Every time I read a mainstream summary of PCOS (think WebMD-level blurbs), it boils down to “lose weight, go on the pill, maybe take metformin.” That’s a caricature that ignores a lot of nuance. For those who’ve actually dug into the primary literature or practice in this space, can we pressure-test some assumptions and fill in the gaps the popular sites gloss over?
Questions for clinicians, researchers, and well-read patients:
- Diagnosis criteria creep:
- Rotterdam vs NIH vs AE-PCOS: who should actually require hyperandrogenism, and when is “PCOM only” a misdiagnosis?
- Modern ultrasound machines inflate follicle counts. Are practices updating AFC thresholds, or still using outdated cutoffs?
- AMH as a surrogate for PCOM: any consensus on when it helps vs harms? Why is it still used as a shortcut despite guidance against using AMH alone?
- Adolescents and postpartum/perimenopause: how are you avoiding overdiagnosis in teens (where PCOM is common) and mislabeling during perimenopause?
- Lab pitfalls:
- Androgen testing: do your labs use LC-MS/MS or still immunoassays for total/free T and DHEA-S? How much does assay choice change who “has hyperandrogenism”?
- SHBG and free androgen index: useful in real life or just muddying the waters? How long off OCPs/antiandrogens before testing is actually meaningful?
- Nonclassic CAH screening (17-OHP) and thyroid/prolactin checks: are these still inconsistently done before slapping on a PCOS label?
- Metabolic risk beyond BMI:
- Fasting glucose/insulin vs 75g OGTT: who’s getting missed without a 2-hour measure (especially “lean PCOS”)?
- NAFLD screening: are you checking ALT, CAP/FibroScan, or is this still an afterthought despite elevated risk?
- Sleep apnea screening in normal-BMI PCOS-any protocols, or only if symptomatic?
- Treatment defaults under the microscope:
- OCPs: Are we honest about differences between progestins (e.g., drospirenone) and VTE risk trade-offs? Any data guiding progestin choice for hirsutism/acne vs mood/metabolic effects?
- Spironolactone: realistic timelines (6-12 months), pregnancy precautions, potassium monitoring in healthy users-what’s your threshold? Any role for low-dose oral minoxidil for AGA in PCOS with proper contraception?
- Fertility: why are some clinics still reaching for clomiphene first when letrozole has better ovulation/live-birth outcomes in anovulatory PCOS?
- Metformin beyond glycemia: does it do anything meaningful for non-insulin-resistant or “lean” phenotypes?
- GLP-1/SGLT2 era:
- For non-diabetic PCOS, who actually benefits from GLP-1 RAs or SGLT2 inhibitors in RCTs (ovulation, androgen levels, NAFLD), and who just gets side effects?
- Any evidence on fertility outcomes or medication washout timing prior to conception that you’re using in practice?
- Supplements and the evidence gap:
- Myo-inositol vs D-chiro (ratios, dosing): which phenotypes show real benefit in high-quality trials?
- NAC, berberine, omega-3, vitamin D: signal vs noise? What actually moves A1c/androgens/ovulation in randomized studies?
- Lifestyle specifics, not platitudes:
- Diets with RCT support in PCOS: Mediterranean, low-GI, higher-protein-what’s durable and helps androgens/ovulation independent of weight change?
- Resistance training and HIIT dosing: any data on improving SHBG/insulin sensitivity with specific protocols?
- Anyone using CGMs in non-diabetic PCOS to personalize diet/exercise-helpful or just biohacking theater?
- Hair/skin management:
- Best practical combos for hirsutism (e.g., OCP + spironolactone + eflornithine + laser), realistic timelines, and how you set expectations.
- Bias and outcomes that matter:
- How are you mitigating weight bias in counseling while still addressing metabolic risk?
- Which endpoints do you prioritize with patients: menstrual regularity, ovulation/live birth, androgen symptoms, cardiometabolic risk-how do you sequence goals?
If you’ve got references-guidelines, RCTs, lab method papers-bring them. I’m specifically looking for what’s changed in the last few years (updated AFC thresholds, AMH guidance, letrozole-first protocols, metabolic screening standards, GLP-1/SGLT2 evidence), and what you’re actually doing differently in clinic that contradicts the one-size-fits-all advice.