PCOS
Rotterdam 2023 update, metabolic features, and inositol
Last updated: October 2026 — Sources: Cochrane / EAU / ESHRE / WHO / CDC
Key takeaways
2023 PCOS guideline updates Rotterdam: AMH replaces ultrasound in adults only; COC first-line for hyperandrogenism, metformin metabolic. Inositol ‘could be considered’ cautiously, no fixed dose.
Dx: 2 of 3 (hyperandrogenism/ovulation/PCOM/AMH) with exclusions; AMH not for adolescents.
Fitz 2024: D-chiro may ↑ ovulation OR 11.5 but on 2 trials — caution.
Guideline: inositol any form could be considered per patient preference — metabolic possible, reproductive not proven.
Letrozole beats clomiphene for PCOS ovulation induction (Franik Cochrane 2022): ovulation OR 1.73, pregnancy 1.69, live birth 1.68.
When to evaluate?
- Young irregular cycles + hirsutism/acne — check androgen + US/AMH if adult.
- Desiring pregnancy with PCOS — lifestyle/metabolic first, then ovulation induction.
- Repeated clomiphene failure — discuss letrozole before surgery/stimulation.
What not to do?
- Don't prescribe inositol as first infertility therapy — no type/dose recommended.
- Don't use AMH to diagnose PCOS in adolescents.
- Don't skip metabolic screening (glucose/lipids/weight) in PCOS.
Healthcare-professional notice
This hub is independent of NPF products and does not promote them. It is informational only and does not replace individual clinical judgment. Surrogate outcomes (SDF, motility, HOMA, IIEF) are never converted into pregnancy/cure promises, and GRADE certainty is quoted as published.
Binding rule: surrogate outcomes are never converted into patient outcomes. Every certainty grade and limitation is quoted as published.
Deep dive
Inositol in guideline
‘Could be considered’ EBR low — some HOMA/lipid improvement but no consistent ovulation/hirsutism/weight effect.
Regulation varies — shared decision.
Letrozole vs clomiphene
Franik 2022: 41 trials 6,522 women — ovulation/pregnancy/live birth better with letrozole, no miscarriage/multiple diff.
OHSS rare 0.5% equal — caution most trials unblinded.
Evidence in this domain
Each study broken into five questions: why it was run, who was studied, how it was done, the finding, and why it came out that way — then the clinical takeaway and limits, as published.
FAQ
Which inositol?
Guideline doesn't specify — Myo or D-chiro per preference/availability, no standard dose.
Notice: this reference is informational only and not a substitute for medical advice. Consult your doctor before making any treatment decision.