Skip to main content
Download PDF

International evidence-based recommendations for polycystic ovary syndrome in adolescents

BMC Medicine volume 23, Article number: 151 (2025) Cite this article

Abstract

Background

During adolescence, accurate diagnostic criteria and/or identification of adolescents “at risk” of polycystic ovary syndrome (PCOS) are critical to establish appropriate screening, treatment, and lifelong health plans. The 2023 International Evidence-Based Guideline for PCOS aimed to provide the most up-to-date evidence-based recommendations to improve health outcomes for individuals with PCOS, emphasizing accurate and timely diagnosis of PCOS from adolescence.

Methods

The best practice methods following the Appraisal of Guidelines for Research and Evaluation (AGREE-II) criteria were applied. Healthcare professionals and patients/consumers reviewed extensive evidence synthesis/meta-analysis for 55 prioritized clinical questions. Databases (OVID MEDLINE, All EBM, PsycInfo, EMBASE, CINAHL) were searched until August 2022 as part of the 2023 update of the Guideline. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework guided experts on evidence quality, feasibility, acceptability, cost, implementation, and ultimately recommendation strength.

Results

This manuscript focuses on the adolescent-specific recommendations of the 2023 Guideline. The diagnosis is based on the presence of both irregular menstrual cycles (defined according to the time postmenarche) and clinical/biochemical hyperandrogenism following the exclusion of other disorders that mimic PCOS. Adolescents with only one of these features can be considered “at risk” of PCOS requiring the management of symptoms and ongoing follow-up. Polycystic ovarian morphology on pelvic ultrasonography or anti-Müllerian hormone levels should not be used for diagnosis during adolescence. Lifelong health planning is recommended to include healthy lifestyles, screening for depression and metabolic features and the transition to adult care, all underpinned by shared decision-making. Healthcare professionals should explain weight-related health risks to adolescents, while minimizing weight stigma. In adolescents with PCOS or “at risk” of PCOS, combined oral contraceptive pills are indicated for menstrual irregularity and clinical hyperandrogenism, focusing on low dose preparations, and metformin could be considered for metabolic features and cycle regulation. Overall, the evidence is limited in adolescents with PCOS, and recommendations are based on low to moderate certainty evidence.

Conclusions

Extensive international engagement and rigorous processes generated International Guideline diagnostic criteria for adolescents that differ from adult criteria and clarified appropriate screening and management strategies for PCOS during adolescence.

Peer Review reports

Background

Polycystic ovary syndrome (PCOS) is a common endocrine condition affecting ~ 8% of adolescents [1]. The adolescent PCOS diagnostic criteria have been controversial due to the overlap of the pubertal changes with adult PCOS diagnostic criteria. These pubertal changes including menstrual irregularities, acne, and polycystic ovarian morphology (PCOM) are well recognized [2, 3]. Given the prevalence of menstrual irregularities during the early postmenarcheal years, mild acne or PCOM, these PCOS diagnostic criteria during adolescence can result in overdiagnosis. Conversely, disregarding diagnostic features can result in delayed or underdiagnosis with adverse long-term consequences [2, 4,5,6]. Delayed diagnosis has been reported by individuals who described symptoms starting in adolescence [7]. Hence, nuanced diagnostic criteria are key to accurate and timely diagnosis.

The original consensus-based Rotterdam criteria for PCOS diagnosis were upgraded to evidence-based criteria in the 2018 and 2023 International Evidence-based PCOS Guideline. The 2023 Guideline recommends adult diagnosis on the basis of the identification of at least two of these recognized features: (1) menstrual irregularities/ovulatory dysfunction, (2) clinical/biochemical hyperandrogenism, and (3) PCOM on ultrasound or elevated anti-Müllerian hormone (AMH) levels [4, 8, 9]; however, neither PCOM nor AMH levels are suitable for diagnosing PCOS during adolescence [2, 4, 9].

In the 2023 update of the PCOS International Evidence-based Guideline (“The Guideline”), we aimed to develop and provide comprehensive evidence-based recommendations for diagnosis, assessment, and treatment to improve the lives of those with PCOS worldwide from adolescence to adulthood [8, 9]. This manuscript highlights the adolescent-specific recommendations from the 2023 Guideline with supporting evidence. The term “adolescent” refers to individuals between 10 and 19 years of age according to the World Health Organization definition and women within 8 years postmenarche (gynecological age of 8 years or less) have also been identified for specific recommendations.

Methods

Methods used to develop, update, and expand this Guideline align with international best practices and comply with the Appraisal of Guidelines for Research and Evaluation (AGREE II) process. Databases (OVID MEDLINE, All EBM, PsycInfo, EMBASE, CINAHL) were searched until August 2022. Evidence synthesis procedures included integrity assessments using the Research Integrity in Guideline Development framework, which incorporates tools such as the Research Integrity Assessment and the Trustworthiness in Randomized Controlled Trials checklist [1, 10, 11]. Full details of the methodology are included in the publicly available Guideline and Technical report (https://www.monash.edu/medicine/mchri/pcos/guideline) [1, 8].

An international advisory board, project board and five guideline development groups (GDGs) with 80 members representing 39 organizations across six continents (71 countries) were engaged over 12 months. The GDGs included individuals with PCOS and multidisciplinary experts in PCOS including pediatricians, endocrinologists, gynecologists, reproductive endocrinologists, psychologists, allied health professionals, researchers, and others, who were involved at all stages of guideline development. The guideline addressed 55 questions via 52 systematic reviews and three narrative reviews conducted and/or overseen by an evidence team. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Judging each outcome for risk of bias, inconsistency, indirectness, imprecision, and other considerations, evidence quality was ranked from very low to high, reflecting certainty in the effect estimate from evidence synthesis (Tables 1 and 2) [12].

Table 1 Quality (certainty) of evidence (adapted from GRADE)
Full size table
Table 2 The Grading of Recommendations, Assessment Development, and Evaluation (GRADE) framework recommendation strength
Full size table

The Guideline recommendation categories were then formulated by applying the GRADE evidence-to-decision framework (Table 3) [13]. GDGs members drafted recommendations that were international peer reviewed by partnering societies and the general public. Evidence was required to support recommendation modifications. Peer review results are available online: https://www.monash.edu/medicine/mchri/pcos/guideline, and the final Guideline was approved by the Australian National Health and Medical Research Council and endorsed by participating societies.

Table 3 Categories of the PCOS Guideline recommendations
Full size table

Results

The full 2023 Guideline update provides recommendations in five areas: screening, diagnosis, and risk assessment; psychological features; lifestyle; management of nonfertility features; and infertility [8, 9]. This paper summarizes 63 adolescent recommendations (Table 4) and does not cover infertility.

Table 4 Adolescent recommendations for the assessment and management of polycystic ovary syndrome.
Full size table

Screening, diagnostic, and risk assessment

The criteria required to diagnose adolescent PCOS include menstrual irregularities and hyperandrogenism, following the exclusion of conditions that mimic PCOS.

  1. 1)

    Diagnostic criteria required

    • 1a) Menstrual irregularities

    • The updated search using the clinical question “In adolescents, at what time point after onset of menarche do irregular cycles indicate ongoing menstrual dysfunction?” revealed no studies that met the selection criteria [1]. Based on the natural history of menstrual cycles/ovulation in healthy adolescents, there was no change in the previous definition of irregular menstrual cycles according to years postmenarche [1, 2, 4, 9]. Menstrual irregularities can occur during the physiological maturation of the hypothalamic-pituitary-ovarian axis over several years [14, 15]. The timing at which menstrual irregularities may indicate PCOS remains unclear as the cycle’s length can vary considerably in the first postmenarcheal years. However, by the third postmenarcheal year, 95% of cycles had an average adult length of 28 days (range 24–35 days) [14, 16]. Therefore, well defined menstrual irregularities are one of the two criteria required for adolescent PCOS diagnosis (Table 4).

    • 1b) Hyperandrogenism: biochemical and/or clinical

    • The updated search using the clinical question “In women with suspected PCOS, what is the most effective measure to diagnose PCOS-related hyperandrogenism (biochemical)?” revealed 17 studies (two studies including 249 adolescents) [1, 17, 18]. Most studies (n = 11) have evaluated total testosterone and calculated the free androgen index (FAI). Four evidence-based recommendations (EBRs) (Table 4) were generated and supported by a meta-analysis showing that compared with other androgens, the calculated free testosterone level and FAI had the best sensitivity (80.3% and 80.2%) and specificity (93.3% and 86.4%) for the diagnosis of hyperandrogenism. Total testosterone, androstenedione, and dehydroepiandrosterone had sensitivity of approximately 70% and specificity of approximately 75–85% and are not routinely recommended for diagnosis [1].

    • The updated search using the clinical question “In women with suspected PCOS, what is the most effective measure to clinically diagnose PCOS-related hyperandrogenism?” identified seven studies (none in adolescents) with significant heterogeneity [1]. Only consensus recommendations (CRs) were made for adolescents (Table 4). These findings were based on the fact that mild acne is common in adolescents, but severe acne during perimenarcheal years is uncommon and is more likely to indicate hyperandrogenism [1, 2]. Modified Ferriman-Gallwey score cut-offs were based on adult studies [1, 2].

  1. 2)

    Investigations not recommended for adolescent PCOS diagnosis.

Pelvic ultrasound for PCOM evaluation and AMH levels are not recommended for the PCOS diagnosis until 8 years postmenarche, when the hypothalamic-pituitary-ovarian axis is deemed mature and evidence-based criteria for the diagnosis of PCOM are available (Table 4). Normative data on ultrasonographic and serum markers of ovarian morphology show a rapid increase in ovarian size and follicle populations during adolescence, peaking in early adulthood (20 years) [19, 20]. The elevated and dynamic nature of ovarian morphology during adolescence renders adult definitions for PCOM inappropriate for use during this developmental stage [1, 17, 18, 21, 22]. While pooled evidence suggests that ovarian volume and AMH have some diagnostic value in adolescents, these data are limited by small sample sizes, a focus on older adolescents, the use of multiple imaging modalities or assays, and variable criteria to define adolescent PCOS cases [1, 8, 17, 18, 21, 23,24,25].

  1. 3)

    Adolescents “at risk” of PCOS

Adolescents who have only one of the two features required for adolescent PCOS diagnosis (menstrual irregularities/ovulatory dysfunction or hyperandrogenism) should be considered “at risk” for PCOS and require longitudinal evaluation (Table 4).

  1. 4)

    Other risks associated with PCOS

While PCOS in adults is associated with increased cardiovascular disease, impaired glucose tolerance/type 2 diabetes, obstructive sleep apnea, endometrial hyperplasia, and cancer, PCOS in adolescents is associated with increased risk for impaired glucose tolerance/type 2 diabetes (Table 4). While there were studies evaluating the performance of tests for dysglycemia in adult women with PCOS, there were none in adolescents with PCOS. These studies showed that the 75 oral glucose tolerance test was the most accurate test to assess dysglycemia in women with PCOS regardless of body mass index (BMI). Recommendation in adult women also highlighted that if an oral glucose tolerance test cannot be performed, fasting plasma glucose and/or glycated hemoglobin could be considered noting reduced accuracy. In the absence of evidence, the Guidelines did not recommend any specific test to assess dysglycemia in adolescents.[1] An increased risk of diabetes also occurs in first degree relatives of those with PCOS [1, 8].

Psychological features

Four EBRs were formulated for psychological features (Table 4). The first recommends screening for depression on the basis of a meta-analysis of 47 studies (six studies including1098 adolescents) showing up to a four-fold higher prevalence of depression in adolescents with PCOS than those without PCOS [1, 26,27,28,29,30,31]. Generic online screening resources are available [1, 32] and should be used for screening and rescreening according to clinical judgment, life changes, and risk factors. A qualitative evidence synthesis reported challenges for adolescents in interactions with healthcare professionals. These challenges were attributed to their impression that their symptoms were normalized, dismissed, or not taken seriously, that doctors failed to discuss all available options with them, that follow-up plans were inappropriate because they focused primarily on future fertility, and that the immediate concerns of young people were overlooked [1, 7]. Healthcare professionals should become more knowledgeable of shared decision-making and methods for sharing medical news and supporting patient activation in adolescents.

Other EBRs underscore awareness regarding other psychological comorbidities in adults with PCOS (Table 4). EBRs were based on a meta-analysis of 27 studies (3 studies including 455 adolescents) showing that adults with PCOS had a greater prevalence of anxiety that did those without PCOS; however, this was not reflected in the small number of adolescents. [1, 27, 29, 30] Similarly, few studies on negative body image and eating disorders have not shown a higher prevalence in adolescents with PCOS compared to controls [1, 27, 33]. However, healthcare providers should note the limited studies to date, the associations in adulthood and the fact that negative body image and eating disorders are commonly observed in adolescents without PCOS.

Lifestyle

Excess weight and weight gain risks are prevalent in the general population and are exacerbated in adolescents and adults with PCOS, due to our obesogenic environment [34]. Obesity and excessive weight gain adversely affect reproductive, metabolic, and psychological health and are particularly challenging in adolescents when their self-image is developing [35]. The risk associated with excess weight should be discussed with sensitivity to avoid weight bias and stigma. Similarly, health care professionals should consider asking permission prior to obtaining weight [36].

Lifestyle interventions have been shown to have beneficial effects on adolescents, but randomized intervention trials to inform best practice are limited [1, 37, 38]. On the basis of population data, it is recommended that all adolescents, including those who are not currently overweight, pursue healthy lifestyles, and prevent excess weight gain. If the adolescent’s goal is to achieve weight loss, a tailored energy deficit could be prescribed, considering individual energy requirements, weight, and physical activity levels.

EBRs highlight that no specific diet or exercise over another is recommended. Rather evidence-based general population strategies should focus on healthy individual preferences that are sustainable, recognizing the role of broader family engagement. The CR in relation to the duration of exercise was also based on population guidelines (Table 4) [1, 39].

Management of nonfertility features

Regardless of whether an adolescent is diagnosed with PCOS or is “at risk” for PCOS, specific individual concerns should guide interventions. The first management step involves a decision-making discussion with the adolescent and parents/guardians to identify specific treatment goals. The topics that merit discussion include the following: (1) lifestyle changes, (2) the use of combined oral contraceptive pills (COCP) and metformin for PCOS is evidence-based, (3) both COCP and metformin are generally “off-label” for PCOS, and (4) considerations of other interventions.

COCP could be considered for the management of hirsutism and/or menstrual irregularities in adolescents with or “at risk” of PCOS according to 10 studies (420 adolescents) [1, 40, 41]. Metformin alone could be considered in adolescents with or “at risk” of PCOS for cycle regulation, acknowledging limited evidence (six studies [185 adolescents]) [1, 42]. Metformin could be used over COCP for metabolic features and COCP could be used over metformin for hirsutism and/or menstrual irregularities based on four studies (142 adolescents) [1, 43]. The combination of COCPs and metformin in those with a body mass index < 30 kg/m2 has minimal additional benefit in women with no data in adolescents. The role of antiandrogens is limited according to 26 studies (two studies in adolescents that used antiandrogens combined with two insulin sensitizers) (Table 4) [1, 44].

No specific adolescent recommendations were made for anti-obesity medications and cosmetic therapies due to lack of data in this population. However, anti-obesity medications have beneficial effects in individuals with obesity and there is some evidence in PCOS. Additionally, laser and light therapy are effective treatments for hirsutism and related psychological features according to eight studies in adults with PCOS. Inositol preparations cannot currently be recommended in adolescents as no data exist in this population and only biochemical efficacy has been demonstrated in adults with PCOS (Table 4) [1, 45].

Models of care and transition

Limited data are available regarding models of care in women and adolescents with PCOS [1, 35, 46, 47]. General considerations are included in Table 4.

Only one qualitative study evaluated the transition to adult care [48]. Adolescents with PCOS and those “at risk” of PCOS should have longitudinal follow-up; hence, appropriate transition to adult care is important [2]. Some adolescents have failed to connect with healthcare professionals for several years. During these years, obesity, dysglycemia, dyslipidemia, depression, and subfertility often progress. Consequently, reliable accurate information sources, including the free AskPCOS app, are important. Prior to transition, healthcare professionals and adolescents should discuss comorbidities and develop lifelong plans [48]. Shared decision-making discussions to educate adolescents regarding their health care needs are designed to improve their ability to assume responsibility for self-care during and beyond transition. Transition should be a planned process with the ultimate goals of continued, high-quality health care and increased patient responsibility for self-care.

Discussion

This manuscript summarizes specific adolescent recommendations from the 2023 International Evidence-based PCOS Guideline [8, 9]. The Guideline was a result of extensive international engagement and robust methodological evidence-based processes and was independently reviewed. This manuscript provides healthcare professionals, adolescents, and their families with the most recent evidence-based recommendations to improve health outcomes. There are fewer recommendations for adolescents than for adult women highlighting the limited number of adolescent PCOS studies and emphasizing the need for further research.

Adolescent PCOS diagnosis has always been challenging as normal physiological changes overlap with adult PCOS diagnostic criteria resulting in delayed and underdiagnosis as well as potential overdiagnosis [2, 3]. While evidence supports the use of PCOM and AMH levels for the diagnosis of PCOS in adults [1, 8, 9], PCOM or AMH should not be used for diagnosis in adolescents to minimize the risk of overdiagnosis [2, 4,5,6, 9]. PCOM or AMH can be used at approximately 8 years postmenarche when the hypothalamic-pituitary-ovarian axis is mature and evidence-based criteria for PCOM are available [8, 9].

For adolescent PCOS diagnosis, the Guideline recommends the combination of menstrual irregularities defined according to the time postmenarche and clinical/biochemical hyperandrogenism following the exclusion of other disorders [8, 9]. The use of these well-defined criteria for PCOS diagnosis during adolescence will promote accurate and timely diagnosis during this life stage. This approach will allow the detection of adolescents at considerable risk of weight gain and diabetes by establishing early screening with the management of long-term metabolic risks and enabling the optimization of long-term fertility outcomes [1, 6, 34]. As delayed diagnosis has been reported in adolescents [7], adolescents with either menstrual irregularities or clinical/biochemical hyperandrogenism can be considered “at risk” for PCOS. This tactic addresses concerns of inappropriately labeling an adolescent with a PCOS diagnosis while avoiding delayed diagnosis when appropriate follow-up is in place.

Adolescents “at risk” of PCOS require ongoing follow-up and management according to symptoms [2, 8, 9]. Timing of follow-up and re-evaluation of the diagnosis should be discussed and emphasized with adolescents and their families to avoid disruption in care which frequently occurs during transition. Adolescents “at risk” of PCOS can be diagnosed with PCOS during follow-up if they present with a combination of both menstrual irregularities and hyperandrogenism, even before 8 years postmenarche. Thus, re-evaluations before and following transition are essential to ascertain outcomes. Additionally, recent data suggest that adolescents “at risk” for PCOS have abnormal metabolic profiles [49]. Prospective longitudinal studies evaluating adolescents “at risk” of PCOS and healthy adolescents are needed to provide evidence-based data to better advise on the timing of follow-up and the future risk of developing PCOS.

The Guideline provides increasing evidence of psychological features and highlights the need for routine screening and management of depression in adolescents with PCOS due to the high prevalence of this condition [1, 8, 26,27,28,29,30,31]. Adolescents with PCOS reported suboptimal emotional wellbeing management and dissatisfaction in relation to the education and emotional support offered [7]. More research is required on other psychological features and on strategies to optimize emotional wellbeing management and evaluate anxiety, quality of life, body image, and eating disorders in adolescents with PCOS.

A lifelong health plan, including age-appropriate education, healthy lifestyles, timely screening for long-term metabolic risks, reproductive life plans, and the transition to adult care, is recommended. Management should be guided by shared decision-making addressing adolescent-specific concerns [8, 9, 48]. The Guideline recommends that adolescents with PCOS or “at risk” of PCOS be treated with COCP for menstrual irregularity and hyperandrogenism. COCP with lowest effective estrogen dose are recommended but specific types or doses of progestins, estrogens, or combinations of COCP cannot currently be recommended. Although relatively safe, COCP have absolute and relative contraindications that need consideration, and this should be guided by general recommendations from the World Health Organization Medical Eligibility Criteria. When prescribing COCP to adolescents “at risk” of PCOS, adolescents and parents should be counseled about the potential need of at least 3-month withdrawal of COCP for re-evaluation of diagnosis especially if there is lack of hyperandrogenism and there is a possibility of hypogonadism. Metformin is recommended for metabolic features and cycle regulation in adolescents with PCOS or “at risk” of PCOS. Of note, assessment of insulin resistance can be challenging and while most common in those with a higher BMI adolescents with normal BMI can have insulin resistance and metformin therapy have been beneficial in this population. More studies are needed to evaluate other treatments in adolescents with PCOS, including patient preferences for contraception, hair reduction therapies, antiandrogens, and antiobesity medications. The latter addresses one of the most important adolescent concerns: weight management [7, 48].

The strengths of the Guideline include the following: extensive international engagement including consumers and a range of multidisciplinary healthcare professionals, rigorous methods aligned with international best practices and complying with AGREE-II, and detailed evidence synthesis processes including integrity assessments [1, 10,11,12]. Additionally, the Guideline was independently evaluated as being of high quality and has a comprehensive and multifaceted translation program aiming for consistent worldwide implementation of evidence-based care [47, 50]. Limitations include that priorities were determined mostly from women with PCOS, not adolescents. However, data are accumulating in adolescents highlighting similar priorities except for infertility [7, 48]. Despite an increased number of studies involving adolescents with PCOS, studies including “only adolescents” or those defining the postmenarcheal period or applying current Guideline diagnostic criteria are limited in number and quality [1, 2]. This highlights that research, using well defined cohorts of adolescents with PCOS, on the natural history of PCOS, emotional wellbeing, optimal treatments, strategies to improve weight, models of care, and transition, is a priority. Additionally, where there are no adolescent studies, some adult recommendations are likely to have applicability, but they need to be considered in the context of adolescence.

Conclusions

Adolescent-specific recommendations from the 2023 International Evidence-based PCOS Guideline enable accurate and timely diagnosis with well-defined Guideline criteria for PCOS diagnosis during adolescence that differ from adult diagnostic criteria. Additionally, recommendations highlight the importance of identifying and managing adolescents “at risk” of PCOS, screening for depression and glucose abnormalities in adolescents with PCOS and establishing management strategies guided by adolescents’ concerns including a lifelong health plan. The overall evidence is limited and of low to moderate quality, highlighting the critical need for further research on PCOS during adolescence and in the longer term.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

AGREE-II:

Appraisal of Guidelines for Research and Evaluation

AMH:

Anti-Müllerian hormone

BMI:

Body mass index

COCP:

Combined oral contraceptive pills

CR:

Consensus recommendation

EBR:

Evidence-based recommendation

GDGs:

Guideline development groups

GRADE:

Grading of Recommendations, Assessment, Development, and Evaluation

IPL:

Intense pulse light

mFG:

Modified Ferriman Gallwey

PCOM:

Polycystic ovarian morphology

PCOS:

Polycystic ovary syndrome

PP:

Practice point

References

  1. Mousa A, Tay CT, Teede HJ. Technical report for the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Australia: Monash University; 2023. https://bridges.monash.edu/articles/report/Technical_Report_for_the_2023_International_Evidence-based_Guideline_for_the_Assessment_and_Management_of_Polycystic_Ovary_Syndrome/23625288?file=41455206.

  2. Peña AS, Witchel SF, Hoeger KM, Oberfield SE, Vogiatzi MG, Misso M, et al. Adolescent polycystic ovary syndrome according to the international evidence-based guideline. BMC Med. 2020;18(1):72.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Ibanez L, Oberfield SE, Witchel S, Auchus RJ, Chang RJ, Codner E, et al. An international consortium update: pathophysiology, diagnosis, and treatment of polycystic ovarian syndrome in adolescence. Horm Res Paediatr. 2017;88(6):371–95.

    Article  CAS  PubMed  Google Scholar 

  4. Teede HJ, Misso ML, Costello MF, Dokras A, Laven J, Moran L, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Hum Reprod. 2018;33(9):1602–18.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Fulghesu AM, Canu E, Casula L, Melis F, Gambineri A. Polycystic ovarian morphology in normocyclic non-hyperandrogenic adolescents. J Pediatr Adolesc Gynecol. 2021;34(5):610–6.

    Article  PubMed  Google Scholar 

  6. Tay CT, Hart RJ, Hickey M, Moran LJ, Earnest A, Doherty DA, et al. Updated adolescent diagnostic criteria for polycystic ovary syndrome: impact on prevalence and longitudinal body mass index trajectories from birth to adulthood. BMC Med. 2020;18(1):389.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Peña AS, Teede H, Hewawasam E, Hull ML, Gibson-Helm M. Diagnosis experiences of adolescents with polycystic ovary syndrome: cross-sectional study. Clin Endocrinol (Oxf). 2022;96(1):62–9.

    Article  PubMed  Google Scholar 

  8. Teede HT, Thien C, Laven JSE, Dokras A, Moran LJ, Piltonen T, et al. International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2023. Monash University: Australia; 2023. https://doiorg.publicaciones.saludcastillayleon.es/10.26180/24003834.v1.

  9. Teede HJ, Tay CT, Laven JJE, Dokras A, Moran LJ, Piltonen TT, et al. Recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Eur J Endocrinol. 2023;189(2):G43-g64.

    Article  PubMed  Google Scholar 

  10. Weibel S, Popp M, Reis S, Skoetz N, Garner P, Sydenham E. Identifying and managing problematic trials: a research integrity assessment tool for randomized controlled trials in evidence synthesis. Res Synth Methods. 2023;14(3):357–69.

    Article  PubMed  Google Scholar 

  11. Mol BW, Lai S, Rahim A, Bordewijk EM, Wang R, van Eekelen R, et al. Checklist to assess Trustworthiness in RAndomised Controlled Trials (TRACT checklist): concept proposal and pilot. Res Integr Peer Rev. 2023;8(1):6.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Coleman K, Norris S, Weston A, Grimmer-Somers K, Hillier S, Merlin T et al. NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. Stage 2 consultation. Early 2008 – end June 2009. Australia: National Health and Medical Research Council. https://www.mja.com.au/sites/default/files/NHMRC.levels.of.evidence.2008-09.pdf.

  13. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839–42.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Flug D, Largo RH, Prader A. Menstrual patterns in adolescent Swiss girls: a longitudinal study. Ann Hum Biol. 1984;11(6):495–508.

    Article  CAS  PubMed  Google Scholar 

  15. Legro RS, Lin HM, Demers LM, Lloyd T. Rapid maturation of the reproductive axis during perimenarche independent of body composition. J Clin Endocrinol Metab. 2000;85(3):1021–5.

    CAS  PubMed  Google Scholar 

  16. Treloar AE, Boynton RE, Behn BG, Brown BW. Variation of the human menstrual cycle through reproductive life. Int J Fertil. 1967;12(1 Pt 2):77–126.

    CAS  PubMed  Google Scholar 

  17. Villarroel C, Lopez P, Merino PM, Iniguez G, Sir-Petermann T, Codner E. Hirsutism and oligomenorrhea are appropriate screening criteria for polycystic ovary syndrome in adolescents. Gynecol Endocrinol. 2015;31(8):625–9.

    Article  CAS  PubMed  Google Scholar 

  18. Khashchenko E, Uvarova E, Vysokikh M, Ivanets T, Krechetova L, Tarasova N, et al. The relevant hormonal levels and diagnostic features of polycystic ovary syndrome in adolescents. J Clin Med. 2020;9(6):1831.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Kelsey TW, Dodwell SK, Wilkinson AG, Greve T, Andersen CY, Anderson RA, et al. Ovarian volume throughout life: a validated normative model. PLoS One. 2013;8(9): e71465.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Kelsey TW, Wright P, Nelson SM, Anderson RA, Wallace WH. A validated model of serum anti-müllerian hormone from conception to menopause. PLoS One. 2011;6(7): e22024.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Chen Y, Yang D, Li L, Chen X. The role of ovarian volume as a diagnostic criterion for Chinese adolescents with polycystic ovary syndrome. J Pediatr Adolesc Gynecol. 2008;21(6):347–50.

    Article  PubMed  Google Scholar 

  22. Villa P, Rossodivita A, Sagnella F, Moruzzi MC, Mariano N, Lassandro AP, et al. Ovarian volume and gluco-insulinaemic markers in the diagnosis of PCOS during adolescence. Clin Endocrinol (Oxf). 2013;78(2):285–90.

    Article  CAS  PubMed  Google Scholar 

  23. Kim JY, Tfayli H, Michaliszyn SF, Lee S, Nasr A, Arslanian S. Anti-Mullerian hormone in obese adolescent girls with polycystic ovary syndrome. J Adolesc Health. 2017;60(3):333–9.

    Article  PubMed  Google Scholar 

  24. Song J, Park Y, Cho HW, Lee SG, Kim S, Lim JB. Age-group-specific reference intervals for anti-Müllerian hormone and its diagnostic performance for polycystic ovary syndrome in a Korean population. J Clin Lab Anal. 2021;35(7): e23861.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Farooq SBS, Awan SF. Relationship of anti-Mullerian hormone in polycystic ovary syndrome patients with different subgroups. Pak J Med Health Sci. 2022;16(5):612–5.

    Article  Google Scholar 

  26. Benson J, Severn C, Hudnut-Beumler J, Simon SL, Abramson N, Shomaker LB, et al. Depression in girls with obesity and polycystic ovary syndrome and/or type 2 diabetes. Can J Diabetes. 2020;44(6):507–13.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Sari SA, Celik N, Uzun CA. Body perception, self-esteem, and comorbid psychiatric disorders in adolescents diagnosed with polycystic ovary syndrome. J Pediatr Adolesc Gynecol. 2020;33(6):691–6.

    Article  PubMed  Google Scholar 

  28. Maya J, Siegel J, Cheng TQ, Rousseau-Pierre T. Prevalence and risk factors of polycystic ovarian syndrome among an ethnically diverse overweight/obese adolescent population. Int J Adolesc Med Health. 2020;34(1):20190109.

    Article  Google Scholar 

  29. Almis H, Orhon F, Bolu S, Almis BH. Self-concept, depression, and anxiety levels of adolescents with polycystic ovary syndrome. J Pediatr Adolesc Gynecol. 2021;34(3):311–6.

    Article  PubMed  Google Scholar 

  30. Zachurzok A, Pasztak-Opilka A, Gawlik AM. Depression, anxiety and self-esteem in adolescent girls with polycystic ovary syndrome. Ginekol Pol. 2021;92(6):399–405.

  31. Donbaloğlu Z, Tuhan H, Çoban ÖG, Kızılay D, İsmailoğlu E, Önder A, et al. Hyperandrogenism correlates with psychological symptoms in adolescents with polycystic ovary syndrome. Clin Pediatr Endocrinol. 2022;31(2):68–76.

    Article  PubMed  PubMed Central  Google Scholar 

  32. National Institute for Health and Care Excellence (NICE). Depression in children and young people: identification and management: NICE Guideline [NG134]. UK: NICE. https://www.nice.org.uk/guidance/ng134/resources/depression-in-children-and-young-people-identification-and-management-pdf-66141719350981.

  33. Karacan E, Caglar GS, Gürsoy AY, Yilmaz MB. Body satisfaction and eating attitudes among girls and young women with and without polycystic ovary syndrome. J Pediatr Adolesc Gynecol. 2014;27(2):72–7.

    Article  PubMed  Google Scholar 

  34. Li L, Feng Q, Ye M, He Y, Yao A, Shi K. Metabolic effect of obesity on polycystic ovary syndrome in adolescents: a meta-analysis. J Obstet Gynaecol. 2017;37(8):1036–47.

    Article  CAS  PubMed  Google Scholar 

  35. Torres-Zegarra C, Sundararajan D, Benson J, Seagle H, Witten M, Walders-Abramson N, et al. Care for Adolescents with PCOS: development and prescribing patterns of a multidisciplinary clinic. J Pediatr Adolesc Gynecol. 2021;34(5):617–25.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Rubino F, Puhl RM, Cummings DE, Eckel RH, Ryan DH, Mechanick JI, et al. Joint international consensus statement for ending stigma of obesity. Nat Med. 2020;26(4):485–97.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Hoeger K, Davidson K, Kochman L, Cherry T, Kopin L, Guzick DS. The impact of metformin, oral contraceptives, and lifestyle modification on polycystic ovary syndrome in obese adolescent women in two randomized, placebo-controlled clinical trials. J Clin Endocrinol Metab. 2008;93(11):4299–306.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Wong JM, Gallagher M, Gooding H, Feldman HA, Gordon CM, Ludwig DS, et al. A randomized pilot study of dietary treatments for polycystic ovary syndrome in adolescents. Pediatr Obes. 2016;11(3):210–20.

    Article  CAS  PubMed  Google Scholar 

  39. 2018 Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Scientific Report Washington, D.C.: U.S. Department of Health and Human Services; 2018. https://odphp.health.gov/sites/default/files/2019-09/PAG_Advisory_Committee_Report.pdf.

  40. Forslund M, Melin J, Alesi S, Piltonen T, Romualdi D, Tay CT, et al. Combined oral contraceptive pill compared with no medical treatment in the management of polycystic ovary syndrome: a systematic review. Clin Endocrinol (Oxf). 2023;99(1):79–91.

    Article  PubMed  Google Scholar 

  41. Forslund M, Melin J, Alesi S, Piltonen T, Romualdi D, Tay CT, et al. Different kinds of oral contraceptive pills in polycystic ovary syndrome: a systematic review and meta-analysis. Eur J Endocrinol. 2023;189(1):S1-s16.

    Article  PubMed  Google Scholar 

  42. Melin J, Forslund M, Alesi S, Piltonen T, Romualdi D, Spritzer PM, et al. The impact of metformin with or without lifestyle modification versus placebo on polycystic ovary syndrome: a systematic review and meta-analysis of randomized controlled trials. Eur J Endocrinol. 2023;189(2):S37-s63.

    Article  PubMed  Google Scholar 

  43. Melin J, Forslund M, Alesi S, Piltonen T, Romualdi D, Spritzer PM, et al. Metformin and combined oral contraceptive pills in the management of polycystic ovary syndrome: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2024;109(2):e817–36.

    Article  PubMed  Google Scholar 

  44. Alesi S, Forslund M, Melin J, Romualdi D, Peña A, Tay CT, et al. Efficacy and safety of anti-androgens in the management of polycystic ovary syndrome: a systematic review and meta-analysis of randomised controlled trials. EClinicalMedicine. 2023;63: 102162.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Fitz V, Graca S, Mahalingaiah S, Liu J, Lai L, Butt A, et al. Inositol for polycystic ovary syndrome: a systematic review and meta-analysis to inform the 2023 update of the international evidence-based PCOS guidelines. J Clin Endocrinol Metab. 2024;109(6):1630–55.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Hajivandi L, Noroozi M, Mostafavi F, Ekramzadeh M. Health system-related needs for healthy nutritional behaviors in adolescent girls with polycystic ovary syndrome (PCOS): a qualitative study in Iran. BMC Health Serv Res. 2022;22(1):998.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Melson E, Davitadze M, Malhotra K, Mousa A, Teede H, Boivin J, et al. A systematic review of models of care for polycystic ovary syndrome highlights the gap in the literature, especially in developing countries. Front Endocrinol (Lausanne). 2023;14:1217468.

    Article  PubMed  Google Scholar 

  48. Young CC, Rew L, Monge M. Transition to self-management among adolescents with polycystic ovary syndrome: parent and adolescent perspectives. J Pediatr Nurs. 2019;47:85–91.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Teede HJ, Neven ACH, Pena A. Evolution of evidence-based diagnostic criteria in adolescents with polycystic ovary syndrome. Hum Reprod. 2024;39(5):876–7.

    Article  CAS  PubMed  Google Scholar 

  50. Tay CT, Garrad R, Mousa A, Bahri M, Joham A, Teede H. Polycystic ovary syndrome (PCOS): international collaboration to translate evidence and guide future research. J Endocrinol. 2023;257(3):e220232.

    CAS  PubMed  Google Scholar 

Download references

Acknowledgements

Not applicable

Funding

The Australian National Health Medical Research Council (NHMRC) (APP1171592) primarily funded this work. The American Society for Reproductive Medicine, Endocrine Society, the European Society of Human Reproduction and Embryology, and the European Society for Endocrinology provided partnership funding. Collaborating organizations provided in-kind support. The Commonwealth Government of Australia also supported Guideline Translation through the Medical Research Future Fund (MRFCRI000266). HJT and AM are funded by NHMRC fellowships and CTT by an RACP fellowship. Funders had no specific role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

Author information

Authors and Affiliations

  1. Discipline of Paediatrics and Endocrine Department, The University of Adelaide Robinson Research Institute and Women’s and Children’s Hospital, 72 King William Road, North Adelaide, SA, 5006, Australia

    Alexia S Peña

  2. Division of Pediatric Endocrinology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA

    Selma Feldman Witchel

  3. School of Psychology, Cardiff University, 70 Park Place, Cardiff, Wales, CF10 3AT, UK

    Jacky Boivin

  4. University of Missouri Kansas City, 3101 Broadway, Kansas City, MO, 64111, USA

    Tania S. Burgert

  5. NICM Health Research Institute, Western Sydney University, Locked Bag 1797, Penrith, Australia

    Carolyn Ee

  6. University of Rochester, 500 Red Creek Drive, Suite 220, Rochester, NY, 14623, USA

    Kathleen M Hoeger

  7. Division of Nutritional Sciences, Cornell University, Ithaca, NY, 14850, USA

    Marla E. Lujan

  8. Cornell Nutrition, 244 Garden AvenueRoom 216, Savage HallIthaca, NY, 14853, USA

    Marla E. Lujan

  9. Monash Centre for Health Research & Implementation, School of Public Health and Preventive Medicine. Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, VIC, 3168, Australia

    Aya Mousa

  10. Division of Pediatric Endocrinology, Columbia University Irving Medical Center, CUIMC/Presbyterian Hospital, 622 West 168 Street, Suite 307 West, New York, NY, 10032, USA

    Sharon Oberfield

  11. Monash Centre for Health Research and Implementation, Monash University, Clayton, VIC, 3168, Australia

    Chau Thien Tay

  12. Monash Centre for Health Research and Implementation, School of Clinical Sciences, Monash University, Clayton, VIC, 3168, Australia

    Helena Teede

Authors
  1. Alexia S Peña
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Selma Feldman Witchel
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Jacky Boivin
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Tania S. Burgert
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Carolyn Ee
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Kathleen M Hoeger
    View author publications

    You can also search for this author inPubMed Google Scholar

  7. Marla E. Lujan
    View author publications

    You can also search for this author inPubMed Google Scholar

  8. Aya Mousa
    View author publications

    You can also search for this author inPubMed Google Scholar

  9. Sharon Oberfield
    View author publications

    You can also search for this author inPubMed Google Scholar

  10. Chau Thien Tay
    View author publications

    You can also search for this author inPubMed Google Scholar

  11. Helena Teede
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

AP and HT conceptualized this manuscript. AP wrote the first draft of the manuscript. HT led the guidelines from funding, engaging partners, coordinating processes, prioritizing clinical questions, co-chairing guidelines meetings, coordinating peer review responses and leading writing, approval, and publication responses. AM and CTT led the evidence synthesis network. SW, TB, JB, CE, KH, ML, AM, SO, CTT wrote specific sections of the manuscript. All authors reviewed and critically revised the manuscript. All authors read and approved the final manuscript. All authors have full access to all the evidence included in the manuscript and accept responsibility to submit for publication.

Authors’ X handles

Alexia Peña @AlexiaPena8.

Jacky Boivin @boivincardiff.

Carolyn Ee@drcarolynee.

Marla Lujan @CornellOvaryLab.

Aya Mousa @AyaMousa_PhD.

Chau Thien Tay @TayJillian.

Helena Teede @helenateede.

Corresponding author

Correspondence to Alexia S Peña.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Peña, A.S., Witchel, S.F., Boivin, J. et al. International evidence-based recommendations for polycystic ovary syndrome in adolescents. BMC Med 23, 151 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12916-025-03901-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12916-025-03901-w

Keywords

BMC Medicine

ISSN: 1741-7015

Contact us