PCOS (DRAFT)

Overview

See CKS guidelines - Polycystic ovarian syndrome for advice on diagnosis and management of PCOS in primary care.

Please also see local advice on diagnostic tests and use of USS in the diagnosis section below. 

Diagnosis

CKS guidelines (1) advise that PCOS should  be diagnosed in adults (age 18 and over) if two of three of the following criteria are present, provided other causes of menstrual disturbance and hyperandrogenism are excluded such as:Thyroid disease (thyroid stimulating hormone), Hyperprolactinemia (prolactin), Non-classic congenital adrenal hyperplasia (17-hydroxy progesterone).

Further evaluation recommended in those with amenorrhea and more severe clinical features including consideration of hypogonadotropic hypogonadism, Cushing’s disease, or suspected androgen producing tumors, noting that overt virilisation is not consistent with PCOS.

Criteria 1: Infrequent or no ovulation (usually manifested as infrequent or no menstruation).

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 
• 1 year post menarche: > 90 days for any one cycle
• 3 years post menarche to perimenopause: < 21 or > 35 days or < 8 cycles per year 

Criteria 2: Clinical and/or biochemical signs of hyperandrogenism such as hirsutism, acne, or elevated levels of total or free testosterone or raised free androgen index (FAI)*

*Local clinical scientists have confirmed that Luteinising Hormone (LH) is not a useful test in diagnosis of PCOS and is not part of the Rotterdam criteria (2,3). Raised levels of LH or LH:FSH ratio should not therefore be used in making a diagnosis.

(For further information on hirsutism please see the Hirsutism page in the Endocrinology chapter for further advice regarding investigation, and when to refer.)

Criteria 3: Polycystic ovaries on ultrasound scan, defined as the presence of 20 or more follicles (measuring 2–9 mm in diameter) in one or both ovaries and/or increased ovarian volume (greater than 10 cm³ or 10ml)

Note that:

• Polycystic ovaries do not have to be present to make the diagnosis, and the finding of polycystic ovaries does not alone establish the diagnosis.
• Women with non-Caucasian ethnicity might need different criteria to diagnose PCOS, due to ethnic variations in PCOS.
  • Evidence from a systematic review and meta-analysis suggests lowest prevalence in Chinese women, and then in ascending order of increasing prevalence for Caucasian women, Middle Eastern women and Black women
  • severity of hirsutism may vary by ethnicity but the prevalence of hirsutism appears similar across ethnicities
• In adolescents, consider investigations after only 1 year of irregular cycles if the combined oral contraceptive (COC) pill is about to be started, as COCs will mask diagnosis of PCOS by suppressing hyperandrogenemia. 
• Whilst AMH can be used for defining PCOS, this is only in accordance with diagnostic algorithms and is not needed for patients with irregular cycles and hyperandrogenism.
• AMH should not be used as a single test for the diagnosis of PCOS including in adolescents

USS for diagnosis of PCOS in BNSSG:

USS should only be used as a diagnostic test in patients in whom a diagnosis cannot be made based on clinical features and biochemical tests alone (i.e. if criteria 1 and 2 above are already met then USS should not be required).

Local radiology departments across BNSSG have therefore agreed that ultrasound requests for diagnosis of PCOS will only be accepted in the following patients:

• Patients over 18 years and greater than 8 years from the onset on menarche, who have clinical features for PCOS or hyperandrogenism, but who have normal blood results. 

Ultrasound requests that are not justified for diagnosis of PCOS will be returned by the USS departments including: 

• Patients under 18 years old.
• Patients less than 8 years since the onset of menarche.
• Suspected PCOS with oligo/amenorrhoea as the only information – bloods results are required and the referral will only be accepted if bloods are normal (see criteria 2 above).
• Patients with hyperandrogenism – biochemical and clinical (e.g. oligo/amenorrhoea, hirsutism, acne)  suggesting PCOS.  If a patient has symptoms and confirmatory bloods, the diagnosis can be made without USS.

Please see the USS requesting guidelines for details of justified USS requests agreed for BNSSG.

Management

PCOS can usually be managed in primary care and secondary care referral is rarely indicated.

Further information about management in primary care can be found below:

• CKS guidelines for management of adult with PCOS
• CKS guidelines for management of adolescents with PCOS

Other related pages that may be helpful include:

• The Hirsutism page in the endocrinology section has advice on investigation and when to refer.
• The Fertility page has advice about referral criteria for fertility issues including use of clomiphene (criteria based access policy applies).
• The Acne vulgaris page in the dermatology section.

Referral

Advice and Guidance

If  a secondary care opinion is still required then consider using advice and guidance via eRS initially :

• Gynaecology advice and guidance service
• Endocrinology advice and guidance service 

Referral for Fertility issues in patients with PCOS

Referrals for fertility issues in patients with PCOS (for example clomiphene prescribing) will not be accepted by gynaecology or endocrinology. Patients can be referred to fertility services but only if they fulfil criteria in the Infertility Assessment and Treatment - NHS BNSSG ICB policy. Please also see the Infertility page for further details.

Resources

References:

1. CKS guidelines - Polycystic ovarian syndrome
2. ESHRE guidance (2023): Guideline - Monash Centre for Health Research and Implementation (MCHRI)
3. Rotterdam Criteria (2003) (Please note the criteria to diagnose using USS are not up to date and criteria 3 above should be used)
4. The National Institute for Health and Care Excellence (www.nice.org.uk): Polycystic ovary syndrome: metformin in women not planning pregnancy.

Patient Information:

The following links may be helpful for patients:

• The Royal College of Obstetricians and Gynaecologists (RCOG) website (www.rcog.org.uk): Polycystic ovary syndrome: what it means for your long-term health.
• PCOS Challenge: The National Polycystic Ovary Syndrome Association (www.pcoschallenge.org).
• Verity (www.verity-pcos.org.uk).
• NHS (www.nhs.uk): Polycystic ovary syndrome.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.