Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in females, with a high prevalence. The etiology of this heterogeneous condition remains obscure, and its phenotype expression varies. Two widely cited previous ESHRE/ASRM sponsored PCOS consensus workshops focused on diagnosis (published in 2004) and infertility management (published in 2008), respectively. The present third PCOS consensus report summarizes current knowledge and identifies knowledge gaps regarding various women’s health aspects of PCOS. Relevant topics addressed—all dealt with in a systematic fashion—include adolescence, hirsutism and acne, contraception, menstrual cycle abnormalities, quality of life, ethnicity, pregnancy complications, long-term metabolic and cardiovascular health, and finally cancer risk. Additional, comprehensive background information is provided separately in an extended online publication. Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in females, with a high prevalence. The etiology of this heterogeneous condition remains obscure, and its phenotype expression varies. Two widely cited previous ESHRE/ASRM sponsored PCOS consensus workshops focused on diagnosis (published in 2004) and infertility management (published in 2008), respectively. The present third PCOS consensus report summarizes current knowledge and identifies knowledge gaps regarding various women’s health aspects of PCOS. Relevant topics addressed—all dealt with in a systematic fashion—include adolescence, hirsutism and acne, contraception, menstrual cycle abnormalities, quality of life, ethnicity, pregnancy complications, long-term metabolic and cardiovascular health, and finally cancer risk. Additional, comprehensive background information is provided separately in an extended online publication. Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women, with a prevalence between 6% and 10% based on the U.S. National Institutes of Health (NIH) criteria and as high as 15% when the broader Rotterdam criteria are applied. Typically, PCOS is first identified during the early reproductive years. The clinical expression varies but commonly includes oligo-ovulation or anovulation, hyperandrogenism (either clinical or biochemical), and the presence of polycystic ovaries. The etiology of the syndrome remains obscure, and the variability in phenotype expression continues to render the clinical care and research concerning this heterogeneous condition challenging.Two ESHRE/ASRM-sponsored PCOS consensus workshops have previously been organized. The first one in Rotterdam, the Netherlands, in 2003 focused on diagnostic criteria for PCOS (1Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop GroupRevised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS).Hum Reprod. 2004; 19: 41-47Crossref PubMed Scopus (1317) Google Scholar, 2Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop GroupRevised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome.Fertil Steril. 2004; 81: 19-25Scopus (0) Google Scholar); the second in Thessaloniki, Greece, in 2007 dealt with infertility management in PCOS (3Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop GroupConsensus on infertility treatment related to polycystic ovary syndrome.Fertil Steril. 2008; 89: 505-522Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 4Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop GroupConsensus on infertility treatment related to polycystic ovary syndrome.Hum Reprod. 2008; 23: 462-477Crossref PubMed Scopus (118) Google Scholar). The conclusions of these meetings were subsequently jointly published simultaneously in both Human Reproduction and Fertility and Sterility. These papers are highly cited, suggesting a great interest in this area and underlining the value of such consensus contributions.A third PCOS consensus workshop—the focus of the present report—took place in Amsterdam, the Netherlands, in October 2010 and attempted to summarize current knowledge and to identify gaps in knowledge regarding various women’s health aspects of PCOS. Diverse aspects of care during the reproductive and postreproductive years were addressed, including adolescence, hirsutism and acne, contraception, menstrual cycle abnormalities, quality of life and sexual health, ethnicity, pregnancy complications, long-term (metabolic) cardiovascular health, and cancer risk (Fig. 1) . Due to the complexity of the many issues discussed, this contribution will address each topic separately in a fixed format: a brief introduction, concluding statements (where there was agreement), a summary of areas of disagreement (if any) and knowledge gaps, with recommended directions for future research. These concluding statements in relation to each specific topic mentioned are published in the journals (maximum of 5 references per paragraph). An extended version of this article is available online with Supplemental Material that provides comprehensive background information.The hierarchy of the evidence available in the literature assessed for this conference was graded as follows:Level A requires at least one randomized, controlled trial (RCT) as part of a body of literature of overall good quality and consistency that addresses the specific recommendation.Level B requires the availability of well-controlled clinical studies, but no RCTs on the topics of recommendation.Level C requires evidence obtained from expert committee reports of opinions and/or clinical experiences of respected authorities, which indicates an absence of directly applicable clinical studies of good quality.Good practice points (GPP) are also addressed.AdolescenceThere is no overall agreement as to how to diagnose PCOS in adolescence. Acne is common during the adolescent years, whether or not PCOS is present, whereas hirsutism—associated with PCOS—typically develops over time. Hyperandrogenemia may be a more consistent marker for PCOS during the teenage years (5Blank S.K. Helm K.D. McCartney C.R. Marshall J.C. Polycystic ovary syndrome in adolescence.Ann NY Acad Sci. 2008; 1135: 76-84Crossref PubMed Scopus (20) Google Scholar). In all young women, irregular menses are common in the years immediately after menarche. As many as 85% of menstrual cycles are anovulatory during the first year after menarche, and up to 59% are still anovulatory during the third year after menarche (6Apter D. Endocrine and metabolic abnormalities in adolescents with a PCOS-like condition: consequences for adult reproduction.Trends Endocrinol Metab. 1998; 9: 58-61Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar). In one study, persisting oligomenorrhea was not predicted by increased androgens, polycystic ovaries on ultrasound, or increased serum luteinizing hormone (LH) levels (7van Hooff M.H. Voorhorst F.J. Kaptein M.B. Hirasing R.A. Koppenaal C. Schoemaker J. Predictive value of menstrual cycle pattern, body mass index, hormone levels and polycystic ovaries at age 15 years for oligo-amenorrhoea at age 18 years.Hum Reprod. 2004; 19: 383-392Crossref PubMed Scopus (46) Google Scholar). Increased body mass index (BMI), however, was the major risk factor for persistent anovulation.Only approximately 40% of adolescent women with menstrual irregularity have polycystic ovaries on ultrasound (8Venturoli S. Porcu E. Fabbri R. Pluchinotta V. Ruggeri S. Macrelli S. et al.Longitudinal change of sonographic ovarian aspects and endocrine parameters in irregular cycles of adolescence.Pediatr Res. 1995; 38: 974-980Crossref PubMed Google Scholar). These considerations have led to the suggestion that all three elements of the Rotterdam criteria should be present in teenagers to make the diagnosis of PCOS (9Carmina E. Oberfield S.E. Lobo R.A. The diagnosis of polycystic ovary syndrome in adolescents.Am J Obstet Gynecol. 2010; 203: 201-205Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar). These investigators suggest that oligomenorrhea or amenorrhea should be present for at least 2 years after menarche (or primary amenorrhea at age 16 yrs), the diagnosis of polycystic ovaries on ultrasound should include increased ovarian size (>10 cm3), and hyperandrogenemia rather than just signs of androgen excess should be documented.Conclusions (Agreement)•Criteria for the diagnosis of PCOS in adolescents differ from those used for older women of reproductive age (level B).•Groups at risk (e.g., obese, hirsute, irregular menses) should be identified, but physicians should be cautious of overdiagnosing PCOS (level B).•Individual PCOS manifestations in adolescents (e.g., obesity, hirsutism, irregular menses) (level B) should be treated.Knowledge Gaps/Recommended Future Research•Absence of longitudinal studies through adolescence.•Absence of specific diagnostic criteria for identifying PCOS early in adolescence.•Absence of normative values for a number of biochemical markers during adolescence.•Assessment of value of intervention in PCOS early in adolescence.•Lack of clarity as to whether the severity of symptoms during adolescence predicts the extent of the disorder in later life.Hirsutism/acne/alopeciaHirsutism is a good marker for hyperandrogenism even when considering ethnic differences and systemic factors such as obesity. Hirsutism is present in approximately 70% of women with PCOS, but hyperandrogenemia should be evaluated biochemically in all women suspected of having PCOS. By comparison, acne and alopecia are not commonly associated with hyperandrogenemia and therefore should not be regarded as evidence of hyperandrogenemia.For women with PCOS in whom hirsutism is a major concern, treatment is focused on reduction of androgen production, decreasing the fraction of circulating free testosterone (T), and limiting androgen bioactivity to hair follicles. In those women with PCOS who have acne vulgaris, clinical benefit may be derived from many systemic therapeutic modalities. Because terminal hair turnover occurs slowly, at least 6 months of treatment is generally considered the minimal interval to see a response.The main therapeutic emphasis has focused on inhibition of ovarian steroid production and decreased bioavailability through augmentation of sex hormone–binding globulin (SHBG) levels with the use of oral contraceptive pills (OCPs). Often OCPs are prescribed in combination with an antiandrogen to block androgen action at the hair follicles. Antiandrogens include spironolactone (an aldosterone-antagonist diuretic), flutamide (an androgen receptor antagonist), and finasteride (a 5α-reductase type 2 inhibitor). In general, the addition of an antiandrogen to OCPs has not appeared to increase the overall treatment benefit. Each of these agents have been shown to reduce hirsutism, and all appear (without head-to-head comparisons) to have equivalent efficacy (10O’Brien R.C. Cooper M.E. Murray R.M. Seeman E. Thomas A.K. Jerums G. Comparison of sequential cyproterone acetate/estrogen versus spironolactone/oral contraceptive in the treatment of hirsutism.J Clin Endocrinol Metab. 1991; 72: 1008-1013Crossref PubMed Google Scholar, 11Erenus M. Yucelten D. Durmusoglu F. Gurbuz O. Comparison of finasteride versus spironolactone in the treatment of idiopathic hirsutism.Fertil Steril. 1997; 68: 1000-1003Abstract Full Text PDF PubMed Scopus (59) Google Scholar, 12Moghetti P. Tosi F. Tosti A. Negri C. Misciali C. Perrone F. et al.Comparison of spironolactone, flutamide, and finasteride efficacy in the treatment of hirsutism: a randomized, double blind, placebo-controlled trial.J Clin Endocrinol Metab. 2000; 85: 89-94Crossref PubMed Scopus (128) Google Scholar). Notably, antiandrogens should not be used without effective contraception (given their potential fetal toxicity). Flutamide is of limited value because of associated hepatotoxicity. In addition, drospirenone is not antiandrogenic in the dosage used as a component of some OCPs. Insulin-sensitizing agents, such as metformin and pioglitazone, have little effect on hirsutism or acne (13Harborne L. Fleming R. Lyall H. Sattar N. Norman J. Metformin or antiandrogen in the treatment of hirsutism in polycystic ovary syndrome.J Clin Endocrinol Metab. 2003; 88: 4116-4123Crossref PubMed Scopus (114) Google Scholar, 14Cosma M. Swiglo B.A. Flynn D.N. Kurtz D.M. Labella M.L. Mullan R.J. et al.Clinical review: insulin sensitizers for the treatment of hirsutism: a systematic review and metaanalyses of randomized controlled trials.J Clin Endocrinol Metab. 2008; 93: 1135-1142Crossref PubMed Scopus (37) Google Scholar). Physical approaches to remove unwanted hair, including electrolysis and laser treatments, may be acceptable to many patients.In severe acne, isotretinoin can be beneficial, but individual responses vary. It is not effective for hirsutism and occasionally may lead to alopecia. Physical approaches to remove unwanted hair, including electrolysis and laser treatments, may be acceptable to many patients. Topical treatment with eflornithine hydrochloride, an inhibitor of ornithine decarboxylase, limits cell division and has been shown to be effective for decreasing the development of new unwanted facial hair (15Balfour J.A. McClellan K. Topical eflornithine.Am J Clin Dermatol. 2001; 2: 197-201Crossref PubMed Google Scholar). No effective pharmacologic treatment for alopecia exists.Conclusions (Agreement)•Hirsutism, considering ethnic differences, is a good marker for hyperandrogenism (level B).•Isolated acne and alopecia are not necessarily related to and are not good markers for hyperandrogenism (level B).•Hirsutism should be evaluated biochemically (level B).•Prolonged (>6 months) medical therapy for hirsutism is necessary to document effectiveness (level B).•Many drugs used for the treatment of hirsutism are not approved by the U.S. Food and Drug Administration (FDA) for this indication (GPP).•No effective treatment for alopecia is known (level B).•Antiandrogens should not be used without effective contraception (level B).•Flutamide is of limited value because of its dose-dependent hepatotoxicity (level B).•Drospirenone in the dosage used in some OCPs is not antiandrogenic (level B).Knowledge Gaps/Recommended Future Research•Unclear what is the best medical therapy for hirsutism.•Unclear how long therapy should be continued.•Unclear how best to evaluate hirsutism clinically.•Measurement of serum androgens fraught with error but the best estimate we have for hyperandrogenism.Menstrual irregularityAlthough cycle abnormalities are common during the reproductive years, women with PCOS may ovulate spontaneously. How frequently this occurs is unknown (16Laven J.S. Imani B. Eijkemans M.J. Fauser B.C. New approach to polycystic ovary syndrome and other forms of anovulatory infertility.Obstet Gynecol Surv. 2002; 57: 755-767Crossref PubMed Scopus (108) Google Scholar), but ovulations have been reported in up to 32% of “cycles.” Women with oligomenorrhea or amenorrhea have about a 90% chance of being diagnosed with PCOS, and up to 95% of affected adults have oligomenorrhea or amenorrhea (17Kumarapeli V. Seneviratne R.A. Wijeyaratne C.N. Yapa R.M. Dodampahala S.H. A simple screening approach for assessing community prevalence and phenotype of polycystic ovary syndrome in a semi-urban population in Sri Lanka.Am J Epidemiol. 2008; 168: 321-328Crossref PubMed Scopus (22) Google Scholar). The definition used to establish the diagnosis of PCOS affects the proportion of women included with menstrual irregularities (18Vutyavanich T. Khaniyao V. Wongtra-Ngan S. Sreshthaputra O. Sreshthaputra R. Piromlertamorn W. Clinical, endocrine and ultrasonographic features of polycystic ovary syndrome in Thai women.J Obstet Gynaecol Res. 2007; 33: 677-680Crossref PubMed Scopus (6) Google Scholar).Amenorrheic women with PCOS usually have the most severe hyperandrogenism and higher antral follicle counts as compared with women presenting with oligomenorrhea or regular menstrual cycles. Menstrual cycles in women with PCOS become more regular as they approach menopause (19Dahlgren E. Johansson S. Lindstedt G. Knutsson F. Oden A. Janson P.O. et al.Women with polycystic ovary syndrome wedge resected in 1956 to 1965: a long-term follow-up focusing on natural history and circulating hormones.Fertil Steril. 1992; 57: 505-513Abstract Full Text PDF PubMed Google Scholar, 20Elting M.W. Korsen T.J. Schoemaker J. Obesity, rather than menstrual cycle pattern or follicle cohort size, determines hyperinsulinaemia, dyslipidaemia and hypertension in ageing women with polycystic ovary syndrome.Clin Endocrinol (Oxf). 2001; 55: 767-776Crossref PubMed Scopus (37) Google Scholar). Obesity rather than the menstrual cycle pattern or the size of the follicular cohort determines hyperinsulinemia, dyslipidemia, and hypertension in aging women with PCOS (20Elting M.W. Korsen T.J. Schoemaker J. Obesity, rather than menstrual cycle pattern or follicle cohort size, determines hyperinsulinaemia, dyslipidaemia and hypertension in ageing women with polycystic ovary syndrome.Clin Endocrinol (Oxf). 2001; 55: 767-776Crossref PubMed Scopus (37) Google Scholar).Conclusions (Agreement)•Both amenorrheic and oligomenorrheic women may occasionally ovulate (level B).•Menstrual cycles in women with PCOS may become more regular later in life (level B).•Irregular menses are associated with increased metabolic risk (level B).•The greater the menstrual irregularity, the more severe the PCOS phenotype (level B).Disagreement•The time needed before regular menstrual cycles occur in young women.•The extent to which irregular menses (especially amenorrhea) are a source of psychological morbidity and/or decreased quality of life.Knowledge Gaps/Recommended Future Research•It is unclear to what extent the severity of the menstrual disturbance is associated with the severity of the PCOS phenotype.•The natural history and progression of menstrual irregularity in PCOS are not well understood.•It remains unclear whether PCOS patients have a longer reproductive life span.•How often do oligomenorrheic or amenorrheic women ovulate?ContraceptionWomen with PCOS who do not desire pregnancy need contraception. No contraceptive methods are contraindicated in PCOS. However, some of the features associated with PCOS (such as obesity and insulin resistance) may represent a relative contraindication to the use of combined OCPs. Cycle control is usually achieved by the use of OCP in women with PCOS.Oral contraceptives suppress LH secretion and lead to a decrease in ovarian androgen production. The estrogenic component increases the levels of sex hormone–binding globulin (SHBG), which, in turn, results in a decrease in circulating free T levels. The progestin in the pill can compete for 5α-reductase at the level of the androgen receptor. Oral contraception also decreases adrenal androgen production by a mechanism yet unclear, possibly due to a decrease in adrenocorticotropin hormone (ACTH) production.There are few randomized double-blind studies comparing the metabolic effects of a combination of two OCPs, or combined with an insulin sensitizer (21Yildiz B.O. Oral contraceptives in polycystic ovary syndrome: risk-benefit assessment.Semin Reprod Med. 2008; 26: 111-120Crossref PubMed Scopus (20) Google Scholar). A Cochrane review, based on limited evidence, concluded that OCP use does not increase metabolic risk (22Costello M.F. Shrestha B. Eden J. Johnson N.P. Sjoblom P. Metformin versus oral contraceptive pill in polycystic ovary syndrome: a Cochrane review.Hum Reprod. 2007; 22: 1200-1209Crossref PubMed Scopus (49) Google Scholar). Findings from a few small studies suggest that insulin resistance worsens during the natural course of PCOS, but long-term OCP use either does not change or improves cardiometabolic risk parameters, including insulin resistance, lipoprotein profile, and possibly body fat distribution.Conclusions (Agreement)•Overall, the benefits of OCPs outweigh the risks in most patients with PCOS (level B).•Women with PCOS are more likely to have contraindications for OCP use than normal women (level C).•In the absence of other risk factors, there is no evidence that women with PCOS are at increased risk with OCPs compared with normal women (level C).•There is no evidence for differences in effectiveness and risk among the various progestogens and when used in combination with a 20 versus a 30 μg daily dose of estrogen (level B).•Subsequent fertility is not negatively affected by OCPs (level C).•There is no definitive evidence that the type of OCP determines efficacy of hirsutism control (level C).Knowledge Gaps/Recommended Future Research•Head-to-head blinded trials comparing different OCP strategies are lacking.•There is a lack of longitudinal follow-up studies after a course of OCPs.Quality of lifePatients with PCOS are an at-risk group for psychological and behavioral disorders and reduced quality-of-life (QOL) (23Himelein M.J. Thatcher S.S. Polycystic ovary syndrome and mental health: a review.Obstet Gynecol Surv. 2006; 61: 723-732Crossref PubMed Scopus (57) Google Scholar, 24Jones G.L. Hall J.M. Balen A.H. Ledger W.L. Health-related quality of life measurement in women with polycystic ovary syndrome: a systematic review.Hum Reprod Update. 2008; 14: 15-25Crossref PubMed Scopus (49) Google Scholar, 25Dokras A. Clifton S. Futterweit W. Wild R. Increased risk for abnormal depression scores in women with polycystic ovary syndrome: a systematic review and meta-analysis.Obstet Gynecol. 2011; 117: 145-152Crossref PubMed Scopus (21) Google Scholar). Studies in this area have been hampered by the existence of only one validated disease-specific questionnaire, the QOL Questionnaire for Women with PCOS (PCOSQ) (26Cronin L. Guyatt G. Griffith L. Wong E. Azziz R. Futterweit W. et al.Development of a health-related quality-of-life questionnaire (PCOSQ) for women with polycystic ovary syndrome (PCOS).J Clin Endocrinol Metab. 1998; 83: 1976-1987Crossref PubMed Scopus (95) Google Scholar). A review of generic and specific quality-of-life studies in women with PCOS concluded that (1) PCOS has a significant detrimental effect on QOL compared with controls, (2) weight issues are most apt to affect quality of life, (3) few studies include an instrument specific for PCOS in their assessment, and (4) very few studies include QOL instruments in their assessment of the benefits of the investigated treatment (24Jones G.L. Hall J.M. Balen A.H. Ledger W.L. Health-related quality of life measurement in women with polycystic ovary syndrome: a systematic review.Hum Reprod Update. 2008; 14: 15-25Crossref PubMed Scopus (49) Google Scholar).The PCOSQ cannot be used to evaluate the prevalence of emotional and other disorders (e.g., sexual or eating disorders). However, from other validated measures, it appears that patients with PCOS are at higher risk for developing significant psychological difficulties (i.e., depression, anxiety) compared with healthy and other controls and may also be at risk for eating disorders and sexual and relational dysfunction, though this evidence is inconsistent (23Himelein M.J. Thatcher S.S. Polycystic ovary syndrome and mental health: a review.Obstet Gynecol Surv. 2006; 61: 723-732Crossref PubMed Scopus (57) Google Scholar). It has been suggested that women with PCOS should undergo psychological screening to improve their long-term prognosis. However, until it is possible to disentangle potential features of the disorder from reactions to it, recommending psychological screening is premature.Conclusions (Agreement)•There is evidence of increased prevalence of psychological disorders in women with PCOS (level B).•Psychological issues should be considered in all women with PCOS because of evidence suggesting increased prevalence and associated comorbidities (level C).•It is unclear if this increased prevalence is due to the disorder itself or its manifestations (e.g., obesity, hirsutism, irregular menses, infertility) (level C).•Based on the consultation and the patient’s perception of her problems, appropriate counseling and intervention should be offered (level C).Knowledge Gaps/Recommended Future Research•Evaluation of the validity of existing instruments for psychopathology as screening tools in PCOS.•Determination of the prevalence of psychological disorders using appropriate instruments.•Development of appropriate screening instruments and interventions (level C).•Determination whether disease, its manifestations, or its consequences lead to psychological disorders.PregnancyWomen with PCOS may be subfertile. This may be explained by the effects of obesity and/or metabolic, inflammatory, and endocrine abnormalities on ovulatory function, oocyte quality, and endometrial receptivity. Ovarian hyperandrogenism and hyperinsulinemia may promote premature granulosa cell luteinization, and paracrine dysregulation of growth factors may disrupt the intrafollicular environment and impair cytoplasmic and/or nuclear maturation of oocytes (27Dumesic D.A. Padmanabhan V. Abbott D.H. Polycystic ovary syndrome and oocyte developmental competence.Obstet Gynecol Surv. 2008; 63: 39-48Crossref PubMed Scopus (22) Google Scholar). These features are not universal, and oocyte quality, fertilization, and implantation rates in an individual woman with PCOS can be normal (28Weghofer A. Munne S. Chen S. Barad D. Gleicher N. Lack of association between polycystic ovary syndrome and embryonic aneuploidy.Fertil Steril. 2007; 88: 900-905Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar).During early pregnancy, the embryo may be exposed to androgen excess in utero. This may have long-term effects, particularly on female offspring. Fetal hyperandrogenism may disturb epigenetic programming, in particular those genes regulating reproduction and metabolism. Data in relation to the risk of miscarriage in women with PCOS are conflicting, although miscarriage rates are generally thought to be comparable with other subfertile populations (29Tang T. Lord J.M. Norman R.J. Yasmin E. Balen A.H. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility.Cochrane Database Syst Rev. 2010; 1: CD003053PubMed Google Scholar, 30Vanky E. Stridsklev S. Heimstad R. Romundstad P. Skogoy K. Kleggetveit O. et al.Metformin versus placebo from first trimester to delivery in polycystic ovary syndrome: a randomized, controlled multicenter study.J Clin Endocrinol Metab. 2010; 95: E448-E455Crossref PubMed Scopus (41) Google Scholar). When pregnancy occurs in women with PCOS, there is a higher incidence of gestational diabetes (GDM) (40% to 50%) and associated fetal macrosomia, gestational hypertensive disorders (such as preeclampsia and pregnancy-induced hypertension) (5%), and birth of small-for-gestational-age (SGA) babies (10% to 15%) (31Boomsma C.M. Eijkemans M.J. Hughes E.G. Visser G.H. Fauser B.C. Macklon N.S. A meta-analysis of pregnancy outcomes in women with polycystic ovary syndrome.Hum Reprod Update. 2006; 12: 673-683Crossref PubMed Scopus (185) Google Scholar). The use of metformin for women with anovulatory PCOS has no benefit with respect to enhancing either fertility or live-birth rates, and its routine use is not recommended.Conclusions (Agreement)•Women with PCOS who desire a pregnancy may be at increased risk for adverse pregnancy outcomes, and this may be exacerbated by obesity and/or insulin resistance (level B).•Health should be optimized before conception, with advice about smoking cessation, lifestyle, diet, and appropriate vitamin supplementation (e.g., folic acid) (GPP).•Miscarriage rates are not increased in natural conceptions in women with PCOS, independent of obesity. Miscarriage rates after induction of ovulation mirror those found in other infertile populations (level A).•Women with PCOS should be observed closely during pregnancy as they may be at increased risk for the development of GDM, gestational hypertension, and associated complications (level B).•Pregnancy-associated risks are greater in women diagnosed by more classic (NIH) criteria as opposed to nonhyperandrogenic women (level B).•Babies born from women with PCOS may have increased morbidity and mortality (level B).•There is no evidence for improved live-birth rates or decreased pregnancy complications with the use of metformin either before conception or during pregnancy (level A).Knowledge Gaps/Recommended Future Directions for Research•Is there any value to specific periconceptional diets for women with PCOS?•Should pregnancies of women with PCOS have increased antenatal monitoring, including earlier screening for GDM and additional Doppler studies?•What is the long-term outcome of children born from women with PCOS?•What is the long-term outcome for women with PCOS who develop gestational hypertension and GDM compared with women with PCOS who do not conceive?Ethnic differences in the phenotypeThere is considerable ethnic variation in the expression of PCOS, including the prevalence and severity of obesity, metabolic disturbances, and their correlates. There are differences in psychosocial aspects affecting QOL and health-seeking behaviors (32Goodarzi M.O. Quinones M.J. Azziz R. Rotter J.I. Hsueh W.A. Yang H. Polycystic ovary syndrome in Mexican-Americans: prevalence and association with the severity of insulin resistance.Fertil Steril. 2005; 84: 766-769Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar). For example, Asian women are generally shorter, have a lower BMI, and a milder hyperandrogenic phenotype. South Asians in particular have a high prevalence of the metabolic syndrome (MetS) and are at risk for type 2 diabetes (T2D), with central obesity more than BMI reflectin