PCOS - clinical fact sheet and MCQ

Polycystic ovary syndrome (PCOS) overview

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting 10–13% of women of reproductive age globally, with higher prevalence in First Nations peoples and those of South East Asian or Eastern Mediterranean ethnicity. 

The condition is characterised by hyperandrogenism, menstrual disturbances, and polycystic ovarian morphology (PCOM) on ultrasound. It significantly impacts reproductive, dermatologic, and psychological health, and comes with an increased risk of impaired glucose tolerance, type 2 diabetes, and cardiovascular disease. Early diagnosis and tailored management are essential to minimise long-term health impacts.

Diagnosis

After other causes have been excluded, PCOS may be diagnosed using the Rotterdam criteria:

• for adults, at least two of the following are required:

• clinical/ biochemical hyperandrogenism

• ovulatory dysfunction (eg, irregular menstrual cycles)

• PCOM on ultrasound or elevated anti-Müllerian hormone (AMH) levels

• for adolescents, both features must be present:

• hyperandrogenism 

• menstrual disturbances persisting for >2 years after menarche

Ultrasound and AMH are not recommended for adolescent patients due to poor specificity, as a polycystic appearance can be normal for adolescent ovaries. Due to the complexity of PCOS diagnosis in adolescents, consider specialist referral if PCOS is suspected in this cohort.

Differential diagnoses:

• androgen-secreting tumours of the ovaries or adrenal glands (characterised by overt and rapid virilisation, which is a red flag that excludes PCOS)

• hypothyroidism (assess thyroid stimulating hormone)

• hyperprolactinaemia (assess serum prolactin levels)

• non-classic congenital adrenal hyperplasia (assess 17-hydroxy progesterone levels)

• idiopathic/ familial hirsutism (assess for other symptoms consistent with PCOS)

• Cushing’s syndrome (assess for signs of hypercortisolism, eg thin skin, atrophic purple striae, muscle atrophy)

PCOS Management

Management is patient-centred and varies based on symptoms and individual goals, while also addressing the long-term risks associated with PCOS.

1. Screen for long-term risks:

• assess lipid profile and glycaemic status at time of PCOS diagnosis, then regularly thereafter depending on individual risk profiles

• although PCOS confers a significantly higher risk of endometrial hyperplasia and endometrial cancer, overall risk remains low, and routine screening is not recommended 

• screen for obstructive sleep apnoea due to a higher prevalence in women with PCOS

2. Lifestyle modifications are recommended for all women with PCOS:

• emphasise sustainable, healthy eating patterns and/or regular physical activity to improve metabolic health

• there is no evidence to recommend one diet over another

• there is no evidence to recommend one exercise regime over another

3. Pharmacological treatment:

• pharmacological therapies in PCOS are generally considered as off-label use

• combined oral contraceptive pills (COCPs): recommended as first-line for managing menstrual irregularities, acne, androgenic alopecia, and hirsutism by suppressing ovarian androgen secretion

• metformin: recommended for improving metabolism and suppressing ovarian androgen secretion in patients with infertility, BMI >25 kg/m2, or a high risk of type 2 diabetes 

• combined therapy with COCP and metformin is most beneficial in patients with BMI >30 kg/m2, impaired glucose tolerance, increased diabetes risk, or ethnicities at high risk of metabolic disease

4. Weight management improves menstrual regulation and fertility, hirsutism, hypertension, and diabetes management.

• Navigate with sensitivity the issue of weight stigma when discussing lifestyle interventions and bodyweight 

• Lifestyle interventions include recommendations around diet and physical activity

• If insufficient in obese patients, consider adding anti-obesity medications such as glucagon-like peptide-1 receptor agonists (contraindicated in women trying to conceive)

• Bariatric surgery may be considered to aid weight loss

5. Infertility management:

• letrozole is the preferred first-line treatment for ovulation induction in women with anovulation and no other causes of infertility  

• second-line options include clomiphene (alone or with metformin), gonadotrophins, or ovarian surgery

• assisted reproductive technologies may be considered if other ovulation induction therapies are unsuccessful, with similar outcomes to women without PCOS

6. Dermatological features:

• hair removal with mechanical laser or light therapies (eg, intense pulsed light) 

• anti-androgens, such as spirolactone or finasteride, are used selectively when other therapies are unsuccessful or contraindicated, but are not recommended for women attempting to conceive due to the risk of undervirilisation of the male foetus

7. Psychological support:

• screen all women with PCOS for depression, anxiety, eating disorders, and psychosexual dysfunction

• psychological and support therapy as first-line and antidepressant medications if required

References

Yesiladali M, Yazici MGK, Attar E, Kelestimur, F. Differentiating Polycystic Ovary Syndrome from Adrenal Disorders. Diagnostics. 2022;12:2045. https://doi.org/10.3390/diagnostics12092045. 

Rasquin LI, Anastasopoulou C, Mayrin JV. Polycystic Ovarian Disease. [Updated 2022 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459251/ 

Monash University Medicine, Nursing and Health Sciences. International Evidence-based Guideline for the assessment and management of polycystic ovary syndrome 2023 - summary. 2023. https://www.monash.edu/__data/assets/pdf_file/0003/3371133/PCOS-Guideline-Summary-2023.pdf (last viewed January 2025).

Therapeutic Guidelines. Polycystic ovary syndrome. 2020. (last viewed January 2025). 

American College of Obstetrics and Gynaecologists. Endometrial hyperplasia.2024. Available at: https://www.acog.org/womens-health/faqs/endometrial-hyperplasia. (last viewed February 2025).

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