Executive summary (primary care priorities)
- Think PCOS with irregular cycles + clinical/biochemical hyperandrogenism ± polycystic ovaries.
- Primary care focus: confirm diagnosis, exclude mimics, screen metabolic risk, manage symptoms (cycles, acne/hirsutism), and plan fertility pathway.
- Endometrial protection: prolonged anovulation increases endometrial hyperplasia risk—ensure regular withdrawal bleeds or effective cycle control.
Diagnosis (practical approach)
- History/exam: cycle pattern, acne/hirsutism, weight trajectory, family history of T2DM/CVD, mood, sleep/OSA symptoms.
- Exclude key differentials: thyroid disease, hyperprolactinaemia, non-classic CAH, androgen-secreting tumour (rapid virilisation), Cushing syndrome if suggested.
- Investigations commonly used: total testosterone (± SHBG/FAI per local), prolactin, TSH; consider HbA1c/fasting glucose, lipids, BP, BMI/waist.
Metabolic risk screening (don’t skip this)
- Baseline and periodic: weight/BMI, BP, HbA1c (or glucose strategy), lipid profile.
- Higher risk groups: BMI elevated, strong family history, prior gestational diabetes, or features of insulin resistance.
- Behavioural prescription: structured weight/lifestyle intervention can improve cycles, fertility, and metabolic risk.
Cycle control, acne and hirsutism (high-yield prescribing)
- COC pill is commonly used for menstrual irregularity and hyperandrogenism symptoms (ensure CHC eligibility).
- Metformin may be considered (shared decision) particularly where metabolic features/insulin resistance are prominent; it may help cycles in some.
- Hirsutism: explain slow timeline (3–6+ months). Add cosmetic/physical methods (laser, waxing) early; pharmacological options require careful contraception counselling if anti-androgens are considered (usually specialist).
- Endometrial protection: if not using a COC/LNG-IUS and cycles are very infrequent, consider periodic progestogen-induced withdrawal bleeds per local pathway.
When to refer (fast triggers)
Urgent/specialist referral if rapid-onset virilisation, very high androgens, or Cushing features. Fertility referral if trying to conceive and anovulatory infertility suspected, especially age >35 or prolonged subfertility.
Frequently asked questions
Do I need an ultrasound to diagnose PCOS?
Not always. Diagnosis can be clinical using a combination of cycle irregularity and hyperandrogenism; ultrasound may support but is not universally required, and in adolescents can be misleading.
How do I reduce endometrial risk in infrequent periods?
Ensure endometrial protection via regular cycles (e.g., COC), LNG-IUS, or planned withdrawal bleeds per local guidance if cycles are very infrequent.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.