The impact of multidisciplinary care on attrition rates in weight management programs for women with polycystic ovary syndrome: a scoping review

Abstract

Background:

Polycystic ovary syndrome (PCOS) is one of the most prevalent endocrine system disorders affecting reproductive-aged women of all races and ethnicities. A high prevalence of obesity exists in women with PCOS, who are also vulnerable to attrition from weight management programs. Despite recommendations the implementation of multidisciplinary approaches in weight management programs, there is a lack of literature evaluating their usage in their treatment programs.

Objectives:

The objectives of this scoping review are to critically examine existing empirical literature to describe multidisciplinary approaches to weight management in populations diagnosed with PCOS and to identify potential factors associated with attrition.

Eligibility criteria:

This review includes prospective studies of individuals aged 15 and older diagnosed with PCOS enrolled in a multidisciplinary weight management program. Multidisciplinary interventions were defined as participants receiving two or more multidisciplinary lifestyle interventions.

Sources of evidence:

A systematic search of five electronic databases (MEDLINE, Cochrane, Embase, Cumulative Index to Nursing and Allied Health Literature, and Web of Science) identified articles with a multidisciplinary approach and reported data on attrition in PCOS weight management programs.

Charting methods:

A descriptive analytical approach and narrative synthesis was conducted to identify themes related to intervention delivery, attrition, and facilitators/barriers of PCOS lifestyle interventions.

Results:

From a total of 10,944 unique results, 11 articles met inclusion criteria for this review. Attrition rates ranged from 0% to 79.2%. Longer interventions were associated with higher rates of attrition. Control groups generally had lower attrition rates than their corresponding intervention groups. Studies incorporating technology-based interventions reported greater weight loss among participants.

Conclusion:

Attrition is inconsistently reported among PCOS weight management studies. Variation in attrition rates is likely influenced by several factors such as intervention length and intensity, identified facilitators and barriers to PCOS weight management, and the extent to which care plans are individualized.

Introduction

Understanding polycystic ovary syndrome: A brief overview

Polycystic ovary syndrome (PCOS) is one of the most prevalent endocrine system disorders affecting women of all races and ethnicities. ¹ A systematic screening estimated that PCOS globally affects around 9.2% of women. ¹ Previous research into the etiology of PCOS has identified genetic and lifestyle components contributing to the disorder; however, this body of knowledge remains open to further investigations. ² Women with PCOS have an increased risk of weight gain and a higher prevalence of being overweight and obese in comparison to their counterparts without the disorder. ³ This can worsen associated clinical and biochemical co-morbidities by contributing to insulin resistance, hyperandrogenism, sleep disorders, and diabetes. ³

Evidence-based guidelines recommend weight management, that is, preventing weight gain or losing and maintaining a loss of 5%–10% of initial body weight, through lifestyle interventions including diet, physical activity, and behavioral modification, as a first line of treatment for PCOS. ⁴ A recent review has highlighted that non-adherence to PCOS treatments can result in suboptimal management of symptoms and an increased risk of developing complications such as cardiovascular diseases. ⁵ Adherence is described by the World Health Organization as “the extent to which a person’s behavior, taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.” ⁶ In contrast, non-adherence refers to the extent to which an individual does not follow recommendations from health care providers, causing both external and internal validity of research studies to be hindered.^6,7 Attrition is an extreme form of non-adherence (i.e., the loss of study participants from a sample population). Presently, attrition is one of the most reported indicators of adherence in lifestyle modification programs and other weight loss programs.^7,8

Management of PCOS: Multidisciplinary care and current gaps in clinical practice

The 2023 International Evidence-based Guideline for the Assessment and Management of PCOS cites multidisciplinary care as an important part of PCOS management. ³ Efforts to treat PCOS usually incorporate a multidisciplinary approach to care as the heterogeneity of the disorder requires different professional disciplines to manage each aspect of treatment. ⁹ The presence of multidisciplinary health teams in clinical contexts is well documented in the literature, whereby different professional health disciplines (e.g., physicians, psychologists, dieticians, physiotherapists, etc.) collaborate to provide patient care based on individualized expertise. ¹⁰ Health professionals can integrate individual expertise when administering interventions recommended for PCOS treatment.^11,12 Despite these recommendations, there is a lack of literature documenting multidisciplinary approaches in treatment clinics for women with PCOS. ⁹ Challenges also remain with women maintaining adherence to care plans, highlighting attrition as an underexplored issue in PCOS research. ¹³ Thus, the need arises to investigate how multidisciplinary interventions are delivered to optimize their use and reduce attrition in clinical practice.

Participant attrition in PCOS interventions: A critical barrier

Women diagnosed with PCOS may be especially vulnerable to high attrition rates in clinical trials, evidenced by a recent review reporting attrition rates of up to 86%. ¹³ Attrition is a critical barrier to effective PCOS care within clinical contexts. With suboptimal adherence to interventions, participants may not experience sustained weight loss. Adequate interventions to address various mental, metabolic, and reproductive health outcomes may also be overlooked. ⁴ Previous literature has identified predictors of lifestyle intervention attrition among women who are overweight or obese and diagnosed with PCOS; namely, higher baseline depressive symptoms are associated with greater attrition rates. ⁴ However, other potential factors are not yet fully understood, and current literature lacks a comprehensive summary of why attrition rates can be high in this population. ⁴ Challenges associated with attrition in this population may compromise individual patient efforts to adhere to evidence-based guidelines in multidisciplinary PCOS management and, therefore, their clinical outcomes. As multidisciplinary weight management programs play a key role in PCOS treatment, further investigation of attrition in this population is warranted.

Objectives

The objective of this scoping review is to describe current multidisciplinary approaches to weight management in PCOS populations. This review also examines existing empirical literature to identify potential factors associated with attrition among women with PCOS within these multidisciplinary programs.

Methods

Stage 1: Identifying the research question

The following research questions guided this review:

• (1) What multidisciplinary approaches to weight management in PCOS populations are used as interventions? In what settings are these interventions provided?

• (2) What are potential factors associated with attrition during multidisciplinary PCOS interventions?

Stage 2: Identifying relevant studies

Eligibility Criteria In this review, adherence was gauged by participants’ complete follow-up of the weight management/loss program. Adherence indicators included self-reported dietary and physical activity adherence levels, attendance of recommended interventions, and self-monitoring, such as technology usage. ⁷ Consequently, attrition was defined as leaving the study after enrolment, any time after the intervention was allocated and received, excluding gestation (pregnancy). Adherence and attrition were defined this way during the preliminary scoping phase to account for differences in intervention contexts.

Before identifying the main research question, an exploratory review of existing empirical literature on weight management in women with PCOS helped refine the search strategy. The search strategy was developed in consultation with a Health Sciences librarian and included the following themes for key terms: polycystic ovary syndrome, lifestyle interventions (defined as diet, exercise, behavioral interventions, and/or pharmacotherapy), and weight management. The following five databases were searched in September 2024: MEDLINE (via Ovid), Embase (via Ovid), CINAHL, Cochrane Library, and Web of Science.

Stage 3: Study selection

Titles, abstracts, and full texts were reviewed by two authors (N.T. and S.N.). Missing data (i.e., body mass index (BMI) before and/or after the study intervention) was requested from the study’s corresponding author. Disagreements during the screening or data extraction phase were resolved in consultation with a third author (E.B.).

Stage 4: Charting the data

Data extraction was conducted by two authors (N.T. and S.N.) using a form that was iteratively refined as the authors gained familiarity with the literature. Data included the following information: author, year, country of publication, study design, sample size, criterion for PCOS diagnosis, intervention type and duration including comparators, intervention administrators, anthropometric outcomes of weight and BMI pre and post-intervention, attrition rates for each intervention arm, other commonly reported outcomes in PCOS weight management trials (i.e., anxiety, depression, blood pressure, menstrual frequency, and body composition), and facilitators/barriers of lifestyle management in women with PCOS.

Stage 5: Collating, summarizing and reporting the results

A descriptive analytical approach categorized studies by intervention context and outcomes related to attrition. These findings are summarized in Tables 2 and 3. A narrative synthesis was conducted to interpret data and support the objectives of this scoping review. The reporting of this study conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. ¹⁷ The checklist from this relevant guideline is shared as a Supplemental File.

Table 1.

Eligibility criteria used in this review.

Category	Inclusion criteria	Exclusion criteria
Population	• Specified criterion for PCOS diagnosis • Age ⩾15	• Unclear PCOS diagnostic criteria • Age <15
Concept	• Focus on a weight loss and/or weight management program as reported in objectives • Reporting of anthropometric measures and/or clinical parameters (i.e., weight/BMI) as an outcome of interest rather than a treatment effect	• Studies not addressing core concept
Intervention context	• Multidisciplinary approach as defined by: ○ ⩾2 different lifestyle interventions (i.e., diet, exercise, behavioral interventions, and/or pharmacotherapy) ○ Mention of intervention development and/or deliverance by ⩾2 different health disciplines (e.g., physician, dietician, psychologist, etc.) or as described equivalent in the study methodology • When conventional pharmacological interventions are mentioned, the assumption that its prescription was made from a health professional (i.e., a physician) will be made if not explicitly stated	• A stand-alone pharmacological or surgical intervention • Interventions not mentioned • Unclear intervention administrators • Non-multidisciplinary interventions and/or details not explicit in methodology • Comparison of multidisciplinary interventions against a non-multidisciplinary intervention across arms
Study design	• Quantitative or mixed methods • Published prospective peer-reviewed articles	• Retrospective studies, systematic and/or other literature reviews • Editorials, opinion pieces, study protocols, or gray literature
Study attrition	• Attrition rates reported as an indicator of adherence to a weight management/loss program, and/or have quantifiable data describing the effect size (i.e., some absolute or relative measure of program attrition)	• No reporting of study attrition

BMI, body mass index; PCOS, polycystic ovary syndrome.

Table 2.

Trial descriptions where PCOS participants were allocated to weight management programs interventions and completed trial.

References	Interventions completed by participants excluding lost-to-follow up (n=)	Intervention length, frequency, and follow-up (weeks/months)	Disciplinary team members involved in intervention development and/or administration	BMI (kg/m2) of participants before intervention	BMI (kg/m2) of participants after intervention
Glueck et al. 18	Dietary advice and 2550 mg metformin tablet (n = 74)	Initial dietary instruction at baseline and re-instruction once per 12 months for 48 months	Dietician, medical practitioner (pharmacotherapy)	34.9 ± 7.6*	Not reported for participants who completed the trial Percentage of reductions in weight ranged from 7.8% to 8.2% based on stratified BMI classes
Cooney et al. 19	Arm 1: Nutrition and exercise counseling (n = 8) Arm 2: CBT, nutrition counseling, and exercise counseling (n = 7)	Arm 1: Weekly 30-minute nutrition and exercise counseling sessions for 4 months Arm 2: Weekly 30-minute nutrition and exercise counseling sessions for 4 months; weekly 30-minute CBT sessions for 2 months	Psychologist, counselor	Not reported for participants who completed the trial. Baseline BMI for all recruited participants reported as follows: Arm 1: 35 (31–40)** (n = 12) Arm 2: 38 (35–42)** (n = 19)	Not reported for participants who completed the trial. BMI change from baseline reported as follows: Arm 1: −0.6 (−1.5 to −0.4)** Arm 2: −0.9 (−3.1 to −0.8)**
Elkind-Hirsch et al. 20	Arm 1: Liraglutide injection; diet and physical activity recommendations (n = 44) Arm 2: Placebo; diet and physical activity recommendations (n = 23)	Arm 1: One subcutaneous injection of liraglutide (3 mg) daily for 32 weeks, along with one informal assessment mid-study on individualized diet and exercise lifestyle recommendations Arm 2: Visually matching placebo as compared to Arm 1, along with one informal assessment mid-study on individualized diet and exercise lifestyle recommendations	Dietician, medical practitioner (pharmacotherapy) research nurse	Arm 1: 41.6 ± 1.1*** Arm 2: 43.9 ± 1.7***	Arm 1: 39.1 ± 1.1*** Arm 2: 43.4 ± 1.8***
Nidhi et al. 21	Arm 1: Individualized counseling; holistic yoga program (n = 37) Arm 2: Individualized counseling; control exercises (n = 35)	Arm 1: One-hour daily sessions of a group lecture and yoga practices, 7 days a week for 12 weeks Arm 2: One-hour daily sessions of a group lecture and physical exercises, 7 days a week for 12 weeks	Psychiatrist, gynecologist, yoga therapy physician, counselor	Arm 1: 20.39 ± 2.00* Arm 2: 21.39 ± 3.20*	Arm 1: 20.41 ± 2.07* Arm 2: 21.70 ± 2.88*
Asad et al. 22	Arm 1: Counseling with dietary and exercise advice; metformin (n = 61) Arm 2: Counseling with dietary and exercise advice and oral contraceptive pill (n = 77)	Arm 1: Lifestyle intervention advised along with initiation of a dose of 500 mg of oral metformin at start of study, and adjusted to a maximum of 2000 mg/day over 6 months Arm 2: Lifestyle intervention advised along with oral contraceptive pills (fixed dose combination of 50 mg ethinyl estradiol 2 mg cyproterone acetate per day for 6 months)	Nutritionist, medical practitioner (pharmacotherapy)	Arm 1: 29.05 ± 2.73* Arm 2: 24.74 ± 2.22*	Arm 1: 26.77 ± 2.25* Arm 2: 26.21 ± 2.25*
Lindholm et al. 23	Arm 1: Dietary and physical activity advice and sibutramine tablet (n = 17) Arm 2: Dietary and physical activity advice and placebo tablet (n = 16)	Arm 1: One tablet sibutramine (15 mg) with lifestyle modification advice with eight visits throughout study for 6 months Arm 2: Placebo tablet with lifestyle modification advice with eight visits throughout study for 6 months	Research nurse, medical practitioner (pharmacotherapy)	Not reported for participants who completed the trial. Baseline BMI for all recruited participants reported as follows: Arm 1: 32.5 ± 4.9* (n = 21) Arm 2: 35.6 ± 5.5* (n = 20)	Not reported Percentage of reductions in weight reported as follows: Arm 1: −9.0% Arm 2: −1.7%
Ou et al. 24	Arm 1: routine nursing including prescription of examinations and drugs with precautions, simple education, and diet/exercise instructions (n = 50) Arm 2: Multidisciplinary management model including gynecological endocrinology consultations with treatment objectives for participants including pharmacotherapy; individualized diet plan conducted; disease education tailored for gynecological specialized nurses (n = 50)	Arm 1: Follow-up conducted 6 months after initiation of the intervention Arm 2: Follow-up using an internet-based platform with educational health information and telephone guidance from dietician, 24-h online consultation system for questions, compliance assessed at 1, 3, and 6 months	Gynecological endocrinologists, gynecological specialist nurses, nutrition specialist nurses, psychological specialist nurse, dietician	Arm 1: 28.57 ± 1.34* Arm 2: 28.69 ± 1.43*	Arm 1: 26.19 ± 1.76* Arm 2: 23.39 ± 1.11*
Jiskoot et al. 25	Arm 1: Nutrition advice, exercise, and CBT (n = 27) Arm 2: Nutrition advice, exercise, CBT, and SMS feedback (n = 16) Arm 3: Care as usual (n = 24)	Arm 1: Standardized dietary advice; exercise recommendations; 20 sessions of 2.5 h group CBT over 1 year Arm 2: Standardized dietary advice; exercise recommendations; 20 sessions of 2.5 h group CBT over 1 year; SMS communication Arm 3: Five total unstructured consultations over 1 year	Physician, psychologist, physical therapist, therapist	Arm 1: 33.9**** Arm 2: 34.7**** Arm 3: 32.7****	Arm 1: 32.3**** Arm 2: 31.9**** Arm 3: 31.8****
Tang et al. 26	Arm: Dietary advice; metformin tablet (n = 56) Arm 2: Dietary advice; placebo tablet (n = 66)	Arm 1: One metformin tablet (850 mg) 12 hourly for 6 months with standardized dietary advice and monthly review visits Arm 2: One placebo tablet 12 hourly for 6 months with standardized dietary advice with monthly review visits	Medical practitioner (pharmacotherapy), dietician	Arm 1: 38.1 ± 5.08* Arm 2: 37.9 ± 6.5*	Arm 1: 37.1 ± 5.04* Arm 2: 37.4 ± 6.3*
Amiri et al. 27	Arm 1: Dietary advice and metformin tablet (n = 25) Arm 2: Dietary advice and flutamide tablet (n = 27) Arm 3: Dietary advice, metformin tablet, and flutamide tablet (n = 27) Arm 4: Dietary advice; placebo tablet (n = 26)	Arm 1: One tablet metformin (500 mg) three time a day for 6 months; standardized hypocaloric diet with monthly follow-up visits $ Arm 2: One flutamide tablet (250 mg) twice a day for 6 months; standardized hypocaloric diet with monthly follow-up visits $ Arm 3: One tablet metformin (500 mg) three times a day + one flutamide tablet (250 mg) twice a day for 6 months; standardized hypocaloric diet with monthly follow-up visits $ Arm 4: Placebo tablets; standardized hypocaloric diet with monthly follow-up visits $	Medical practitioner (pharmacotherapy), dietician	Not reported Inclusion criteria of BMI >19 and <35 kg/m2	Arm 1: 28.9 ± 5* Arm 2: 29.57 ± 4* Arm 3: 29.3 ± 2.6* Arm 4: 29.2 ± 3.6*
De Frène et al. 28	Diet, exercise, and psychological subprogram (n = 31)	Prescribed hypocaloric diet with dietary consultations, step pedometer records, and psychological counseling sessions with four visits over 24 weeks	Dietician, psychologist, physiotherapist	35.49 ± 5.96*	33.78 ± 4.84*

^*Mean ± standard deviation as reported in study.

^**Median (interquartile range) as reported in study.

^***Mean ± standard error of mean as reported in study.

^****Estimation as reported in study.

^$Diet initiated 1 month prior to pharmacotherapy.

BMI, body mass index; CBT, cognitive behavioral therapy; PCOS, polycystic ovary syndrome; SMS, short message service.

Stage 6: Consultation

External stakeholder consultation was not conducted in this review.

Results

Study characteristics

A total of 10,944 unique records were eligible for abstract screening after removal of duplicates. A total of 152 full text articles were screened, and 141 of these were excluded to leave 11 articles for data extraction and synthesis (Figure 1). Studies were conducted across eight countries: three in the United States,^{18 –20} two in India,^21,22 one in Sweden, ²³ one in China, ²⁴ one in the Netherlands, ²⁵ one in the United Kingdom, ²⁶ one in Iran, ²⁷ and one in Belgium. ²⁸ Study designs included seven randomized control trials^{19 –21,23,25 –27} and four prospective cohort trials.^18,22,24,28 To confirm a PCOS diagnosis, seven studies used the Rotterdam Criteria,^{18,21 –23,25,27,28} one of which had been devised before the Rotterdam consensus of PCOS definitions, but participants would have met these criteria (i.e., anovulation and polycystic ovarian morphology). ²⁶ Two studies used the National Institutes of Health Criteria for PCOS,^19,20 and one study outlined participants who had met relevant standards of the 2018 International Evidence-based Guidelines for PCOS. ²⁴ The age range for participants across all the studies ranged from 15 to 44 years old. Eight studies had a BMI inclusion criterion ranging from 19 to 50 kg/m²,^{19,20,23 –28} and three studies did not set any BMI inclusion criteria.^18,21,22

Figure 1.

PRISMA-ScR diagram indicating records screened in this review.

Source: Moher et al. ²⁹

Intervention types and contexts

Multidisciplinary approaches to weight management varied among studies, which are summarized in Table 2. Physicians directly involved in patient consultations for lifestyle interventions were mentioned in two studies.^24,25 The use of pharmacotherapy in seven studies was presumed to be prescribed by a medical practitioner (i.e., physician, nurse practitioner). Thus, prescribers of pharmacotherapy were the most prevalent disciplinary team role,^{18,20,22 –24,26,27} followed by the presence of a dietician reported in five studies.^{18,20,26 –28} The most prevalent type of lifestyle was diet counseling, reported in nine studies.^{18,20,22 –28}

Seven studies incorporating diet counseling had ongoing participant follow-up by health professionals.^{18,20,24 –28} In addition, a calorie-specific diet was used in six of these studies.^{18 –20,22,26,27} Seven studies implemented an exercise program for participants.^{19,21 –25,28} In three studies, physical activity was encouraged even if it was not an explicit intervention.^19,23,25 These studies instructed participants to keep an exercise log of physical activity,^19,23,25 one of which provided a step recorder and encouraged participants to walk a minimum of 10,000 steps a day most days of the week; however, this was not monitored by a health professional. ²⁵

Seven studies used pharmacotherapy as an adjunct to other diet, exercise, and cognitive behavioral therapy interventions.^{18,20,22 –24,26,27} Among these studies, oral metformin was the most common prescription.^18,22,26,27 Other administered pharmacotherapies included subcutaneous liraglutide injections, ²⁰ oral sibutramine tablets, ²³ oral flutamide tablets,^20,27 and oral contraceptive pills. ²²

The total length of multidisciplinary intervention follow-up of the included trials varied from 3 to 48 months. Studies had ongoing follow-up with multidisciplinary teams to assess compliance and/or reinforce interventions. These consultations mainly focused on personalized plans and individualized goals for study participants. Review visits assessed adherence to prescribed lifestyle interventions, including diet, physical activity, and pharmacological treatments. Nidhi et al. ²¹ did not have an ongoing follow-up with a disciplinary team member as yoga, and control interventions were given in a group setting; however, participants had at least one individualized counseling session.

Jiskoot et al. ²⁵ is the only study in this review that did not have an individual component of interventions. Instead, all interventions were in group settings, which included cognitive behavior therapy, nutrition advice, and exercise. Two studies implemented both individual and group-based interventions.^21,28 Nidhi et al. ²¹ investigated the effects of a holistic yoga program by incorporating group yoga or physical movements combined with individualized counseling sessions. De Frène et al. ²⁸ utilized individualized coaching within a lifestyle modification program where participants were also allowed to have support present (e.g., partner, parent) to attend consultations.

Three studies included an asynchronous component to stay connected to participants in between follow-ups for interventions.^20,24,25 Jiskoot et al. ²⁵ used short message service (SMS) for participants to report self-monitored information regarding their diet, physical activity, and emotions. Elkind-Hirsch et al. ²⁰ had participants text a photo of monthly home pregnancy tests per their study protocol. Ou et al. ²⁴ used an internet-based application to facilitate follow-up for weight loss needs and offered a 24-h consultation system to answer questions. Four studies also implemented remote interventions, which included telephone/telehealth appointments and interactive SMS messaging.^20,24,25,28 Notably, Elkind-Hirsch et al. ²⁰ amended their study protocol to include telehealth visits for participants in response to the evolving COVID-19 pandemic.

Attrition rates

Attrition rates across all study participants ranged from 0% to 72.9%. Table 3 summarizes the attrition rates reported in studies. Most studies defined attrition as a loss-to-follow-up or dropout before the end of the weight management program for various reasons; however, addressing attrition was generally not discussed a priori, other than for calculating sample sizes. One study specified dropout as an outcome of interest within the study design. ²⁵ Attrition in another study was defined as attending less than 75% of the prescribed intervention sessions. ²¹ Two studies did not include a flow chart summarizing intervention allocation and subsequent dropout rates.^23,28 One study provided general information on attrition among all participants rather than information on separate intervention arms. ²³ Reported reasons for dropout among participants who received an allocated intervention varied among the studies and are summarized in Table 3. Two studies did not report complete information on reasons for dropout,^18,28 two studies reported dropout for unknown reasons,^19,23 and one study specified that they could not confirm reasons for study dropout. ²¹

Table 3.

Program duration, attrition rates among participants who received allocated intervention, and reported reasons for dropout.

Study	Intervention duration (months)	Number of participants who received any allocation of intervention (n=)	Attrition rate after intervention allocation (excluding pregnancy)	Reason for dropout
Glueck et al. 18	48 months	n = 274	72.9%	Not reported (n = 200)
Cooney et al. 19	4 months	n = 9	Arm 1: 11.1%	Unable to commit time (n = 1)
		n = 15	Arm 2: 53.3%	Unable to commit time (n = 4) Desire to continue weekly therapy with personal therapist (n = 1) Unrelated medical issues (n = 1) Unknown (n = 2)
Elkind-Hirsch et al. 20	8 months	n = 55	Arm 1: 16.3%	Intolerable nausea (n = 6) Noncompliant (n = 2) Concern about medication (n = 1) Pregnancy (n = 2)
		n = 27	Arm 2: 14.8%	No benefit of meds (n = 2) Gallbladder surgery (n = 1) COVID exposure/quarantine (n = 1)
Nidhi et al. 21	3 months	n = 45	Arm 1: 17.8%	Sick leave or unexpected events in the family (n = 8)
		n = 45	Arm 2: 22.2%	Sick leave or unexpected events in the family (n = 10)
Asad et al. 22	6 months	n = 71	Arm 1: 14.1%	Not reported (n = 10)
		n = 91	Arm 2: 15.4%	Not reported (n = 14)
Lindholm et al. 23	6 months	n = 21	9.5% across intervention arms	Pregnancy (n = 4) Unable to comply with study protocol (n = 3) Unknown (n = 1)
		n = 21*
Ou et al. 24	6 months	n = 100	Arm 1: 0%	N/A
			Arm 2: 0%	N/A
Jiskoot et al. 25	12 months	n = 63	Arm 1: 34.9%	No show for group meetings (n = 14) Treatment abroad (n = 2) Dissatisfied with the intervention (n = 3) Work and other commitments (n = 1) Treatment for breast cancer (n = 1) Bariatric surgery (n = 1) Pregnancy (n = 14)
		n = 60	Arm 2: 46.7%	No show for group meetings (n = 10) Dissatisfied with the intervention (n = 5) Language barrier (n = 3) Work and other commitments (n = 8) Relationship ended (n = 2) Pregnancy (n = 16)
		n = 60	Arm 3: 43.3%	No show for treatments (n = 19) No wish to conceive anymore (n = 2) Dissatisfied with the study (n = 3) Didn’t want to lose weight (n = 1) Partner not motivated (n = 1) Pregnancy (n = 10)
Tang et al. 26	6 months	n = 69	Arm 1: 15.9%	Side-effects (n = 11) Pregnancy (n = 2)
		n = 74	Arm 2: 8.1%	Side-effects (n = 6) Pregnancy (n = 2)
Amiri et al. 27	6 months	n = 25	Arm 1: 10.7%	High transaminase value (n = 2) Changing place of living (n = 1)
		n = 27	Arm 2: 3.7%	High transaminase value (n = 1)
		n = 27	Arm 3: 10%	No contribution after receiving allocated intervention (n = 2) Changing place of living (n = 1)
		n = 26	Arm 4: 3.7%	Consumed medicine (n = 1)
De Frène et al. 28	6 months	n = 31	25.8%	Not reported (n = 8)

Attrition rates are rounded to the nearest 10th decimal.

^*One patient was excluded from analyses but received allocated intervention, and therefore, their dropout is included in this study to determine attrition.

Technology use

Two randomized control trials used technology as part of study interventions.^24,25 Ou et al. ²⁴ implemented an internet-based platform that gave access to telephone guidance, an online consultation system, and published educational health information. Jiskoot et al. ²⁵ allocated a group of participants in their intervention to receive additional support through SMS after 3 months of lifestyle modification consisting of nutrition advice, exercise, and cognitive behavioral therapy. SMS was used for participants to send self-monitored information, and feedback was given to provide social support and encourage positive behavior strategies.

Reported outcome indicators

Commonly reported outcome indicators related to PCOS weight management were identified by scoping prior literature (i.e., menstrual frequency, anxiety, depression, quality of life, blood pressure, body fat, and/or X-ray absorptiometry) to report in this review. Among these indicators, menstrual frequency was the most reported and included in all but one of the studies. ¹⁸ Methods to measure body composition, including body fat analysis or dual-energy X-ray absorptiometry, were reported in two studies.^20,24 Two studies reported quality of life outcome indicators,^19,20 and two also reported health outcome indicators related to anxiety and depression.^19,24

Facilitators and barriers of PCOS lifestyle management

Empirical literature was consulted to identify potential facilitators and barriers associated with PCOS lifestyle management.^30,31 Identified facilitators included ongoing check-ins with health professionals, structured dietary advice, social support, and motivational interviewing. Ongoing multidisciplinary intervention delivery was implemented in all the studies with varying follow-up frequencies (Table 2). Structured dietary advice was provided in six studies; interventions included prescribed diets and individualized diet counseling.^{19,22,24,26 –28} Four studies indicated that research teams provided check-ins in between visits.^20,24,25,28 One study integrated social support from other women with PCOS (i.e., other study participants) in its intervention. ²⁵ Barriers to PCOS lifestyle management included a lack of patient motivation related to treatment plans and accessibility issues related to participating in studies.^30,31 Lack of motivation as a reason for dropout was not explicitly mentioned in this review; however, one study did report participant dissatisfaction with the intervention as a reason for attrition. ²⁵ Without further context, it is unclear to what extent perceived barriers, such as motivation, were addressed within the study methodologies.

Discussion

The complexity of multidisciplinary PCOS management

PCOS is a complex condition that requires a multifaceted treatment approach. Behavioral adherence to prescribed PCOS interventions contributes to successful treatment. Few studies have investigated a multidisciplinary approach to PCOS interventions, despite evidence-based recommendations indicating its benefit. ³ This scoping review aimed to describe multidisciplinary PCOS weight management interventions and examine attrition rates among populations with the condition. In this review, Table 2 summarizes multidisciplinary intervention delivery, and Table 3 summarizes reported reasons for study attrition. Overall, this review presents inconsistencies in how attrition is reported among studies using multidisciplinary interventions. Many studies provided no or incomplete reasons for program attrition; the wide variation is likely associated with intervention length and intensity, identified facilitators and barriers to PCOS weight management, and individualized care plans.

The impact of intervention length and intensity on attrition rates

Studies had varying lengths of follow-up, treatment types, composition of the multidisciplinary team, and settings where interventions were delivered (Table 2). These differences may contribute to the variation in reported attrition rates (Table 3). The results indicate that the longer interventions were associated with higher attrition. However, the shortest intervention duration was not associated with the lowest attrition rate reported in this review. The intensity of the program intervention may affect the attrition rates. Not all studies reported reasons behind attrition and used a variety of classifications for study dropout reasons, which made it difficult to track underlying reasons for attrition between studies. It was also noted that the control groups generally tended to have lower attrition rates compared to the intervention groups of the same study.

Most interventions ranged from 3 to 6 months; however, three studies had longer interventions ranging between 7 months and 4 years.^18,20,25 The study with the longest intervention demonstrated the highest attrition rates in this review, with 72.9% attrition rate at 4 years. ¹⁸ Contrastingly, the study with the shortest duration was 3 months and did not have the lowest attrition rates. ²¹ This review did note that more intense interventions (i.e., a comparatively longer study duration and/or more frequent follow-ups with the multidisciplinary team) seem to result in worse attrition rates. To further investigate PCOS populations, intervention delivery methods must be carefully considered to minimize attrition while optimizing care.

Implications of high attrition rates in populations with PCOS

Current literature has not comprehensively explored potential factors associated with attrition in this population. ⁴ In considering the objectives for this scoping review, the inconsistent reporting of attrition did not allow for a systematic investigation into identifying factors that may worsen dropout within clinical contexts. Therefore, these inconsistencies make evaluating adherence to multidisciplinary interventions difficult. Nonetheless, the high attrition rates across studies, as evidenced in this review, highlight the importance of addressing potential implications. Attrition to care plans for PCOS lifestyle management may adversely impact individual health outcomes, further worsening clinical and biochemical complications related to obesity, insulin resistance, diabetes, and hyperandrogenism. ³ There is also a risk that patient motivation to address PCOS through lifestyle management may be negatively impacted if an individual regards a prior intervention as “unsuccessful” despite suboptimal adherence and/or premature attrition. This finding highlights the need for future clinical research to investigate the operationalization of multidisciplinary approaches, especially as the diversity of PCOS clinical presentations and diagnoses can require an individualized approach to lifestyle management.

The potential for a multidisciplinary approach to mitigate attrition

In this review, Ou et al. ²⁴ had the most comprehensive multidisciplinary management model for PCOS care, which included disease-related knowledge and health education for participants and health providers. Ou et al. ²⁴ did not report any attrition and was the only study in this review that used an entirely individualized approach during their weight management interventions. This comprehensive approach to PCOS management may reflect the lack of attrition in the study. Future studies can investigate whether individualized care plans are associated with lower attrition rates. Involvement of health professionals within a multidisciplinary team may mitigate participant attrition. For example, increased care coordination through a multidisciplinary approach could improve health outcomes and patient–provider satisfaction. Patients with PCOS may especially benefit from this increased accountability due to the risk of attrition in this population.

This review found that technology use led to more weight loss among study participants when compared to other intervention arms within the original study. ²⁵ As the heterogeneity of PCOS lends itself to a multidisciplinary treatment approach, this finding may also help to direct future intervention planning. It may interest clinicians to consider how patient accountability for care can be encouraged through individualized approaches that integrate technology. However, it is difficult to extrapolate the impacts of technology within this population as there is limited evidence, with only one study in this review reporting on its use.

Facilitators and barriers associated with lifestyle interventions for PCOS

Facilitators and barriers to lifestyle management were identified by consulting published literature on PCOS populations.^30,31 All studies included ongoing check-ins with health professionals, which is a factor that supports weight management.^30,31 Structured dietary advice is another weight management facilitator; in this review, dietary advice was provided in the form of a hypocaloric diet and/or individualized programs. Barriers to weight management programs within PCOS populations include a perceived lack of patient motivation for weight loss, time pressures, financial reimbursement, costs of accessing allied health professionals, and personal/work commitments.^30,31 Many of these barriers are present in this review. Table 3 highlighted a theme of attrition across studies attributed to time constraints and illness. Other barriers related to social determinants of health, such as socioeconomic status (e.g., financial pressures), may have impacted participants’ ability to follow-up in studies. Yet, these barriers were not addressed in the study methodologies. This scoping review did not aim to determine definite associations between barriers to participant attrition. Regardless, professionals should be aware of barriers to PCOS care and how contextual factors beyond the interventions themselves can impact adherence when planning treatment.

Strengths and limitations

A comprehensive and systematic methodology is a strength of this review. Studies captured in this review highlight the complexity of PCOS management across health disciplines and the need for further investigation into mitigating attrition. This review concluded that reasons for attrition within PCOS weight management interventions are not often fully reported. Explicit attention to attrition reporting within clinical studies can further contribute to investigating how PCOS care can be optimized by proactively addressing attrition. Despite a comprehensive and systematic search strategy, its inherent effectiveness and restriction to the English language may have contributed to publication bias. This review has a weight-focused approach, which may overlook other aspects of PCOS care benefiting from multidisciplinary approaches such as mental health and reproductive outcomes. Additionally, the results from this review should be interpreted with caution due to the challenges of synthesizing the heterogeneous data within a relatively small sample size of PCOS studies. Specifically, this review reports a wide variation of intervention types, settings, and durations (i.e., 3–48 months) as it investigates multidisciplinary approaches in PCOS management. The studies included in this review were published across eight countries, primarily in high-income settings. The disproportionate representation of high-income countries may not reflect global challenges in the diverse management of PCOS and could subsequently limit overall generalizability of findings. Furthermore, this scoping review did not report a formal quality assessment or risk of bias evaluation of included studies. As this review includes a variety of study designs (i.e., randomized control trials and prospective cohorts), no single bias tool would be fully appropriate to use. The application of multiple tools may risk inconsistent judgments across designs and/or add disproportionate complexity given the narrowed focus of this review. Overall, this scoping review raises awareness about gaps related to the operationalization of PCOS care in clinical practice; nonetheless, these variations can impact generalizability and/or reliability of conclusions made in this review.

Recommendations

Future clinical research in PCOS populations should incorporate more standardized reporting of attrition. Clarity on common reasons for attrition can assist clinicians in making evidence-based decisions, as well as help shape policy recommendations regarding future PCOS care. Current research lacks incorporation of patient-reported mental health and/or reproductive outcomes to allow parallel investigation among multidisciplinary approaches. Although the 2023 International Evidence-based Guideline for the Assessment and Management of PCOS acknowledges various geographic and cultural contexts that impact care needs, clinical research does not comprehensively reflect globally diverse settings. Thus, more inclusion of diverse populations and a broader exploration of multidisciplinary care beyond weight management are warranted.

Conclusion

Attrition rates ranged from 0% to 79.2% among women enrolled in PCOS weight management studies in this review. Inconsistencies in attrition reporting among studies did not allow for a systematic investigation into reasons for suboptimal treatment adherence. Future studies investigating PCOS should include indications of attrition as an outcome of interest to gain a better understanding of how intervention adherence plays a role in treatment effectiveness. This review found a wide variance in intervention types, duration, and settings within clinical research. More intense interventions (i.e., a comparatively longer study duration and/or more frequent follow-ups with health professionals) seem to result in worse attrition rates; however, definite conclusions were not made in this review. Clinicians involved in providing evidence-based care PCOS for weight management must consider how attrition can be mitigated while optimizing care through a multidisciplinary approach.