Rotterdam Criteria for PCOS Diagnosis and Management
The Rotterdam criteria require that women fulfill two of three criteria to be diagnosed with PCOS: oligo/anovulation, clinical and/or biochemical hyperandrogenism, and polycystic ovaries on ultrasound, with the exclusion of other relevant disorders. 1
Diagnostic Criteria Details
Rotterdam Criteria Components
Oligo/anovulation
- Manifests as menstrual cycle anomalies
- Includes amenorrhea, oligomenorrhea, or long cycles
Hyperandrogenism
- Can be clinical (hirsutism, acne, male-pattern hair loss)
- And/or biochemical (elevated androgen levels)
- Note: Diagnosis of hirsutism should not be based solely on the Ferriman-Gallway score 2
Polycystic Ovarian Morphology (PCOM)
- Ultrasound criteria: presence of at least 12 follicles in each ovary measuring 2-9 mm in diameter, and/or increased ovary size >10 ml 2
- These criteria must be included in the ultrasound report
Important Diagnostic Considerations
- The presence of two of these three criteria is sufficient once all other diagnoses have been ruled out 2
- Screening for elevated plasma LH is no longer necessary 2
- Testing for GnRH serves no purpose in diagnosis 2
- Recent international PCOS guidelines recommend against using ultrasound in PCOS diagnosis within 8 years of menarche 1
- Anti-Müllerian Hormone (AMH) is being investigated as a potential alternative to ultrasound for detecting PCOM, but is not yet officially part of the diagnostic criteria 1
Management Options for PCOS
First-Line Management: Lifestyle Interventions
- Lifestyle management is the first-line approach in the intervention hierarchy for PCOS 1
- Multicomponent lifestyle intervention including diet, exercise, and behavioral strategies is central to PCOS management 1
- Focus should be on weight management and healthy lifestyle behaviors 1
- For patients with BMI >30 kg/m², lifestyle modifications should precede other treatments 2
Metabolic Screening and Management
- Routine screening for metabolic abnormalities should be conducted systematically:
- Anthropometric measurements: weight, height, BMI, waist circumference
- Blood pressure
- Laboratory parameters: plasma glucose, triglycerides, HDL cholesterol 2
- For obese patients (BMI >30 kg/m²), oral glucose tolerance testing (OGTT) is recommended when fasting serum glucose is normal 2
Fertility Management
- Clomiphene citrate (CC) remains the first-line therapy for ovulation induction 2
- In patients with BMI >30 kg/m², ovulation induction should be preceded by improvement of metabolic status through appropriate lifestyle modifications 2
Management of Menstrual Irregularities and Hyperandrogenism
- Hormonal contraceptives are the first-line management for menstrual abnormalities and hirsutism/acne in PCOS 3
- Metformin is beneficial for metabolic/glycemic abnormalities and for improving menstrual irregularities, but has limited or no benefit in treating hirsutism, acne, or infertility 3
Special Populations
Adolescents
- Diagnosis of PCOS in adolescents is challenging 3
- Hyperandrogenism is central to the presentation in adolescents 3
- Hormonal contraceptives and metformin are the treatment options in adolescents with PCOS 3
Menopausal Women
- Establishing a diagnosis of PCOS is problematic in menopausal women 3
- There is no consistent phenotype in postmenopausal women 3
Evaluation for Comorbidities
- Women with PCOS should be evaluated for:
Emerging Diagnostic Approaches
- AMH is being investigated as a potential alternative to ultrasound FNPO count for detection of PCOM 1
- AMH levels are significantly higher in women with PCOS compared with normal ovulatory women 1
- However, challenges with AMH measurement include variations across the life span and problems with defining PCOM for comparison 1
The Rotterdam criteria remain the most widely accepted diagnostic framework for PCOS, though there is ongoing discussion about updating specific components, particularly the ultrasound criteria as technology advances 4.