🧬 Rotterdam Criteria Diagnostic Simulator

The Rotterdam Criteria Assessment

Two of three findings confirm PCOS — no single test suffices.

• 2 of 3: Criteria required (Rotterdam 2003 consensus)
• 8–13%: Global prevalence (reproductive-age women)
• ~2 yrs: Average diagnostic delay (symptom onset to diagnosis)
• ≥20: PCOM follicle threshold (per ovary, modern transducers)

The Rotterdam consensus

2003 ESHRE/ASRM meeting redefined PCOS diagnostic criteria.

Two of three criteria required — no single test confirms PCOS.

Oligo-ovulation criterion

Cycles longer than 35 days, or fewer than 8 per year.

Exclusion of mimics

Thyroid disease and hyperprolactinemia must be ruled out first.

Classic Severe PCOS — All Three Criteria

Oligo-ovulation, hyperandrogenism, and polycystic morphology co-occur here.

• ~50–65%: Share of PCOS cases (most common phenotype)
• ~70%: Insulin resistance (of phenotype A patients)
• Highest: Metabolic risk (among the four phenotypes)
• Elevated: Hirsutism score (Ferriman-Gallwey ≥8)

Full expression

All three Rotterdam criteria co-occur simultaneously.

Phenotype A carries the highest metabolic and cardiovascular risk.

Hormonal profile

Elevated LH:FSH ratio and hyperandrogenemia dominate.

Clinical management

Lifestyle intervention plus insulin sensitizers are first-line.

Classic Non-PCOM PCOS

Ovulatory dysfunction and androgen excess without polycystic ovaries.

• ~8–15%: Share of PCOS cases (less common phenotype)
• 0: Polycystic follicles (morphology criterion absent)
• Elevated: Androgen levels (clinical or biochemical)
• >35 days: Typical cycle length (oligomenorrhea)

Classic non-PCOM

Ovulatory dysfunction and androgen excess without polycystic ovaries.

Diagnostic nuance

Ultrasound can miss transient or resolved morphology.

Phenotype B still carries significant metabolic risk despite normal ultrasound.

Phenotype overlap

Some phenotype B cases evolve from phenotype A over time.

Ovulatory PCOS

Regular cycles mask underlying androgen and ultrasound findings.

• ~10–15%: Share of PCOS cases (ovulatory subtype)
• Regular: Ovulatory cycles (no oligo-ovulation)
• Moderate: Metabolic risk (milder than phenotype A)
• Favorable: Fertility outlook (relative to anovulatory types)

Ovulatory PCOS

Regular cycles mask underlying androgen excess.

Phenotype C is often missed because cycles appear normal.

Ultrasound findings

Polycystic morphology confirms diagnosis despite normal ovulation.

Fertility outlook

Generally better fertility prognosis than anovulatory phenotypes.

Mild, Non-Hyperandrogenic PCOS

Oligo-ovulation and morphology present, androgens stay normal.

• ~10–20%: Share of PCOS cases (mildest recognized phenotype)
• Normal: Androgen levels (non-hyperandrogenic)
• Lowest: Metabolic risk (among the four phenotypes)
• Ongoing: Diagnostic debate (some argue against true PCOS)

Mildest phenotype

Oligo-ovulation and morphology without hyperandrogenism.

Some experts debate whether phenotype D represents true PCOS.

Lower metabolic burden

Insulin resistance and cardiovascular risk are comparatively reduced.

Diagnostic caution

Other causes of oligo-ovulation must be excluded first.