Digital Repository Masters Projects Spring 2025 Addressing Polycystic Ovarian Syndrome Treatment within a Clinical Setting Audree Carlson Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Carlson, A. 2025. Addressing Polycystic Ovarian Syndrome Treatment within a Clinical Setting Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Addressing Polycystic Ovarian Syndrome Treatment within a Clinical Setting Project Title by Audree Carlson Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY 04/26/2025 Ogden, UT Date Audree Carlson, BSN, RN, MSN Student 04/21/2025 Student Name, Credentials (electronic signature) Date Kasey Grubb, DNP, RN, CNE 04/21/2025 MSN Project Faculty Date (electronic signature) Anne Kendrick, DNP, RN, CNE (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. 04/22/2025 Date 1 Addressing Polycystic Ovarian Syndrome Treatment within a Clinical Setting Audree Carlson, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: Polycystic ovarian syndrome (PCOS) is frequently misdiagnosed, and if diagnosed, it can often be poorly managed. Correct diagnosis and treatment for PCOS patients is essential because PCOS can contribute to many comorbidities, such as type II diabetes. Rationale/Background: Presently, there are many gaps in the treatment, diagnosis, and provider/patient education of PCOS. In the United States, there are an estimated 75% of women with PCOS that have not been diagnosed in a clinical setting. PCOS also has a variety of related aspects, including comorbidities, such as type II diabetes and cardiovascular disease. The Rotterdam Criteria, a diagnostic tool for PCOS, is a guideline for clinical practitioners. The criteria requires that a patient present with two out of three clinical symptoms for diagnosis. Methods: A literature review was performed to find the most up-to-date and evidence-based materials on PCOS diagnosis and treatment for patients. Instructional materials were developed for healthcare providers within a Western state women’s clinic. The quality improvement project will incorporate pre-surveys, educational sessions for providers, and post-surveys to measure the effectiveness of this quality improvement project. Results: This project aims to improve provider knowledge and increase patient diagnosis and treatment utilizing the Rotterdam Criteria. Survey Data is expected to show an increase in provider knowledge and usage of Rotterdam Criteria to promote better patient outcomes. Conclusions: Utilization of the Rotterdam Criteria can aid in providing correct diagnosis and timely treatment of PCOS. The use of evidence-based guidelines can have a positive impact on patient care. Keywords: Rotterdam Criteria, PCOS, polycystic ovarian syndrome, practice guidelines, women’s health, treatment for PCOS 3 Addressing Polycystic Ovarian Syndrome Treatment within a Clinical Setting Women’s reproductive health has many areas that need continuing research and attention within clinical settings. Polycystic ovarian syndrome (PCOS) is a disease that can affect up to 22% of the female population (Blanco, 2022; Divya & Raganathan, 2022 ). PCOS is also considered to be one of the most common disorders of the endocrine system within the female population who are in their reproductive years (Dokras et al., 2017). Despite this syndrome affecting so many females in the reproductive stage, around 75% of patients in a clinical setting remain undiagnosed and have PCOS (Christ & Cedars, 2023). Historically, PCOS has had several defining characteristics, but not all are always present in every female diagnosed with PCOS. This phenomenon has led to several different criteria being used to diagnose and treat PCOS (Dokras et al., 2017). Due to the existence of multiple criteria basis for this disease, many women reported dissatisfaction with their diagnosis due to the length it took to diagnose, the number of providers that they had to see, as well as the lack of education and information they were given by their providers (Blanco, 2022; Dokras et al., 2017). Due to the need to create more uniform criteria to diagnose and treat PCOS, the Rotterdam Criteria was created in 2003 by a consensus of PCOS experts who met in Rotterdam, Netherlands (Christ & Cedars, 2023). Within the Rotterdam Criteria, there must be present two of three clinical signs/symptoms present to fit the criteria for diagnosis, which include hyperandrogenism verified by a biochemical/clinical finding, ovaries that are polycystic and verified by ultrasound, and oligo-amenorrhea which is defined as irregular or lengthened menstrual cycles, which is considered greater than a 35-day cycle (Blanco, 2022; Ismayilova & Yaya, 2022). Hyperandrogenism can be defined as the presence of an increased testosterone 4 level in the blood and/or the presence of hirsutism, which is an abnormal male-patterned hair growth on the chest, face, or back (Pasquali et al., 2016). Overall, the Rotterdam Criteria can assist physicians and healthcare providers to clarify and provide specific clinical findings that can more definitively diagnose PCOS within a clinical setting. Statement of Problem The diagnosis of PCOS can be controversial in many settings, and often, management and assessment of this disease are not consistent without evidence-based guidelines (Christ & Cedars, 2023). Though this disease process is unique to women, many clinical settings lack the best practices and guidelines, and this disease process is frequently misdiagnosed, lacks awareness, or is improperly managed. PCOS can also contribute to comorbidities such as type II diabetes, obesity, cardiovascular disease, and increased risks of infertility (Christ & Cedars, 2023). Working within a Western state women's health clinic, an observed issue specifically in the female population is improperly or undiagnosed PCOS. This project aims to find gaps within a clinical setting and help show whether implementing the Rotterdam Criteria for diagnosing PCOS helps improve patients' diagnosis, treatment, and education. Significance of the Project A few key outcomes and goals for this project would be to help improve healthcare providers' utilization of the Rotterdam Criteria for diagnosing PCOS. A critical objective of this project is to ensure that the diagnosis of PCOS is more uniform within clinical settings to help decrease the length between diagnosis, education, and treatment for the patient (Blanco, 2022; Dokras et al., 2017). With the findings within this project, healthcare providers can implement changes in guidelines, and the best diagnostic criteria for the disease can be utilized in healthcare settings to help more accurately diagnose and treat PCOS in clinical settings. 5 Another aim of this project is to explore and find ways that providers can better address present patient concerns with the knowledge they gain of the Rotterdam Criteria and present treatment for patients. As found by Divya & Ranganathan (2022), patients reported that living with PCOS is not just treating a disease but also requires a heavy amount of lifestyle changes to reach the best health outcomes. Previous studies on PCOS have found that many healthcare providers still have knowledge gaps in diagnosing and treating PCOS (Ismayilova & Yaya, 2022). Within North American settings, females with PCOS are most often treated by reproductive endocrinologists or gynecologists (Dokras et al., 2017). Christ & Cedars (2023) reported that the Rotterdam Criteria is presently the most accepted and widely used criteria for diagnosing PCOS and is supported by evidence-based guidelines. The focus population for this project will be healthcare providers in a Western state women's clinic who work directly with the group of females most at risk for PCOS. Review of the Literature A literature review was conducted to gather current evidence regarding PCOS and components relating to the disease process within healthcare settings. The components explored within the review pertaining to PCOS included the background and present use of the Rotterdam Criteria, current healthcare provider knowledge, education, and diagnostic approaches to PCOS, relevant treatment methods, and public awareness of the disease process and treatments. The literature review focused on the PICOT question: For providers at a Western state women's clinic (P), does implementing a process for using the Rotterdam Criteria for diagnosis and treatment for females with polycystic ovarian syndrome (PCOS) (I), compared to not using the Rotterdam 6 Criteria (C), improve provider utilization for patient diagnosis, treatment, and education (O) over a one-year period (T). Framework Within this project, the evidence-based practice model that will be applied is the Model for Evidence-based Practice Change (Melnyk & Fineout-Overholt, 2023). The Model for Evidence-based Practice Change will allow for a structured way to help implement the evidencebased practices discussed within this project (Melnyk & Fineout-Overholt, 2023). Dusin & Lawson (2023) report that the best way to support evidence-based practices occurs when the chosen framework provides clear guidelines and suits the environment where the evidence can best be implemented. The Evidence-based Practice Change model has six steps, including assessing the change needed, finding the best evidence, analyzing evidence critically, planning the changes with the practices, implementing, and then integrating and maintaining the changes within the healthcare setting (Melnyk & Fineout-Overholt, 2023). All six steps will be performed to find the right body of evidence, which will then aid in the development of a plan for implementing that evidence, after which monitoring and maintenance of these changes will be implemented to keep the standards of care at a higher level for a more lasting change. The framework for this project addresses the need to implement a change process within the women's clinic following the guidelines, diagnosis, and treatment of PCOS regarding use of the Rotterdam Criteria. The next step of the chosen model will be to find the best evidence; this will be completed by surveying the providers within the women’s clinic, and a literature review will be performed using reliable databases. An analysis of the evidence from the survey and literature reviews will then be completed, and the next stage of the model of planning for 7 changes will be accomplished by creating provider deliverables to acknowledge knowledge gaps in PCOS diagnosis and treatment. Deliverables will then be given to the healthcare providers within the women's clinic to follow the implementation step within the model. As a final step within the model, a post-survey will be given to the healthcare providers to help assess for integration and to address maintenance of the evidence-based practices within the clinic. Strengths and Limitations The strengths of using the Model for Evidence-based Practice Change (Melnyk & Fineout-Overholt, 2023) include the ability to follow a structured model that will help generate and synthesize the body of evidence that will be generated to help provide solutions for the PICOT question. The articles selected for the body of evidence will have been published within the last eight years and aim to provide the most current and up-to-date information regarding the various PCOS components. This project is seen to have limitations in its scope of evidence. Various components of the disease process of PCOS that were explored were found in evidence outside of the United States. However, in contrast, most of the literature and findings were aimed toward healthcare systems and society within the United States, as the project aims to support evidence to be used within a Western state women’s clinic. Should future projects be created, a broader spectrum of PCOS treatment and culture would be beneficial to explore in finding the most relevant body of evidence that would be more applicable internationally. Analysis of Literature Beneficial to the aims of this project was the use of practical techniques for acquiring the needed body of evidence to best explore PCOS and the components found within the disease process. Throughout the literature review and synthesis of the body of evidence, various themes 8 were found, including the need for improvement of care from healthcare providers on PCOS diagnosis, management and education, the components, history, and use of the Rotterdam Criteria in diagnosing PCOS, and the evidence-based treatments for PCOS as well as needed patient and public support to aide patients with the PCOS disease process. Search Strategies The evidence was gathered using several databases, including PubMed, CINHAL, Ovid, Medline, and Google Scholar. These databases were used to help find evidence-based practices and current findings that best support patients and healthcare providers with diagnostics using the Rotterdam Criteria and treatment and education for PCOS. Various search terms were used in regards to gathering evidence, including Rotterdam Criteria, PCOS, polycystic ovarian syndrome, practice guidelines, current treatment methods, PCOS education, and women's health. A combination of various Boolean operators was used to gather the most relevant data for the aim of this project. Synthesis of the Literature The central body of evidence regarding polycystic ovarian syndrome can be discussed and presented through three different themes, which themes include 1) background and present use of the Rotterdam Criteria, 2) current healthcare provider knowledge, education, and diagnostic approaches to PCOS, and 3) relevant treatment methods and public awareness of PCOS processes and treatments. The discussion of these three themes will aim to provide supporting evidence for the PICOT question. Background and Present Use of the Rotterdam Criteria The literature review of current evidence found that the Rotterdam Criteria have both a history and current presence in the diagnosis of PCOS in healthcare settings (Blanco, 2022; 9 Christ & Cedars, 2023; Ismayilova & Yaya, 2022; Smet & McLennan, 2018). Discussion on the historical creation of the Rotterdam Criteria concluded that the criteria were created in 2003 by experts in the field of women’s health and PCOS (Blanco, 2022; Christ & Cedars, 2023). The Rotterdam Criteria were explained as presenting three specific characteristics; two of the three would need to be present to be seen as evidence of a positive diagnosis of PCOS (Blanco, 2022; Christ & Cedars, 2023). The three specific criteria for the Rotterdam Criteria include oligoamenorrhea, polycystic ovaries that are verified by ultrasound findings, and hyperandrogenism that is verified by clinical and biochemical findings (Blanco, 2022; Ismayilova & Yaya, 2022; Smet & McLennan, 2018). While all of the articles found within this theme present the Rotterdam Criteria as the past and present model that is considered the most standard and evidence-based, some authors also argue that there are needed reforms and increases in diagnostic criteria that would better support the Rotterdam Criteria and healthcare providers' utilization of standardized diagnostic guidelines (Christ & Cedars, 2023; Smet & McLennan, 2018). One article argued that the diverse features of PCOS could be confused when presented to healthcare providers and that this explicitly called for an increased umbrella of diagnostic criteria (Christ & Cedars, 2023). Another article reported that the use of sonography to identify polycystic ovaries has advanced so that there is a lack of identifying either of the other two criteria to confirm PCOS within the Rotterdam Criteria, and the authors cite this as a reason to update the standards of the Rotterdam Criteria (Smet & McLennan, 2018). The Rotterdam Criteria continues to be an evidence-based model that has been found to be used in clinical settings to identify PCOS. The current literature reports that though arguments 10 exist for changes or updates to the Rotterdam Criteria, they are most often used for diagnosis in clinical settings compared with other models (Christ & Cedars, 2023). Current Healthcare Provider Approaches to PCOS Healthcare providers who work with the highest-risk population for PCOS are often missing the Rotterdam Criteria with approaches to provider knowledge, education, and diagnosis of PCOS (Blanco, 2022; Christ & Cedars, 2023; Dokras et al., 2017; Ismayilova & Yaya, 2022; Malik et al., 2021; Siddiqui et al., 2022). An estimated one-third of patients who were diagnosed with PCOS received their diagnosis two years after the onset of symptoms (Blanco, 2022). The evidence also reported that multiple providers were often consulted about the presentation of PCOS symptoms before a diagnosis was made (Blanco, 2022; Christ & Cedars, 2023; Dokras et al., 2017). Within healthcare settings, there has been an increase in the need to standardize and provide the most recent evidence-based practices for diagnosing PCOS to help prevent further health comorbidities for patients (Malik et al., 2021; Siddiqui et al., 2022). Women with PCOS are found to be at a higher risk for developing hypertension, gestational diabetes with pregnancy, and an increased risk for cardiovascular disease (Malik et al., 2021; Siddiqui et al., 2022). Comorbidities regarding mental health issues, such as depression and anxiety, increased in relation to the length between symptom presentation and time of diagnosis (Dokras et al., 2017; Dybciak et al., 2023; Ismayilova & Yaya, 2022). The pervasiveness of depression within women diagnosed with PCOS can range from 16 to 55% (Dybciak et al., 2023). Studies suggest that there is an increased need for screenings for mood and depressive disorders in women diagnosed with PCOS (Dybciak et al., 2023). Specifically, primary healthcare providers lack knowledge 11 regarding PCOS, even as early as medical school as medical schools do not provide enough education regarding the diagnosis of PCOS (Blanco, 2022; Ismayilova & Yaya, 2022). Healthcare providers' approaches to PCOS were found to have knowledge gaps for diagnosing PCOS, treatment as well as current education for themselves and the patients regarding PCOS (Blanco, 2022; Christ & Cedars, 2023; Ismayilova & Yaya, 2022). Confusion over standardized criteria being under-utilized, along with lengthy diagnosis times, has increased patient dissatisfaction and comorbidities in mental health (Dokras et al., 2017; Dybciak et al., 2023; Ismayilova & Yaya, 2022). Relevant Treatment Methods and Public Awareness of the Disease Process and Treatments The need for awareness, adequate support, and proper treatment for patients was discussed within the PCOS disease process components. Once PCOS has been diagnosed, evidence shows a variety of treatment methods that can presently be used to improve patient health outcomes (Blanco, 2022; Divya & Ranganathan, 2022; Ismayilova & Yaya, 2022; Malik et al., 2021). Some of the initial treatment options included diet modification and lifestyle changes, as obesity was often found to accompany a diagnosis of PCOS (Blanco, 2022; Divya & Ranganathan, 2022; Malik et. al, 2021). As insulin resistance is often also found within PCOS, metformin therapy was also used and found to help decrease the risk of type II diabetes and obesity in PCOS patients (Centers for Disease Control and Prevention [CDC], 2024; Garzia et al., 2022). Insulin resistance occurs when chronically high amounts of blood sugar are present in the body, and the pancreas increases its insulin output to compensate; with the increase in insulin over long periods, the cells in the body can become resistant to insulin and with the higher blood sugar level, the pancreas continues to increase insulin production (CDC, 2024). Blood sugars continue to rise, and this is classified as insulin resistance in the body (CDC, 2024). 12 Within the body of evidence was found a needed increase in the use of complementary and alternative therapies, as well as a more holistic approach to the treatment of PCOS (Chowdhury et al., 2022; Hu et al., 2021; Shi et al., 2022; Yang et al., 2023). As described in recent studies, the use of acupuncture in combination with Western medicine approaches was clinically shown to decrease the abnormality of the endometrial lining in PCOS patients (Hu et al., 2021; Shi et al., 2022). Studies also found that acupuncture used in conjunction with lifestyle modifications helped to decrease the rate of infertility in women with PCOS (Shi et al., 2022, Yang et al., 2023). The use of a combination of acupuncture and Moxibustion therapy, a therapy that involves burning a traditional Chinese herb moxa, was shown to increase follicle development within the ovaries, which increased fertility and positively affected endometrial lining in women with PCOS (Yang et al., 2023). The literature review found that patients often desired a better support system once diagnoses occurred from both healthcare providers and through public awareness (Divya & Ranganathan, 2022; Ismayilova & Yaya, 2022). Specifically, patients found they could receive a more precise diagnosis when seeing a female healthcare specialist rather than a primary healthcare provider (Blanco, 2022; Ismayilova & Yaya, 2022). Primary healthcare providers were presently reported to be most often seen before specialists by most women diagnosed with PCOS (Ismayilova & Yaya, 2022). Patients interviewed within the studies in the literature review were found to have an increased need for awareness and support to provide the best health outcomes (Divya & Ranganathan, 2022; Ismayilova & Yaya, 2022). Summary of Literature Review Findings and Application to the Project The various components of PCOS and the focus on supporting knowledge gaps regarding PCOS for healthcare providers within healthcare settings have been shown to have relevant 13 evidence-based literature. The Rotterdam Criteria have provided a current, evidence-based model that has and presently provides a diagnosis structure for healthcare providers. Knowledge gaps in the diagnosis, treatment, and education of PCOS for providers is a current issue and can increase adverse patient health outcomes. Patients have also been shown to require additional support and education through both provider support and the support of greater public awareness of the disease process of PCOS. This literature review has aimed to help support the need for increased healthcare provider support in education on the disease processes and treatment plans of PCOS. Project Plan and Implementation This section further discusses the plan and implementation process, which includes the interdisciplinary team, project deliverables, and timeline. Within this section, the discussion of how to best implement the evidence and research found regarding PCOS through the literature review will be discussed. The three themes discovered within the literature review, including background and present use of the Rotterdam Criteria, current healthcare provider knowledge, education, and diagnostic approaches to PCOS, and relevant treatment methods and public awareness of PCOS processes and treatments, will help provide the evidence needed to create and then form the necessary steps to implement the plan for beneficial change within a women's clinic. Plan and Implementation Process The next step to complete within the project framework and using the Model for Evidence-based Practice Change will be collecting data from the surveys given to the healthcare providers within the women's clinic setting (Melnyk & Fineout-Overholt, 2023). Different members of an interdisciplinary team will need to be involved to collect the information needed to progress the goals and aims of the PICOT question: For providers at a Western state women's 14 clinic (P), does implementing a process for using the Rotterdam Criteria for diagnosis and treatment for females with polycystic ovarian syndrome (PCOS) (I), compared to not using the Rotterdam Criteria (C), improve provider utilization for patient diagnosis, treatment, and education (O) over a one-year period (T). Over the one year, quarterly meetings will be held with the healthcare providers of the women’s clinic to complete the surveys, present the PowerPoint presentation, and also give the providers the patient deliverables. These meetings will allow for data collection, education, follow-up, and encouragement to include more of the presented materials within their practice. These quarterly meetings will also allow for the project implementation and analysis of the data over the one-year time span. Providers Within the women's clinic, a pre-survey will be conducted among the healthcare providers who work with a portion of the population most at risk for developing or presenting with PCOS. The pre-survey will specifically evaluate the healthcare providers' knowledge on evidence gathered from the literature review, including 1) questions to assess their knowledge of the background and present use of the Rotterdam Criteria, 2) questions formed to evaluate their knowledge, education, and diagnostic approaches to PCOS, 3) questions to determine their current treatment methods and awareness of PCOS. The data collected from the pre-survey will help establish a baseline of knowledge for the healthcare providers within the clinic. This, in turn, will be analyzed to identify areas where knowledge gaps occur between the healthcare provider's current baseline with PCOS elements and the body of evidence identified within the literature review. Overall, this analysis aims to help find the areas where healthcare providers can 15 better support and improve patient outcomes for patients with PCOS by implementing current evidence and research to reach this aim. Patients The patients will be the intended beneficiaries of the improved healthcare provider initiatives that will be implemented through this project. Healthcare providers will receive education through the form of a presentation, as well as receive a patient handout to help support a more patient-centered care approach to managing and treating symptoms of PCOS, which in turn can help improve overall health outcomes. The healthcare providers will be provided a patient handout with information regarding PCOS (see Appendix F) and a copy of a table containing the Rotterdam Criteria and explanations for the clinical findings (see Appendix G). This collaboration aims to help patients through the analysis and education of healthcare providers who work with patients most at risk for PCOS. Description and Development of Project Deliverables The project involved creating three different surveys, an education PowerPoint presentation, as well as a patient information handout using best evidence practices. To help gather information and facilitate analysis, a pre-survey was created to distribute to healthcare providers and clinicians within a women's clinic. Healthcare providers and clinicians within a women's clinic are the target interdisciplinary team members to facilitate understanding, learning, and collaboration for the other team members. Healthcare providers play an essential role in helping to identify signs and symptoms, indicating the need to further test and evaluate patients for PCOS (Christ & Cedars, 2023). As identified within the literature review, many clinical settings lack the best practices and guidelines, and PCOS is frequently misdiagnosed, lacks awareness, or is improperly 16 managed. PCOS can also contribute to comorbidities such as obesity, type II diabetes, cardiovascular disease, and increased risks of infertility, and more evidence-based guidelines should be in place to better identify and manage PCOS (Christ & Cedars, 2023; Garzia et al., 2022). The aim and purpose of the pre-survey (see Appendix A) and presentation (see Appendix B) deliverables is to gather data to evaluate and analyze the current baseline knowledge and beliefs of PCOS of healthcare providers or clinicians within a women's clinic and then provide education in the form of a presentation in regards to PCOS. A patient information handout (see Appendix F) and the Rotterdam Criteria in a table format (see Appendix G) were also created to give to the providers. An evaluation of whether or not the presentation and deliverables are an effective means to help facilitate education and learning to help bridge knowledge gaps that were identified within the literature review will be completed by conducting and then analyzing the post-survey answers (see Appendix C) and the follow-up survey answers (see Appendix D). Another aim of the deliverables is to ensure knowledge of evidence-based guidelines, such as the Rotterdam Criteria, for diagnosing, treating, educating, and supporting patients at risk and diagnosed with PCOS. Pre-Survey. Identified within the literature review was that many healthcare providers still have knowledge gaps in diagnosing and treating PCOS (Ismayilova & Yaya, 2022). The presurvey specifically poses questions that aim to evaluate healthcare providers and clinicians’ knowledge gaps regarding diagnosing, educating, and treating patients with PCOS. The presurvey asks questions regarding the volume of PCOS patients diagnosed, use of the Rotterdam Criteria, use of clinically proven methods for diagnosis within the Rotterdam Criteria, standard treatment methods, healthcare providers beliefs on necessary support for PCOS patients, 17 evaluation of their education on PCOS, and if current treatment methods are effective (see Appendix A). Presentation. After completing the pre-survey, healthcare providers and clinicians within a women's clinic will be given a presentation titled Improving Care for Clients with PCOS in the Clinical Setting created by the author of this project (see Appendix B). This presentation starts by introducing the topic of PCOS and providing statistics regarding patient statistics with a diagnosis of PCOS. The presentation then goes on to address knowledge gaps and introduces confusion over non-standardized criteria as a key knowledge gap for providers in the diagnosis of PCOS (Dokras et al., 2017; Dybciak et al., 2023; Ismayilova & Yaya, 2022). This leads to the next topic of introducing the Rotterdam Criteria as a standardized and clinically proven set of criteria to diagnose PCOS for patients and sets forth the standard (Ismayilova & Yaya, 2022; Smet & McLennan, 2018). The education presentation then presents comorbidities and treatment methods shown to help manage PCOS (Blanco, 2022; Divya & Ranganathan, 2022; Dybciak et al., 2023; Garzia et al., 2022; Malik et al., 2021). The presentation also addresses the need for support for patients with PCOS from healthcare providers, family, friends, and the general public (Divya & Ranganathan, 2022; Ismayilova & Yaya, 2022). The table for the Rotterdam Criteria (see Appendix G) and the patient information handout (see Appendix F) are provided to the providers as resources to utilize the Rotterdam Criteria better. Post-Survey. Once the presentation has been completed, a post-survey will be completed at the next quarterly meeting to evaluate whether the presentation was effective in answering questions posed within the pre-survey (see Appendix C). The post-survey specifically asks healthcare providers if they will implement the Rotterdam Criteria as standardized clinical findings to diagnose PCOS and if they will use any of the standard treatments presented within 18 the presentation within the clinical setting. The post-survey also evaluates if healthcare providers or clinicians find public awareness or support for patients with PCOS important. The post-survey also addresses whether healthcare providers or clinicians still agree that their medical school/training prepared them enough to diagnose, treat, and educate PCOS patients, as this was an identified issue within the literature review (Blanco, 2022; Ismayilova & Yaya, 2022). Follow-up Survey. The follow-up survey aims to provide a deliverable and tool that will help re-evaluate to see whether changes were implemented within the one-year time frame that this project aims to span (see Appendix D). The follow-up survey aims to analyze whether the healthcare providers or clinicians within the women's clinic were able to recognize the increased volume of patients diagnosed with PCOS, evaluate if they are now implementing any of the treatment methods that were presented or the evidence-based guidelines, and criteria use of the Rotterdam Criteria. Timeline The proposed timeline for implementing the change regarding PCOS diagnosis with the use of the Rotterdam Criteria, treatment, education, and support for patients using evidencebased guidelines will occur over a one-year time frame. The deliverables will be given, evaluated, and analyzed within a three-month period to help promote completion and a sufficient time frame to allow for more real-time evaluation. The timeline has also been outlined within a graphic to provide a visual organization of the project (see Appendix E). The plan for this project is to provide healthcare providers within a Western state women's clinic with the pre-survey and allow for completion and data gathering from the survey over three months. The presentation regarding PCOS education, Improving Care for Clients with PCOS in the Clinical Setting, will be presented either by a presenter or else given online for 19 convenience for the healthcare providers' review and learning over three months to allow for sufficient time for providers to view the content within the presentation. The patient information handout and Rotterdam Criteria table will also be given to providers during this three-month period. The post-survey will then be completed, evaluated, and the data will be analyzed over a three-month period. Finally, the follow-up survey will be completed three months later to end the year-long timeline to evaluate the data and find whether healthcare providers within the women's clinic utilized the information within the presentation. Project Evaluation A crucial element of any project's success is evaluating whether the project is effective in bringing the changes the project sets out to implement and whether any changes should be made to reach the project goals more efficiently. Project evaluation is crucial for project success and progress toward the project's objectives (Plummer, 2023). The evaluation of the project also helps to provide transparency as to whether or not there have been positive or adverse effects. Communicating these findings can help benefit future projects (Plummer, 2023). This project will utilize formative and summative assessments to evaluate intervention effectiveness. The questions posed within the surveys focus on the frequency of interaction with PCOS patients, knowledge of the Rotterdam Criteria and utilizing the criteria for diagnosis, utilization of treatment practices that are founded with evidence-based research, recognition of knowledge gaps for healthcare providers within medical school/training, and whether the healthcare provider is currently diagnosing PCOS within the clinical setting. A formative assessment will be done using a pre-survey (see Appendix A). Each survey will be presented at a quarterly meeting with the healthcare providers of the women's clinic, with the formative assessment and the pre-survey being presented within the first quarter. The presentation of the PowerPoint to the healthcare 20 providers will be held during the second quarterly meeting, presenting education on the diagnosis and treatment and focusing on the use of the Rotterdam Criteria with patients diagnosed and at risk for PCOS (see Appendix B). There will also be a patient information handout (see Appendix F) and Rotterdam Criteria table (see Appendix G) given during the second quarter for the providers to utilize within the women’s clinic. During the third quarterly meeting, the postsurvey will be presented to the healthcare providers with a reminder discussion of the information regarding use of the Rotterdam Criteria (see Appendix C). The follow-up survey will be presented within the fourth quarter at the quarterly meeting with the healthcare providers, and an open discussion will be facilitated on their utilization of the Rotterdam Criteria within a clinical setting and whether they have observed any changes regarding PCOS practices (see Appendix D). For the summative assessment, the data collected from each survey within the oneyear time frame will allow for comparison of the pre-survey data to post-presentation and education data gathered within the post and follow-up surveys. The summarized data will be presented to the healthcare providers within the women's clinic. The data comparison will help show the positive or negative effects and help find areas where improvements may be made for future projects or research (Plummer, 2023). Ethical Considerations Ethical considerations must be made when implementing a project that could affect patient care. One consideration is to ensure that all participants have the choice if they want to participate and that no healthcare providers will be forced to participate (National Institutes of Health [NIH], 2016). Another consideration is to ensure that all answers and data gathered from the surveys and meetings within the project are presented anonymously and afford protection to the privacy of those who participate (NIH, 2016). 21 The literature review identified three major themes: the background and present use of the Rotterdam Criteria, current healthcare provider knowledge, education, diagnostic approaches to PCOS, relevant treatment methods, and public awareness of PCOS processes and treatments. There must be consideration for the participating healthcare providers' current practices, preferences, and treatment models that are presently in place that could be evidence-based and found to be effective within a clinical setting. Social and clinical considerations also need to be considered, as questions asked within research need to be shown to aim to improve treatment, prevention, or caring for patients with a disease process (NIH, 2016). Another ethical consideration is to avoid personal bias by implementing integrity and impartiality. The project lead will must ensure they are taking into account bias and the other ethical considerations that have been addressed. Taking ethical considerations into account will further confirm and validate the project and the outcomes achieved through the implementation process. Discussion Providing healthcare providers who work with populations most at risk for PCOS with current evidence-based criteria for diagnosing, educating, and treating patients could improve patient health outcomes. By collecting data from healthcare providers within a Western state women's clinic on their current knowledge and practices regarding PCOS, then presenting the evidence-based practice education on the use of the Rotterdam Criteria for diagnosis, evidencebased treatment options, and an educational handout utilized for PCOS patients; healthcare providers can better empower patients with resources, education and healthcare plans to better manage PCOS as a chronic illness (Divya & Ranganathan, 2022; Ismayilova & Yaya, 2022). 22 This section will discuss evidence-based solutions for dissemination of information, the significance to nursing practice, implications, and recommendations for the MSN project. Evidence-based Solutions for Dissemination After this project is implemented, several methods will be used to disseminate the results. Data evaluating knowledge and current and future use of the Rotterdam Criteria will first need to be gathered for analysis from the pre-survey, post-survey, and follow-up surveys collected from the healthcare providers throughout the quarterly meetings, respectively. Once all the data is collected, a PowerPoint presentation will be made to help facilitate the dissemination of the data. This presentation will then be shared with the management and leadership within the clinic at a staff meeting that will include the healthcare providers and clinical staff. The data gathered and analyzed will help determine if the healthcare providers within the clinic are utilizing best practice standards and evidence-based criteria for diagnosing PCOS using the Rotterdam Criteria and evidence-based practices for patient treatment. The gathered data will also help to identify knowledge gaps for healthcare providers and determine if there are other areas regarding PCOS diagnosis, education, and treatment that need to be addressed within the clinic. In addition, the findings will be summarized in a poster presentation that will be presented to the Annie Taylor Dee School of Nursing at Weber State University, relevant faculty, and peers within the MSN program. Significance to Advance Nursing Practice Providing evidence-based practices and diagnostics criteria to healthcare providers in a women's clinic can affect the teaching, resources, and materials providers share with patients regarding their education and knowledge when creating a care plan for patients with PCOS. Healthcare providers play a vital and valuable role in helping to educate patients. The education 23 of patients will help improve their decision-making regarding treatments and ongoing care, as PCOS is a chronic illness (Fereidouni et al., 2019). By providing healthcare providers with evidence-based education and treatment methods, they can help create care plans that are more tailored to patients with PCOS. Patients who are diagnosed with PCOS are at a higher risk of developing comorbidities, including obesity, type II diabetes, infertility, mood disorders, depression, and cardiovascular disease (Christ & Cedars, 2023; Dybciak et al., 2023). Patients with PCOS need to implement lifestyle changes, medication regimens, and/or other recommended treatments from their healthcare providers that help improve health outcomes (Divya & Ranganathan, 2022). Healthcare providers will play a pivotal role in helping to empower patients with the knowledge, resources, and support they need to reach their goals and improve their overall health while managing their PCOS (Fereidouni et al., 2019). Implications Several limitations and strengths have been identified within the MSN project. One strength of this project is in utilizing the Evidence-based Practice Change model with the six steps that allow for a structured way to help implement the evidence-based practices discussed within this project (Melnyk & Fineout-Overholt, 2023). Another strength is using various project deliverables, including multiple surveys for collecting data, education presentations for healthcare providers, and a patient information handout. The data collected within this project will also be disseminated to stakeholders within the clinic, including management, leadership, and healthcare providers so they can better utilize the information gained from the project. Several limitations have been identified regarding implementing this MSN project, including the sample size, healthcare provider and nursing buy-in, and the assessment of the 24 incorporation of patient education. The sample size includes one women's clinic in a Western state and those healthcare providers within the clinic who are willing to participate in the surveys and education presentations. Buy-in is also another factor to consider as a limitation as healthcare providers may believe their current methods of diagnosing, treating, and educating patients on PCOS are sufficient, and nursing staff may have bias depending on the healthcare providers or current beliefs on PCOS. By presenting healthcare providers with current evidencebased criteria, including the Rotterdam Criteria, and information to help effect diagnosis, treatment, and education of patients to improve health outcomes, providers may find additional information and methods that can benefit their patients. Without data collected from patients, evaluating whether the education incorporated by healthcare providers is beneficial would be challenging. This project will aim to benefit healthcare providers by providing them with evidence-based knowledge and resources that can be beneficial if applied within their healthcare settings to more positively affect the diagnosis, education, and treatment of a patient population that is most at risk for PCOS. Recommendations Within this project, the evaluation of current literature and the use of the Rotterdam Criteria to assist in adequately diagnosing PCOS for patients most at risk was performed to help identify knowledge gaps, issues, and ways to improve patient health outcomes. The evidence within the literature review has limitations in its scope of evidence. The literature review was used to develop a body of evidence aimed at helping to effect change within a Western state women's clinic. One recommendation from this project would be to broaden the spectrum of PCOS treatment and culture to find the most relevant body of evidence that could be more nationally, or even internationally applicable. Another recommendation could be to involve the 25 nursing staff in the quarterly meetings with a survey of their own on patient education of PCOS for a separate category of data collected, rather than just from the healthcare providers within the clinical setting. Increasing resources and ideas for helping patients find support outside of the clinical or healthcare setting could also be a way to benefit patients and better improve health outcomes. Conclusions Healthcare providers play a significant role in the early and correct diagnosis of PCOS for patients by utilizing the Rotterdam Criteria for proper diagnosis (Blanco, 2022). Patients diagnosed with PCOS are also at an increased risk for developing comorbidities that can further increase the need for proper diagnosis and evidence-based treatment methods for developing patient healthcare plans (Christ & Cedars, 2023; Dybciak et al., 2023). Healthcare providers need to utilize evidence-based guidelines to diagnose and implement patient treatment and patient education about PCOS to better empower patients in the management of PCOS as a chronic illness and improve patient health outcomes (Blanco, 2022; Divya & Ranganathan, 2022; Fereidouni et al., 2019; Ismayilova & Yaya, 2022). 26 References Blanco C. E. (2022). Early diagnosis in polycystic ovary syndrome. The Nurse practitioner, 47(10), 18–24. https://doi.org/10.1097/01.NPR.0000873528.58247.9e Centers for Disease Control and Prevention (2024, May 15). About Insulin Resistance and Type 2 Diabetes. CDC. https://www.cdc.gov/diabetes/about/insulin-resistance-type-2diabetes.html#cdc_health_safety_special_topic_how-what-is-insulin-resistance Chowdhury, D., Afrozab, T., & Kamal, S. (2022). Individualised homoeopathic treatment in a case of PCOS - an evidence-based case report. Homoeopathic Heritage, 49(4), 66–69 Christ, J. P., & Cedars, M. I. (2023). Current Guidelines for Diagnosing PCOS. Diagnostics (Basel, Switzerland), 13(6), 1113. https://doi.org/10.3390/diagnostics13061113 Divya, M., & Ranganathan, S. (2022). "PCOS is like having a disease": The everyday stress of living with polycystic ovarian syndrome (PCOS). Indian journal of community medicine: Official publication of Indian Association of Preventive & Social Medicine, 47(4), 622– 623. https://doi.org/10.4103/ijcm.ijcm_1374_21 Dokras, A., Saini, S., Gibson-Helm, M., Schulkin, J., Cooney, L., & Teede, H. (2017). Gaps in knowledge among physicians regarding diagnostic criteria and management of polycystic ovary syndrome. Fertility and sterility, 107(6), 1380–1386.e1. https://doi.org/10.1016/j.fertnstert.2017.04.011 Dusin, J., Melanson, A., & Mische-Lawson, L. (2023). Evidence-based practice models and frameworks in the healthcare setting: a scoping review. BMJ open, 13(5), e071188. https://doi.org/10.1136/bmjopen-2022-071188 Dybciak, P., Raczkiewicz, D., Humeniuk, E., Powrózek, T., Gujski, M., Małecka-Massalska, T., Wdowiak, A., & Bojar, I. (2023). Depression in polycystic ovary syndrome: A systematic 27 review and meta-analysis. Journal of clinical medicine, 12(20), 6446. https://doi.org/10.3390/jcm12206446 Fereidouni, Z., Sabet Sarvestani, R., Gholamerza, H., Kuhpaye, S. A., Amirkhani, M., & Kalyani, M. N. (2019). Moving into action: The master key to patient education. Journal of Nursing Research, 27(1), e6. https://doi.org/10.1097/jnr.0000000000000280 Garzia, E., Galiano, V., Marfia, G., Navone, S., Grossi, E., & Marconi, A. M. (2022). Hyperandrogenism and menstrual imbalance are the best predictors of metformin response in PCOS patients. Reprod Biol Endocrinol, 20(6). https://doi.org/10.1186/s12958-021-00876-0 Hu, J., Shi, W., Xu, J., Liu, S., Hu, S., Fu, W., Wang, J., & Han, F. (2021). Complementary and alternative medicine for the treatment of abnormal endometrial conditions in women with PCOS: A systematic review and meta-analysis of randomized controlled trials. EvidenceBased Complementary & Alternative Medicine (ECAM), 1–17. https://doi.org/10.1155/2021/5536849 Ismayilova, M., & Yaya, S. (2022). What can be done to improve polycystic ovary syndrome (PCOS) healthcare? Insights from semi-structured interviews with women in Canada. BMC women's health, 22(1), 157. https://doi.org/10.1186/s12905-022-01734-w Malı̇ k, T. H., Alı̇ , H., Hassan, A., Qayyum, J., & Naseem, A. (2021). Pharmacotherapy and Neoteric dietary approaches for polycystic ovary syndrome: A systematic review. Turkish Journal of Endocrinology & Metabolism, 25(1), 113–122. https://doiorg/10.25179/tjem.2020-78987 Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-Based Practice in Nursing & Healthcare (5th ed.). Wolters Kluwer. 28 National Institutes of Health (2016, March 16). Guiding Principles for Ethical Research. NIH. https://www.nih.gov/health-information/nih-clinical-research-trials-you/guidingprinciples-ethical-research Pasquali, R., Zanotti, L., Fanelli, F., Mezzullo, M., Fazzini, A., Morselli Labate, A. M., & Gambineri, A. (2016). Defining hyperandrogenism in women with polycystic ovary syndrome: A challenging perspective. The Journal of Clinical Endocrinology & Metabolism, 101(5), 2013-2022. https://doi.org/10.1210/jc.2015-4009 Plummer, D. (2023, September 6). The importance of evaluation in driving improvement. https://healthinnovation-em.org.uk/news-blog/blog/the-importance-of-evaluation-indriving-improvement Shi, Y.-Q., Wang, Y., Zhu, X.-T., Yin, R.-Y., Ma, Y.-F., Han, H., Han, Y.-H., & Zhang, Y.-H. (2022). The application of complementary and alternative medicine in polycystic ovary syndrome infertility. Evidence-Based Complementary & Alternative Medicine (ECAM), 1–21. doi: 10.1155/2022/5076306. Siddiqui, S., Mateen, S., Ahmad, R., & Moin, S. (2022). A brief insight into the etiology, genetics, and immunology of polycystic ovarian syndrome (PCOS). Journal of assisted reproduction and genetics, 39(11), 2439–2473. https://doi.org/10.1007/s10815-02202625-7 Smet, M., & McLennan, A. (2018). Rotterdam Criteria, the end. Australasian Journal of Ultrasound in Medicine, 21(2), 59–60. doi: 10.1002/ajum.12096. Yang, L., Yang, W., Sun, M., Luo, L., Li, H. R., Miao, R., Pang, L., Chen, Y., & Zou, K. (2023). Meta analysis of ovulation induction effect and pregnancy outcome of acupuncture & 29 moxibustion combined with clomiphene in patients with polycystic ovary syndrome. Frontiers in endocrinology, 14, 1261016. https://doi.org/10.3389/fendo.2023.1261016 30 Appendix A Pre-Survey For Healthcare Providers Pre-Survey for Healthcare Providers This survey has been created to evaluate your current knowledge of PCOS as well as current standards of diagnosis and treatment. Thank you for your participation. How often do you interact with patients diagnosed with PCOS?  Not at all  Somewhat  Neutral  Mostly  Always Would you say you are knowledgeable about standardized criteria for diagnosing PCOS, including the Rotterdam Criteria?  Not at all  Somewhat  Neutral  Mostly  Always Does your current diagnosis criteria for PCOS include… Clinically verified hyperandrogenism  Yes |  No Ultrasound verified polycystic ovaries  Yes |  No Irregular or lengthened menstrual cycles  Yes |  No Other:_________________________________ Yes |  No Do you include any of the following as standard treatment for PCOS patients… Diet modification and lifestyle changes  Yes |  No Metformin therapy for insulin resistance  Yes |  No Complementary and alternative therapies  Yes |  No Other:_________________________________ Yes |  No Do you believe that medical school/training discussed PCOS to a deep enough extent for practical application in healthcare settings?  Not at all  Somewhat  Neutral  Mostly  Always 31 Have you found your current treatment methods to be effective in treating PCOS?  Not at all  Somewhat  Neutral  Mostly On average, how often do you diagnose patients with PCOS?  3-5 times per month  Once every 2 months  1-2 times per month  Other:____________  Always 32 Appendix B Improving Care for Clients with PCOS in the Clinical Setting Educational Presentation 33 34 35 36 37 Appendix C Post-Survey For Healthcare Providers Post-Survey for Healthcare Providers This survey is a follow-up to re-evaluate whether the information presented increased your knowledge and understanding of PCOS in regards to patient care. Thank you for your participation. How often do you interact with patients diagnosed with PCOS?  Not at all  Somewhat  Neutral  Mostly  Always Would you say you are now knowledgeable about standardized criteria for diagnosing PCOS, including the Rotterdam Criteria?  Not at all  Somewhat  Neutral  Mostly  Always Will your current diagnosis criteria for PCOS include… Clinically verified hyperandrogenism  Yes |  No Ultrasound verified polycystic ovaries  Yes |  No Irregular or lengthened menstrual cycles  Yes |  No Other:_________________________________ Yes |  No Will you include any of the following as standard treatment for PCOS patients… Diet modification and lifestyle changes  Yes |  No Metformin therapy for insulin resistance  Yes |  No Complementary and alternative therapies  Yes |  No Other:_________________________________ Yes |  No Do you believe that medical school/training discussed PCOS to a deep enough extent for practical application in healthcare settings?  Not at all  Somewhat  Neutral  Mostly  Always 38 Have you found your current treatment methods to be effective in treating PCOS?  Not at all  Somewhat  Neutral  Mostly On average, how often do you diagnose patients with PCOS?  3-5 times per month  Once every 2 months  1-2 times per month  Other:____________ Please share any additional comments or observations.  Always 39 Appendix D Follow-up Survey for Healthcare Providers Follow-up Survey for Healthcare Providers This survey is a follow-up to re-evaluate whether the information presented increased your knowledge and understanding of PCOS in regards to patient care. Thank you for your participation. How often do you interact with patients diagnosed with PCOS?  Not at all  Somewhat  Neutral  Mostly  Always On average, how often do you diagnose patients with PCOS?  3-5 times per month  Once every 2 months  1-2 times per month  Other:____________ Would you say you are now more knowledgeable about standardized criteria for diagnosing PCOS, including the Rotterdam Criteria?  Not at all  Somewhat  Neutral  Mostly  Always Does your current diagnosis criteria for PCOS NOW include… Clinically verified hyperandrogenism  Yes |  No Ultrasound verified polycystic ovaries  Yes |  No Irregular or lengthened menstrual cycles  Yes |  No Other:_________________________________ Yes |  No Do you now include any of the following as standard treatment for PCOS patients… Diet modification and lifestyle changes  Yes |  No Metformin therapy for insulin resistance  Yes |  No Complementary and alternative therapies  Yes |  No Other:_________________________________ Yes |  No 40 Do you still feel that medical school/training discussed PCOS to a deep enough extent for practical application in healthcare settings?  Not at all  Somewhat  Neutral  Mostly  Always Have you found your current treatment methods to be effective after utilizing the Rotterdam Criteria in treating PCOS?  Not at all  Somewhat  Neutral Please share any additional comments or observations.  Mostly  Always 41 Appendix E Timeline Addressing PCOS Treatment Project Timeline Introduction This visual timeline seeks to organize the project aimed at researching the PICOT question: For providers at a Western state women's clinic (P), does implementing a process for using the Rotterdam Criteria for diagnosis and treatment for females with polycystic ovarian syndrome (PCOS) (I), compared to not using the Rotterdam Criteria (C), improve provider utilization for patient diagnosis, treatment, and education (O) over a one-year period (T). The timeline of a one-year period will be given in regards to deliverables, evaluation of the data and conclusions. One Year Timeline Months 1 to 3 Pre-Survey Healthcare providers within a women’s clinic will be given a presurvey to complete within three months to evaluate the current baseline of PCOS. Months 4 to 6 Presentation Months 7 to 9 Post-Survey Months 10 to 12 Follow-up Survey Healthcare providers within a women’s clinic will be given a presentation, either in person or online, to be completed in three months to provide knowledge concerning PCOS diagnosis, treatment, and education based on the literature review previously completed. Healthcare providers within a women’s clinic will be given a postsurvey to gather data and evaluate whether the presentation effectively educates the healthcare providers on current PCOS evidence in healthcare settings. Healthcare providers at a women’s clinic will complete a follow-up survey to evaluate if any changes have occurred in diagnosis, treatment, and education within the healthcare setting. Conclusions will be drawn from the collected data. 42 Appendix F Patient information handout PCOS: What do I need to know? Polycystic Ovarian Syndrome (PCOS) is considered to be one of the most common disorders of the endocrine system within the female population who are in their reproductive years (1). PCOS also has several defining characteristics, but not all are present with every female that is diagnosed with PCOS. Your healthcare provider can use what is called the Rotterdam Criteria to clinically diagnose PCOS where there must be present two of three clinical signs/symptoms present to fit the criteria for diagnosis (2). What do these clinical findings mean for me? You may have a few or several of the following symptoms (3): • • • • • • • • • Light: shorter or lighter flow; irregular: longer than 35 day cycle; or even missed periods Polycystic ovaries: they have many cysts or are enlarged Hirsutism: the presence of body hair, including on the chest, stomach, and/or back Extra weight, mostly around the belly Presence of oily skin or acne Thinning hair or even male-pattern baldness Possible Infertility Skin tags or extra small pieces of skin around the neck or armpits Thickened or darker patches of skin located in the armpits, on the back of the neck, and/or under the breasts What will treatment and management look like? While your healthcare provider will speak with you to discuss the best ways to manage and treat your symptoms, there are some things that you could speak with your healthcare provider about. These include: • • • Diet modification and lifestyle changes: Decreasing simple carbohydrate and sugar intake and balancing macronutrients can help decrease the risk of obesity and weight gain with having PCOS(4)(5)(6). *Metformin therapy (Prescription Medication): Metformin can be used to help with insulin resistance, and metformin was found to help decrease the risk of type II diabetes and obesity in PCOS patients (7). Insulin resistance is caused when the blood sugar levels remain high for long periods and the pancreas makes too much insulin because of the high levels, which causes the cells in the body to become more resistant to insulin (8). Complementary and alternative therapies, and a holistic approach: Acupuncture in combination with Western medicine, such as metformin therapy, was clinically shown to decrease the abnormality of the endometrial lining in PCOS patients (9)(10). Studies have shown that acupuncture used in conjunction with lifestyle changes helped to decrease the rate of infertility in women with PCOS (10)(11). The use of a combination of acupuncture and Moxibustion therapy, a therapy that involves burning a traditional Chinese herb, moxa, 43 increased follicle development in the ovaries, and helped to increase fertility and positively affected the endometrial lining in women with PCOS (11). *Always consult your healthcare provider before starting any medication to see if it is necessary. Takeaways and Support: Your healthcare provider can be a valuable support in helping to create a treatment plan that works for you. Your healthcare provider can also help you find more resources for education regarding PCOS; please do not hesitate to discuss your concerns and questions with your healthcare provider to help provide support. It is also important to know that depression within women diagnosed with PCOS occurs more often (12). Helping to involve your healthcare provider in how you are feeling and whether you need help with feelings of anxiety or depression, or even with possible clinical diagnosis of anxiety or depression, your healthcare provider can help give you the support and resources you need to improve your mental health. Also, don’t forget to involve family and friends; help them with ideas on how they can be supportive of your diagnosis and treatment, and help teach them what PCOS is and what it means to you. (1) (2) (3) (4) (5) (6) Dokras, A., Saini, S., Gibson-Helm, M., Schulkin, J., Cooney, L., & Teede, H. (2017). Gaps in knowledge among physicians regarding diagnostic criteria and management of polycystic ovary syndrome. Fertility and sterility, 107(6), 1380–1386.e1. https://doi.org/10.1016/j.fertnstert.2017.04.011 Ismayilova, M., & Yaya, S. (2022). What can be done to improve polycystic ovary syndrome (PCOS) healthcare? Insights from semi-structured interviews with women in Canada. BMC women's health, 22(1), 157. https://doi.org/10.1186/s12905022-01734-w John Hopkins Medicine (2025). Polycystic Ovary Syndrome (PCOS). Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-anddiseases/polycystic-ovary-syndrome-pcos Malı̇k, T. H., Alı̇, H., Hassan, A., Qayyum, J., & Naseem, A. (2021). Pharmacotherapy and Neoteric dietary approaches for polycystic ovary syndrome: A systematic review. Turkish Journal of Endocrinology & Metabolism, 25(1), 113–122. https://doiorg/10.25179/tjem.2020-78987 Blanco C. E. (2022). Early diagnosis in polycystic ovary syndrome. The Nurse practitioner, 47(10), 18–24. https://doi.org/10.1097/01.NPR.0000873528.58247.9e Divya, M., & Ranganathan, S. (2022). "PCOS is like having a disease": The everyday stress of living with polycystic ovarian syndrome (PCOS). Indian journal of community medicine: Official publication of Indian Association of Preventive & Social Medicine, 47(4), 622–623. https://doi.org/10.4103/ijcm.ijcm_1374_21 (7) Garzia, E., Galiano, V., Marfia, G., Navone, S., Grossi, E., & Marconi, A. M. (2022). Hyperandrogenism and menstrual imbalance are the best predictors of metformin response in PCOS patients. Reprod Biol Endocrinol, 20(6). https://doi.org/10.1186/s12958-021-00876-0 (8) Centers for Disease Control and Prevention (2024, May 15). About Insulin Resistance and Type 2 Diabetes. CDC. https://www.cdc.gov/diabetes/about/insulin-resistance-type2-diabetes.html#cdc_health_safety_special_topic_how-whatis-insulin-resistance (9) Hu, J., Shi, W., Xu, J., Liu, S., Hu, S., Fu, W., Wang, J., & Han, F. (2021). Complementary and alternative medicine for the treatment of abnormal endometrial conditions in women with PCOS: A systematic review and meta-analysis of randomized controlled trials. Evidence-Based Complementary & Alternative Medicine (ECAM), 1–17. https://doi.org/10.1155/2021/5536849 (10) Shi, Y.-Q., Wang, Y., Zhu, X.-T., Yin, R.-Y., Ma, Y.-F., Han, H., Han, Y.-H., & Zhang, Y.-H. (2022). The application of complementary and alternative medicine in polycystic ovary syndrome infertility. Evidence-Based Complementary & Alternative Medicine (ECAM), 1–21. doi: 10.1155/2022/5076306. (11) Yang, L., Yang, W., Sun, M., Luo, L., Li, H. R., Miao, R., Pang, L., Chen, Y., & Zou, K. (2023). Meta analysis of ovulation induction effect and pregnancy outcome of acupuncture & moxibustion combined with clomiphene in patients with polycystic ovary syndrome. Frontiers in endocrinology, 14, 1261016. https://doi.org/10.3389/fendo.2023.1261016 (12) Dybciak, P., Raczkiewicz, D., Humeniuk, E., Powrózek, T., Gujski, M., Małecka-Massalska, T., Wdowiak, A., & Bojar, I. (2023). Depression in polycystic ovary syndrome: A systematic review and meta-analysis. Journal of clinical medicine, 12(20), 6446. https://doi.org/10.3390/jcm12206446 44 Appendix G Table for the Rotterdam Criteria The Rotterdam Criteria Criteria: Must meet at least 2 of 3 for Clinical Diagnosis Explanation and Clinical Verification Hyperandrogenism is verified by the biochemical/clinical findings of the presence of an Hyperandrogenism increased testosterone level in the blood and/or the presence of hirsutism, which is an abnormal male-patterned hair growth on the chest, face, or back (1). Polycystic ovaries can be verified by ultrasound, Polycystic Ovaries and findings must show that the ovaries have a volume of 10mL or more and/or that the ovaries have a minimum of 12+ follicles per ovary (2) (3). Oligo-amenorrhea can be defined as irregular or Oligo-amenorrhea lengthened menstrual cycles, with a cycle length that is longer than 35 days in an adult female (2) (4). (1) Pasquali, R., Zanotti, L., Fanelli, F., Mezzullo, M., Fazzini, A., Morselli Labate, A. M., & Gambineri, A. (2016). Defining hyperandrogenism in women with polycystic ovary syndrome: A challenging perspective. The Journal of Clinical Endocrinology & Metabolism, 101(5), 2013-2022. https://doi.org/10.1210/jc.20154009 (2) Blanco C. E. (2022). Early diagnosis in polycystic ovary syndrome. The Nurse practitioner, 47(10), 18–24. https://doi.org/10.1097/01.NPR.0000873528.58247.9e (3) National Library of Medicine (2020, January 1). Polycystic ovary syndrome. MedlinePlus. https://medlineplus.gov/genetics/condition/polycystic-ovary-syndrome/ (4) Ismayilova, M., & Yaya, S. (2022). What can be done to improve polycystic ovary syndrome (PCOS) healthcare? Insights from semi-structured interviews with women in Canada. BMC women's health, 22(1), 157.