PCOS

Diagnosis, comorbidity screening & lifelong care

Field: Women's HealthCode: WH-04Updated: June 2026Reference: 2023 International Evidence-based PCOS Guideline (Monash)

Rotterdam criteria: 2 of 3 in adults. AMH can now replace ultrasound for polycystic morphology. Lifestyle change restoring just 5–10% weight loss is first-line therapy for every phenotype — pharmacotherapy is then directed at the dominant symptom.

Rotterdam criteria — 2 of 3

Anovulation: cycles >35 or <21 days, or <8 cycles/year.
Hyperandrogenism: clinical (hirsutism, acne, alopecia) or biochemical (raised testosterone, low SHBG).
Polycystic ovarian morphology: ≥12 follicles or volume >10mL on ultrasound, or AMH >35 pmol/L in adults.
Exclude mimics first: TSH, prolactin, 17-OH progesterone, DHEAS.

Symptom-driven management

Hirsutism/acne: combined pill first-line; add spironolactone if insufficient at 6 months.
Cycle control: combined pill or cyclic progestogen — aim for a minimum of 4 bleeds a year for endometrial protection.
Insulin resistance: metformin, titrated up — PBS-subsidised for T2DM, used off-label for PCOS metabolic features.
Fertility: letrozole is commonly first-line (not clomiphene); refer if ovulation isn't restored after 3 cycles.
Mental health: psychology/CBT; screen with PHQ-9/GAD-7 annually.

Key comorbidities — screen at diagnosis

Metabolic: insulin resistance, ~4× T2DM risk, gestational diabetes, NAFLD — OGTT pre-pregnancy or if BMI >25.
Cardiovascular: higher rates of hypertension, dyslipidaemia and metabolic syndrome — calculate CVD risk.
Mental health: depression and anxiety at 2–3× population prevalence — screen at diagnosis and annually.
Endometrial: unopposed oestrogen from anovulation raises hyperplasia risk if fewer than 4 bleeds a year.

Baseline workup at diagnosis

Order together to avoid repeat visits: androgens (early-morning total testosterone, SHBG), exclusion bloods (TSH, prolactin, 17-OH progesterone, β-hCG if cycle disturbance), and metabolic screening (HbA1c or OGTT, fasting lipids, LFTs).

Ongoing screening schedule

Annually: HbA1c or OGTT (sooner pre-pregnancy or if BMI >25 or family history), BP and lipids (statin if 5-year CVD risk >10%), and a mental health check. At every visit: BMI and waist circumference, with a lifestyle goal of 5–10% weight loss.

Safety

Don't diagnose PCOS in adolescents on imaging or AMH alone — they need both other Rotterdam criteria.
Maintain a minimum of 4 bleeds a year on any cycle-control regimen to protect the endometrium.
Letrozole, not clomiphene, is commonly first-line for ovulation induction.

Red flags / refer

Rapid virilisation (sudden voice deepening, clitoromegaly) → exclude an androgen-secreting tumour.
Anovulation despite 3 cycles of letrozole → fertility specialist.
Diagnostic uncertainty in a patient under 18 → paediatric endocrine.
Post-menopausal/intermenstrual bleeding, or endometrial thickness >7mm on ultrasound.

WH-04 v1.0 · Reviewed Jun 2026 · Review Jun 2027

For health-professional use. Framework: 2023 International Evidence-based PCOS Guideline (Teede et al., Monash). Doses are a guide only — confirm current PBS status & exact dosing at pbs.gov.au / eTG.