From PCOS to PMOS – a practical update for GPs

As part of our series highlighting sessions from our Pulse 365 Live and Virtual events, GPwER in Gynaecology Dr Mehreen Ali Khan provides her key takeaway messages for GPs to update on the diagnosis and management of polycystic ovary syndrome (PCOS) – newly named polyendocrine metabolic ovarian syndrome (PMOS)

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive age, affecting 1 in 8 women, with a likely higher prevalence in South Asian and Mediterranean populations. Up to 70% of cases may remain undiagnosed.

It was announced at the European Congress of Endocrinology in May 2026 that the name PCOS has now officially been changed to polyendocrine metabolic ovarian syndrome (PMOS), following agreement by international societies and patient groups across six continents. The new name better reflects the multisystemic effects of this condition including metabolic, mental, skin, cardiovascular and reproductive health.

Here I outline my key takeaway messages for GPs to support improved recognition and treatment of this debilitating condition.

Note that current UK best practice for diagnosis and management is to follow the 2023 international guidelines developed by Monash University in partnership with other specialist organisations, and endorsed by the Royal College of Obstetrics and Gynaecology (RCOG). NICE is currently developing guidance on PCOS which is due to be released in December 2026.

PCOS is a multisystem condition underpinned by insulin resistance

It is now understood to be a complex, long-term condition with metabolic, reproductive, dermatological, cardiovascular and psychological sequelae. 

Insulin resistance is considered the key mechanism driving the hormonal dysfunction.

Diagnosis is principally based on clinical history

A diagnosis of PCOS can be made based on:

• Irregular menstrual cycles plus
• Clinical or biochemical hyperandrogenism.

This means many patients can be potentially diagnosed clinically without the need for further investigations or ultrasound.

However, if the patient presents only with irregular menstrual cycles, or hyperandrogenism, further tests can be done in adults – specifically:

• USS for polycystic ovarian morphology or
• Raised anti-Müllerian hormone (AMH); however, AMH can be affected by factors such as age, BMI, and access to testing limited in primary care.

Irregular cycles need to be defined properly

Menstrual irregularity varies by years since menarche; adolescent diagnosis is difficult because irregular periods and acne are often physiological.

The definition of irregular cycles is summarised in the box below.

Remember that any irregularity in the first-year post-menarche is considered normal, as part of the pubertal transition.

It is also important to understand that gynaecological maturity is only reached 8 years after menarche – therefore it is difficult to diagnose PCOS in this in this cohort of patients. Therefore, they can be deemed as ‘at risk’ of PCOS and reassess regularly.

Clinical hyperandrogenism should be assessed carefully

Hirsutism

Ask patients to fill out the Ferriman–Gallwey score using the following link: Ferriman Gallwey score – My Endo Consult. A score of 4-6 is classed as significant, however this can be ethnicity dependent.

Acne

Assess acne as per the PCDS (Primary Care Dermatology Society) guidelines.

Hair loss

Assess degree of female-pattern hair loss by use of the Ludwig Scale, which includes Stages 1 to 3 – principally based on the level of frontal parting separation. Stage 2 is classed as clinically significant.  

Biochemical hyperandrogenism – check serum testosterone

Biochemical testing is only required if clinical hyperandrogenism is not definitive.

Serum testosterone is the most useful initial test. A level of 1.6 nmol/L or above is significant (local laboratories may vary).

Remember if patients are already on the combined oral contraceptive pill (COCP) they must stop taking it at least 3 months before this test (the COCP increases SHBG and reduces gonadotrophin-dependent androgen production).

If testosterone is normal, but there is still clinical concern, further tests may include the following:

• Androstenedione
• DHEAS (dehydroepiandrosterone sulfate)

However, if considering the above blood tests, referral to Endocrinology is advisable at this stage.

Note that oestradiol has no diagnostic value in PCOS.

Transvaginal USS is recommended as second-line investigation

As above, USS is no longer a first-line investigation; if required, request transvaginal US as this has better specificity than transabdominal US for detecting polycystic ovarian morphology.

Polycystic ovarian morphology is confirmed on the scan if there is:

• 20 follicles per ovary; or
• 10 per section of an ovary; or
• Ovarian volume >10ml

Remember that ultrasound findings on their own are not sufficient to diagnose PCOS, as one in four women have polycystic ovarian morphology on their ultrasound scan without any clinical/ biochemical hyperandrogenism.

In adolescence, up to 70% of patients can show polycystic ovarian morphology on USS irrespective of PCOS, but as above this group often have irregular cycles anyway and therefore can only be considered ‘at risk’ of PCOS and reassessed later once mature.

Lifestyle modification is key

It is important to provide a personalized, holistic management plan for the patient. Screen for metabolic risk factors – patients with PCOS are at increased risk of type 2 diabetes, dyslipidemia, hypertension and obstructive sleep apnea. PCOS is also considered high risk for pregnancy- increased risk of GDM, pre-eclampsia, miscarriage and premature delivery so it is important to counsel for this.

Recommended assessments for this include:

• HbA1c
• Lipid profile
• Blood pressure
• BMI
• Sleep apnea screening tools (STOP-BANG/Epworth).

No single diet is specifically recommended for PCOS. Any healthy diet that is sustainable, financially viable and the patient enjoys is what is advised.

Crucially it is worth mentioning that weight loss of just 5% of total body weight can have significant effects on fertility and metabolic outcomes.

Mental health screening is essential

PCOS is strongly associated with mental health disorders including anxiety, depression, eating disorders, psychosexual dysfunction and body image distress.

Menstrual symptoms – combined oral contraception remains the first-line treatment

Any standard COCP is acceptable if the patient has no contraindications.  Aim for preparations with <30mcg ethinyloestradiol where possible.

Levonorgestrel (LNG)-IUD or POP are alternatives.

Dianette can be considered second-line, but it has higher oestrogen and therefore increased VTE risk.

Note patients with oligomenorrhoea (less than three periods in a year) who decline hormonal treatment will have high circulating unopposed oestrogen, which can lead to endometrial hyperplasia, so will they require prescription of cyclical progestogen.

Metformin for cardiometabolic regulation can be started in primary care

Consider metformin for:

• BMI >25 (lower BMI thresholds in South Asian patients).

Typical dose:

• Start at 500mg daily.
• Titrate up gradually to a max dose of 2.5g in adults and 2g in adolescents.

Remember this is off-licence use and we are now expected to routinely monitor patients on metformin who have symptoms or are at risk of B12 deficiency.

Obesity – ensure patients on contraception prior to bariatric surgery

Management may involve anti-obesity medication or bariatric surgery.

Note patients should already be on long-term contraception before undergoing bariatric surgery – their fertility may return very quickly after, and there are risks associated with pregnancy very soon after surgery with potentially worse neonatal outcomes.

Hirsutism options remain limited

Unfortunately few treatments are available on the NHS.

Cosmetic treatments (such as laser, phototherapy, electrolysis, waxing and shaving) can be accessed privately.

Other options include:

• COCP (limited evidence)
• Eflornithine (Vaniqa) is rarely used.

Treat acne as per PCDS guidelines

In summary this involves:

• Topical treatments including retinoids +/- antibiotics.
• COCP.

If the above are ineffective, off-license anti-androgen treatments that you may consider include:

• Spironolactone 25-100mg OD (baseline U+E and ongoing monitoring >45).

When to refer

Patients should be referred where there is:

• Treatment failure in primary care.
• Fertility treatment required.
• Testosterone >5 nmol/L (urgent endocrine referral to exclude tumour).

Key points

• Monash guidelines on PCOS are the gold standard – however, NICE is due publish guidelines at the end of 2026.
• The name PCOS has officially changed to polyendocrine metabolic ovarian syndrome.
• Diagnosis is based on irregular cycles and hyperandrogenism, whether that’s clinical or biochemical.
• Ultrasound or AMH can be undertaken if only one of the above are present.
• Start metformin in most patients with raised BMI above 25 to improve metabolic outcomes.
• Screen for and treat risk factors accordingly.

Dr Mehreen Ali Khan is a GPwER in Community Gynaecology in Greater Manchester

Sources and further information

• Teede H et al. International evidence-based guideline for the assessment and management of polycystic ovary syndrome (PCOS). Copyright Monash University, Melbourne, Australia 2023
• May N et al. ‘Unprecedented’ global effort gives new name to polycystic ovary syndrome – and new hope to millions of women. Guardian 12 May 2026
• Verity – charity for people with PCOS. Available at: https://www.verity-pcos.org.uk/

Dr Khan will also be speaking at our upcoming Pulse 365 Live event in Birmingham, on Endometriosis: What a GP needs to know. The session will provide GPs with a clear and practical overview of endometriosis, supporting earlier recognition and more confident management in primary care. It will include considerations around fertility, as well as an update on emerging treatment options and appropriate referral pathways to specialist care. Book your place now – you can view the full agenda here: Pulse LIVE Birmingham agenda

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