Patient handout

Polycystic ovary syndrome (Rotterdam 2023 — dx, metabolic, fertility)

PRODUCTION

1. Your condition

This handout is for polycystic ovary syndrome (rotterdam 2023 — dx, metabolic, fertility). Your care team identified this based on: oligo/amenorrhoea (cycles >35 d or <8/year) ± infertility (2023 int’l pcos guideline, teede).

Other reasons your team may use this plan: hirsutism / acne / androgenic alopecia (clinical hyperandrogenism) (2023 int’l pcos guideline); elevated calculated free testosterone / free androgen index on testing (2023 int’l pcos guideline); incidental polycystic ovarian morphology on pelvic ultrasound (≥20 follicles/ovary or volume ≥10 ml) (2023 update).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
exclude thyroid / prolactin / 17-OHP (NCAH) / Cushing / acromegaly / androgen-secreting tumour BEFORE Rotterdam	—	—	—	2023 Int’l PCOS Guideline (Teede) — PCOS is a diagnosis of exclusion; thyroid → endo.hypothyroidism.core.v1, prolactin → endo.hyperprolactinemia.core.v1, 17-OHP is the NCAH pivot
structured lifestyle (≥5–10% weight loss; no specific diet superior)	—	—	—	2023 Int’l PCOS Guideline — first-line for ALL; modest weight loss improves ovulation, hyperandrogenism and metabolic profile regardless of phenotype

Plan: PCOS goal-stratified ladder — exclude mimics → lifestyle (all) → COC (menstrual/HA, US-MEC gate) → spironolactone (hirsutism, contraception mandatory) → metformin (metabolic/anovulation) → GLP-1 RA (weight, stop pre-conception) → LETROZOLE-led fertility → endometrial progestin protection (2023 Int’l PCOS Guideline, Teede; Legro PPCOS-II NEJM 2014)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Stable, goal-directed plan working

If you have:

Cycles regular on your plan OR ≥4 periods/year if not on the pill (2023 Int’l PCOS Guideline)
Weight stable or improving; OGTT normal at last check
Hirsutism/acne stable on current treatment

Do this:

Keep up the lifestyle plan — even 5–10% weight loss improves cycles, skin and metabolism (2023 Int’l PCOS Guideline)
Take the pill / anti-androgen / metformin exactly as prescribed (2023 Int’l PCOS Guideline)
Keep your diabetes (OGTT) and cholesterol checks on schedule (2023 Int’l PCOS Guideline)
If you have fewer than 4 periods a year and are not on the pill, ask about progestin protection (Barry MA PMID 24688118)
If you plan a pregnancy, contact your provider FIRST — some medicines must be stopped and letrozole is the preferred fertility tablet (Legro PPCOS-II PMID 25006718)

YELLOW — Changing symptoms, new medicine, or planning pregnancy

If you have:

New or worsening hair growth, acne, or weight gain
Mood low, anxious, or disordered eating
Planning pregnancy, or a positive pregnancy test
Periods stopped completely for several months

Do this:

If planning pregnancy or newly pregnant — contact your provider NOW; stop weight-loss injections / anti-androgen and arrange diabetes screening (2023 Int’l PCOS Guideline; GDM risk PMID 35172306)
Do not start/stop your own medicines; book a review (2023 Int’l PCOS Guideline)
Report low mood or eating concerns — these are common with PCOS and treatable (GWAS PMID 30566500)
No periods for 3+ months and not on the pill → arrange endometrial protection review (Barry MA PMID 24688118)

Call your provider if:

Planning or confirmed pregnancy (2023 Int’l PCOS Guideline)
Persistent low mood, anxiety, or disordered eating (GWAS PMID 30566500)
No periods for 3 or more months off the pill (Barry MA PMID 24688118)

RED — Urgent features

If you have:

Rapid deepening of voice, new male-pattern balding, or clitoral enlargement over weeks–months
Thoughts of self-harm
Severe abdominal pain / very heavy abnormal bleeding

Do this:

Seek urgent medical care — rapid virilisation needs prompt evaluation for a hormone-producing tumour (2023 Int’l PCOS Guideline)
For thoughts of self-harm, contact emergency services or a crisis line now
Bring your medication list and recent results

Call your provider if:

Always seek urgent care for rapid virilisation or self-harm thoughts (2023 Int’l PCOS Guideline; GWAS PMID 30566500)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Rapid virilisation (voice change, clitoromegaly, frontal balding, short symptom duration) + very high total testosterone (commonly cited >150–200 ng/dL) — androgen-secreting ovarian/adrenal tumour, NOT PCOS (2023 Int’l PCOS Guideline, Teede)

5. Follow-up

Lifelong metabolic + reproductive surveillance. Pre-conception optimisation: weight, glycaemia, stop GLP-1 RA / teratogenic anti-androgen, plan letrozole-led ovulation induction, and route to ob.gdm.core.v1 for early + 24–28-week OGTT (GDM OR 2.02). Reinforce lifestyle, endometrial protection in oligo/amenorrhoea, mood support, and CV-risk follow-up; re-evaluate adolescent "at-risk" patients at maturity (2023 Int’l PCOS Guideline; 2025 adolescent recommendations; PMID 35172306)

6. Sources

Guideline: 2023 International Evidence-based Guideline for the Assessment and Management of PCOS (Teede et al.; endorsed by ASRM/ESHRE/Endocrine Society; 254 recommendations) + 2025 international adolescent recommendations; reconciled with Legro PPCOS-II (NEJM 2014), Cochrane metformin reviews, guideline-commissioned anti-androgen/inositol systematic reviews, and the guideline-commissioned + independent AMH-diagnostic-accuracy and 17-OHP NCAH-screening meta-analyses (Bayesian LR ledger)