Diagnosis, 2/3 of the following:

  • Oligo-ovulation/anovulation (LH:FSH >2)
    • Oligomenorrhea (>35d) or amenorrhea
  • Hyperandrogenism (clinical or biochemical)
    • Acne, androgenic alopecia, hirsutism (terminal hairs >5mm)
    • Elevated serum total/bioavailable/free testosterone or DHEAS
  • Polycystic ovaries on ultrasound

Consider waiting 8 years post-menarche before diagnosing PCOS, given likelihood for physiological anovulation of adolescence


  • b-hCG, Prolactin, TSH, FSH/LH
  • Serum total/bioavailable/free testosterone
    • If normal, unlikely PCOS (may consider repeat testing, preferably early morning)
  • Pelvic ultrasound
    • Optional if already met other criteria for PCOS

Consider endocrine work-up

    • If rapidly progressive hirsutism, lowering of the voice, and clitoromegaly
      • DHEAS >700mcg/dL, r/o virilizing tumour
      • Morning 17OHP >170ng/dL, r/o CAH or virilizing tumour
      • Abdo/Pelvic ultrasound, r/o adrenal/ovarian tumor
    • If central obesity, striae, proximal myopathy, early osteoporosis/hypertension
      • Mid-day/afternoon Cortisol, r/o Cushing's
        • If elevated, consider 24-h urine collection for free cortisol and creatinine
    • If acromegaly features,
      • IGF-1, r/o acromegaly


  • Monitor for diabetes, dyslipidemia, hypertension, weight (BMI)
  • Weight loss (diet, exercise) first-line
  • Combined OCP for hyperandrogenism, irregular menses , contraception
    • For hirsutism, if OCP not effective after 6 months, consider adding Spirinolactone 50-100mg/day
  • If desires pregnancy, target of BMI <35 and/or 5% to 10% weight loss
    • Letrozole first-line medication for infertility
    • Clomiphene citrate
    • Consider adding Metformin to Clomiphene citrate