Recommendations From the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome

Helena J. Teede; Marie L. Misso; Michael F. Costello; Anuja Dokras; Joop Laven; Lisa Moran; Terhi Piltonen; Robert J. Norman; on behalf of the International PCOS


Hum Reprod. 2018;33(9):1602-1618. 

In This Article


The International Guideline for the Assessment and Management of PCOS and the related translation program aims to provide clinicians with a quality, reliable source of international EBR to guide consistent clinical practice and to empower women with evidence-based information. All recommendations were formulated after an assessment of the best available evidence, multidisciplinary clinical expertise, consumer preferences and structured review by the five GDGs. Detailed methods for stakeholder engagement and guideline development can be found at The guideline provides 166 recommendations: EBR = 31, clinical consensus recommendations (CCR) = 59, and clinical practice points (CPP) = 76. Overall, evidence is of low to moderate quality, requiring significant research expansion in this neglected, yet common condition.

We endorse the Rotterdam PCOS Diagnostic Criteria in adults (two of oligo- or anovulation, clinical and/or biochemical hyperandrogenism, or polycystic ovaries on ultrasound), after exclusion of related disorders. Where both oligo- or anovulation and hyperandrogenism are present, ultrasound is not necessary for diagnosis. In adolescents, both oligo-anovulation and hyperandrogenism are required, with ultrasound not recommended for diagnosis. Ultrasound criteria are refined with advancing technology. Anti-Müllerian hormone levels are not yet adequate for diagnosis of PCOS. Insulin resistance is recognized as a key feature of PCOS, yet clinical measurement is not recommended at the current time. Once diagnosed, assessment and management includes reproductive, metabolic, and psychological features. Education, self-empowerment, multidisciplinary care and lifestyle intervention for prevention or management of excess weight are prioritized. Depressive and anxiety symptoms should be screened, assessed and managed, and health professionals should be aware of other impacts on emotional wellbeing and quality of life. Combined oral contraceptive pills are first-line pharmacological management for menstrual irregularity and hyperandrogenism, with no specific formulation recommended and with low-dose preparations preferred. Metformin is recommended in addition or alone, primarily for management of metabolic features. Letrozole is first-line pharmacological infertility therapy; with clomiphene and metformin both having a role, alone and in combination. In women with PCOS and anovulatory infertility, gonadotrophins are second line. In the absence of an absolute indication for IVF, women with PCOS and anovulatory infertility could be offered IVF third line where other ovulation induction therapies have failed.

The combined effects of the provision of a single source of evidence-based recommendations and a comprehensive international translation and dissemination program will amplify the impact of the guideline and recommendations globally. It will support and build the capability of health professionals to deliver high-quality, evidence-based assessment and management of PCOS and will augment the health literacy and self-management of PCOS health consumers. The guideline recommendations are protected under copyright, however the process for adaption of guideline recommendations to the regional context is available at The guideline and translation program will contribute to early diagnosis and improved health outcomes, and promote best-practice PCOS models of care. The translation program will be inclusive of a range of outputs such as the first evidence-based PCOS APP (AskPCOS), a rigorously developed question prompt list to optimize health professional engagement, health literacy enhancing tools, comprehensive PCOS-related health information; internationally accessible health professional accredited courses, webinars with international expert panels, and e-health information resources available at Most importantly, the guideline and translation of the guideline is expected to improve patient experiences through the provision of timely and accurate diagnosis, accessible evidence-based information and improved multidisciplinary support. Ultimately, this initiative may serve as an exemplar for international collaborative engagement and healthcare impact. Key elements included extensive collaboration, broad stakeholder representation, including consumer partnership, distributive leadership, adequate funding, robust project management and governance, adherence to best practice and integrated comprehensive translation and evaluation.