Understanding PCOS.
A comprehensive, evidence-based guide to polycystic ovary syndrome for Australian women. From the 2023 international guideline through diagnosis, treatment, daily management, and fertility, with current research citations throughout.
What is PCOS?
Polycystic ovary syndrome (PCOS) is a common hormonal condition affecting the ovaries, metabolism, and reproductive system. Despite its name, PCOS is not primarily about cysts on the ovaries. The “cysts” are actually small, immature follicles (antral follicles) that have not developed to the point of ovulation. The condition involves a complex interplay of hormonal imbalance, insulin resistance, and chronic low-grade inflammation.
PCOS is diagnosed using the Rotterdam criteria, which require two of three features: irregular or absent ovulation, clinical or biochemical signs of excess androgens (male-type hormones), and polycystic ovarian morphology on ultrasound. Because only two of three criteria are needed, PCOS can present very differently between individuals.
Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, Hum Reprod, 2004; Teede et al., International Evidence-Based Guideline for PCOS, 2023
How does it develop?
Insulin resistance
Approximately 50-70% of women with PCOS have insulin resistance, regardless of body weight. When cells respond poorly to insulin, the pancreas produces more to compensate (hyperinsulinaemia). Excess insulin stimulates the ovaries to produce more androgens and reduces the liver’s production of sex hormone-binding globulin (SHBG), leaving more free testosterone circulating. This is considered a central driver of the condition.
Dunaif A, Endocr Rev, 1997; Diamanti-Kandarakis and Dunaif, Endocr Rev, 2012
HPO axis disruption
The hypothalamic-pituitary-ovarian (HPO) axis is disrupted in PCOS. GnRH pulse frequency is increased, which favours luteinising hormone (LH) secretion over follicle-stimulating hormone (FSH). The resulting elevated LH-to-FSH ratio drives excess ovarian androgen production and disrupts normal follicular development, preventing the dominant follicle from maturing and ovulating.
Balen AH et al., Hum Reprod Update, 2016; McCartney and Marshall, Endocr Rev, 2016
Genetic factors
PCOS has a strong hereditary component, with heritability estimated at approximately 70%. Genome-wide association studies have identified multiple susceptibility loci linked to gonadotrophin action, insulin signalling, and androgen biosynthesis. Having a mother or sister with PCOS substantially increases your risk, though the condition is polygenic with no single causative gene.
Vink et al., J Clin Endocrinol Metab, 2006; Day et al., PLoS Genet, 2015
Chronic low-grade inflammation
Women with PCOS show elevated inflammatory markers (C-reactive protein, IL-6, TNF-alpha) independent of obesity. This chronic inflammation contributes to insulin resistance, impairs follicular development, and may underlie the increased cardiovascular risk seen in PCOS. It also drives some of the fatigue and malaise women experience.
Gonzalez F, Steroids, 2012; Repaci et al., J Endocrinol Invest, 2011
Prevalence
Jean Hailes for Women's Health; Teede et al., 2023
March et al., Hum Reprod, 2010
PCOS Australian Alliance, 2023
Vink et al., J Clin Endocrinol Metab, 2006
Teede et al., International Evidence-Based Guideline for PCOS, 2023
PCOS phenotypes
The four PCOS phenotypes arise from the Rotterdam criteria, which require two of three features for diagnosis. The phenotype matters because metabolic risk, symptom burden, and management priorities differ between them. The 2023 international guideline emphasises that all four phenotypes are valid PCOS diagnoses, though metabolic screening should be adjusted to phenotype.
Teede et al., International Evidence-Based Guideline for PCOS, 2023; Rotterdam ESHRE/ASRM, 2004
Phenotype A (Classic, full)
Meets all three Rotterdam criteria: hyperandrogenism, oligo-anovulation, and polycystic ovarian morphology. This is the most metabolically severe phenotype, with the highest rates of insulin resistance, dyslipidaemia, and metabolic syndrome. It accounts for roughly 40-45% of PCOS diagnoses.
Lizneva et al., Fertil Steril, 2016; Daan et al., J Clin Endocrinol Metab, 2014
Phenotype B (Classic, no PCO morphology)
Has hyperandrogenism and oligo-anovulation but does not show polycystic ovaries on ultrasound. Metabolic risk is comparable to Phenotype A. This phenotype underscores that PCOS is not defined by ovarian appearance alone. Accounts for roughly 8-15% of diagnoses.
Lizneva et al., Fertil Steril, 2016; Clark et al., Semin Reprod Med, 2014
Phenotype C (Ovulatory)
Has hyperandrogenism and polycystic ovarian morphology but ovulates regularly. Periods may be normal. Because ovulation is present, this phenotype is sometimes overlooked. Metabolic risk is intermediate, between classic phenotypes and the general population. Accounts for roughly 15-20% of diagnoses.
Dewailly et al., Hum Reprod Update, 2016; Moran et al., J Clin Endocrinol Metab, 2015
Phenotype D (Non-hyperandrogenic)
Has oligo-anovulation and polycystic ovarian morphology but no clinical or biochemical hyperandrogenism. This is considered the mildest phenotype with the lowest metabolic risk, though it can still cause significant distress through irregular cycles and fertility difficulties. Accounts for roughly 20-30% of diagnoses.
Lizneva et al., Fertil Steril, 2016; Moghetti et al., Hum Reprod Update, 2020
Teede et al., International Evidence-Based Guideline for PCOS, 2023
Signs and symptoms
PCOS presents with a wide range of symptoms that extend well beyond the reproductive system. The combination and severity of symptoms varies greatly between individuals and between phenotypes. Many women describe PCOS as affecting every area of their life.
Hyperandrogenism
Excess hair growth in a male-type pattern, affecting the face (chin, upper lip, sideburns), chest, back, and abdomen. Present in 65-75% of women with PCOS. Assessed using the modified Ferriman-Gallwey score (mFG). A score of 4-6 or above (depending on ethnicity) indicates hirsutism.
Persistent acne, typically along the jawline, chin, and lower face. Often continues well beyond adolescence and does not respond to standard skincare. Driven by androgen-stimulated sebum production. Present in 15-30% of women with PCOS.
Thinning hair on the crown and temples in a diffuse pattern, distinct from male-pattern baldness. Can be distressing and is often the symptom that prompts women to seek help. Present in approximately 22% of women with PCOS.
Azziz et al., J Clin Endocrinol Metab, 2009; Yildiz et al., Hum Reprod Update, 2010
Symptom prevalence
Metabolic features
Present in 50-70% of women with PCOS across all weight categories. Lean women with PCOS can be insulin resistant. Drives androgen production, weight gain (particularly central/abdominal), and increases risk of type 2 diabetes. Fasting insulin and OGTT are recommended for screening.
Diamanti-Kandarakis and Dunaif, Endocr Rev, 2012; Teede et al., 2023
Women with PCOS have increased rates of dyslipidaemia (elevated LDL, triglycerides, reduced HDL), hypertension, and subclinical atherosclerosis. Cardiovascular risk factors emerge early, often in the twenties and thirties. Long-term cardiovascular event data are still being accumulated.
Wild et al., J Clin Endocrinol Metab, 2010; Randeva et al., Clin Endocrinol, 2012
PCOS is associated with significantly elevated rates of depression (OR 3.78) and anxiety (OR 5.62) compared to the general population. The psychological burden stems from the visible symptoms (hirsutism, acne, alopecia, weight), fertility concerns, chronic nature of the condition, and the metabolic disturbances themselves. Screening for depression and anxiety is recommended at every PCOS visit.
Cooney et al., Hum Reprod, 2017; Dokras et al., J Clin Endocrinol Metab, 2012
Women with PCOS are 5-30 times more likely to have obstructive sleep apnoea (OSA) than weight-matched controls. OSA worsens insulin resistance, fatigue, and mental health. It is underdiagnosed in women generally, and particularly in women with PCOS. The 2023 guideline recommends screening for OSA symptoms.
Tasali et al., J Clin Endocrinol Metab, 2008; Teede et al., 2023
Economic burden
PCOS costs the Australian economy an estimated $4 billion or more per year, encompassing direct healthcare costs, fertility treatment, lost productivity, and reduced quality of life. The per-person annual cost is estimated at $5,000-$8,000 including out-of-pocket expenses, with fertility treatment adding substantially for those who need it.
PCOS Australian Alliance, 2023; Teede et al., J Clin Endocrinol Metab, 2018
Getting diagnosed
Despite being the most common endocrine condition in women of reproductive age, PCOS remains widely underdiagnosed. An estimated 70% of women with PCOS are undiagnosed, and those who do receive a diagnosis often wait years, seeing multiple clinicians before getting answers. The 2023 international guideline aimed to standardise diagnosis and reduce this gap.
March et al., Hum Reprod, 2010; Teede et al., International Evidence-Based Guideline for PCOS, 2023
The 2023 diagnostic algorithm
Rotterdam criteria (two of three required)
Cycles outside 21-35 days in adults, or cycles outside 21-45 days in adolescents within 1-3 years of menarche. Fewer than 8 cycles per year. Cycle irregularity reflects disrupted ovulation.
Clinical signs include hirsutism (mFG score 4-6+), acne, or androgenic alopecia. Biochemical hyperandrogenism is assessed via calculated free testosterone (preferred), free androgen index, or total testosterone. The guideline recommends calculated free testosterone using liquid chromatography-tandem mass spectrometry (LC-MS/MS) where available.
On transvaginal ultrasound: 20 or more follicles per ovary (2-9mm) or ovarian volume of 10mL or more, using a transducer frequency of 8MHz or higher. The threshold was increased from 12 follicles in the 2003 criteria due to improved ultrasound technology. Ultrasound is not recommended for diagnosis within 8 years of menarche because multi-follicular ovaries are a normal finding in adolescents.
Teede et al., International Evidence-Based Guideline for PCOS, 2023; Rotterdam ESHRE/ASRM, 2004
Exclusions first
Before diagnosing PCOS, other conditions that mimic its features must be excluded. These include thyroid dysfunction (TSH), hyperprolactinaemia (prolactin), congenital adrenal hyperplasia (17-hydroxyprogesterone), and rarely Cushing syndrome or androgen-secreting tumours. A standard blood panel at diagnosis includes TSH, prolactin, 17-OHP, and androgen levels.
Teede et al., 2023; Azziz et al., J Clin Endocrinol Metab, 2009
Metabolic screening at diagnosis
The 2023 guideline recommends the following metabolic assessments at diagnosis for all women with PCOS:
Teede et al., 2023; Kakoly et al., Clin Endocrinol, 2019
Diagnosing PCOS in adolescents
Diagnosis in adolescents (within 8 years of menarche) has specific considerations. Irregular cycles are common in the first few years after menarche, and multi-follicular ovaries are a normal finding. The 2023 guideline recommends using only hyperandrogenism and cycle irregularity for adolescent diagnosis, reserving ultrasound criteria for adults. An “at-risk” label can be applied when features are suggestive but do not yet meet full criteria, with reassessment after 3-4 years.
Teede et al., 2023; Witchel et al., Horm Res Paediatr, 2015
Diagnostic delay
March et al., Hum Reprod, 2010
Gibson-Helm et al., J Clin Endocrinol Metab, 2017
Gibson-Helm et al., 2017
Treatment options
There is no cure for PCOS. Treatment focuses on managing specific symptoms, reducing metabolic risk, and supporting overall wellbeing. The 2023 international guideline emphasises lifestyle intervention as first-line treatment for all women with PCOS, with pharmacological options added based on specific symptoms and goals.
Teede et al., International Evidence-Based Guideline for PCOS, 2023
Lifestyle modification is recommended as the first-line treatment for all PCOS symptoms and phenotypes. This includes healthy eating, regular physical activity, and behavioural strategies. The evidence supports modest weight loss (5-10% of body weight in those with overweight) for improving insulin resistance, androgen levels, cycle regularity, and fertility. However, lifestyle approaches should be framed in a weight-neutral way, focusing on health behaviours rather than numbers on a scale.
No single diet has been shown to be superior for PCOS. The Mediterranean diet is the most studied, with evidence for improved insulin sensitivity and reduced inflammation. Low-GI diets may improve menstrual regularity. Anti-inflammatory dietary patterns are reasonable. The key principle is a sustainable, balanced approach rather than restrictive dieting, which can worsen the relationship with food already strained by PCOS.
Moran et al., Cochrane Database Syst Rev, 2011; Barrea et al., J Transl Med, 2019
The guideline recommends at least 150 minutes per week of moderate-intensity exercise, or 75 minutes of vigorous exercise, plus muscle-strengthening activities on 2 or more days. Exercise improves insulin resistance, mental health, and body composition independently of weight loss. Any movement counts: walking, swimming, cycling, resistance training, yoga.
Teede et al., 2023; Harrison et al., Hum Reprod Update, 2011
Weight management is approached with weight-neutral language in the 2023 guideline. Not all women with PCOS are overweight, and weight stigma from healthcare providers is a documented barrier to care. For women who do carry excess weight, modest loss of 5-10% improves metabolic and reproductive outcomes. The focus should be on healthy behaviours and metabolic health markers rather than BMI alone.
Teede et al., 2023; Lim et al., Obes Rev, 2019
Living with PCOS
Managing PCOS is an ongoing process that involves medical treatment, daily health behaviours, and self-advocacy. Building the right team and developing sustainable routines makes a meaningful difference to both symptoms and quality of life.
PCOS is best managed with a coordinated team approach. You may not need all of these professionals at once, but knowing who to access when you need them helps.
Your main coordinator. A GP who understands PCOS will order the right tests, screen for metabolic complications, and refer appropriately. Ask whether they follow the 2023 international PCOS guideline.
For complex hormonal management, insulin resistance, and metabolic monitoring. Particularly useful for phenotypes A and B, or when standard treatment is not working.
For menstrual management, endometrial monitoring, and fertility planning. A gynaecologist with PCOS experience can manage ovulation induction if needed.
For evidence-based nutrition advice tailored to PCOS and insulin resistance. Helps navigate the overwhelming and often contradictory dietary information online. Look for someone experienced in PCOS specifically.
For managing the psychological burden of PCOS, body image concerns, disordered eating, anxiety, and depression. Consider someone experienced in chronic illness or health psychology.
For persistent hirsutism, acne, or alopecia that does not respond to first-line treatment. Can coordinate medical and cosmetic approaches.
For developing a sustainable exercise programme tailored to PCOS, insulin resistance, and your fitness level. Particularly helpful if you are new to exercise or managing other conditions.
Myths vs evidence
PCOS is surrounded by misconceptions that cause unnecessary guilt, delay diagnosis, and lead to ineffective treatment. Tap each card to see the evidence.
Additional misconceptions
Misconception: “If you have regular periods, you can’t have PCOS.”
Phenotype C (ovulatory PCOS) involves regular ovulation but with hyperandrogenism and polycystic ovarian morphology. These women still have PCOS, still have elevated androgen effects, and still have intermediate metabolic risk. Regular periods do not exclude PCOS.
Dewailly et al., Hum Reprod Update, 2016
Misconception: “You need an ultrasound to diagnose PCOS.”
An ultrasound is only one of the three Rotterdam criteria, and only two are required for diagnosis. A woman with irregular cycles and hyperandrogenism has PCOS without an ultrasound. In adolescents, ultrasound should not be used for diagnosis at all within 8 years of menarche.
Teede et al., 2023
PCOS and fertility
If fertility is part of your plan
This section covers how PCOS affects fertility and the treatment options available. If fertility is not currently relevant to you, feel free to skip ahead to the next section.
PCOS and pregnancy
If pregnancy is relevant to you
This section covers pregnancy-related considerations for women with PCOS. Skip to the next section if this is not currently relevant.
PCOS after birth
If postpartum is relevant to you
This section covers postpartum considerations for women with PCOS. Skip ahead if this is not currently relevant.
Questions for your doctor
Tick off questions as you discuss them. You can screenshot or print this list to bring to your appointment.
Getting diagnosed
Managing symptoms
Metabolic health
Fertility planning
Pregnancy
The Australian context
Australia played a leading role in developing the international evidence-based guideline for PCOS. The 2023 guideline, led by Monash University in Melbourne, involved over 3,000 health professionals and consumers from 71 countries. Despite this leadership in research, gaps remain in clinical implementation, access, and funding.
The 2023 International PCOS Guideline
The guideline, led by Professor Helena Teede at Monash University, is the most comprehensive PCOS clinical guideline ever produced. It covers diagnosis, assessment, lifestyle, psychological wellbeing, fertility, pregnancy, and long-term health. It was endorsed by over 40 medical societies globally and includes a free translation app (AskPCOS) for patients and clinicians.
Key changes from previous guidance include the recommendation of letrozole as first-line for ovulation induction (replacing clomiphene), increased ultrasound follicle threshold (from 12 to 20), emphasis on psychological screening, and weight-neutral language throughout.
Teede et al., International Evidence-Based Guideline for PCOS, Monash University, 2023
Medicare and PBS coverage
GP consultations: Bulk-billed or with Medicare rebate. A GP chronic condition management plan (which replaced Chronic Disease Management Plans in July 2025) allows up to five allied health visits per calendar year, shared across all allied health, with a Medicare rebate. These can cover appointments such as a dietitian, psychologist or exercise physiologist.
Blood tests and OGTT: Medicare-rebated when ordered by a GP or specialist. The OGTT (recommended for PCOS screening) is fully covered.
Specialist referral: Endocrinologist and gynaecologist consultations attract Medicare rebates, though gap fees vary. Access to specialists in rural and regional areas is limited.
PBS-listed medications: Metformin (PBS-listed for type 2 diabetes, used off-label for PCOS insulin resistance). Clomiphene citrate (PBS-listed for anovulatory infertility). Spironolactone (PBS-listed for other indications, used off-label for PCOS hirsutism).
Letrozole: NOT PBS-listed for ovulation induction. PBS-listed only for breast cancer. Used off-label for PCOS fertility treatment, with patients bearing the full cost. This is a significant gap between guideline recommendation and funding, given letrozole is now first-line internationally.
MBS Online, 2024; PBS Schedule, 2024; Teede et al., 2023
Support organisations
National advocacy and research translation body. Works with Monash University and the Centre for Research Excellence in PCOS. Coordinates consumer engagement in PCOS research and guideline development.
National women's health organisation with comprehensive PCOS resources, translated materials, and a free health line (1800 JEAN HAILES). Provides evidence-based consumer information on diagnosis, treatment, and lifestyle.
Free app developed alongside the 2023 guideline to help women with PCOS and their clinicians navigate evidence-based management. Includes symptom tracking, guideline summaries, and appointment preparation tools.
Australia's leading PCOS research and clinical centre. Led the development of the international guideline. Offers specialist PCOS clinics and participates in clinical trials for new treatments.
Economic burden
PCOS Australian Alliance, 2023
Teede et al., J Clin Endocrinol Metab, 2018
March et al., Hum Reprod, 2010
Access gaps and inequities
The most significant policy gap for PCOS fertility treatment in Australia. Letrozole is first-line internationally for ovulation induction, but patients must pay the full cost because it is only PBS-listed for breast cancer. Advocacy for PBS listing for PCOS is ongoing.
Women outside major cities face barriers to specialist endocrinology, gynaecology, and fertility services. Telehealth has improved access to consultations, but monitoring for ovulation induction and metabolic screening still requires in-person visits.
Despite Australia leading the guideline development, many GPs remain unaware of the 2023 recommendations, including the updated diagnostic criteria, letrozole as first-line, and the importance of psychological screening. Education and implementation are ongoing challenges.
Very limited data on PCOS prevalence and management in Indigenous Australian women. Culturally safe care pathways are needed. Insulin resistance and type 2 diabetes are already disproportionately prevalent in Indigenous communities, suggesting PCOS may be underdiagnosed.
Diagnostic thresholds for hirsutism vary by ethnicity, but clinicians may not always apply ethnicity-adjusted scoring. Translated PCOS resources are limited. Cultural attitudes toward weight, body hair, and fertility can affect how women seek care and engage with treatment.
Many women with PCOS report that their symptoms are attributed solely to their weight, with clinicians defaulting to "just lose weight" advice rather than investigating PCOS properly. The 2023 guideline explicitly addresses weight stigma and recommends weight-neutral approaches, but implementation varies.
Teede et al., 2023; Gibson-Helm et al., J Clin Endocrinol Metab, 2017; PBS Schedule, 2024
herjourney.com.au · Health education, not medical advice
Evidence: Monash PCOS Guideline 2023, Cochrane, PubMed, RANZCOG · 2014-2026 · © Her Journey 2026