline processes. Full details of conflicts declared across the guideline development groups are available at https://www.monash.edu/medicine/sphpm/ mchri/pcos/guideline in the Register of disclosures of interest. Of named authors, Dr Costello has declared shares in Virtus Health and past sponsorship from Merck Serono for conference presentations. Prof. Laven declared grants from Ferring, Euroscreen and personal fees from Ferring, Euroscreen, Danone and Titus Healthcare. Prof. Norman has declared a minor shareholder interest in an IVF unit. The remaining authors have no conflicts of interest to declare. The guideline was peer reviewed by special interest groups across our partner and collaborating societies and consumer organizations, was independently assessed against AGREE-II criteria, and underwent methodological review. This guideline was approved by all members of the guideline development groups and was submitted for final approval by the NHMRC.

Polycystic Ovary Syndrome (PCOS) affects 12 to 21% of Australian reproductive-aged women and is a major public health concern (1-5). Whilst reproductive features (anovulation, infertility) are prominent, PCOS also has major metabolic [obesity, metabolic syndrome, type 2 diabetes (T2DM), cardiovascular disease risk factors] and psychological features (6-8). Obesity is a major chronic disease, with rising prevalence and diverse health impacts. The interplay between PCOS and weight contributes to the long-term consequences of PCOS, but is not well understood. Women with PCOS demonstrate insulin resistance (IR), which leads to adverse health consequences, both independent of and exacerbated by obesity. Here, I explore the poorly understood interplay between PCOS, IR, metabolic complications and weight. My clinical research aims to assess prevalence and severity of IR in PCOS and explore novel markers of IR: Pigment Epithelium-Derived Factor (PEDF) and vitamin D. Women with PCOS were more insulin resistant than body mass index (BMI)-matched controls. IR was present in 75% of lean women with PCOS, 62% of overweight controls and 95% of overweight women with PCOS. IR was exacerbated by increased BMI. PEDF was not elevated in PCOS, was not associated with IR and was not reduced by exercise training, despite improved IR. It was mainly obesity related and is not a useful marker of IR. Despite similar adiposity, vitamin D levels were lower in overweight women with PCOS compared with overweight controls. Vitamin D was associated with IR in PCOS, but not in the non-PCOS group. PCOS is an insulin resistant state with intrinsic IR, exacerbated by lifestyle/obesity mediated extrinsic IR. Measurement of IR remains a challenge; novel simple markers of IR are needed. New interventions to manage IR, including potentially vitamin D, need to be studied. My epidemiological research examines the natural history of PCOS and the relationship between PCOS, weight and complications. Extensive data from the Australian Longitudinal Study on Women’s Health (ALSWH) was analysed to explore the prevalence of PCOS, the impact of obesity and relationship to reproductive and metabolic complications. We found that weight, body mass index (BMI) and weight gain over 10 years was higher in women reporting PCOS compared to those not reporting PCOS. BMI was the key predictor of PCOS status. Women with PCOS reported less contraception use and higher rates of trying to conceive, higher rates of infertility and use of fertility treatment including ovulation induction, but not increased in-vitro fertilisation. Reported pregnancy loss was higher in PCOS (related to fertility treatment and BMI, but not PCOS per se). The number of children per woman was similar in PCOS and non-PCOS groups, albeit with higher rates of fertility treatment. After conception and delivery, high BMI was negatively correlated with breastfeeding, suggesting the need for greater lactation support for overweight women. PCOS alone does not appear to impact on breastfeeding. PCOS was associated with higher prevalence of gestational diabetes and T2DM, independent of BMI. This suggests that all women with PCOS should be screened pre-conception or early in pregnancy, during pregnancy and in non-pregnant states for gestational diabetes and T2DM. PCOS status was not associated with hypertension, however BMI was, highlighting the need for blood pressure monitoring in overweight and obese women. This thesis addresses key gaps in our understanding of the natural history of PCOS. It provides important insight into aetiology and natural history of PCOS and advances the area by providing greater understanding of the interplay between BMI and PCOS and related complications.

SPIRIT Checklist. (DOC 115 kb)

SPIRIT Checklist. (DOC 115 kb)