PCOS
Red Flags — not PCOS until excluded
| Red flag | Condition to exclude | Action |
|---|---|---|
| Rapid onset severe virilisation (clitoromegaly, deep voice, marked alopecia within months) | Androgen-secreting tumour. PCOS does not cause rapid severe virilisation. Testosterone about 6–7 nmol/L or higher (or any virilisation) means urgent referral; about 5 nmol/L or higher warrants prompt confirmation and investigation. Neither is a diagnosis. | Urgent endocrinology referral; do not start COC first |
| Central obesity, purple striae, easy bruising, proximal weakness, hypertension | Cushing's syndrome. Elevated cortisol suppresses GnRH causing oligomenorrhoea with hyperandrogenism. | Overnight dexamethasone suppression test or late-night salivary cortisol; endocrinology |
| Galactorrhoea (spontaneous nipple discharge) | Hyperprolactinaemia causes oligo/amenorrhoea and can be misdiagnosed as PCOS without prolactin measurement. | Prolactin + MRI pituitary |
| Amenorrhoea + vasomotor symptoms <40 years | Premature ovarian insufficiency (POI) must be distinguished. FSH differentiates: high in POI, normal-low in PCOS. | FSH x2 six weeks apart; oestradiol; POI clinic |
| Severely elevated testosterone (about 6–7 nmol/L or higher) | PCOS rarely causes testosterone around or above 5 nmol/L. This is severe biochemical androgen excess — not proof of a tumour or CAH; confirm with a reliable assay (preferably LC-MS/MS). | Urgent endocrinology/gynaecology assessment; ovarian/adrenal imaging as the specialist directs |
Safeguarding Considerations
👴 Body dysmorphia and eating disorders
- Severe body image distress in PCOS can lead to disordered eating and exercise behaviours
- Screen for eating disorder (EDE-Q or direct questioning) if BMI dropping rapidly or extreme dietary restriction reported
- Refer to eating disorder service if identified
🧠 Suicide risk in severe PCOS distress
- Infertility + cosmetic symptoms + depression: elevated suicide risk
- Suicidal ideation or expressed hopelessness (PHQ-9 ≥15 alone = prompt review, not automatically same-day) → same-day mental health assessment
- Never dismiss psychological symptoms as secondary to PCOS
🕊 Fertility coercion
- Pressure to conceive against patient's wishes is reproductive coercion
- Explore fertility intent in a one-to-one setting if partner is present and controlling behaviour is suspected
🌼 Cultural pressure and stigma
- South Asian women report higher PCOS-related stigma from family and cultural expectations around fertility and appearance
- Explore cultural context sensitively without assumptions
👴 Body image and self-esteem
Hirsutism and acne have profound effects on self-esteem, social confidence, sexual function and quality of life. Body image dissatisfaction in PCOS is comparable to eating disorder populations in validated studies.
"Has the hair growth or skin been affecting your confidence or how you feel about yourself? I want to make sure we address that directly."🧠 Depression and anxiety
The International PCOS guideline 2023 explicitly recommends screening for depressive and anxiety symptoms in all adults with PCOS. 34–57% of women with PCOS have depression or anxiety. Screen with PHQ-9 and GAD-7. Treat in parallel with physical symptoms.
"How has your mood been? I ask because depression and anxiety are really common with PCOS and it's something I want to address alongside everything else."🕊 Fertility anxiety
Many women with PCOS are told they will "struggle to have children" without qualification. Most women with PCOS do achieve pregnancy, with or without treatment. Accurate prognostic framing reduces unnecessary anxiety.
"Most women with PCOS do go on to have families — the irregular ovulation is very treatable. I don't want you to feel this is a barrier."👤 Cultural and family pressure
Cultural pressure around weight, fertility, and cosmetic appearance can be immense. Women from South Asian backgrounds report particularly high PCOS-related stigma. The GP must explore this without assumptions.
"Is there any pressure from family or your wider community that's been adding to how you're feeling?"- Not asking fertility intention before prescribing COC
- Not screening for Cushing's, prolactinoma, or tumour
- Ignoring psychological impact of cosmetic symptoms
- Diagnosing PCOS on USS alone (1 criterion only)
999 / Urgent
Immediate- Suspected androgen-secreting tumourRapid severe virilisation → urgent testosterone and urgent endocrinology referral (imaging specialist-led); do not start COC first
- Suicidal ideation secondary to PCOS distressSame-day MH crisis referral; safety plan
Specialist input
Weeks- Cushing's syndrome featuresOvernight dexamethasone suppression test or late-night salivary cortisol; endocrinology
- Testosterone >4 nmol/LRefer to endocrinology; about 5 nmol/L or higher: confirm (LC-MS/MS) and investigate promptly; about 6–7 nmol/L or higher: urgent — not proof of tumour or CAH
- POI suspected (<40 with vasomotor + amenorrhoea)FSH x2; oestradiol; POI clinic
GP-managed
Planned- PCOS diagnosis and first managementRotterdam criteria; investigations; lifestyle; COC or metformin or fertility plan
- Annual reviewBP, weight and mood yearly; glucose every 1–3 years (75 g OGTT preferred; yearly if HbA1c 42–47); lipids per result and CV risk
- Fertility referral (letrozole pathway)Folic acid; early fertility clinic referral — do not delay for weight loss
"PCOS is a hormonal condition where the ovaries produce slightly too many male-type hormones. This can disrupt the monthly ovulation process, causing irregular periods, and can also cause the skin and hair effects you've been noticing. The good news is that it's very manageable, and most women with PCOS do go on to have families if that's something they want."
PCOS (2/3 Rotterdam criteria)
Four phenotypes (oligo+HA+PCOM; oligo+HA; HA+PCOM; oligo+PCOM). Manage in primary care with appropriate monitoring. Cosmetic, fertility and metabolic domains all addressed.
Androgen-secreting tumour
Rapid onset, severe virilisation, testosterone about 6–7 nmol/L or higher. Urgent endocrinology referral.
Cushing's syndrome
Central obesity, purple striae, proximal weakness. Overnight dexamethasone suppression test or late-night salivary cortisol; endocrinology.
Hypothyroidism / Hyperprolactinaemia
TSH and prolactin screen for all PCOS presentations. Both cause oligo/amenorrhoea; treatable.
Validate
Name the most distressing symptom specifically before moving to investigations or management.
"The hair and skin changes have been really affecting your confidence — I want to make sure we address that directly, not just the irregular periods."Explain
Frame PCOS as a spectrum, manageable condition. Most women with PCOS live full reproductive lives with appropriate treatment.
"PCOS is common, it's manageable, and most women with it go on to have families. The main aim of treatment is to address whatever is bothering you most right now, while looking after your health long-term."Agree a plan
Three domains to address: cosmetic, fertility, metabolic. Today should address all three with appropriate prioritisation.
"I'd like to think about three things today — the symptoms affecting your appearance, the fertility side, and keeping your long-term health in the best shape. What feels most important to focus on first?"Reduces insulin resistance → reduces androgen production from theca cells → restores ovulation. Also reduces acne and hirsutism severity. Where excess weight is present, modest weight loss may restore ovulation; agree an individualised goal rather than a fixed percentage.
NHS Tier 2/3 weight management referral. Low GI diet reduces insulin spikes. Bariatric surgery for BMI >40 if indicated. Screen for disordered eating first; do not delay fertility referral for weight loss.
Improves insulin sensitivity independently of weight loss. Resistance training increases muscle mass (glucose sink). Aerobic exercise reduces CVD risk and improves mood (depression in PCOS).
NHS exercise on prescription referral where available. Walking + resistance band programme minimum. International PCOS guideline 2023: physical activity is part of the lifestyle management recommended for all women with PCOS.
High GI foods cause insulin spikes driving androgen production. Mediterranean diet reduces TG, improves HDL, reduces insulin resistance and endometrial cancer risk.
Advise oats, pulses, non-starchy vegetables; reduce refined carbohydrates and processed foods. NHS dietitian referral for structured guidance.
"This pill will regulate your cycle and help the acne over about 3 months; the unwanted hair takes about 6 months to judge and up to 9–12 months for the full effect. If you get a painful swollen leg or sudden breathlessness, please go to A&E and mention you're on the pill."
SCA pearl: Always ask fertility intention before prescribing COC for PCOS. Prescribing COC to a woman who says she wants children "in the next year" without exploring this = missed expectation and a scored Relating to Others deduction.
"Metformin helps your body respond better to insulin. Start with one tablet a day with food and build up slowly to reduce stomach side effects."
SCA pearl: Metformin alone does not reliably induce ovulation. International PCOS guideline 2023: letrozole is first-line for ovulation induction; metformin alone is a less effective option, considered only after discussing benefits, risks and efficacy. This distinction is a scored Tasks item.
"This tablet helps trigger ovulation. You'll need monitoring scans. It's not licenced specifically for this use but is the recommended and well-evidenced treatment for your type of irregular ovulation."
SCA pearl: The International PCOS guideline 2023 specifically recommends letrozole over clomifene as first-line for PCOS anovulation. Mentioning this correctly demonstrates up-to-date guideline knowledge — scored Tasks.
"This blocks the effect of male hormones on hair follicles. It takes 6–12 months for full effect. Reliable contraception is essential while taking it."
SCA pearl: Spironolactone is teratogenic — must always be co-prescribed with reliable contraception. Prescribing to a woman planning pregnancy = patient safety failure and scored deduction.
"Because your periods have been so infrequent, the womb lining can build up and that carries a long-term risk. These tablets will cause a withdrawal bleed and protect you from that risk."
SCA pearl: Prolonged anovulation in PCOS = endometrial hyperplasia risk. Mentioning the need for endometrial protection in amenorrhoea >90 days (not TTC, not on COC) is a scored Tasks safety item.
"Inositol is a safe supplement that may help with insulin sensitivity. The evidence is growing. It's available over the counter — a useful addition but not a replacement for other treatments."
SCA pearl: Acknowledging inositol as a safe adjunct when a patient raises it demonstrates patient-centred awareness and respects autonomy. Scores Relating to Others.
PCOS monitoring rule
Annual review: BP, BMI, mood; glucose every 1–3 years (75 g OGTT preferred; yearly if HbA1c 42–47); lipids per result and CV risk. Endometrial protection reviewed yearly (withdrawal bleed at least every 3–4 months if not on COC/LNG-IUS); no routine endometrial USS. PHQ-9 + GAD-7 at every review (International PCOS guideline 2023: screen at diagnosis, then as clinically indicated). Cervical smear and breast screening as normal schedule.
⚠ Three scenario-specific phrases
Why these safety-nets matter
- COC without fertility intent check
- Spironolactone without contraception counselling
- Diagnosed on USS alone
- No endometrial protection in prolonged amenorrhoea
- No metabolic monitoring arranged
- Fatalistic fertility message
Who you are
Priya, 24, accountant. Irregular periods since age 17 (cycles 35–90 days). Ferriman-Gallwey score approximately 10. Persistent acne despite topical treatments. BMI 31. Non-smoker. Drinks 4 units/week. Recently married. HbA1c 43 (prediabetes range) — patient unaware. Family history of T2DM (mother). South Asian ethnicity.
Hidden agenda
You are deeply distressed about the facial hair and acne — it has stopped you socialising and affects your intimacy with your husband. You believe you will never conceive naturally and have been researching IVF. You are also worried about the long-term health implications but haven't asked. You haven't been told about the prediabetes finding from a previous blood test.
If asked directly
- Yes, you want children — "probably in the next 1–2 years"
- No contraception currently (married, not actively TTC but "not preventing")
- Mood: "pretty low most of the time because of how I look" — PHQ-9 would score ~13
- Periods: last period 11 weeks ago; before that, 8 weeks gap
- Mother has T2DM; you've never had your blood sugar checked
Lifestyle
- Diet: high carbohydrate (rice/bread-heavy), skips breakfast
- No regular exercise
- Sleep poor (anxiety)
- Does not take folic acid
Resolution: Accept the plan if the doctor: (1) Applies Rotterdam criteria to confirm diagnosis (not USS alone); (2) Asks about fertility intention before treatment discussion; (3) Addresses body image distress directly; (4) Discusses the prediabetes finding (HbA1c 43) and metabolic risk; (5) Offers specific lifestyle advice with an individualised weight goal; (6) Arranges psychological support; (7) Gives accurate, hopeful fertility prognosis; (8) Mentions folic acid if TTC in near future.
→ 2 of 3 Rotterdam criteria needed; PCOM is only 1 criterion
→ Always ask "are you hoping to conceive?" before any prescription
→ Teratogenic; reliable contraception essential; document counselling
→ Amenorrhoea >90 days without COC = cyclical progestogen needed
→ Refer; about 5 nmol/L or higher: confirm and investigate promptly; about 6–7 nmol/L or higher: urgent endocrinology/gynaecology assessment
→ Glucose (OGTT preferred) + lipids + BP at diagnosis; BP yearly, glucose every 1–3 years
→ International PCOS guideline 2023: letrozole now preferred over clomifene in PCOS
→ International PCOS guideline 2023: psychological wellbeing is a core domain, not optional
→ "PCOS doesn't mean you can't have children" — most women with PCOS do conceive