From the Guidelines
The Rotterdam criteria for diagnosing polycystic ovary syndrome (PCOS) require the presence of at least two out of three features: oligo/anovulation, clinical and/or biochemical hyperandrogenism, and polycystic ovaries on ultrasound, as defined in the most recent evidence-based guideline for the assessment and management of PCOS 1. The management of PCOS depends on the patient's primary concerns and reproductive goals.
- For women not seeking pregnancy, combined hormonal contraceptives are first-line treatment to regulate menstrual cycles and reduce androgen effects.
- Metformin helps improve insulin sensitivity and may restore ovulation.
- For hirsutism, options include spironolactone, finasteride, or flutamide, though these require contraception due to teratogenicity.
- For women seeking pregnancy, letrozole is the preferred ovulation induction agent, with clomiphene citrate as an alternative. Weight loss of 5-10% in overweight patients can significantly improve symptoms and fertility, as supported by the 2020 evidence-based guideline 1. Lifestyle modifications, including regular exercise and a balanced diet, are fundamental to PCOS management, as they address the metabolic aspects of the syndrome and can improve insulin resistance, which underlies many PCOS symptoms. The diagnostic accuracy of androgen measurement in PCOS is crucial, and the most recent systematic review and diagnostic meta-analysis inform evidence-based guidelines for the diagnosis of PCOS 1. The most accurate androgen measurement for detecting biochemical hyperandrogenism among women with PCOS should be based on the latest evidence, considering the limitations and challenges of current methods, as discussed in the 2025 systematic review 1.
From the Research
Definition of Rotterdam Criteria
The Rotterdam criteria are used to diagnose polycystic ovary syndrome (PCOS) and require the presence of two of the following three criteria:
Diagnosis of PCOS
The diagnosis of PCOS is primarily clinical, based on the presence of at least two of the three Rotterdam criteria 5.
- The ultrasound definition of PCOS contains precise criteria that must be included in the report: presence of at least 12 follicles in each ovary measuring 2-9 mm in diameter, and/or increase in ovary size >10 ml 2
- Diagnosis of hirsutism should not be based on the Ferriman-Gallway score 2
- Screening for elevated plasma LH is no longer necessary, and testing for GnRH serves no purpose 2
Management Options
Management options for PCOS include:
- Hormonal contraceptives as the first-line management for menstrual abnormalities and hirsutism/acne in PCOS 4, 5
- Clomiphene citrate (CC) as the first-line therapy for ovulation induction, which should be preceded by improvement of metabolic status through appropriate lifestyle modifications in patients with BMI >30 2, 4
- Metformin as beneficial for metabolic/glycemic abnormalities and for improving menstrual irregularities, but it has limited or no benefit in treating hirsutism, acne, or infertility 4, 5
- Lifestyle modification, including caloric restriction and increased physical activity, as the foundation of therapy 5
- Letrozole as first-line therapy for ovulation induction in patients who want to become pregnant 5
- Antiandrogens such as spironolactone as second-line agents for dermatologic complications such as hirsutism and acne 5
Screening and Prevention
Screening for metabolic abnormalities should be carried out systematically based on weight, height, and BMI, waist circumference, blood pressure, and laboratory parameters: plasma glucose, triglycerides, HDL cholesterol 2