Are Current Criteria for PCOS Too Broad?

Re-examining the Diagnostic Landscape of a Common Yet Controversial Syndrome

Polycystic Ovary Syndrome (PCOS) is now one of the most frequently diagnosed endocrine disorders in reproductive-aged women. Yet, for a condition so prevalent, its diagnostic boundaries remain surprisingly fluid. Ask ten clinicians how they diagnose PCOS, and you may encounter ten different interpretations.

Over the years, diagnostic frameworks have widened, capturing a broader array of presentations—but at what cost? Some argue this expansion empowers patients with earlier recognition and intervention. Others fear we’re labeling natural variations as pathology and inadvertently medicalizing physiology.

Let’s explore the historical background, current controversies, and clinical implications of possibly over diagnosing PCOS.

A Brief History of PCOS Diagnosis

The term “Polycystic Ovary Syndrome” traces back to the 1930s, originating with Stein and Leventhal’s description of women with amenorrhea and enlarged, cyst-filled ovaries. However, the evolution of modern diagnostic criteria didn’t truly take off until the late 20th century, and with that came complexity.

The Three Most Recognized Diagnostic Systems:

• NIH (1990): Requires both chronic anovulation and hyperandrogenism (clinical or biochemical).
  
  
• Rotterdam (2003): The most inclusive, requiring two out of three: oligo/anovulation, hyperandrogenism, or polycystic ovarian morphology on ultrasound.
  
  
• AE-PCOS Society (2006): Requires hyperandrogenism, along with either ovulatory dysfunction or polycystic ovaries.
  

Of these, the Rotterdam criteria remain the most widely used—but their flexibility has sparked debate within both endocrinology and gynecology.

The Case for “Too Broad”

a. Too Many People Fit the Diagnosis

Rotterdam’s 2-out-of-3 rule dramatically broadens the diagnostic net. Under this framework, it’s not difficult for women with otherwise mild or transient symptoms to meet the criteria:

• Irregular cycles and mild hirsutism? That’s PCOS.
  
  
• Irregular cycles and polycystic ovaries, but no hyperandrogenism? Still PCOS.
  

Depending on the population and methodology used, prevalence estimates for PCOS vary widely—from 8% up to 21%. Such a wide range calls into question how consistently the criteria are being applied across patient groups.

b. Normal Variants Are Getting Labeled

Some of the diagnostic features embedded in PCOS criteria are not pathological in isolation:

• Polycystic ovaries (defined as ≥12 follicles or increased volume) can be found in 20–30% of healthy reproductive-age women.
  
  
• Oligomenorrhea may be physiologically normal in adolescents, postpartum patients, or women under stress.
  
  
• Mild hirsutism may have ethnic or familial roots and not necessarily indicate androgen excess.
  

When these features are not contextualized properly, many women receive a diagnosis that may not reflect a pathologic condition.

c. Teenagers Are Especially Vulnerable

Adolescents represent a particularly sensitive group when it comes to PCOS diagnosis. That's because many "abnormal" features in teens may actually be part of normal pubertal development:

• Menstrual irregularities are common during the first 1–2 years post-menarche.
  
  
• Ovaries often appear multicystic during adolescence.
  
  
• Acne and minimal hirsutism are not unusual in teens.
  

Despite this, adult-oriented criteria are often applied without caution, potentially leading to unnecessary labeling, treatment, and long-term anxiety for young patients.

d. Psychological Harm of Overdiagnosis

Beyond physiology, the psychological ramifications of an early or inappropriate PCOS diagnosis can be significant:

• Concerns about future infertility
  
  
• Anxiety over body weight, hair growth, and acne
  
  
• A sense of chronic illness or endocrine failure
  
  
• Increased risk for anxiety, depression, and poor self-image
  

When a diagnosis is not framed carefully or is given prematurely, the emotional burden can outweigh the intended clinical benefit.

But... Underdiagnosis Still Happens Too

Paradoxically, while some patients may be overdiagnosed, others go unrecognized for years. Underdiagnosis tends to occur in:

• Lean women without obvious cosmetic symptoms
  
  
• Women from ethnic backgrounds where PCOS presentations differ
  
  
• Patients whose complaints (e.g., acne or fatigue) are minimized or attributed to stress
  

The issue isn’t just the breadth of criteria—it’s the inconsistency in how they are applied and interpreted across clinical settings.

What About the Ultrasound Criteria?

The term “polycystic” often draws focus to ovarian morphology. Yet as imaging technology has improved, more ovaries appear "polycystic" under newer standards.

Originally, the threshold was 12 follicles per ovary. Now, some suggest raising that number to 20 to avoid over-diagnosis due to technological sensitivity. The problem? Relying too heavily on ultrasound can result in:

• Diagnoses made in women without functional or hormonal abnormalities
  
  
• Misinterpretation of benign findings as pathological
  
  
• Overemphasis on structural rather than functional assessments
  

Imaging should support—not define—the diagnosis, especially when unaccompanied by clinical symptoms.

Phenotypes of PCOS: Not All Are Equal

The Rotterdam criteria outline four PCOS phenotypes:

• A: Hyperandrogenism + ovulatory dysfunction + polycystic ovaries
  
  
• B: Hyperandrogenism + ovulatory dysfunction
  
  
• C: Hyperandrogenism + polycystic ovaries
  
  
• D: Ovulatory dysfunction + polycystic ovaries (no hyperandrogenism)
  

Phenotypes A and B tend to present with more pronounced metabolic and reproductive risks. Phenotype D, however, is more ambiguous—sometimes displaying minimal clinical significance. Critics argue this group may reflect normal hormonal variability rather than a disease state.

And yet, it still qualifies as PCOS under Rotterdam.

Are We Treating Labels or People?

This distinction matters. Once a label is applied, clinicians may feel compelled to prescribe treatments—such as metformin, hormonal contraceptives, or lifestyle interventions—even in patients with:

• Mild or non-bothersome symptoms
  
  
• No metabolic or fertility concerns
  
  
• Minimal risk of progression
  

This approach risks overtreatment, potential side effects, and unnecessary lifestyle restrictions, particularly in women who don’t perceive themselves as unwell.

International Debate and Calls for Change

In 2018, an international guideline—backed by ESHRE and ASRM—sought to bring order to the diagnostic chaos. Key proposals included:

• Standardizing diagnostic tools across regions
  
  
• Reducing dependence on ultrasound in adolescents
  
  
• Centering care on patient concerns rather than rigid categories
  
  
• Emphasizing shared decision-making in management strategies
  

Yet, the debates persist:

• Should hyperandrogenism be a mandatory feature of diagnosis?
  
  
• Should follicle thresholds be age-adjusted or revised altogether?
  
  
• Should the term “PCOS” be abandoned, since not all patients have ovarian cysts?
  

These discussions highlight a broader dissatisfaction with current classification systems.

What Should Clinicians Do Now?

In the absence of global consensus, a more patient-centered and flexible approach is necessary:

a. Don’t Rush to Diagnose in Adolescents

Adolescent physiology is in flux. Diagnostic caution is warranted, particularly in the first 1–2 years after menarche. Terms like “hormonal imbalance” or “PCOS tendency” may be more appropriate than definitive labels.

b. Use Clinical Judgment Beyond Criteria

Diagnostic tools are just that—tools. They shouldn’t override professional judgment or patient context. Consider whether assigning a diagnosis will truly change the clinical approach.

c. Focus on Function, Not Just Findings

PCOS should be approached as a syndrome—meaning a pattern of symptoms and signs, not just an image on ultrasound or an elevated lab value. Emphasize menstrual regularity, fertility status, metabolic risk, and symptom burden.

d. Communicate Clearly with Patients

Educate patients about the variability and spectrum of PCOS. Highlight:

• That not all features are harmful or need treatment
  
  
• That management is often symptom-based
  
  
• That lifestyle changes can be beneficial regardless of label
  

This transparency can alleviate fear and empower patients to participate in decisions.

Final Thoughts

The current PCOS criteria—especially the inclusive Rotterdam model—have broadened awareness and captured more women at risk. But they’ve also made the diagnosis so elastic that it sometimes overlaps with normal physiology.

Yes, PCOS is a real and potentially serious condition. But not every irregular period, polycystic ovary, or teenage acne breakout merits a lifelong diagnosis.

When diagnostic labels expand without clear boundaries, they risk becoming less clinically useful—and more psychologically burdensome.

As clinicians, it’s our job to balance early detection with clinical nuance, and to ensure our diagnostic enthusiasm doesn’t compromise patient-centered care.

PCOS deserves attention—but so does precision.