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endo.pcos.core.v1PRODUCTION
endo.pcos.core.v1

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

endocrinologychronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

PCOS is a DIAGNOSIS OF EXCLUSION on the Rotterdam 2/3 rule: exclude thyroid / prolactin / non-classic CAH (17-OHP) / Cushing / acromegaly / androgen-secreting tumour / hypothalamic amenorrhoea / pregnancy BEFORE scoring Rotterdam (H/O/P, 2 of 3). Adolescent criteria are STRICTER (H+O, no morphology) (2023 Int’l PCOS Guideline, Teede; 2025 adolescent recommendations)

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Two-gate frame explicit: exclusion ladder named before Rotterdam scoring

Patient inputs (15)

Adolescent (<8 y post-menarche) needs STRICTER H+O criteria with no morphology; postmenopausal changes goals; reproductive-age drives fertility branch

Splits the goal-stratified regimen: fertility-seeking (letrozole) vs not (COC/anti-androgen/metabolic) — the single most important management fork

Pregnancy is an exclusion for oligo-amenorrhoea AND contraindicates COC/spironolactone/letrozole-after-conception/GLP-1 RA; PCOS raises GDM risk (route ob.gdm.core.v1)

Weight drives lifestyle-first dosing, GLP-1 RA candidacy, and metformin-vs-clomiphene choice in obese fertility patients (Cochrane 29183107)

US-MEC inputs — VTE history, migraine with aura, uncontrolled HTN, smoking ≥35 y gate combined oral contraceptive eligibility

PCOS carries elevated depression/anxiety/eating-disorder burden (genetic causal link, GWAS 30566500) — screen at diagnosis

Calculated free testosterone / free androgen index is the biochemical-hyperandrogenism Rotterdam criterion; very high total T prompts tumour workup

Thyroid dysfunction mimics ovulatory dysfunction — mandatory exclusion before Rotterdam (route endo.hypothyroidism.core.v1)

Hyperprolactinaemia mimics oligo-amenorrhoea — mandatory exclusion before Rotterdam (route endo.hyperprolactinemia.core.v1)

Early-follicular 17-hydroxyprogesterone is the CARDINAL pivot for non-classic CAH (>2 ng/mL screen, >10 ng/mL diagnostic) — must exclude before labelling PCOS

75 g OGTT (preferred over A1c/FPG in PCOS) screens IGT/T2DM at diagnosis and on a 1–3-yearly cadence — core metabolic surveillance

RAPID virilisation (deepening voice, clitoromegaly, short symptom duration) is the red-flag pivot to an androgen-secreting tumour — NOT PCOS

2023 update: AMH may substitute for ultrasound for the PCOM criterion IN ADULTS (assay-specific cutoff; NOT valid in adolescents)

Follicle count (≥20/ovary with ≥8 MHz transducer) or ovarian volume ≥10 mL — the PCOM criterion; also images an androgen-secreting ovarian mass

Obstructive sleep apnoea, MASLD/NAFLD and cardiovascular risk are part of the PCOS comorbidity stack to screen/treat

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Severity triggers (10)

10 need judgement
  • informationalsevererapid_virilisation_androgen_tumour
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenon_classic_cah_17ohp_pivot
    Elevated early-follicular 17-hydroxyprogesterone (>2 ng/mL screen, >10 ng/mL diagnostic) — non-classic CAH, NOT PCOS (2023 Int’l PCOS Guideline)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefertility_seeking_ovulation_induction
    Anovulatory subfertility, actively pursuing pregnancy — switch goal to LETROZOLE-first ovulation induction (2023 Int’l PCOS Guideline; Legro PPCOS-II)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_or_preconception_gdm_risk
    PCOS patient pregnant or planning pregnancy — elevated GDM risk (OR/RR 2.02, 95% CI 1.74–2.34) (Qiu MA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemetabolic_comorbid_igt_t2dm
    PCOS with impaired glucose tolerance / T2DM on OGTT, or high-metabolic-risk phenotype A/B with obesity/dyslipidaemia (2023 Int’l PCOS Guideline; GWAS metabolic correlation PMID 30566500)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatechronic_oligoamenorrhea_endometrial_risk
    Chronic oligo/amenorrhoea (<4 bleeds/year) with unopposed estrogen and NOT on COC — endometrial hyperplasia/cancer risk (2023 Int’l PCOS Guideline; Barry MA)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateus_mec_contraindication_to_coc
    US-MEC category 3/4 for combined hormonal contraception (VTE history, migraine WITH aura, uncontrolled HTN, smoking ≥35 years) (2023 Int’l PCOS Guideline)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildadolescent_strict_criteria
    Adolescent (<8 years post-menarche) with hyperandrogenism + irregular cycles — apply STRICTER criteria (H+O both required; NO ultrasound/AMH morphology) (2025 adolescent recommendations)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildlean_pcos_normal_bmi_phenotype
    Lean PCOS — normal BMI (commonly <25 kg/m²) yet meeting Rotterdam: insulin resistance and dyslipidaemia still occur and must NOT be assumed absent; weight-loss-centred lifestyle advice does not apply unchanged and GLP-1 RA / orlistat are not indicated (2023 Int’l PCOS Guideline)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildperimenopausal_pcos_straw10_transition
    Perimenopausal/menopausal-transition PCOS — cycles may regularise with age and ovarian ageing; PCOM/AMH lose diagnostic validity, the diagnosis is often retrospective, but cardiometabolic and endometrial surveillance must CONTINUE (2023 Int’l PCOS Guideline; STRAW+10 staging)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

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)
axis: pcos_goal_stratified_ladderstep 1 - Step 1 — Exclude mimics & lifestyle first-line for ALL (no PCOS drug yet)
Selected step "Step 1 — Exclude mimics & lifestyle first-line for ALL (no PCOS drug yet)" — Any oligo-anovulation/hyperandrogenism before labelling PCOS
  • exclude thyroid / prolactin / 17-OHP (NCAH) / Cushing / acromegaly / androgen-secreting tumour BEFORE Rotterdam
    first line
    diagnostic_exclusion_gate
    triggers: oligoamenorrhea_or_hyperandrogenism
    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)
    first line
    lifestyle_intervention
    triggers: all_pcos_phenotypes
    2023 Int’l PCOS Guideline — first-line for ALL; modest weight loss improves ovulation, hyperandrogenism and metabolic profile regardless of phenotype

outpatient playbook — drug actions (7)

  1. 1. exclude mimics + structured lifestyle (all phenotypes)
    ≥5–10% weight loss target; no PCOS drug yet • n/a • ongoing
    trigger: Any oligo-anovulation/hyperandrogenism
    PCOS is a diagnosis of exclusion; lifestyle first-line for all (2023 Int’l PCOS Guideline)
  2. 2. combined oral contraceptive
    low-dose combined OC • PO • once daily
    trigger: Menstrual irregularity / hyperandrogenism, not fertility-seeking, US-MEC permits
    First-line for menstrual + hyperandrogenism behind US-MEC gate (2023 Int’l PCOS Guideline)
  3. 3. spironolactone
    50 → 100 mg/day • PO • once–twice daily
    trigger: Hirsutism inadequate after ≥6 mo COC or COC contraindicated; contraception in place
    Anti-androgen for hirsutism, contraception MANDATORY (Alesi SR PMID 37583655)
  4. 4. metformin
    500 → 1500–2000 mg/day • PO • BID–TID with meals
    trigger: IGT/T2DM, high-metabolic-risk phenotype, anovulation adjunct
    Metabolic + ovulation benefit (Cochrane PMID 29183107); inferior to clomiphene in obese fertility
  5. 5. GLP-1 receptor agonist
    per weight-management labelling • SC • weekly/daily
    trigger: Obesity-dominant, lifestyle ± metformin inadequate, not pursuing pregnancy
    BMI −2.42, waist −5.16 cm (PMID 39178623); STOP pre-conception
  6. 6. letrozole (then clomiphene ± metformin → gonadotropins/IVF)
    letrozole 2.5 → 5–7.5 mg ×5 d • PO • cycle days 3–7
    trigger: Anovulatory subfertility, fertility-seeking
    Letrozole first-line: LB 27.5% vs clomiphene 19.1%, RR 1.44 (Legro PPCOS-II PMID 25006718)
  7. 7. cyclic progestin / LNG-IUD
    cyclic q1–3 mo or continuous IUD • PO/intrauterine • ≥4 withdrawal bleeds/year
    trigger: Chronic oligo/amenorrhoea not on COC
    Endometrial protection — endometrial-Ca OR 2.79 (Barry PMID 24688118)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Oligo/amenorrhoea (cycles >35 d or <8/year) ± infertility (2023 Int’l PCOS Guideline, Teede); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Polycystic ovary syndrome (Rotterdam 2023 — dx, metabolic, fertility)** (endo.pcos.core.v1).
Phenotype framing: MECE terminal split: PCOS (Rotterdam 2/3 after exclusion) vs non-classic CAH (17-OHP pivot) vs androgen-secreting ovarian/adrenal tumour (rapid virilisation + very high T pivot) vs hypothalamic amenorrhoea (low LH/FSH, low BMI, energy deficit, NO hyperandrogenism) vs thyroid dysfunction vs hyperprolactinaemia vs Cushing/acromegaly vs primary ovarian insufficiency. Phenotype A–D sub-classification within PCOS (2023 Int’l PCOS Guideline, Teede)
Scope: PCOS is a DIAGNOSIS OF EXCLUSION on the Rotterdam 2/3 rule: exclude thyroid / prolactin / non-classic CAH (17-OHP) / Cushing / acromegaly / androgen-secreting tumour / hypothalamic amenorrhoea / pregnancy BEFORE scoring Rotterdam (H/O/P, 2 of 3). Adolescent criteria are STRICTER (H+O, no morphology) (2023 Int’l PCOS Guideline, Teede; 2025 adolescent recommendations)

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)** — step "Step 1 — Exclude mimics & lifestyle first-line for ALL (no PCOS drug yet)".
1. exclude thyroid / prolactin / 17-OHP (NCAH) / Cushing / acromegaly / androgen-secreting tumour BEFORE Rotterdam (diagnostic_exclusion_gate, first line) — 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
2. structured lifestyle (≥5–10% weight loss; no specific diet superior) (lifestyle_intervention, first line) — 2023 Int’l PCOS Guideline — first-line for ALL; modest weight loss improves ovulation, hyperandrogenism and metabolic profile regardless of phenotype

Setting playbook (outpatient) — Exclude mimics, score Rotterdam 2/3, phenotype A–D, then deliver the GOAL-stratified plan (lifestyle for all; COC/anti-androgen for menstrual-HA; metformin/GLP-1 RA for metabolic/weight; letrozole-led for fertility; progestin for endometrial protection) with lifelong metabolic + reproductive surveillance (2023 Int’l PCOS Guideline, Teede)
3. exclude mimics + structured lifestyle (all phenotypes) ≥5–10% weight loss target; no PCOS drug yet n/a ongoing — Any oligo-anovulation/hyperandrogenism (PCOS is a diagnosis of exclusion; lifestyle first-line for all (2023 Int’l PCOS Guideline))
4. combined oral contraceptive low-dose combined OC PO once daily — Menstrual irregularity / hyperandrogenism, not fertility-seeking, US-MEC permits (First-line for menstrual + hyperandrogenism behind US-MEC gate (2023 Int’l PCOS Guideline))
5. spironolactone 50 → 100 mg/day PO once–twice daily — Hirsutism inadequate after ≥6 mo COC or COC contraindicated; contraception in place (Anti-androgen for hirsutism, contraception MANDATORY (Alesi SR PMID 37583655))
6. metformin 500 → 1500–2000 mg/day PO BID–TID with meals — IGT/T2DM, high-metabolic-risk phenotype, anovulation adjunct (Metabolic + ovulation benefit (Cochrane PMID 29183107); inferior to clomiphene in obese fertility)
7. GLP-1 receptor agonist per weight-management labelling SC weekly/daily — Obesity-dominant, lifestyle ± metformin inadequate, not pursuing pregnancy (BMI −2.42, waist −5.16 cm (PMID 39178623); STOP pre-conception)
8. letrozole (then clomiphene ± metformin → gonadotropins/IVF) letrozole 2.5 → 5–7.5 mg ×5 d PO cycle days 3–7 — Anovulatory subfertility, fertility-seeking (Letrozole first-line: LB 27.5% vs clomiphene 19.1%, RR 1.44 (Legro PPCOS-II PMID 25006718))
9. cyclic progestin / LNG-IUD cyclic q1–3 mo or continuous IUD PO/intrauterine ≥4 withdrawal bleeds/year — Chronic oligo/amenorrhoea not on COC (Endometrial protection — endometrial-Ca OR 2.79 (Barry PMID 24688118))

Non-pharmacologic actions:
- Route exclusion-positive patients OUT: thyroid → endo.hypothyroidism.core.v1; prolactin → endo.hyperprolactinemia.core.v1 (2023 Int’l PCOS Guideline)
- Urgent gynaecology/endocrinology + imaging for suspected androgen-secreting tumour (rapid virilisation / very high T) (2023 Int’l PCOS Guideline)
- Pre-conception optimisation + route to ob.gdm.core.v1 for early and 24–28-week OGTT (GDM OR 2.02, PMID 35172306)
- Reproductive-endocrinology referral for gonadotropins / laparoscopic ovarian surgery / IVF after oral-agent failure (2023 Int’l PCOS Guideline)
- Psychology/psychiatry referral for active eating disorder or suicidality on mood screen (2023 Int’l PCOS Guideline)
- Re-evaluate adolescent "at-risk" patients at reproductive maturity (2025 adolescent recommendations PMID 40069730)

AVOID / contraindication checks:
- PCOS is a diagnosis of EXCLUSION — never label/treat as PCOS before excluding thyroid / prolactin / 17 OHP (NCAH) / Cushing / acromegaly / androgen secreting tumour (2023 Int’l PCOS Guideline, Teede)
- Combined oral contraceptive gated by US MEC — avoid with VTE history, migraine WITH aura, uncontrolled HTN, or smoking ≥35 years (2023 Int’l PCOS Guideline)
- Anti androgen (spironolactone) is teratogenic (male fetus undervirilisation) — reliable contraception MANDATORY throughout therapy (2023 Int’l PCOS Guideline; Alesi SR PMID 37583655)
- STOP GLP 1 RA and teratogenic anti androgen BEFORE any conception attempt; GLP 1 RA is NOT an ovulation induction agent (2023 Int’l PCOS Guideline)
- Metformin is inferior to clomiphene for live birth in OBESE women — do not use metformin monotherapy as primary ovulation induction in obesity (Cochrane PMID 29183107)
- Chronic oligo/amenorrhoea needs endometrial protection (cyclic progestin / COC / LNG IUD) — unopposed estrogen raises endometrial cancer risk (OR 2.79; <54 y OR 4.05) (Barry MA PMID 24688118)
- Adolescent diagnosis is STRICTER — require BOTH hyperandrogenism AND ovulatory dysfunction; do NOT use ultrasound/AMH morphology in adolescents; label "at risk" and re evaluate (2025 adolescent recommendations PMID 40069730)
- Rapid virilisation + very high total testosterone is an androgen secreting tumour until proven otherwise — NOT PCOS; urgent imaging (2023 Int’l PCOS Guideline)

Monitoring

Regimen monitoring:
- 75 g OGTT at diagnosis then every 1–3 years (annually if high-risk / prior GDM / pre-pregnancy) (2023 Int’l PCOS Guideline, Teede)
- fasting lipid profile periodically; weight/BMI and BP at each visit (2023 Int’l PCOS Guideline)
- endometrial protection check — ≥4 withdrawal bleeds/year or continuous progestin in oligo/amenorrhoea (Barry MA PMID 24688118)
- on COC: re-check BP and re-screen US-MEC periodically (2023 Int’l PCOS Guideline)
- on spironolactone: serum potassium + confirm ongoing reliable contraception (Alesi SR PMID 37583655)
- on metformin: GI tolerance and B12 on long-term use (Cochrane PMID 29183107)
- depression / anxiety / eating-disorder reassessment at intervals (GWAS depression causal link PMID 30566500)
- confirm GLP-1 RA / teratogenic anti-androgen discontinued before conception attempts (2023 Int’l PCOS Guideline)

Setting (outpatient) monitoring:
- 75 g OGTT every 1–3 years (annually if high-risk/prior GDM/pre-pregnancy) (2023 Int’l PCOS Guideline)
- Fasting lipids periodically; weight/BMI + BP each visit (2023 Int’l PCOS Guideline)
- Endometrial protection adequacy in oligo/amenorrhoea (Barry MA PMID 24688118)
- Spironolactone: K + contraception confirmation; metformin: GI/B12; COC: BP + US-MEC re-screen (2023 Int’l PCOS Guideline)
- Depression/anxiety/eating-disorder reassessment (GWAS PMID 30566500)

Follow-up plan: 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)
- Close-out criterion: Lifelong surveillance, pre-conception plan and adolescent re-evaluation booked

Monitoring phase: OGTT every 1–3 years (annually if high-risk / prior GDM / pre-pregnancy); fasting lipids periodically; weight/BMI each visit; mood/eating-disorder reassessment; endometrial surveillance (ensure ≥4 withdrawal bleeds/year or progestin protection in oligo/amenorrhoea — endometrial-Ca OR 2.79); on COC re-check BP and re-screen US-MEC; on spironolactone monitor K and confirm ongoing contraception; on metformin watch GI tolerance + B12; on GLP-1 RA confirm discontinuation before any conception attempt (2023 Int’l PCOS Guideline; PMIDs 24688118, 36720508)

Disposition

Current setting: outpatient — Exclude mimics, score Rotterdam 2/3, phenotype A–D, then deliver the GOAL-stratified plan (lifestyle for all; COC/anti-androgen for menstrual-HA; metformin/GLP-1 RA for metabolic/weight; letrozole-led for fertility; progestin for endometrial protection) with lifelong metabolic + reproductive surveillance (2023 Int’l PCOS Guideline, Teede)

Disposition criteria:
- Continue outpatient (primary care / endocrinology / gynaecology / reproductive endocrinology by goal) once goal-directed plan stable (2023 Int’l PCOS Guideline)
- Route exclusion-positive (thyroid/prolactin), pregnant/pre-pregnancy (GDM), or tumour-suspected patients to the appropriate engine/specialist (2023 Int’l PCOS Guideline)

Escalation triggers (move to higher acuity):
- Rapid virilisation + very high total testosterone → urgent androgen-secreting-tumour imaging (2023 Int’l PCOS Guideline)
- Active eating disorder / suicidality on mood screen → urgent psychiatry (GWAS depression causal link PMID 30566500)
- New diabetes / severe dyslipidaemia on metabolic screen → intensify metabolic management (2023 Int’l PCOS Guideline)
- Pregnancy achieved → stop ovulation/teratogenic agents, route to ob.gdm.core.v1 (GDM OR 2.02 PMID 35172306)

Patient Action Plan

**PCOS goal-directed self-management plan**
Personalised values: phenotype, reproductive_intent, treatment_goal, bmi, ogtt_status.

**Stable, goal-directed plan working** (green):
Triggers:
- 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
Actions:
- 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)

**Changing symptoms, new medicine, or planning pregnancy** (yellow):
Triggers:
- 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
Actions:
- 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)
Contact provider when:
- 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)

**Urgent features** (red):
Triggers:
- 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
Actions:
- 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
Contact provider when:
- Always seek urgent care for rapid virilisation or self-harm thoughts (2023 Int’l PCOS Guideline; GWAS PMID 30566500)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] 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)
- [MODERATE] Elevated early-follicular 17-hydroxyprogesterone (>2 ng/mL screen, >10 ng/mL diagnostic) — non-classic CAH, NOT PCOS (2023 Int’l PCOS Guideline)
- [MODERATE] Anovulatory subfertility, actively pursuing pregnancy — switch goal to LETROZOLE-first ovulation induction (2023 Int’l PCOS Guideline; Legro PPCOS-II)

Citations

- 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) [PMID:37580314](https://pubmed.ncbi.nlm.nih.gov/37580314/)
- Cited evidence (PMID 37589624) [PMID:37589624](https://pubmed.ncbi.nlm.nih.gov/37589624/)
- Cited evidence (PMID 37580037) [PMID:37580037](https://pubmed.ncbi.nlm.nih.gov/37580037/)
- Cited evidence (PMID 37580861) [PMID:37580861](https://pubmed.ncbi.nlm.nih.gov/37580861/)
- Cited evidence (PMID 40069730) [PMID:40069730](https://pubmed.ncbi.nlm.nih.gov/40069730/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 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) — PMID:37580314
  • Cited evidence (PMID 37589624) — PMID:37589624
  • Cited evidence (PMID 37580037) — PMID:37580037
  • Cited evidence (PMID 37580861) — PMID:37580861
  • Cited evidence (PMID 40069730) — PMID:40069730