New update of the international PCOS guideline—Focus on evidence‐based medicine in the treatment of PCOS

Sir,

We thank Dr. Francis de Zegher and Dr. Lourdes Ibáñez for their commentary. ¹

The critique directed at our article ² primarily revolves around its failure to address insulin resistance as a key element in the pathogenesis of PCOS. Additionally, the criticism notes that the authors did not promote the treatment option that has been advocated by Dr. de Zegher and Dr. Ibáñez.

First, we would like to clarify that the primary focus of our article was not on exploring the syndrome's pathogenesis but rather on presenting an overview of the updated guidelines and current evidence‐based treatment modalities. Given that at present, metabolic variables are not integrated into the diagnostic criteria, ² , ³ hyperandrogenism remains as the core element of the syndrome. We do agree on the well‐established role of insulin resistance in hyperandrogenism, and this was already recognized in the original text. It is also worth noting that not all women with PCOS are insulin resistant. ⁴ , ⁵ Consequently, insulin‐sensitizing therapy may not effectively reverse hyperandrogenism‐related symptoms in these women.

The latest guideline ³ does mention the treatment combinations proposed by Dr. de Zegher and Dr. Ibáñez as potential future therapeutics. However, it refrains from endorsing them at present due to insufficient evidence. As our article only included medications and therapies that are evidence‐based, future treatment alternatives without evidence were left out. ²

As a summary, we feel that the criticism may not be well placed here. We understand the urge to promote new possible therapies, however here, the idea was to summarize the updated guideline in the Nordic perspective. ² As the Nordic population is not known as the most insulin‐resistant population (eg compared to the Asian) and as the therapy indicated by Dr. de Zegher and Dr. Ibáñez is not in use in the Nordics, although some of the authors are involved in their clinical trial. We are, however, very much looking forward to the results from the SPIOMET trial.