Rotterdam criteria for diagnosing PCOS

The Rotterdam criteria is an ever-evolving diagnostic guideline for the diagnosis of polycystic ovarian syndrome (PCOS).

Because PCOS is a syndrome – meaning, a collection of signs and symptoms often found together – no one set of criteria can be used exclusively for diagnosis. The original 1990 criteria were updated in 2004.

The Rotterdam criteria and diagnosis of PCOS requires two of these three manifestations:

  • Irregular or absent ovulation
  • Elevated levels of androgenic hormones
  • Enlarged ovaries or one ovary containing at least 12 follicles, measuring 2-9mm or have an increased volume of 10ml or more

Symptoms of PCOS that may assist diagnosis include:

Symptoms of PCOS include

  • Hirsutism (male-type hair growth)
  • Menstrual irregularities
  • Acne

As updated by the European Society for Human Reproduction and Embryology (ESHRE), the American Society for Reproductive Medicine (ASRM), and cosponsored by the Rotterdam PCOS consensus workshop group in 2004, published in the January 2004 issue of Fertility and Sterility.

Testing should include metabolic syndrome testing for abdominal obesity (visceral fat), fat levels in the blood, high blood pressure, and glucose testing.

Those who have symptoms but don’t fit the clinical criteria may still have PCOS, however in a ‘mild’ form. Not everyone experiences PCOS the same way, with varying degrees of issues found.

Diagnosis of exclusion – things to rule out

  • Cushing’s syndrome
  • Androgen-secreting tumours
  • Congenital adrenal hyperplasia
  • Check follicle-stimulating hormone (FSH) levels and prolactin levels for thyroid conditions

Things to know about PCOS diagnosis

If the ovaries appear normal and there is no sign of hyperandrogenism, further testing is required. Just having polycystic ovaries is not enough, without other clinical signs, to provide a diagnosis of PCOS.

About half of those diagnosed with PCOS have insulin resistance, requiring glucose testing. LH/FSH ratios may be elevated in those with PCOS without recent ovulation, but researchers are not sure why. PCOS does not come with an increased risk of death.


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Jessica Lloyd - Vulvovaginal Specialist Naturopathic Practitioner, BHSc(N)

Jessica is a degree-qualified naturopath (BHSc) specialising in vulvovaginal health and disease, based in Melbourne, Australia.

Jessica is the owner and lead naturopath of My Vagina, and is a member of the:

  • International Society for the Study of Vulvovaginal Disease (ISSVD)
  • International Society for the Study of Women's Sexual Health (ISSWSH)
  • National Vulvodynia Association (NVA) Australia
  • New Zealand Vulvovaginal Society (ANZVS)
  • Australian Traditional Medicine Society (ATMS)