Polycystic ovary syndrome (PCOS): the AU general practice approach

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder of reproductive life, affecting approximately 10–13% of Australian women of reproductive age, yet significant under-diagnosis means many women wait years for a clear explanation of their symptoms. The condition spans menstrual irregularity, androgenic features such as hirsutism, acne, and hair thinning, difficulty conceiving, insulin resistance, weight gain, and a substantial mental health burden.

PCOS is not a single disease but a heterogeneous syndrome with different phenotypes and different dominant clinical features in different individuals. The unifying pathophysiology involves insulin resistance driving excess ovarian androgen production, combined with disrupted follicle development and anovulation. The clinical implications extend well beyond reproduction — PCOS carries fourfold elevated lifetime risk of type 2 diabetes, significant cardiovascular risk accumulation, and elevated rates of endometrial cancer in women with chronic oligomenorrhoea.

A. Core clinical — the AU general-practice framework

Diagnosis — Rotterdam criteria

The Monash University / NHMRC 2023 International PCOS Guideline — the authoritative international and Australian guideline — requires ≥2 of 3 Rotterdam criteria for diagnosis, after excluding other causes:

1. Oligo/anovulation — menstrual cycles >35 days, fewer than 8 cycles per year, or amenorrhoea
2. Clinical or biochemical hyperandrogenism — hirsutism (modified Ferriman-Gallwey score ≥4–6), moderate-to-severe acne, androgenic alopecia, or raised free androgen index (total testosterone ÷ SHBG × 100)
3. Polycystic ovarian morphology (PCOM) — ≥20 follicles per ovary or ovarian volume ≥10 mL on transvaginal ultrasound; or a raised AMH (increasingly used as an alternative to ultrasound in adults)

In adolescents: do not apply the PCOM criterion in the first 8 years post-menarche — polycystic-appearing ovaries are physiologically common in this period. Diagnose adolescent PCOS only when persistent oligo/amenorrhoea (≥1 year post-menarche) coexists with hyperandrogenism.

Excluding differentials: before confirming PCOS, investigations should exclude thyroid disease (TSH), hyperprolactinaemia (prolactin), late-onset congenital adrenal hyperplasia (17-OH progesterone), Cushing’s syndrome (if clinically suspected), and androgen-secreting tumours (suspected when virilisation onset is rapid and androgen levels are markedly elevated).

History

• Menstrual pattern — age of menarche, cycle length and regularity, amenorrhoea duration, recent changes
• Androgenic symptoms — hirsutism distribution and degree, acne severity and location, scalp hair thinning pattern
• Weight history — rate of gain, BMI trajectory, central adiposity
• Fertility goals — current and planned
• Mental health — depression, anxiety, body image distress, disordered eating or binge eating
• Sleep — snoring, daytime somnolence, witnessed apnoeas (obstructive sleep apnoea is a recognised comorbidity of PCOS, particularly with obesity)
• Family history — PCOS, type 2 diabetes, premature cardiovascular disease
• Drug history — anabolic steroids, glucocorticoids, valproate (associated with ovarian cyst development)

Examination

• BMI and waist circumference — central adiposity (≥80 cm women)
• Blood pressure
• Hirsutism grading — modified Ferriman-Gallwey scoring across nine body-hair areas
• Acne distribution and severity; androgenic alopecia (frontal recession, vertex thinning — Ludwig pattern)
• Acanthosis nigricans — velvety hyperpigmented skin at axillae, neck, or intertriginous areas; marker of significant insulin resistance
• Thyroid examination
• Signs of Cushing’s syndrome if clinically suspected (central obesity, wide purple striae, proximal myopathy, easy bruising)

Investigations

Per Monash 2023 guideline:

• Hormonal panel — free androgen index (total testosterone and SHBG), FSH, LH, oestradiol, prolactin, TSH, 17-OH progesterone (to exclude late-onset CAH; ideally drawn in the early follicular phase), DHEAS (adrenal androgen)
• Metabolic — HbA1c and/or 75 g OGTT (OGTT is more sensitive for early dysglycaemia), fasting lipid panel, liver function tests (PCOS-associated non-alcoholic fatty liver disease is common)
• AMH — useful as an alternative to ultrasound PCOM criterion in adult women
• Pelvic ultrasound (transvaginal preferred for accurate follicle counting) — not the first investigation in adolescents under 8 years post-menarche

B. Management — lifestyle, medications, and fertility

Lifestyle is foundational for all PCOS

The Monash 2023 guideline places lifestyle intervention as the foundation of management across all PCOS phenotypes, regardless of body weight:

• Weight reduction ≥5–10% in women with excess weight produces significant improvements in menstrual regularity, ovulation rate, androgen levels, insulin sensitivity, and fertility — independently of pharmacotherapy
• Mediterranean dietary pattern — highest evidence base for metabolic and cardiovascular benefit in PCOS
• Physical activity ≥150 minutes per week moderate aerobic exercise plus 2 sessions resistance training — improves insulin sensitivity and psychological wellbeing
• Sleep optimisation — obstructive sleep apnoea should be investigated and treated; bidirectional metabolic interactions with PCOS
• Mental health — screen for depression (PHQ-9), anxiety (GAD-7), and eating disorders at diagnosis and annually; refer via Mental Health Care Plan (MBS items 2715 and 2717) as needed

Dietitian and exercise physiologist referrals are accessible via GPCCMP (up to 5 allied health visits per year, 10 for Aboriginal and Torres Strait Islander patients).

Menstrual regulation and endometrial protection

Ensuring at least four withdrawal bleeds per year is essential for endometrial protection in women with oligomenorrhoea. Without this, unopposed oestrogen exposure increases endometrial hyperplasia and cancer risk.

• Combined oral contraceptive (COC) — first-line for menstrual regulation and hyperandrogenism management. Anti-androgenic progestogens (drospirenone, cyproterone) are preferred when hirsutism or acne is prominent. Cyproterone-containing pills (Diane-35, Brenda-35) carry higher VTE risk than levonorgestrel-containing preparations — counsel accordingly.
• Cyclical progestogen — medroxyprogesterone 10 mg for 10–14 days every 1–3 months — for endometrial protection when COC is contraindicated
• Levonorgestrel IUD (Mirena) — endometrial protection plus effective contraception; does not address androgenic symptoms

Hyperandrogenism

• COC with anti-androgenic progestogen — first-line
• Spironolactone 50–200 mg daily — effective for hirsutism in approximately 80% of women; takes 6+ months for full response; check potassium before and after initiation; highly effective pregnancy category B3 — reliable contraception is mandatory during use (feminisation of male fetus risk). Available on the General Schedule PBS (off-label for PCOS hirsutism).
• Topical eflornithine cream (Vaniqa) — facial hirsutism; private cost
• Physical hair removal — laser, IPL, electrolysis; privately funded

Metabolic management

eTG endocrinology guidelines and AMH support metformin as first-line pharmacological metabolic treatment:

• Metformin — PBS Authority Required for PCOS; start 500 mg daily with food, titrate over 4–8 weeks to 1 g twice daily; modified-release (Diabex XR, Glucophage XR) is better tolerated; monitor B12 annually with long-term use
• GLP-1 receptor agonists (semaglutide, liraglutide) — PBS restricted to type 2 diabetes; available privately for PCOS-related obesity and metabolic dysfunction; counsel about cost ($100–300+/month without PBS subsidy)
• Tirzepatide — not PBS-listed as at May 2026 (PBAC declined April 2026); private only

Fertility

• Lifestyle and weight as primary intervention — restores spontaneous ovulation in many women
• Letrozole (off-label via TGA category) — first-line ovulation induction agent per Monash 2023 guideline and the Legro NEJM 2014 landmark trial, which demonstrated superior live birth rates compared with clomiphene (27.5% vs 19.1%); initiated by specialist
• Clomiphene citrate — alternative ovulation induction agent; now second-line
• Metformin — adjunct to ovulation induction
• Gonadotropin injections with intrauterine insemination — refractory anovulation
• IVF — if ovulation induction fails or other infertility factors coexist
• Pre-conception optimisation — folic acid 500 mcg daily, iodine supplementation, optimise glycaemic and cardiovascular risk factors, mental health review

C. Annual monitoring and metabolic surveillance

Women with PCOS carry lifelong risk and benefit from structured annual review per Monash 2023 guideline:

Component	Frequency	Why
Weight, BMI, waist circumference	Annually	Metabolic trajectory
Blood pressure	Annually	Cardiovascular risk
HbA1c or 75 g OGTT	Annually (or 1–3 yearly depending on risk)	T2DM 4× risk
Fasting lipid panel	Annually	Dyslipidaemia
Liver function tests	Annually	Non-alcoholic fatty liver disease
PHQ-9 and GAD-7	Annually	Depression and anxiety prevalence
Menstrual pattern	Every visit	Ensure ≥4 bleeds/year
Fertility goals	Every visit	Adjust management accordingly

For cardiovascular risk assessment in women with PCOS, elevated androgen status and insulin resistance independently upclassify risk. The Australian CVD Risk Calculator does not explicitly include PCOS as a modifier — treat PCOS as an additional upclassifying factor in intermediate-risk women.

D. Australian operations

MBS items

• Standard consultations: 23, 36, 44
• GPCCMP (items 965 and 967) — PCOS qualifies as a chronic condition; allied health (dietitian, exercise physiologist, psychologist) up to 5 visits/year
• Mental Health Care Plan (items 2700, 2701, 2715, 2717) — for depression, anxiety, or eating disorder comorbidity; 10 psychology sessions per year via Better Access
• Pelvic ultrasound (55066) — transvaginal preferred
• AMH (73292) — as alternative to PCOM criterion
• Heart Health Check (699) — applicable for cardiovascular risk assessment from age 45 (Aboriginal and Torres Strait Islander from age 30)
• ATSI Health Assessment (715)
• Pathology: HbA1c (66551), lipids (66536), LFTs (66512), testosterone (66695), TSH (66716), UEC (66500)

PBS

• Metformin — Authority Required (Streamlined) specifically for PCOS
• COC, progesterone-only pill, injectable DMPA — General Schedule
• Diane-35 / Brenda-35 (cyproterone + ethinyl oestradiol) — Authority Required for severe acne (used in PCOS for hyperandrogenism)
• Spironolactone — General Schedule (off-label for PCOS hirsutism)
• GLP-1 receptor agonists — Authority for type 2 diabetes only; private cost for PCOS indication
• Letrozole — Authority for breast cancer treatment; private prescription for ovulation induction

E. Special populations

Adolescents. PCOS is diagnosed more conservatively in adolescents — the PCOM criterion is withheld until ≥8 years post-menarche. Polycystic-appearing ovaries and oligomenorrhoea are both common in early reproductive years as the hypothalamic-pituitary-ovarian axis matures. The emphasis in adolescent management is on normalising cycle irregularity, managing acne and hirsutism, and preventing the emotional and psychological harm of premature over-medicalisation.

Women planning pregnancy. Optimise before conception: achieve a healthy weight, start folic acid 500 mcg and iodine supplementation, check HbA1c and lipids, screen for mental health conditions. Gestational diabetes risk is elevated — arrange an early 75 g OGTT at 16–18 weeks if not available earlier, and the standard 24–28 week OGTT. Refer to RANZCOG for shared antenatal care guidelines.

Women with suspected eating disorder. Disordered eating, particularly binge eating disorder, is significantly over-represented in PCOS. Screen with a validated tool (SCOFF or EDE-Q). Avoid language that over-emphasises weight and body shape in consultations. Refer to a psychologist experienced in eating disorders if screening is positive.

Perimenopausal women with PCOS. Irregular cycles and hyperandrogenism may persist into perimenopause. Ensure continued endometrial surveillance — any abnormal uterine bleeding warrants investigation with pelvic ultrasound and endometrial biopsy where indicated.

When to escalate

• Urgent endocrinology or gynaecology-oncology — rapid-onset virilisation (deepening voice, clitoromegaly), very high free testosterone suggesting androgen-secreting tumour
• Endocrinology — suspected Cushing’s syndrome, late-onset CAH, complex insulin resistance
• Fertility specialist / reproductive endocrinologist — when ovulation induction is required (letrozole initiation is specialist-led), or standard ovulation induction fails after 3–6 cycles
• Gynaecology — abnormal uterine bleeding requiring endometrial assessment, refractory hyperandrogenism
• Severe psychiatric crisis — suicidality, severe eating disorder — immediate mental health referral

What this article is and is not

This is general health information drawn from the Monash University / NHMRC 2023 International PCOS Guideline, Therapeutic Guidelines, Australian Medicines Handbook, and RANZCOG resources. It does not constitute personal medical advice. PCOS management is highly individual — what matters most clinically depends on a person’s primary concern (cycle regulation, fertility, hirsutism, metabolic health, or mental health) and their life stage. Decisions about specific investigation and treatment are made with your own GP and relevant specialists.

For reliable patient-facing resources: HealthDirect — PCOS, Jean Hailes for Women’s Health — PCOS, Better Health Channel — PCOS, Monash AskPCOS app.

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Sources cited

1. Monash University / NHMRC — International PCOS Guideline (2023)
2. RANZCOG
3. Therapeutic Guidelines (eTG) — Endocrinology / Reproductive health
4. Australian Medicines Handbook
5. Jean Hailes for Women’s Health
6. HealthDirect — PCOS
7. Better Health Channel — PCOS
8. TGA
9. PBS — metformin Authority for PCOS
10. Australian CVD Risk Calculator
11. Legro et al — Letrozole versus clomiphene for PCOS (NEJM 2014)