Criteria for diagnosis of PCOS (2023 update)

If you believe you may have PCOS it is important to seek the help of a healthcare professional. However, it is important to know the criteria for diagnosis of PCOS so you can go to your doctor or healthcare professional feeling informed. This article digs into the criteria for diagnosis of PCOS and includes an important 2023 update. Curious about the diagnostic criteria for PCOS? Keep reading!

What is PCOS?

Polycystic ovary syndrome or PCOS is an endocrine (hormone) condition that affects approximately 1 in 10 people assigned female at birth. It is associated with symptoms such as irregular periods, difficulty getting pregnant, alopecia, hirsutism, acne, oily skin and more. It is a syndrome that cannot be cured but can be managed through medication, supplements and lifestyle changes such as nutrition, exercise, sleep and stress management.

How is PCOS diagnosed?

If you suspect that you may have PCOS after looking at a list of symptoms, then you should go to your doctor for further testing. A doctor will usually ask questions to rule out other possible causes and check blood pressure using a blood pressure cuff. Blood tests are then completed to understand the effect hormones are having on your body. You may also have an ultrasound scan.

You may require further testing to screen for diabetes, high cholesterol and thyroid issues.

What are the criteria for diagnosis of PCOS?

In 1990 at the National Institutes of Health (NIH) Consensus Conference, PCOS was defined as a chronic lack of ovulation (anovulation) with symptoms or a blood test confirming excess androgen levels (high testosterone levels). Since then, with more research and evidence emerging, our understanding of PCOS has developed. Now the majority of practitioners across the world use the Rotterdam criteria to diagnose PCOS.

Rotterdam criteria (preferred diagnostic criteria)

The Rotterdam criteria was developed in 2003 during a sponsored consensus workshop by the Rotterdam European Society for Human Reproduction and the American Society of Reproductive Medicine.

This is the preferred criterion, particularly in countries across Europe and North America. A 2018 study found that 77.5% of physicians in Europe use this criteria, and approximately half of North American practitioners use the Rotterdam criteria.

The workshop concluded that to diagnose PCOS two of the following three criteria must be present: oligo- and/or anovulation, clinical and/or biochemical hyperandrogenism, and polycystic ovarian morphology seen via ultrasound. This may sound confusing or overwhelming, so don’t worry – we will break this criterion down for you below.

Lack of ovulation and/or irregular ovulation

People with PCOS often experience irregular ovulation or a complete lack of ovulation (anovulation) because of hormonal imbalances associated with the condition. This is usually implied because of a lack of periods or infrequent menstruation. Ovulation occurs two weeks pre-period. If you have irregular periods, you will experience irregular ovulation.

This is determined via a conversation with your doctor. Before your appointment, you may want to ensure your period tracker is up to date.

Clinical or biochemical hyperandrogenism

Hyperandrogenism is the presence of elevated androgen levels such as testosterone. In PCOS diagnosis, hyperandrogenism may be diagnosed biochemically (i.e. via blood tests) or clinically (i.e. by examining the patient and seeing common symptoms of hyperandrogenism like hirsutism and alopecia).

Commonly, a blood test is carried out even when signs of hyperandrogenism are present. Total testosterone and sex hormone-binding globulin (SHBG) are measured via blood tests. From this, the free androgen index can be calculated. Total testosterone is often normal to moderately elevated in those with PCOS, SHBG is normal to low and free androgen index is normal or elevated.

Polycystic ovaries

An internal ultrasound scan may be carried out to look for polycystic ovarian morphology (PCOM). Polycystic ovaries are defined as the presence of 12 or more follicles in at least one ovary (measuring 2-9mm in diameter) or increased ovarian volume (greater than 10 cm3). An ultrasound should not be used to diagnose PCOS in adolescents.

Other criteria (including 2023 update)

In 2009 the Androgen Excess and PCOS Society published a report urging a revision of the definition to require hyperandrogenism for a diagnosis. This hasn’t been officially adopted by NICE in the UK or NIH in the US as of yet.

In 2023, Monash University published its updated International Evidence-based Guideline for the assessment and management of PCOS 2023. This report is the culmination of over 3,000 healthcare professionals and lived experience experts from 71 countries. They report that an elevated Anti-Müllerian Hormone (AMH) level can be used in place of an ultrasound showing polycystic ovarian morphology (PCOM) in the Rotterdam criteria. This is especially promising for those who find an internal ultrasound painful, uncomfortable and unpleasant. NICE in the UK and NIH in the US have not adopted these revisions yet.

They also suggest that where irregular menstrual cycles and hyperandrogenism are present, an ultrasound showing PCOM or a blood test showing elevated AMH levels is not required. NICE in the UK agrees that if the diagnosis of PCOS is obvious on clinical and biochemical grounds then an ultrasound is not required.

What tests are done to diagnose PCOS?

In people with suspected PCOS, various lab tests are carried out. As mentioned above, according to the Rotterdam criteria a blood test and an internal ultrasound is often carried out to diagnose PCOS, and/or to rule out other conditions.

Can you do a PCOS blood test at home?

There are PCOS blood tests on the market which can help you gauge your hormone levels. However, it is important to take these results to your doctor for analysis and further discussion.

Key takeaways: criteria for PCOS diagnosis

In conclusion, PCOS is a complex syndrome with many symptoms. The diagnostic criteria for PCOS are still developing, but currently, most countries use the Rotterdam criteria. More research is required to conclusively the criteria for PCOS diagnosis, but if you suspect you have PCOS make sure you speak with your doctor or healthcare provider for testing and support.

Annabel Sparrow ANutr Author at The PCOS Collective

Author | Registered Associate Nutritionist


Annabel is a Registered Associate Nutritionist and pilates teacher with an interest in gut health and pre-and post-natal nutrition. She has a BSc degree in Psychology and is passionate about building healthy relationships with food and understanding the connection between food and mood.

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