PCOS Guideline Summary 2023

International evidence-based
guideline for the assessment

and management of
polycystic ovary syndrome
2023 – Summary
Abstract
Objective: To develop and translate rigorous, comprehensive evidence-based guidelines for diagnosis,
assessment and treatment, to improve the lives of those with polycystic ovary syndrome (PCOS) worldwide.
Participants: Extensive health professional and consumer or patient engagement informed the guideline
priority areas. International society-nominated panels included consumers, and experts in paediatrics,
endocrinology, gynaecology, primary care, reproductive endocrinology, psychology, dietetics, exercise
physiology, sleep, bariatric/metabolic surgery, public health, other co-opted experts, project management,
evidence synthesis and translation.
Evidence: Best practice, evidence-based guideline development involved extensive evidence synthesis
and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework covered
evidence quality, feasibility, acceptability, cost, implementation and ultimately recommendation strength.
Process: Governance included an international advisory panel, management committee and five guideline
development groups with 52 members, consumer and translation committees. The Centre for Research
Excellence in Women’s Health in Reproductive Life, funded by the Australian National Health and Medical
Research Council (NHMRC), and led by Monash University, partnered with the American Society for Reproductive
Medicine, the Endocrine Society, the European Society of Endocrinology and the European Society of Human
Reproduction and Embryology. Thirty-six organisations collaborated with international meetings over nine
months. Fifty-five prioritised clinical questions involved 52 systematic and three narrative reviews, generating
evidence-based and consensus recommendations with accompanying practice points. Committee members
nominated by collaborating organisations provided international peer review, and evidence expert-reviewed
methods and outputs were submitted to NHMRC for independent review.
Recommendations: PCOS should be diagnosed using the revised consensus Rotterdam criteria, which are
now updated to evidence-based criteria. In adults this requires the presence of two of i) clinical/biochemical
hyperandrogenism, ii) ovulatory dysfunction and iii) polycystic ovaries on ultrasound or elevated anti-mullerian
hormone (AMH) levels, after other causes of these features are excluded. Where irregular menstrual cycles
and hyperandrogenism are present, ultrasound or AMH are not required for diagnosis. In adolescents, both
hyperandrogenism and ovulatory dysfunction are required, with ultrasound and AMH not recommended,
due to poor specificity. Once diagnosed, assessment and management should address reproductive,
metabolic, cardiovascular, dermatologic, sleep and psychological features. A lifelong reproductive health plan
is recommended including a focus on preconception risk factors, healthy lifestyle and prevention of weight gain
and optimisation of fertility. Metabolic risk factors, diabetes, cardiovascular disease and sleep disorders are all
increased in PCOS and screening and management is recommended. PCOS should be considered a high-risk
condition in pregnancy with women identified and monitored. An increased premenopausal risk of endometrial
cancer should be recognised, whilst absolute risks remain low.
Depressive and anxiety symptoms are significantly increased and should be screened for in all women with
PCOS, with psychological assessment and therapy as indicated. Greater awareness of psychological features
including eating disorders and impacts on body image and quality of life is needed. Dissatisfaction with PCOS
diagnosis and care is high and raised awareness and education is strongly recommended for women and
healthcare professionals including high quality, evidence-based resources. Shared decision making and a
self-empowerment are fundamental and integrated models of care should be developed, funded and evaluated.
2
Supported healthy lifestyle remains vital throughout the lifespan in PCOS, with a strong focus on overall health,
prevention of weight gain and if required, on weight management. Recognising the benefits if many specific
diet and physical activity regimens, there is no one regimen that has benefits over others in PCOS. Weight bias
and stigma should be minimised and healthcare professionals should seek permission to weigh women, with
explanation of weight-related risks. Combined oral contraceptive pills are first-line pharmacological treatment
for menstrual irregularity and hyperandrogenism, with no specific recommended preparation, and a preference
for lower dose preparations and those with less side-effects. Metformin is recommended primarily for metabolic
features and has greater efficacy than inositol, which offers limited clinical benefits in PCOS. Metformin is not
routinely recommended for use in pregnant women with PCOS. Laser therapy is effective for hair reduction in
some subgroups, whilst antiandrogens have a limited role, to be used where other therapies are ineffective
or are contraindicated. Anti-obesity agents and bariatric/metabolic surgery may be considered based
on general population guidelines, balancing potential for benefits and side-effects.
Letrozole is first-line pharmacological infertility therapy, with clomiphene alone or in combination with metformin,
gonadotrophins or ovarian surgery having a role as second-line therapy. In the absence of an absolute indication
for in vitro fertilisation (IVF), women with PCOS and anovulatory infertility could be offered IVF potentially with
in vitro maturation, as third-line therapy where other ovulation induction therapies have failed.
Overall, evidence in PCOS is low to moderate quality. Based on high prevalence and significant health impact,
greater priority, funding and research is recommended. Guideline translation will be extensive including
multilingual education outputs and evidence-based resources for consumers (the AskPCOS app),
healthcare professionals and policy makers.
International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2023 - Summary 3
Context statement on diagnosis: Prelude to the guideline
Here, we build on the 2018 International Evidence-based Guideline for the Assessment, Diagnosis
and Management of PCOS, and on the initial consensus-based Rotterdam PCOS diagnostic criteria.18
Here, we progress evidence-based diagnostic criteria and in adults recommend that this requires two of
i) clinical/biochemical hyperandrogenism, ii) ovulatory dysfunction or iii) polycystic ovaries on ultrasound and here
add elevated anti-mullerian hormone (AMH) levels. We have included the role of AMH in diagnosis in adults but
do not recommend AMH or ultrasound in adolescents, due to overlap with normal reproductive physiology.
Exclusion of thyroid disease (thyroid stimulating hormone), hyperprolactinemia (prolactin), and non-classic
congenital adrenal hyperplasia (17-hydroxy progesterone) is recommended with further evaluation recommended
in those with amenorrhea and more severe clinical features including consideration of hypogonadotropic
hypogonadism, Cushing’s disease, or suspected androgen producing tumors, noting that overt virilisation
is not consistent with PCOS. Clinicians should refer to other relevant guidelines for these diagnoses.
We acknowledge the challenges in defining specific diagnostic features, including around menarche
and menopause, where diagnostic features naturally evolve.
The guideline aims to facilitate timely and appropriate diagnosis for women with PCOS, whilst avoiding
over diagnosis, especially in adolescents. Specific recommendations of relevance here include:
● ultrasound and anti-mullerian (AMH) levels are not recommended in diagnosis in those within
8 years of menarche
● young women 'at risk' can be identified, where diagnosis is unclear, with follow-up reassessment
● diagnostic features are refined, focused on specificity, to improve diagnostic accuracy.
Resource use in diagnosis will also be reduced with a focus on clinical features in diagnosis, limited indications
for ultrasound and AMH as an alternative and with a focus on clinical overt biochemical hyperandrogenism.
We also endorse the recommendation of the National Institutes of Health (NIH) evidence-based methodology
workshop of PCOS 2012 that the name of the condition is a distraction and should be changed. We are building
on the evidence and guideline efforts with consumer partnership and processes towards a change in the name.
The value and optimal timing of assessment and diagnosis of PCOS should be discussed with the individual
patient, considering psychosocial and cultural factors and preferences. Education is vitally important to women at
the time of diagnosis, including reassurance about the potential for prevention of complications and about good
general reproductive potential and family size, acknowledging some medical assistance may be required. As a
general guiding principal, in partnering with women with PCOS in their diagnosis and care, self-empowerment is
a priority and personal characteristics, preferences, culture and values should be considered when undertaking
assessment, providing information or recommending intervention or treatments.
Interpreting the recommendations

Detailed methods for stakeholder engagement and guideline development can be found in Chapter six: Guideline
development methods. In developing and interpreting the guideline, evidence has been evaluated alongside
multidisciplinary health professional expertise and consumer perspectives in all stages from conceptualisation,
prioritisation, development, review and translation. Variability in resources, health systems and access to
healthcare professionals, investigations and therapies was considered across international settings and consistent
with best practice, adaptation may be required in translation. Assistance with adaptation can be obtained by
contacting [email protected].
To assist in interpreting guideline recommendations, these are presented by category, terms used, GRADE
and quality of evidence. The category of the recommendations includes evidence-based or consensus
recommendations and have accompanying relevant practice points as described in Table 1. When sufficient
evidence was available in PCOS, an evidence-based recommendation was made, where there was insufficient
evidence in PCOS, evidence in general or relevant populations was considered and if appropriate and there
was consensus, the GDG made consensus recommendations. Practice points highlight important clinical and
implementation issues arising from GDG consideration of evidence-based or consensus recommendations.
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Table 1: Categories of the PCOS guideline recommendations
EBR Evidence-based recommendations: Evidence sufficient to inform a recommendation made

by the guideline development group.
CR Consensus recommendations: In the absence of adequate evidence, a consensus recommendation

has been made by the guideline development group, also informed by evidence from the
general population.
PP Practice points: Evidence not sought. A practice point has been made by the guideline
development group where important issues arose from discussion of evidence-based
or consensus recommendations.
The recommendation terms include 'should', 'could' and 'should not'. These terms are informed by the nature of
the recommendation (evidence or consensus), the GRADE framework and evidence quality and are independent
descriptors reflecting the judgement of multidisciplinary GDG including consumers. They refer to overall
interpretation and practical application of the recommendation, balancing benefits and harms. 'Should' is used
where benefits of the recommendation exceed harms, and where the recommendation can be trusted to guide
practice. Conditional recommendations are reflected using the terms 'could' or 'should/could consider' which are
used where either the quality of evidence was limited or the available studies demonstrate little clear advantage
of one approach over another, or the balance of benefits to harm was unclear. 'Should not' is used where there
is either a lack of appropriate evidence, or the harms may outweigh the benefits.
The GRADE of the recommendation is determined by the GDG from structured, transparent consideration of the
GRADE framework16 including desirable effects, undesirable effects, balance of effects, resource requirements
and cost effectiveness, equity, acceptability and feasibility and includes:
Conditional recommendation against the option
Conditional recommendation for either the option or the comparison
Conditional recommendation for the option
Strong recommendation for the option
Quality of the evidence is categorised (see Table 2) according to:

● information about the number and design of studies addressing the outcome
● judgments about the quality of the included studies and/or synthesised evidence,
such as risk of bias, inconsistency, indirectness, imprecision and any other considerations
that may influence the quality of the evidence
● key statistical data
● classification of the importance of the outcomes.
The quality of evidence reflects the extent to which our confidence in an estimate of the effect is adequate
to support a particular recommendation16 and was largely determined by the expert evidence synthesis team.
Table 2: Quality (certainty) of evidence categories (adapted from GRADE)16
High Very confident that the true effect lies close to that of the estimate of the effect.
Moderate Moderate confidence in the effect estimate: The true effect is likely to be close
to the estimate of the effect, but there is a possibility that it is different.
Low Limited confidence in the effect estimate: The true effect may be substantially
different from the estimate of the effect.
Very Low Very little confidence in the effect estimate: The true effect is likely to be substantially
different from the estimate of effect.
GRADE note that quality of evidence is a continuum; any discrete categorisation involves a degree of arbitrariness.
Nevertheless, advantages of simplicity, transparency, and vividness outweigh these limitations.16
The recommendations summary in Table 3 below applies the category, descriptive terms, GRADE of the
recommendations and the quality of the evidence. Within the body of the guideline, we outline the clinical
need for the question, the clinical question, the evidence summary, the recommendation and practice points
and a summary of the justification developed by the GDG and modified by extensive international peer review.
The comprehensive evidence reviews, profiles and GRADE frameworks supporting each recommendation,
can be found in the supplementary Technical Report.
Aligned to Cochrane methods, certainty of evidence varies significantly across outcomes for each clinical
question. In this guideline, the recorded evidence certainty reflects the lowest certainty for the top three critical
outcomes for each question. Here, evidence was often stronger for the most critical outcome and often high
quality randomised controlled trials (RCTs) had addressed an individual question, but consideration of multiple
outcomes and inclusion of additional low-quality studies may have resulted in low certainty evidence overall.
These nuances in the evidence were considered by the GDG for every clinical question and are outlined in the
technical report and GRADE tables. Hence, an apparent discrepancy may be observed between the strength
of the recommendation and the certainty of the evidence. Where this occurs, a justification is added to the
guideline under the relevant clinical question.
This is a living guideline as outlined in Chapter 6. For the most rapidly progressing areas of the guideline where
new evidence is anticipated in the shorter term, an annual scoping review will be completed to search for
additional evidence and the process followed as per Chapter 6. In the recommendations table and summary,
these are denoted by #.
6
Recommendations
summary
Table 3: Recommendations
The recommendation and technical report numbers correspond. Consensus recommendations (CR) and practice
points (PP) do not have ‘GRADE’ ratings, however the evidence summaries outline how they were informed by
PCOS and general population evidence. # denoted priority for living guideline updates.
No. Grade/
Living# Type Recommendation Quality
1 Screening, diagnostic and risk assessment and life stages
General principles
PP All diagnostic assessments are recommended for use in accordance with the
diagnostic algorithm one.
1.1 Irregular cycles and ovulatory dysfunction
1.1.1 CR Irregular menstrual cycles are defined as:

● Normal in the first year post menarche as part of the pubertal transition
● > 1 to < 3 years post menarche: < 21 or > 45 days
● > 3 years post menarche to perimenopause: < 21 or > 35 days or < 8 cycles per year
● > 1 year post menarche > 90 days for any one cycle
Primary amenorrhea by age 15 or > 3 years post thelarche (breast development)
When irregular menstrual cycles are present a diagnosis of PCOS should be
considered and assessed according to these PCOS Guidelines.
1.1.2 PP The mean age of menarche may differ across populations.
1.1.3 PP In adolescents with irregular menstrual cycles, the value and optimal timing of
assessment and diagnosis of PCOS should be discussed with the patient and their
parent/s or guardian/s, considering diagnostic challenges at this life stage and
psychosocial and cultural factors.
1.1.4 PP For adolescents who have features of PCOS, but do not meet diagnostic criteria,
an 'increased risk' could be considered and reassessment advised at or before full
reproductive maturity, 8 years post menarche. This includes those with PCOS features
before combined oral contraceptive pill (COCP) commencement, those with persisting
features and those with significant weight gain in adolescence.
1.1.5 PP Ovulatory dysfunction can still occur with regular cycles and if anovulation needs
to be confirmed serum progesterone levels can be measured.
No. Grade/
1.2 Biochemical hyperandrogenism
1.2.1 EBR Healthcare professionals should use total and free testosterone to assess
biochemical hyperandrogenism in the diagnosis of PCOS; free testosterone
can be estimated by the calculated free androgen index.
1.2.2 EBR If testosterone or free testosterone is not elevated, healthcare professionals could
consider measuring androstenedione and dehydroepiandrosterone sulfate (DHEAS),
noting their poorer specificity and greater age associated decrease in DHEAS.
1.2.3 EBR Laboratories should use validated, highly accurate tandem mass spectrometry
(LC-MS/MS) assays for measuring total testosterone and if needed, for
androstenedione and DHEAS. Free testosterone should be assessed
by calculation, equilibrium dialysis or ammonium sulfate precipitation.
1.2.4 EBR Laboratories should use LC-MS/MS assays over direct immunoassays
(e.g. radiometric, enzyme-linked, etc.) for assessing total or free testosterone,
which have limited accuracy and demonstrate poor sensitivity and precision
for diagnosing hyperandrogenism in PCOS.
1.2.5 PP For the detection of hyperandrogenism in PCOS, the assessment of biochemical

hyperandrogenism is of greatest value in patients with minimal or no clinical signs
of hyperandrogenism (i.e. hirsutism).
1.2.6 PP It is very difficult to reliably assess for biochemical hyperandrogenism in women

on the combined oral contraceptive pill (COCP) as the pill increases sex hormone-
binding globulin and reduces gonadotrophin-dependent androgen production.
If already on the COCP, yet assessment of biochemical androgens is imperative,
the pill should be withdrawn for a minimum of three months and contraception
should be managed otherwise during this time.
1.2.7 PP Repeated androgen measures for the ongoing assessment of PCOS in adults
have a limited role.
1.2.8 PP In most adolescents, androgen levels reach adult ranges at 12-15 years of age.
1.2.9 PP If androgen levels are markedly above laboratory reference ranges, causes of
hyperandrogenaemia other than PCOS, including ovarian and adrenal neoplastic
growths, congenital adrenal hyperplasia, Cushing’s syndrome, ovarian hyperthecosis
(after menopause), iatrogenic causes, and syndromes of severe insulin resistance,
should be considered. However, some androgen-secreting neoplasms are
associated with only mild to moderate increases in androgen levels. The clinical
history of time of onset and/or rapid progression of symptoms is critical in assessing
for an androgen-secreting tumour.
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No. Grade/
1.2.10 PP Reference ranges for different methods and laboratories vary widely, and are often
based on an arbitrary percentile or variances of the mean from a population that
has not been fully characterised and is highly likely to include women with PCOS.
Normal values should be determined either by the range of values in a well
characterised healthy control population or by cluster analysis of general
population values.
1.2.11 PP Laboratories involved in androgen measurements in females should consider:

● determining laboratory normal values by either the range of values in a well
characterised healthy control population or by cluster analysis of the values
of a large general population
● applying the most accurate methods where available
● using extraction/chromatography immunoassays as an alternative to mass
spectrometry only where adequate expertise is available
● future improvements may arise from measurement of 11-oxygenated androgens,
and from establishing cut-off levels or thresholds based on large-scale validation
in populations of different ages and ethnicities.
1.3 Clinical hyperandrogenism
1.3.1 EBR The presence of hirsutism alone should be considered predictive of biochemical
hyperandrogenism and PCOS in adults.
1.3.2 EBR Healthcare professionals could recognise that female pattern hair loss and acne
in isolation (without hirsutism) are relatively weak predictors of biochemical
hyperandrogenism.
1.3.3 CR A comprehensive history and physical examination should be completed for

symptoms and signs of clinical hyperandrogenism, including acne, female pattern
hair loss and hirsutism in adults, and severe acne and hirsutism in adolescents.
1.3.4 CR Healthcare professionals should be aware of the potential negative psychosocial

impact of clinical hyperandrogenism and should consider the reporting of unwanted
excess hair growth and/or female pattern hair loss as being important, regardless
of apparent clinical severity.
No. Grade/
1.3.5 CR A modified Ferriman Gallwey score (mFG) of 4–6 should be used to detect hirsutism,
depending on ethnicity, acknowledging that self-treatment is common and can limit
clinical assessment.
1.3.6 CR Healthcare professionals should consider that the severity of hirsutism may vary
by ethnicity but the prevalence of hirsutism appears similar across ethnicities.
1.3.7 PP Healthcare professionals should:

● be aware that standardised visual scales are preferred when assessing hirsutism,
such as the mFG scale in combination with a photographic atlas
● consider the Ludwig or Olsen visual scales for assessing female pattern hair loss
● note that there are no universally accepted visual instruments for assessing the
presence of acne
● recognise that women commonly treat clinical hyperandrogenism cosmetically,
diminishing their apparent clinical severity
● appreciate that self-assessment of unwanted excess hair growth, and possibly
acne and female pattern hair loss, has a high degree of validity and merits close
evaluation, even if overt clinical signs of hyperandrogenism are not readily evident
on examination
● be aware that only terminal hairs need to be considered in defining hirsutism, and
these can reach > 5 mm if untreated, vary in shape and texture and are generally
pigmented
● note that new-onset severe or worsening hyperandrogenism, including hirsutism,
requires further investigation to rule out androgen-secreting tumours and ovarian
hyperthecosis
● monitor clinical signs of hyperandrogenism, including hirsutism, acne and female
pattern hair loss, for improvement or treatment adjustment during therapy.
1.4 Ultrasound and polycystic ovarian morphology
1.4.1 EBR Follicle number per ovary (FNPO) should be considered the most effective
ultrasound marker to detect polycystic ovarian morphology (PCOM) in adults.
1.4.2 EBR Follicle number per ovary (FNPO), follicle number per cross-section (FNPS)
and ovarian volume (OV) should be considered accurate ultrasound markers
for PCOM in adults.
1.4.3 CR PCOM criteria should be based on follicle excess (FNPO, FNPS) and/or ovarian
enlargement (OV).
1.4.4 CR Follicle number per ovary (FNPO) ≥ 20 in at least one ovary should be considered
the threshold for PCOM in adults.
1.4.5 CR Ovarian volume (OV) ≥ 10 ml or follicle number per section (FNPS) ≥ 10 in at least
one ovary in adults should be considered the threshold for PCOM if using older
technology or image quality is insufficient to allow for an accurate assessment
of follicle counts throughout the entire ovary.
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No. Grade/
1.4.6 PP There are no definitive criteria to define polycystic ovary morphology (PCOM)
on ultrasound in adolescents, hence it is not recommended in adolescents.
1.4.7 PP When an ultrasound is indicated, if acceptable to the individual, the transvaginal

approach is the most accurate for the diagnosis of PCOM.
1.4.8 PP Transabdominal ultrasound should primarily report ovarian volume (OV) with
a threshold of ≥ 10 ml or follicle number per section (FNPS) ≥ 10 in either ovary in
adults given the difficulty of assessing follicle counts throughout the entire ovary
with this approach.
1.4.9 PP In patients with irregular menstrual cycles and hyperandrogenism, an ovarian

ultrasound is not necessary for PCOS diagnosis.
1.4.10 PP Thresholds for PCOM should be revised regularly with advancing ultrasound
technology, and age-speciﬁc cut-off values for PCOM should be deﬁned.
1.4.11 PP There is a need for training in careful and meticulous follicle counting per ovary
and clear standardised protocols are recommended for PCOM reporting on
ultrasound including at a minimum:
● last menstrual period (or stage of cycle)
● transducer bandwidth frequency
● approach/route assessed
● total number of 2–9 mm follicles per ovary
● measurements in three dimensions (in cm) or volume of each ovary
● other ovarian features and/or pathology including ovarian cysts, corpus lutea,
dominant follicles (≥ 10 mm) (which should not be included in ovarian
volume calculations)
● reliance on the contralateral ovary FNPO for diagnosis of PCOM,
where a dominant follicle is noted
● uterine features and/or pathology including endometrial thickness and pattern.
1.5 Anti-mullerian hormone in the diagnosis of PCOS
1.5.1 EBR Serum anti-mullerian hormone (AMH) could be used for defining PCOM in adults.
1.5.2 EBR Serum AMH should only be used in accordance with the diagnostic algorithm,
noting that in patients with irregular menstrual cycles and hyperandrogenism,
an AMH level is not necessary for PCOS diagnosis.
1.5.3 EBR We recommend that serum AMH should not be used as a single test for the
diagnosis of PCOS.
No. Grade/
1.5.4 EBR Serum AMH should not yet be used in adolescents.
1.5.5 PP Either serum AMH or ultrasound may be used to define PCOM; however,
both tests should not be performed to limit overdiagnosis.
1.5.6 PP Laboratories and healthcare professionals need to be aware of factors that influence
AMH in the general population including:
● age: Serum AMH generally peaks between the ages of 20-25 years
in the general population
● body mass index (BMI): Serum AMH is lower in those with higher BMI
in the general population
● hormonal contraception and ovarian surgery: Serum AMH may be suppressed
by current or recent COCP use
● menstrual cycle day: Serum AMH may vary across the menstrual cycle.
1.5.7 PP Laboratories involved in AMH measurements in females should use population

and assay specific cut-offs.
1.6 Ethnic variation
1.6.1 EBR Healthcare professionals should be aware of the high prevalence of PCOS in
all ethnicities and across world regions, ranging from 10-13% globally using the
Rotterdam criteria.
1.6.2 EBR Healthcare professionals should be aware that PCOS prevalence is similar across
world regions and ethnicities, but may be higher in South East Asian and Eastern
Mediterranean regions.
1.6.3 PP Healthcare professionals should be aware that the presentation of PCOS may vary
across ethnic groups.
1.7 Menopause life stage
1.7.1 CR A diagnosis of PCOS could be considered as enduring/lifelong.
1.7.2 CR Healthcare professionals could consider that both clinical and biochemical
hyperandrogenism persist in the postmenopause for women with PCOS.
1.7.3 CR PCOS diagnosis could be considered postmenopause, if there is a past diagnosis,

or a long-term history of oligo-amenorrhoea with hyperandrogenism and/or PCOM,
during the earlier reproductive years (age 20-40).
1.7.4 CR Further investigations should be considered to rule out androgen-secreting tumours

and ovarian hyperthecosis in postmenopausal women presenting with new-onset,
severe or worsening hyperandrogenism including hirsutism.
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No. Grade/
1.8 Cardiovascular disease risk
1.8.1 EBR Women with PCOS should be considered at increased risk of cardiovascular
disease and potentially of cardiovascular mortality, acknowledging that the
overall risk of cardiovascular disease in premenopausal women is low.
1.8.2 EBR All women with PCOS should be assessed for cardiovascular disease risk factors.
1.8.3 CR All women with PCOS, regardless of age and BMI, should have a lipid profile
(cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol
and triglyceride level) at diagnosis. Thereafter, frequency of measurement should
be based on the presence of hyperlipidaemia and additional risk factors or global
cardiovascular risk.
1.8.4 CR All women with PCOS should have blood pressure measured annually and when
planning pregnancy or seeking fertility treatment, given the high risk of hypertensive
disorders in pregnancy and the associated comorbidities.
1.8.5 CR Funding bodies should recognise that PCOS is highly prevalent with multisystem
effects including cardiometabolic disease, and should diversify and increase research
support accordingly.
1.8.6 CR Cardiovascular general population guidelines could consider the inclusion

of PCOS as a cardiovascular risk factor.
1.8.7 CR Healthcare professionals, women with PCOS and other stakeholders should
all prioritise preventative strategies to reduce cardiovascular risk.
1.8.8 PP Consideration should be given to the differences in cardiovascular risk factors,

and cardiovascular disease, across ethnicities (see 1.6.1) and age, when determining
frequency of risk assessment.
1.9 Impaired glucose tolerance and type 2 diabetes risk
1.9.1 EBR Healthcare professionals and women with PCOS should be aware that,
regardless of age and BMI, women with PCOS have an increased risk
of impaired fasting glucose, impaired glucose tolerance and type 2 diabetes.
1.9.2 EBR Glycaemic status should be assessed at diagnosis in all adults and adolescents
with PCOS.
1.9.3 CR Glycaemic status should be reassessed every one to three years, based
on additional individual risk factors for diabetes.
1.9.4 CR Healthcare professionals, women with PCOS and other stakeholders should
prioritise preventative strategies to reduce type 2 diabetes risk.
No. Grade/
1.9.5 CR Funding bodies should recognise that PCOS is highly prevalent, has significantly
higher risk for diabetes and should be funded accordingly.
1.9.6 CR Diabetes general population guidelines should consider the inclusion of PCOS
as an independent risk factor for diabetes.
1.9.7 PP Healthcare professionals, adults and adolescents with PCOS and their first-degree
relatives, should be aware of the increased risk of diabetes and the need for regular
glycaemic assessment.
1.9.8 PP Women with type 1 and type 2 diabetes have an increased risk of PCOS and
screening should be considered in individuals with diabetes.
Glycaemic testing
1.9.9 EBR Healthcare professionals and women with PCOS should recommend the 75g
oral glucose tolerance test (OGTT) as the most accurate test to assess glycaemic
status in PCOS, regardless of BMI.
1.9.10 EBR If an OGTT cannot be performed, fasting plasma glucose and/or glycated
haemoglobin (HbA1c) could be considered, noting significantly reduced accuracy.
1.9.11 EBR An OGTT should be considered in all women with PCOS and without pre-existing
diabetes, when planning pregnancy or seeking fertility treatment, given the high risk
of hyperglycaemia and the associated comorbidities in pregnancy. If not performed
preconception, an OGTT could be offered at the first prenatal visit and all women
with PCOS should be offered the test at 24-28 weeks gestation.
1.9.12 PP Insulin resistance is a pathophysiological factor in PCOS, however, clinically available

insulin assays are of limited clinical relevance and are not recommended in routine
care (refer to 3.1.10).
1.10 Obstructive sleep apnea
1.10.1 EBR Healthcare professionals should be aware that women with PCOS have significantly
higher prevalence of obstructive sleep apnea (OSA) compared to women without
PCOS, independent of BMI.
1.10.2 EBR Women with PCOS should be assessed for symptoms (i.e. snoring in combination
with waking unrefreshed from sleep, daytime sleepiness or fatigue) and if present,
screen with validated tools or refer for assessment.
1.10.3 PP Simple obstructive sleep apnea screening questionnaires (such as the Berlin
questionnaire, validated in the general population) can assist in identifying obstructive
sleep apnea in women with PCOS, noting that diagnosis requires a formal sleep study.
1.10.4 PP Goals of treatment should target obstructive sleep apnea related symptom burden.
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No. Grade/
1.11 Endometrial hyperplasia and cancer
1.11.1 EBR Healthcare professionals should be aware that premenopausal women

with PCOS have markedly higher risk of developing endometrial hyperplasia
and endometrial cancer.
1.11.2 PP Women with PCOS should be informed about the increased risk of endometrial
hyperplasia and endometrial cancer, acknowledging that the overall chance
of developing endometrial cancer is low, therefore routine screening is
not recommended.
1.11.3 PP Long-standing untreated amenorrhea, higher weight, type 2 diabetes and persistent
thickened endometrium are additional to PCOS as risk factors for endometrial
hyperplasia and endometrial cancer.
1.11.4 PP Women with PCOS should be informed of preventative strategies including weight
management, cycle regulation and regular progestogen therapy.
1.11.5 PP When excessive endometrial thickness is detected, consideration of a biopsy

with histological analysis and withdrawal bleed is indicated.
1.12 Risks in relatives
1.12.1 EBR Healthcare professionals could consider that fathers and brothers of women
with PCOS may have an increased prevalence of metabolic syndrome,
type 2 diabetes, and hypertension.
1.12.2 PP The cardiometabolic risk in female first-degree relatives of women with

PCOS remains inconclusive.
2 Prevalence, screening and management of psychological features

and models of care
General principles
PP Psychological features are common and important component of PCOS that all
health professionals should be aware of.
PP Funding bodies should recognise that PCOS is highly prevalent, has significantly
higher psychological disorders which should be prioritised and funded accordingly.
2.1 Quality of life
2.1.1 EBR Healthcare professionals and women should recognise the adverse impact
of PCOS and/or PCOS features on quality of life in adults.
2.1.2 PP Women with PCOS should be asked about their perception of PCOS related
symptoms, impact on quality of life, key concerns and priorities for management.
No. Grade/
2.2 Depression and anxiety
2.2.1 EBR Healthcare professionals should be aware of the high prevalence of moderate
to severe depressive symptoms and depression in adults and adolescents with
PCOS and should screen for depression in all adults and adolescents with PCOS,
using regionally validated screening tools.
2.2.2 EBR Healthcare professionals should be aware of the high prevalence of moderate to
severe anxiety symptoms and anxiety disorders in adults and should screen for
anxiety in all adults with PCOS, using regionally validated screening tools.
2.2.3 CR If moderate or severe depressive or anxiety symptoms are detected, practitioners

should further assess, refer appropriately or offer treatment.
2.2.4 PP Severity of symptoms and clinical diagnosis of depression or anxiety should

guide management.
The optimal interval for anxiety and depression screening is not known. A pragmatic
approach could include screening at diagnosis with repeat screening based on clinical
judgement, risk factors, comorbidities and life events, including the perinatal period.
Screening for mental health disorders comprises assessment of risk factors,
symptoms, and risk of self-harm and suicidal intent.
2.3 Psychosexual function
2.3.1 CR Healthcare professionals could consider the multiple factors that can influence
psychosexual function in PCOS including higher weight, hirsutism, mood disorders,
infertility and PCOS medications.
2.3.2 CR Permission to discuss psychosexual function should be sought noting that the
diagnosis of psychosexual dysfunction requires both low psychosexual function,
combined with related distress.
2.4 Body Image
2.4.1 EBR Healthcare professionals should be aware that features of PCOS can have a negative
impact on body image.
2.5 Eating disorders and disordered eating
2.5.1 EBR Eating disorders and disordered eating should be considered in PCOS, regardless
of weight, especially in the context of weight management and lifestyle interventions
(see sections 2.4 and 3.6).
2.5.2 PP If disordered eating or eating disorders are suspected, appropriately qualified

practitioners should further assess via a full diagnostic interview.
If an eating disorder or disordered eating is detected, appropriate management
and support should be offered.
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No. Grade/
2.6 Information resources, models of care, cultural and linguistic considerations
2.6.1 Information needs
2.6.1.1 EBR Tailored information, education and resources that are high-quality, culturally
appropriate and inclusive should be provided to all with PCOS.
2.6.1.2 EBR Information, education and resources are a high priority for patients with PCOS
and should be provided in a respectful and empathic manner.
2.6.1.3 CR Entities responsible for health professional education should ensure that information
and education on PCOS is systemically embedded at all levels of health professional
training to address knowledge gaps.
2.6.1.4 PP The diversity of the population should be considered when adapting

practice paradigms.
Healthcare professional opportunities should be optimised at all stages of graduate
and postgraduate training, continuing professional development and in practice
support resources.
2.6.1.5 PP Women should be counselled on the risk of misinformation and guided to

evidence-based resources.
2.6.2 Models of care
2.6.2.1 CR Models of care should prioritise equitable access to evidence-based primary

care with pathways for escalation to integrated specialist and multidisciplinary
services as required.
2.6.2.2 PP Strategies to deliver optimal models of care could include health professional
education, care pathways, virtual care, broader health professional engagement
(e.g. nurse practitioners) and coordination tools.
2.6.3 Support to manage PCOS
2.6.3.1 CR Public health actors should consider increasing societal awareness and education
on PCOS to reduce stigma and marginalisation.
2.6.3.2 PP Culturally appropriate resources and education on PCOS across the life span
for families of those with the condition, should be considered.
No. Grade/
2.6.4 Patient care
2.6.4.1 EBR Healthcare professionals should employ shared decision making and support
patient agency or ability to take independent actions to manage their health and care.
2.6.4.2 EBR The importance of being knowledgeable about PCOS, of applying evidence-based
practices when sharing news on diagnosis, treatment and health implications,
and of ascertaining and focusing on patient priorities, should be recognised.
2.6.4.3 CR Healthcare system leaders should enable system wide changes to support health
professional training, knowledge and practice in sharing news optimally, shared
decision making and patient agency, including ensuring adequate consultation
time and accessible resources.
2.6.4.4 PP Evidence-based strategies for shared decision making and for sharing news (such as
the SPIKES framework) are readily available and should be used to inform PCOS care.
All healthcare professionals partnering with women with PCOS should be
knowledgeable in sharing news, in shared decision making and in supporting patient
self-management.
Evidence-based strategies and resources can be used to support patient activation,
which refers to modifiable knowledge, skills, ability, confidence and willingness to
self-manage one’s own health and care.
2.7 Psychological therapy
2.7.1 CR Women with PCOS diagnosed with depression, anxiety, and/or eating disorders
should be offered psychological therapy guided by regional general population
guidelines and the preference of the woman with PCOS.
2.7.2 CR Women with PCOS with disordered eating, body image distress, low self-esteem,
problems with feminine identity, or psychosexual dysfunction should be offered
evidence-based treatments (e.g. cognitive behaviour therapy) where appropriate.
2.8 Antidepressant and anxiolytic treatment
2.8.1 CR Psychological therapy could be considered first-line management, and

antidepressant medications considered in adults where mental health disorders
are clearly documented and persistent, or if suicidal symptoms are present,
based on general population guidelines.
2.8.2 PP Lifestyle intervention and other therapies (e.g. COCP, metformin, laser hair removal)
that target PCOS features should be considered, given their potential to improve
psychological symptoms.
Where pharmacological treatment for anxiety and depression is offered in PCOS,
healthcare professionals should apply caution:
● to avoid inappropriate treatment with antidepressants or anxiolytics
● to limit use of agents that exacerbate PCOS symptoms, including weight gain.
Healthcare professionals should be aware that not managing anxiety and depression
may impact adherence to PCOS treatment/management.
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3 Lifestyle management
3.1 Effectiveness of lifestyle interventions
3.1.1 EBR Lifestyle intervention (exercise alone or multicomponent diet combined with
exercise and behavioural strategies) should be recommended for all women with
PCOS, for improving metabolic health including central adiposity and lipid profile.
3.1.2 CR Healthy lifestyle behaviours encompassing healthy eating and/or physical activity
should be recommended in all women with PCOS to optimise general health,
quality of life, body composition and weight management (maintaining weight,
preventing weight gain and/or modest weight loss).
3.1.3 PP Healthcare professionals should be aware that lifestyle management

is a core focus in PCOS management.
3.1.4 PP Lifestyle management goals and priorities should be co-developed in partnership

with women with PCOS, and value women’s individualised preferences.
3.1.5 PP There are benefits to a healthy lifestyle even in the absence of weight loss.
3.1.6 PP In those with higher weight, weight management can be associated with significant
clinical improvements and the following key points need to be considered including:
● a lifelong focus on prevention of further weight gain
● if the goal is to achieve weight loss, a tailored energy deficit could be prescribed
for women, considering individual energy requirements, body weight and physical
activity levels
● the value of improvement in central adiposity (e.g. waist circumference,
waist-hip ratio) or metabolic health
● the need for ongoing assessment and support.
3.1.7 PP Healthcare professionals should be aware of weight stigma when discussing lifestyle
management with women with PCOS [see 3.6].
3.1.8 PP Healthy lifestyle and optimal weight management, in the context of structured,
intensive and ongoing clinical support, appears equally effective in PCOS as
in the general population.
3.1.9 PP In those who are not overweight, in the adolescent and at key life points, the focus
should be on healthy lifestyle and the prevention of excess weight gain.
3.1.10 PP Insulin resistance is a pathophysiological factor in PCOS, however, clinically available

insulin assays are of limited clinical relevance and should not be used in routine care
(refer to 1.9.12).
No. Grade/
3.2 Behavioural strategies
3.2.1 CR Lifestyle interventions could include behavioural strategies such as goal-setting,

self-monitoring, problem solving, assertiveness training, reinforcing changes and
relapse prevention, to optimise weight management, healthy lifestyle and emotional
wellbeing in women with PCOS.
3.2.2 PP Behavioural support could include: goal-setting, problem solving, self-monitoring and
reviewing, or SMART goals (Specific, Measurable, Achievable, Realistic and Timely).
3.2.3 PP Comprehensive healthy behavioural or cognitive behavioural interventions could be

considered to increase support, engagement, retention, adherence and maintenance
of healthy lifestyle and improve health outcomes in women with PCOS.
3.3 Dietary interventions
3.3.1 EBR Healthcare professionals and women should consider that there is no evidence
to support any one type of diet composition over another for anthropometric,
metabolic, hormonal, reproductive or psychological outcomes.
3.3.2 CR Any diet composition consistent with population guidelines for healthy eating will
have health benefits, and within this, healthcare professionals should advise
sustainable healthy eating tailored to individual preferences and goals.
3.3.3 PP Tailoring of dietary changes to food preferences, allowing for a flexible, individual
and co-developed approach to achieving nutritional goals and avoiding unduly
restrictive and nutritionally unbalanced diets, are important, as per general
population guidelines.
3.3.4 PP Barriers and facilitators to optimise engagement and adherence to dietary

change should be discussed, including psychological factors, physical limitations,
socioeconomic and sociocultural factors, as well as personal motivators for change.
The value of broader family engagement should be considered. Referral to suitably
trained allied healthcare professionals needs to be considered when women
with PCOS need support with optimising their diet.
3.4 Exercise interventions
3.4.1 EBR Healthcare professionals and women could consider that there is a lack of evidence
supporting any one type and intensity of exercise being better than another for
anthropometric, metabolic, hormonal, reproductive or psychological outcomes.
3.4.2 CR Any physical activity consistent with population guidelines will have health benefits
and within this, healthcare professionals should advise sustainable physical activity
based on individual preferences and goals.
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No. Grade/
3.4.3 CR Healthcare professionals should encourage and advise the following in

concordance with general population physical activity guidelines:
● All adults should undertake physical activity as doing some physical activity
is better than none.
● Adults should limit the amount of time spent being sedentary (e.g. sitting,
screen time) as replacing sedentary time with physical activity of any intensity
(including light intensity) provides health benefits.
For the prevention of weight gain and maintenance of health, adults (18-64 years)
should aim for a minimum of 150 to 300 minutes of moderate-intensity activities or
75 to 150 minutes of vigorous-intensity aerobic activity per week or an equivalent
combination of both spread throughout the week, plus muscle strengthening
activities (e.g. resistance/flexibility) on two non-consecutive days per week.
For promotion of greater health benefits including modest weight loss and prevention
of weight regain, adults (18-64 years) should aim for a minimum of 250 min/week of
moderate-intensity activities or 150 min/week of vigorous intensities or an equivalent
combination of both, plus muscle strengthening activities (e.g. resistance/flexibility)
ideally on two non-consecutive days per week.
Adolescents should aim for at least 60 minutes of moderate- to vigorous-intensity
physical activity per day including activities that strengthen muscle and bone,
at least three times per week.
3.4.4 PP Physical activity is any bodily movement produced by skeletal muscles that
requires energy expenditure. It includes leisure time physical activity, transportation
(e.g. walking or cycling), occupational (i.e. work), household chores, playing games,
sports or planned exercise, or activities in the context of daily, family and
community activities.
3.4.5 PP Aerobic activity is best performed in bouts of at least 10 minutes duration,

aiming to achieve at least 30 minutes daily on most days.
3.4.6 PP Barriers and facilitators to optimise engagement and adherence to physical activity
should be discussed, including psychological factors (e.g. body image concerns,
fear of injury, fear of failure, mental health), personal safety concerns, environmental
factors, physical limitations, socioeconomic factors, sociocultural factors, and
personal motivators for change. The value of broader family engagement should
be considered. Referral to suitably trained allied healthcare professionals needs
to be considered for optimising physical activity in women with PCOS.
3.4.7 PP Self-monitoring including with fitness tracking devices and technologies for step
count and exercise intensity, could be considered as an adjunct to support and
promote active lifestyles and minimise sedentary behaviours.
No. Grade/
3.5 Factors affecting weight gain in PCOS
3.5.1 EBR Healthcare professionals and women with PCOS could consider that there is a lack
of consistent evidence of physiological or behavioural lifestyle differences, related
to weight, in women with PCOS compared to women without PCOS.
3.5.2 PP Whilst the specific mechanisms are unclear, it is recognised that many women with
PCOS will have underlying mechanisms that drive greater longitudinal weight gain
and higher BMI which may:
● underpin greater challenges with weight management
● highlight the importance of lifelong healthy lifestyle strategies and prevention
of excess weight gain
● assist women with PCOS and healthcare professionals in forming realistic,
tailored lifestyle goals.
3.6 Weight stigma
3.6.1 EBR Many women with PCOS experience weight stigma in healthcare and other settings
and the negative biopsychosocial impacts of this should be recognised.
3.6.2 CR Healthcare professionals should be aware of their weight biases and the impact
this has on their professional practice and on women with PCOS.
3.6.3 CR Health policy makers, managers and educators should promote awareness
of weight stigma and invest in weight stigma education and minimisation strategies.
3.6.4 PP Healthcare professionals should be aware of weight-inclusive practices

which promote acceptance of and respect for body size diversity and focus on
improvement of health behaviours and health outcomes for people of all sizes.
In PCOS this includes:
● acknowledging that whilst higher weight is a risk factor for PCOS and its complications,
it is only one indicator of health and broader factors should be assessed
● asking permission to discuss and measure weight and using strategies to minimise
discomfort (e.g. blind weighing)
● recognising that the terms 'overweight' and 'obese/obesity' can be stigmatising
with suggested alternatives including 'higher weight'
● if weighing, explaining how weight information will be used to inform risks
prevention and treatment and how not knowing may impact on recommendations
● ensuring appropriate equipment is available for women of all sizes
● offering options of weight-centric care (promoting intentional weight loss) or
weight-inclusive care (promoting healthy lifestyle change without focusing on
intentional weight loss) tailored to individual goals and preferences
● offering all women best practice assessment, treatment and support regardless
of weight, acknowledging that weight may be a non-modifiable risk factor when
using lifestyle modification alone.
3.6.5 PP Increasing awareness of weight stigma among family members of women

and adolescents with PCOS should be considered.
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No. Grade/
4 Management of non-fertility features
4.1 Pharmacology treatment principles in PCOS
PP Shared decision making between the patient (and parent/s or guardian/s,

if the patient is a child) and the healthcare professional is required.
PP An individual’s characteristics, preferences and values must be elicited and

considered when recommending any intervention alone or in combination.
PP Understanding how individual adults and adolescents value treatment outcomes

is essential when prescribing medications.
PP Medical therapy is generally not approved for use specifically in PCOS and
recommended use is therefore evidence-based, but off-label. Healthcare
professionals need to inform adults, adolescents and their parents/s or guardian/s
and discuss the evidence, possible concerns and side-effects. Regulatory agencies
should consider approval of evidence-based medications for use in PCOS.
4.2 Combined oral contraceptive pills
4.2.1 EBR The combined oral contraceptive pill (COCP) could be recommended
in reproductive age adults with PCOS for management of hirsutism
and/or irregular menstrual cycles.
4.2.2 EBR The COCP could be considered in adolescents at risk or with a clear diagnosis
of PCOS for management of hirsutism and/or irregular menstrual cycles.
4.2.3 EBR Health professionals could consider that there is no clinical advantage of using
high dose ethinylestradiol (≥ 30 μg) versus low dose ethinylestradiol (< 30 μg)
when treating hirsutism in adults with PCOS.
4.2.4 EBR General population guidelines should be considered when prescribing COCP
in adults and adolescents with PCOS as specific types or doses of progestins,
estrogens or combinations of COCP cannot currently be recommended.
4.2.5 EBR The 35 μg ethinyl estradiol plus cyproterone acetate preparations should be
considered as second-line therapy over other COCPs, balancing benefits and
adverse effects, including venous thromboembolic risks.
No. Grade/
4.2.6 EBR Progestin only oral contraceptives may be considered for endometrial protection,
based on general population guidelines, acknowledging that evidence in women
with PCOS is limited.
4.2.7 PP When prescribing COCPs in adults and adolescents with PCOS, and adolescents
at risk of PCOS:
● It is important to address main presenting symptoms and consider other
treatments such as cosmetic therapies.
● Shared decision making (including accurate information and reassurance on the
efficacy and safety of COCP) is recommended and likely to improve adherence.
● Natural estrogen preparations and the lowest effective estrogen doses (such as
20-30 micrograms of ethinyl estradiol or equivalent), need consideration,
balancing efficacy, metabolic risk profile, side-effects, cost and availability.
● The relatively limited evidence on COCPs specifically in PCOS needs to be
appreciated with practice informed by general population guidelines
● The relative and absolute contraindications and side-effects of COCPs need
to be considered and be the subject of individualised discussion.
● PCOS specific features such as higher weight and cardiovascular risk factors,
need to be considered.
4.3 Metformin
4.3.1 EBR Metformin alone should be considered in adults with PCOS and a BMI ≥ 25 kg/m2
for anthropometric, and metabolic outcomes including insulin resistance, glucose,
and lipid profiles.
4.3.2 EBR Metformin alone could be considered in adolescents at risk of or with PCOS
for cycle regulation, acknowledging limited evidence.
4.3.3 CR Metformin alone may be considered in adults with PCOS and BMI < 25 kg/m2,
acknowledging limited evidence.
4.3.4 PP Where metformin is prescribed the following need to be considered:

● Shared decision making needs to consider feasibility and effectiveness of active
lifestyle intervention. Women should be informed that metformin and active
lifestyle intervention have similar efficacy.
● Mild adverse effects, including gastrointestinal side-effects are generally dose
dependent and self-limiting.
● Starting at a low dose, with 500 mg increments 1-2 weekly and extended-release
preparations may minimise side-effects and improve adherence.
● Suggested maximum daily dose is 2.5 g in adults and 2 g in adolescents.
● Use appears safe long-term, based on use in other populations, however
indications for ongoing requirement needs to be considered.
● Use may be associated with low vitamin B12 levels, especially in those with
risk factors for low vitamin B12 (e.g. diabetes, post bariatric/metabolic surgery,
pernicious anaemia, vegan diet etc.), where monitoring should be considered.
24
No. Grade/
4.4 Metformin and combined oral contraceptive pills
4.4.1 EBR COCP could be used over metformin for management of hirsutism in irregular
menstrual cycles in PCOS.
4.4.2 EBR Metformin could be used over COCP for metabolic indications in PCOS.
4.4.3 EBR The combination of COCP and metformin could be considered to offer little
additional clinical benefit over COCP or metformin alone, in adults with PCOS
with a BMI ≤30 kg/m2.
4.4.4. PP In combination with the COCP, metformin may be most beneficial in high metabolic
risk groups including those with a BMI > 30 kg/m2, diabetes risk factors, impaired
glucose tolerance or high-risk ethnic groups.
4.4.5 PP Where COCP is contraindicated, not accepted or not tolerated, metformin may
be considered for irregular menstrual cycles. For hirsutism, other interventions
may be needed.
4.5 Anti-obesity pharmacological agents
4.5.1 CR Anti-obesity medications including liraglutide, semaglutide, both glucagon-like

peptide-1 (GLP-1) receptor agonists and orlistat, could be considered, in addition
to active lifestyle intervention, for the management of higher weight in adults
with PCOS as per general population guidelines.
4.5.2 PP Healthcare professionals should ensure concurrent effective contraception when

pregnancy is possible, for women who take GLP-1 receptor agonists, as pregnancy
safety data are lacking.
4.5.3 PP Gradual dose escalation for GLP-1 receptor agonists is recommended to reduce
gastrointestinal adverse effects.
4.5.4 PP Shared decision making, when discussing GLP-1 receptor agonist use with women
with PCOS, needs to consider side-effects, and the potential need for long-term use
in weight management, given the high risk for weight regain after discontinuation,
and the lack of long-term safety data.
4.6 Anti-androgen pharmacological agents
4.6.1 EBR In combination with effective contraception, anti-androgens could be considered

to treat hirsutism in women with PCOS, if there is a suboptimal response after
a minimum of six months of COCP and/or cosmetic therapy.
No. Grade/
4.6.2 CR Given the negative psychological impact of female pattern hair loss, anti-androgens
in combination with COCP could be trialed, acknowledging the lack of evidence
in the PCOS population.
4.6.3 PP Whenever pregnancy is possible, healthcare professionals must educate and counsel
women and adolescents, parents/s or guardian/s, regarding the risks of incomplete
development of external genital structures of male fetuses (undervirilisation) when
anti-androgens are used. To prevent this, women who can get pregnant should be
strongly counseled to use effective contraception (e.g. intrauterine device or COCPs).
4.6.4 PP Anti-androgens could be considered to treat hirsutism, in the presence of another

effective form of contraception, for women with contraindications for COCP therapy
or when COCPs are poorly tolerated.
4.6.5 PP When prescribing anti-androgens, based on general population recommendations,

healthcare professionals should consider that:
● spironolactone at 25-100 mg/day appears to have lower risks of adverse effects
● cyproterone acetate at doses ≥ 10 mg is not advised due to an increased risk
including for meningioma
● finesteride has an increased risk of liver toxicity
● flutamide and bicalutamide have an increased risk of severe liver toxicity.
The relatively limited evidence on anti-androgens in PCOS needs to be
appreciated with small numbers of studies and limited numbers of participants.
4.7 Inositol
4.7.1 EBR Inositol (in any form) could be considered in women with PCOS based on
individual preferences and values, noting limited harm, potential for improvement
in metabolic measures, yet with limited clinical benefits including in ovulation,
hirsutism or weight.
4.7.2 EBR Metformin should be considered over inositol for hirsutism and central adiposity,
noting that metformin has more gastrointestinal side-effects than inositol.
4.7.3 PP Women taking inositol and other complementary therapies are encouraged
to advise their health professional.
4.7.4 PP Specific types, doses or combinations of inositol cannot currently be recommended

in adults and adolescents with PCOS, due to a lack of quality evidence.
4.7.5 PP Shared decision making should include discussion that regulatory status and quality
control of inositol in any form (like other nutrient supplements) can differ from those
for pharmacological products and doses and qualities may vary.
4.7.6 PP Policy makers and healthcare professionals have a responsibility to ensure women
have access to unconflicted, evidence-based information to inform shared-decision
making, whilst also acknowledging and respecting individual values and preferences,
including for complementary therapies.
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No. Grade/
4.8 Mechanical laser and light therapies for hair reduction
4.8.1 EBR Mechanical laser and light therapies should be considered for reducing facial
hirsutism and for related depression, anxiety and quality of life in women with PCOS.
4.8.2 EBR A greater number of laser treatment sessions may be required in women with PCOS,
compared to women with idiopathic hirsutism, to achieve hair reduction.
4.8.3 CR Adverse effects appear limited in the hands of experienced and suitably qualified
providers, and women should be encouraged to seek hair reduction therapies
from such providers.
4.8.4 PP Where laser hair removal is prescribed, the following need to be considered:
● Wavelength and delivery of laser treatment varies by skin and hair colour.
● Laser is relatively ineffective in women with blond, grey or white hair.
● The addition of COCP, with or without anti-androgens, to laser treatment may
provide greater hair reduction and maintenance compared to laser alone.
Low and high fluence laser appear to have similar efficacy in reducing facial hair,
while low fluence laser has reduced associated pain.
4.8.5 PP Mechanical hair removal with Intense Pulse Light (IPL) could be considered,
albeit benefits may be less pronounced compared to laser treatment. There is
no evidence to support the efficacy of home-based IPL kits.
4.8.6 PP Policy makers should consider funding this evidence-based effective therapy
for women with PCOS to alleviate distressing symptoms of hirsutism, and related
negative impact on quality of life, body image and psychological health.
4.9 Bariatric/metabolic surgery
4.9.1 CR Bariatric/metabolic surgery could be considered to improve weight loss,

hypertension, diabetes (prevention and treatment), hirsutism, irregular menstrual
cycles, ovulation and pregnancy rates in women with PCOS.
4.9.2 CR Bariatric/metabolic surgery in women with PCOS should be informed by general

population guidelines.
4.9.3 CR PCOS is a metabolic condition and could be considered an indication at a lower

BMI threshold for bariatric/metabolic surgery similarly to other metabolic conditions
including diabetes.
4.9.4 CR Women should be strongly counseled on the likelihood of rapid return of fertility
and the need to commit to effective contraception, ideally prior to surgery. Even
when pregnancy is desired, contraception should be continued until a stable weight
is achieved, usually after one year, to avoid significantly increased risk of growth
restriction, prematurity, small for gestational age, pregnancy complications and
prolonged hospitalisation of the infant.
No. Grade/
4.10 Pregnancy outcomes
4.10.1 EBR Women with PCOS have higher risk pregnancies, and healthcare professionals
should ensure that PCOS status is identified during antenatal care, and
appropriate monitoring and support is provided.
4.10.2 EBR Healthcare professionals should recognise that pregnant women with
PCOS have an increased risk of:
● higher gestational weight gain
● miscarriage
● gestational diabetes
● hypertension in pregnancy and preeclampsia
● intrauterine growth restriction, small for gestational age babies
and low birth weight
● preterm delivery
● caesarean section.
4.10.3 EBR Assisted reproductive technology in women with PCOS should be considered as
not conferring additional risk of miscarriage, preterm birth, impaired fetal growth
and caesarean section, over that observed in women without PCOS.
4.10.4 EBR Women with PCOS should be considered as not having an increased risk of large
for gestational age babies, macrosomia and instrumental delivery.
4.10.5 PP Early lifestyle intervention should be offered to pregnant women with PCOS, given
the risk of higher baseline weight, excess gestational weight gain and pregnancy
complications.
4.10.6 PP Blood pressure measurement should be performed when planning pregnancy or

seeking fertility treatment, given the high risk of hypertensive disorders in pregnancy
and the associated comorbidities in women with PCOS.
4.10.7 PP An OGTT should be offered to all women with PCOS when planning pregnancy or
seeking fertility treatment, given the high risk of hyperglycaemia and the associated
comorbidities in pregnancy. If not performed in the preconception phase, an OGTT
should be offered at the first antenatal visit and repeated at 24-28 weeks gestation.
28
No. Grade/
4.11 Metformin in pregnancy
4.11.1 EBR Healthcare professionals should be aware that metformin in pregnant

women with PCOS has not been shown to prevent:
● gestational diabetes
● late miscarriage (12 weeks +1 day to 21 weeks +6 days gestational age)
● hypertension in pregnancy
● pre-eclampsia
● macrosomia or birthweight ≥ 4000 g.
4.11.2 EBR Metformin could be considered in some circumstances (e.g. risk for preterm birth),
to reduce preterm delivery and limit excess gestational weight gain, in pregnant
women with PCOS.
4.11.3 PP Women should be counselled that the consequences of metformin exposure on

long-term offspring health remain unclear and there is a suggestion of increased
childhood weight, although causality is not certain.
4.11.4 PP Side-effects of metformin are mostly mild, transient gastrointestinal symptoms

and are not worse in pregnancy.
5 Assessment and treatment of infertility
General principles
PP All fertility treatment in PCOS should be guided by the fertility management algorithm.
PP Those with PCOS should be reassured that pregnancy can often be successfully
achieved either naturally or with assistance.
PP Prenatal vitamins supplementation should be commenced with ovulation induction

therapy aligned to routine preconception care.
PP Pregnancy should be excluded prior to ovulation induction therapy.
PP The use of ovulation induction agents, including letrozole, metformin and clomiphene
citrate is off-label in many countries. Where off-label use of ovulation induction agents
is allowed, healthcare professionals need to inform women and discuss the evidence,
possible concerns and side-effects.
PP There should be ongoing monitoring of patients for adverse effects and infants
for congenital anomalies in all studies conducted with ovulation induction agents
and these should be reported in any published papers.
No. Grade/
5.1 Preconception risk factors
5.1.1 EBR Women with PCOS should be counseled on the adverse impact of excess weight
on clinical pregnancy, miscarriage and live birth rates, following infertility treatment.
5.1.2 CR Consistent with routine preconception care, in women with PCOS planning
pregnancy, weight, blood pressure, smoking, alcohol, diet and nutritional status,
folate supplementation (higher dose in those with BMI > 30), exercise, sleep and
mental, emotional and sexual health should be considered and optimised to
improve reproductive and pregnancy outcomes and overall health.
5.1.3 PP A reproductive life plan and age appropriate education on optimising reproductive
health, is recommended in adolescents and women with PCOS, including healthy
lifestyle, prevention of excess weight gain, and optimising preconception risk factors.
5.1.4 PP Healthcare professionals are encouraged to seek permission and if given, to assess
weight and body mass index and initiate a dialogue on the importance of weight and
lifestyle on women’s health before pregnancy. This requires caution to avoid weight
stigma and needs to consider the cultural, social and environmental determinants
of health (see 3.6).
5.1.5 PP Chronic conditions such as diabetes, high blood pressure, anxiety, depression and
other mental health conditions, should be optimally managed and women should
be counseled regarding the risk of adverse pregnancy outcomes.
5.2 Tubal patency testing
5.2.1 CR In women with PCOS and infertility due to anovulation alone with normal semen
analysis, the risks, benefits, costs and timing and techniques of tubal patency testing
in relation to the cost and complexity of the treatment, should be considered on an
individual basis, depending on personal history and population prevalence, prior to
starting ovulation induction with timed intercourse or intrauterine insemination.
5.3 Letrozole
5.3.1 EBR Letrozole should be the first-line pharmacological treatment for ovulation induction
in infertile anovulatory women with PCOS, with no other infertility factors.
5.3.2 PP The use of letrozole is still off-label in many countries.

Where it is not allowed, clinicians should use other ovulation induction agents.
5.3.3 PP Letrozole should not be given where there is any possibility of a pre-existing
pregnancy, though there is no evidence for increased teratogenicity compared
to other ovulation induction agents.
30
No. Grade/
5.4 Clomiphene citrate and metformin
5.4.1 Metformin versus placebo
5.4.1.1 EBR Metformin could be used alone, in women with PCOS with anovulatory infertility
and no other infertility factors, to improve clinical pregnancy and live birth rates,
whilst informing women that there are more effective ovulation agents.
5.4.1.2 PP Women should be counseled as to potential mild gastrointestinal side-effects

with metformin.
5.4.1.3 PP Healthcare and resource burden including monitoring, travel and costs
are lower with metformin.
5.4.1.4 PP Consideration of age and screening for other fertility factors needs to be discussed
before prescribing metformin.
5.4.2 Clomiphene citrate versus metformin
5.4.2.1 EBR Clomiphene citrate could be used in preference to metformin in women with PCOS
with anovulatory infertility and no other infertility factors, to improve ovulation,
clinical pregnancy and live birth rates.
5.4.2.2 PP The risk of multiple pregnancy is increased with clomiphene citrate use
(alone or in combination with metformin) and therefore clomiphene cycles
may require ultrasound monitoring.
5.4.3 Clomiphene citrate and metformin versus clomiphene citrate alone
5.4.3.1 EBR Clomiphene citrate combined with metformin could be used rather than clomiphene
citrate alone in women with PCOS with anovulatory infertility and no other infertility
factors to improve ovulation and clinical pregnancy rates.
5.4.4 Clomiphene citrate and metformin versus metformin alone
5.4.4.1 EBR Clomiphene citrate combined with metformin could be used rather than metformin
alone in women with PCOS with anovulatory infertility and no other infertility factors
to improve live birth rates.
5.4.4.2 PP Monitoring of combined cycles will need to be equivalent to clomiphene citrate alone.
5.4.5 Clomiphene citrate versus Letrozole
5.4.5.1 EBR Letrozole should be used rather than clomiphene citrate in women with PCOS
with anovulatory infertility and no other infertility factors to improve ovulation,
clinical pregnancy, and live birth rates.
5.4.5.2 PP Current evidence demonstrates no difference in fetal abnormality rates between

letrozole or clomiphene citrate ovulation induction or natural conception.
No. Grade/
5.5 Gonadotrophins
5.5.1 EBR Gonadotrophins alone could be considered rather than clomiphene citrate in therapy
naïve women with PCOS with anovulatory infertility and no other infertility factors
to improve ovulation, clinical pregnancy and live birth rates (refer to PP 5.5.6).
5.5.2 EBR Gonadotrophins alone could be used over gonadotrophins combined with
clomiphene citrate in women with PCOS who are anovulatory and infertile with
clomiphene citrate resistance or failure, and no other infertility factors.
5.5.3 EBR Gonadotrophins could be considered rather than the combination of clomiphene
citrate and metformin in women with PCOS who are anovulatory and infertile,
with clomiphene citrate-resistance and no other infertility factors.
5.5.4 EBR Either gonadotrophins or laparoscopic ovarian surgery could be used in women
with PCOS who are anovulatory and infertile, with clomiphene citrate-resistance and
no other infertility factors, following counselling on higher live birth rate and higher
multiple pregnancy rates with gonadotrophins.
5.5.5 EBR Gonadotrophins could be second-line pharmacological therapy for women with
PCOS who are anovulatory and infertile, with no other infertility factors and who
have failed first-line oral ovulation induction.
5.5.6 PP Where gonadotrophins are to be prescribed, the following should be considered:

● Cost of the intervention for ovulation induction.
● Expertise required for the use of the intervention for ovulation induction.
● The degree of intensive ultrasound monitoring that is required.
● A low dose step-up gonadotrophin protocol should be used to optimise
the chance of monofollicular development.
● Implications of potential multiple pregnancy.
5.5.7 PP There appears to be no difference in the clinical efficacy of the available

gonadotrophin preparations.
5.5.8 PP When using gonadotrophins, best clinical practice is to avoid multiple pregnancy.
Considerations here include cancelling cycles when there is more than a total
of two follicles greater than 14 mm in diameter and advising avoidance of
unprotected intercourse.
5.5.9 PP Live birth rate, clinical pregnancy rate per patient and ovulation rate per cycle
are higher with gonadotrophins than with clomiphene citrate.
5.5.10 PP A low dose gonadotrophin protocol should be used to optimise the chance
of monofollicular growth and minimise multiple pregnancy.
5.5.11 PP Cycle monitoring and drug costs coupled with multiple injection will influence
choice in gonadotrophin use.
32
No. Grade/
5.6 Laparoscopic ovarian surgery
5.6.1 EBR Laparoscopic ovarian surgery could be second-line therapy for women with
PCOS who are anovulatory and infertile, with clomiphene citrate resistance
and no other infertility factors.
5.6.2 PP When using laparoscopic ovarian surgery, the following should be considered:
● Comparative cost of the intervention for ovulation induction.
● Expertise required for the safe use of the intervention for ovulation induction.
● Both intraoperative and postoperative risks, which are higher in women who
are above healthy weight.
5.7 In vitro fertilisation and in vitro maturation
5.7.0.1 CR In the absence of an absolute indication for in vitro fertilisation (IVF)/intracytoplasmic

sperm injection (ICSI), IVF could be offered in women with PCOS and anovulatory
infertility, if first- or second-line ovulation induction therapies have failed.
5.7.0.2 PP In women with anovulatory PCOS, the use of IVF is effective and when elective
single embryo transfer is used, multiple pregnancies can be minimised.
5.7.0.3 PP Women with PCOS undergoing IVF/ICSI treatment should be counselled prior to
starting treatment about the increased risk of ovarian hyperstimulation syndrome
and options to reduce the risk should be offered.
5.7.1 Gonadotrophin releasing hormone protocol
5.7.1.1 PP Gonadotrophin releasing hormone protocol (GnRH) antagonist protocol cannot be

recommended over GnRH agonist long protocol for women with PCOS undergoing
IVF/ICSI to improve clinical pregnancy or live birth rate.
5.7.1.2 PP The use of a GnRH antagonist protocol for women with PCOS undergoing IVF/ICSI
is recommended as it enables the use of an agonist trigger, with the freezing of all
embryos generated if required, without compromising the cumulative live birth rate,
to reduce the risk of significant ovarian hyperstimulation syndrome.
5.7.2 Trigger type
5.7.2.1 CR Triggering final oocyte maturation with a GnRH agonist and freezing all suitable
embryos is recommended, in an IVF/ICSI cycle with a GnRH antagonist protocol,
where a fresh embryo transfer is not intended or where there is an increased risk
of ovarian hyperstimulation syndrome.
5.7.3 Choice of follicle stimulating hormone
5.7.3.1 CR Either urinary or recombinant follicle stimulating hormone (FSH) could be used in
women with PCOS undergoing (controlled) ovarian (hyper) stimulation for IVF/ICSI,
with insufficient evidence to recommend a particular type of FSH preparation.
No. Grade/
5.7.4 Exogenous luteinising hormone
5.7.4.1 CR Exogenous recombinant luteinising hormone treatment should not be routinely

used in combination with follicle stimulating hormone therapy in women with
PCOS undergoing controlled ovarian hyperstimulation for IVF/ICSI.
5.7.5 Adjunct metformin
5.7.5.1 EBR Adjunct metformin therapy could be used before and/or during FSH ovarian
stimulation in women with PCOS undergoing IVF/ICSI treatment with GnRH agonist
long protocol, to reduce the risk of developing ovarian hyperstimulation syndrome
and miscarriage.
5.7.5.2 PP Good practice in PCOS and IVF is the use of a GnRH antagonist protocol as it gives
the flexibility of using a GnRH agonist trigger, freeze all strategy to reduce the risk of
ovarian hyperstimulation syndrome. However, if using a GnRH agonist long protocol
then metformin could be considered.
If using metformin, the following could be considered:
● Commence metformin at the start of GnRH agonist treatment.
● Gradually titrate metformin up to a dose of between 1000 mg to 2500 mg
daily in order to minimise side-effects.
● Stopping metformin therapy at the time of the pregnancy test or period,
unless the metformin therapy is otherwise indicated.
5.7.6 In vitro maturation
5.7.6.1 EBR The use of in vitro maturation (IVM) and ICSI could be considered in women with
PCOS, as an alternative to a stimulated IVF/ICSI cycle, where an embryo is frozen
and replaced in a subsequent embryo transfer cycle, acknowledging there is no risk
of ovarian hyperstimulation syndrome, but a lower cumulative live birth rate.
5.7.6.2 CR The use of IVM and ICSI could be considered prior to stimulated IVF/ICSI cycles
acknowledging both benefits and limitations.
5.7.6.3 PP IVM should only be considered in services with sufficient expertise, and advocacy
is needed for regional or national centres of expertise.
5.7.6.4 PP IVM could be offered as an option in women with prior severe ovarian
hyperstimulation syndrome and where the risk of severe ovarian hyperstimulation
syndrome is deemed unacceptably high, provided that expertise in IVM techniques
exists.
5.7.6.5 PP Evidence suggests that IVM/ICSI is less effective than standard IVF/ICSI in terms
of clinical pregnancy per patient and live birth rate per patient.
34
No. Grade/
5.8 Inositol
5.8.1 EBR Inositol in any form alone, or in combination with other therapies, should
be considered experimental therapy in women with PCOS with infertility,
with benefits and risks currently too uncertain to recommend the use of
these agents as fertility therapies.
5.8.2 PP There is limited evidence with uncertain results, on the effect of inositol on ovulation,
clinical pregnancy and live birth rates.
5.8.3 PP Side-effects and safety are not known for inositol.
5.8.4 PP Women need to be aware that these agents can have limited regulation with
variable dose, quality, consistency and combination with other agents.
5.8.5 PP Women’s personal goals and preferences should be considered when discussing
complimentary therapies.
5.9 Anti-obesity pharmacological agents
5.9.1 CR We recommend using anti-obesity agents in PCOS for reproductive outcomes

only in research settings to establish the efficacy and safety.

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International evidence-based

guideline for the assessment

Interpreting the recommendations

EBR Evidence-based recommendations: Evidence sufficient to inform a recommendation made

CR Consensus recommendations: In the absence of adequate evidence, a consensus recommendation

Conditional recommendation against the option

Conditional recommendation for either the option or the comparison

Conditional recommendation for the option

Strong recommendation for the option

Quality of the evidence is categorised (see Table 2) according to:

1 Screening, diagnostic and risk assessment and life stages

1.1 Irregular cycles and ovulatory dysfunction

1.1.1 CR Irregular menstrual cycles are defined as:

1.1.2 PP The mean age of menarche may differ across populations.

1.2 Biochemical hyperandrogenism

1.2.5 PP For the detection of hyperandrogenism in PCOS, the assessment of biochemical

1.2.6 PP It is very difficult to reliably assess for biochemical hyperandrogenism in women

1.2.11 PP Laboratories involved in androgen measurements in females should consider:

1.3 Clinical hyperandrogenism

1.3.3 CR A comprehensive history and physical examination should be completed for

1.3.4 CR Healthcare professionals should be aware of the potential negative psychosocial

1.3.7 PP Healthcare professionals should:

1.4 Ultrasound and polycystic ovarian morphology

1.4.7 PP When an ultrasound is indicated, if acceptable to the individual, the transvaginal

1.4.9 PP In patients with irregular menstrual cycles and hyperandrogenism, an ovarian

1.5 Anti-mullerian hormone in the diagnosis of PCOS

1.5.4 EBR Serum AMH should not yet be used in adolescents.

1.5.7 PP Laboratories involved in AMH measurements in females should use population

1.6 Ethnic variation

1.7 Menopause life stage

1.7.1 CR A diagnosis of PCOS could be considered as enduring/lifelong.

1.7.3 CR PCOS diagnosis could be considered postmenopause, if there is a past diagnosis,

1.7.4 CR Further investigations should be considered to rule out androgen-secreting tumours

1.8 Cardiovascular disease risk

1.8.6 CR Cardiovascular general population guidelines could consider the inclusion

1.8.8 PP Consideration should be given to the differences in cardiovascular risk factors,

1.9 Impaired glucose tolerance and type 2 diabetes risk

1.9.12 PP Insulin resistance is a pathophysiological factor in PCOS, however, clinically available

1.10 Obstructive sleep apnea

1.11 Endometrial hyperplasia and cancer

1.11.1 EBR Healthcare professionals should be aware that premenopausal women

1.11.5 PP When excessive endometrial thickness is detected, consideration of a biopsy

1.12 Risks in relatives

1.12.2 PP The cardiometabolic risk in female first-degree relatives of women with

2 Prevalence, screening and management of psychological features

2.1 Quality of life

2.2 Depression and anxiety

2.2.3 CR If moderate or severe depressive or anxiety symptoms are detected, practitioners

2.2.4 PP Severity of symptoms and clinical diagnosis of depression or anxiety should

2.3 Psychosexual function

2.4 Body Image

2.5 Eating disorders and disordered eating

2.5.2 PP If disordered eating or eating disorders are suspected, appropriately qualified

2.6 Information resources, models of care, cultural and linguistic considerations

2.6.1 Information needs

2.6.1.4 PP The diversity of the population should be considered when adapting

2.6.1.5 PP Women should be counselled on the risk of misinformation and guided to

2.6.2 Models of care

2.6.2.1 CR Models of care should prioritise equitable access to evidence-based primary