2023 International Evidence-Based Guideline
PCOS Diagnosis & Workup
Tick the features your patient has and see whether the diagnostic criteria are met, with the 2023 guideline's refinement of the Rotterdam criteria (including the AMH pathway). Plus the recommended workup and a management framework — a reference, not a recommendation.
⚠ A diagnostic aid, not a diagnosis. This tool reflects the published criteria only. PCOS is a diagnosis of exclusion — the criteria apply only after excluding other causes of the features (see the exclusions section). It does not interpret results, order tests, or manage the patient. The diagnosis is the clinician's, made on the full picture.
Diagnostic criteria (adults)
In adults, PCOS requires at least 2 of 3 features, after excluding other causes. The 2023 guideline refines Rotterdam: where both irregular cycles and hyperandrogenism are present (~70% of cases), ultrasound/AMH is not required. Where only one is present, pelvic ultrasound or AMH (not both) is needed.
Adolescents — a stricter rule
In adolescents, both irregular cycles and hyperandrogenism are required. Ultrasound and AMH should NOT be used to diagnose PCOS within 8 years of menarche (PCOM is common and non-specific in this group). Those with features but not meeting full criteria are considered "at risk" and reassessed over time.
Exclude these first
PCOS is a diagnosis of exclusion. Consider and exclude conditions that mimic the features before applying the criteria:
- Thyroid dysfunction — TSH
- Hyperprolactinaemia — prolactin
- Non-classical congenital adrenal hyperplasia — 17-hydroxyprogesterone
- Where clinically indicated: Cushing's syndrome, androgen-secreting tumour (rapid virilisation, very high androgens), acromegaly, primary ovarian insufficiency
Recommended workup
Reflecting the guideline. The specific tests for an individual are the clinician's decision.
Confirm/assess hyperandrogenism
Calculated free testosterone, free androgen index, or calculated bioavailable testosterone using a reliable assay. Total testosterone alone is a poor measure.
Exclusion bloods
TSH, prolactin, 17-hydroxyprogesterone; further tests (e.g. for Cushing's) only if clinically indicated.
Ultrasound / AMH
Only where needed for diagnosis (i.e. only one of irregular cycles or hyperandrogenism present). Not in adolescents within 8 years of menarche.
Cardiometabolic screen (all with PCOS)
The guideline recommends assessing weight/BMI, blood pressure, fasting lipids, and a glycaemic assessment — an oral glucose tolerance test is preferred, especially before pregnancy or with additional risk factors. Reassess periodically given elevated lifelong cardiometabolic risk.
Psychological screen
Screen for anxiety and depressive symptoms in all; consider eating disorders, body image and psychosexual concerns. PCOS is a psychological as well as reproductive/metabolic condition.
Sleep
Consider screening for obstructive sleep apnoea where symptoms suggest it.
Management framework
A descriptive map of the domains the guideline addresses — not a treatment recommendation for any individual. Choice of therapy is individualised by the clinician and patient against the full guideline.
Lifestyle & cardiometabolic
Healthy lifestyle is recommended for all, framed around general health and prevention rather than weight alone, with attention to weight stigma and psychological wellbeing. No specific diet is recommended over another. Address modifiable cardiometabolic risk over the long term.
Menstrual regulation & endometrial protection
The guideline discusses combined oral contraceptives as an option for managing irregular cycles and clinical hyperandrogenism, and notes endometrial-protection considerations with prolonged amenorrhoea. Agent choice and contraindications are individualised — see the
UKMEC eligibility reference for safety by condition.
Hyperandrogenism (hirsutism/acne)
Cosmetic and pharmacological options are described in the guideline, including combined hormonal contraception and, in some contexts, anti-androgen therapy with appropriate contraceptive cover. Specifics are individualised.
Metabolic (insulin resistance)
Metformin is discussed as an option in some contexts, particularly with metabolic features or for weight and metabolic outcomes. The guideline also addresses the emerging evidence around newer agents. Use is individualised and off-label considerations apply.
Fertility & infertility
For anovulatory infertility the guideline addresses first-line ovulation induction and stepped options through to assisted reproduction, with attention to PCOS pregnancy risks. This is generally specialist-shared care.
Psychological
Screen and manage anxiety, depression and quality-of-life impacts; offer information and support. The patient-facing
AskPCOS resources are evidence-based and free.
Educational reference only. This page summarises published diagnostic criteria and the structure of the 2023 International Guideline. It does not diagnose, interpret investigations, or recommend treatment for any individual — those are clinical decisions for the treating practitioner using the full guideline. Confirm current criteria and management at the
source guideline. Not medical advice.
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