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An update on the international evidence-based guidelines for the assessment and management of PCOS

In august 2023 the latest evidenced-based guidelines for the assessment and management of PCOS were published. Thousands of healthcare professionals and women contributed to the guidelines, which were developed by over 100 experts and patients from 71 countries.

International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2023

Key take-aways from the guidelines include:

  • An update in how PCOS can be diagnosed (Anti-Mullerian hormone can now be used)

  • We need to consider giving PCOS a new name

  • Weight stigma is rife in the world of PCOS, health care professionals need to manage this with more care

  • PCOS is not just a physical condition, support should be offered for depression and anxiety alongside other treatment

  • Personalised treatment plans are required for patients as PCOS manifests differently for everyone, there is no one size fits all approach

It’s great to see more detail being added to how PCOS is diagnosed as this is often such a contentious issue. So many women are told they have ‘borderline’ PCOS, or that they might have PCOS or that they have some symptoms but don’t ‘look like’ they have PCOS.

Here are how the guidelines have provided more clarity:

For years we’ve used the Rotterdam criteria to help diagnose PCOS, and whilst we will continue to do so going forward. It’s important to know that there have been some changes made. If you have not yet been diagnosed with PCOS then this could be really helpful in aiding you to get an accurate diagnosis.

Let’s start by looking at what the Rotterdam criteria is. To be diagnosed according to the

Rotterdam criteria you need to have 2 of the following 3 symptoms:

  1. Hyperandrogenism – elevated male hormones

  2. Ovulatory dysfunction – irregular or absent periods

  3. Polycystic ovaries – the presence of cysts on your ovaries


Here is more detail on how these three symptoms can be used to diagnose PCOS:

1. Hyperandrogenism (elevated testosterone levels) – this can be diagnosed by looking at physical symptoms such as hirsutism (male pattern hair growth on face, chest and back), acne and hair loss

  • When using blood tests total and free testosterone should be used.

  • It’s important to note that the combined oral contraceptive can mask hyperandrogenism therefore, this needs to be withdrawn for a minimum of three months in order to accurately diagnose PCOS.

  • The 2023 guidelines also note that the reference ranges used are arbitrary and most likely include a population sample which contains those with PCOS, making them inaccurate.

2. Ovulatory dysfunction – more detail has been provided to help diagnose adolescents.

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

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.

3. Cysts on the ovaries via transvaginal ultrasound OR elevated Anti-Mullerian hormone (AMH)

  • Previously the requirement was 12 or more follicles measuring 2-9 mm throughout the entire ovary or an ovarian volume ≥ 10 ml. The threshold has now changed to > 20 follicles in at least one ovary

  • Follicle counts should not be used when diagnosing adolescents due to inaccuracies

  • AMH can now be used due to the challenges faced when trying to diagnose with ultrasounds. It is important that only one (either AMH or ultrasound) are used to avoid over diagnosis

  • Testing AMH is not required in those with irregular menstrual cycles and hyperandrogenism as they already meet two of the three criteria

  • AMH should not be used as a single test for PCOS or in adolescents#

These guidelines are a huge step in the right direction and I’m hoping they will go a long way in helping diagnose PCOS earlier and pave the way for better treatment.

You can find the guidelines here.


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Uncover the 3 simple, highly-effective steps used by myself and all my clients to improve their PCOS symptoms, regain their confidence and live a life they love with PCOS (without dieting). 

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