Changes in the diagnosis and management of polycystic ovary syndrome in adolescents based on recommendations from scientific societies over the last decade

Abstract

Introduction

The paper presents a systematic review of current guidelines from scientific societies regarding polycystic ovary syndrome (PCOS) in adolescents published over the past decade.

Aim of the study

To summarize and compare recent international and national PCOS guidelines with emphasis on areas of consensus and divergence.

Material and methods

A systematic review of guidelines published between 2015 and 2025 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Ultimately, twelve documents containing adolescent-specific content were included.

Results

In adolescents with PCOS, clinical symptoms of hyperandrogenism and menstrual irregularities are the main diagnostic criteria, whereas polycystic ovarian morphology and anti-Müllerian hormone concentration are not considered reliable indicators in adolescents. The current approach to PCOS also emphasizes the assessment and management of metabolic and psychological comorbidities.

Conclusions

The diagnosis and treatment of PCOS in girls require a separate approach related to age and ongoing puberty. According to the latest recommendations, lifestyle changes should be a mandatory part of therapy regardless of the background of the presented disorder. The pharmacological treatment should be tailored to the dominant symptoms.

Introduction

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterized by hyperandrogenism in females with an incompletely understood etiology. Research highlights its multifactorial background, suggesting an interplay between genetic factors and environmental influences [1]. PCOS predominantly affects women of reproductive age; however, it often starts in adolescence. Patients with PCOS commonly present with ovulatory dysfunction, menstrual disorders including oligomenorrhea or amenorrhea, as well as acne, polycystic ovarian morphology (PCOM), hirsutism, and obesity. However, it is worth emphasizing that irregular menstrual cycles, acne, and PCOM are also hallmarks of normal puberty, which complicates diagnosis in adolescents [2]. Furthermore, the observation of early adrenarche before the age of eight could be irrelevant, but it could also be a potential risk factor for the development of PCOS in the future [3].

Clinical features of PCOS can result from hormonal dysregulation, including abnormalities in steroidogenesis leading to hyperandrogenemia, as well as alterations in the hypothalamic-pituitary-gonadal axis, influencing luteinizing hormone and follicle-stimulating hormone balance [4]. While hormonal disruptions are central to PCOS pathogenesis, studies also underscore the pivotal role of insulin resistance (IR), hyperinsulinemia, excess adipose tissue, alterations in adiponectin levels, dysregulated kisspeptin signaling, and maladaptive pathways in response to energy overabundance [5]. Insulin exerts selective effects on the ovaries, enhancing excessive androgen production by ovarian theca cells while simultaneously reducing sex hormone-binding globulin (SHBG) level. This reduction of SHBG increases the concentration of free androgens in the bloodstream, exacerbating hyperandrogenemia and contributing to the pathophysiology of PCOS [6]. The substantial overlap between normal pubertal changes and pathological features of PCOS renders adolescents particularly susceptible to overdiagnosis, underdiagnosis, or misdiagnosis. The controversy over diagnostic criteria, evaluation protocols, and therapeutic approaches for adolescents is reflected in the evolution of numerous guidelines and recommendations over time. The diagnosis of PCOS in adolescent girls varies depending on the diagnostic criteria applied within the population [7]. The first formal recommendations for PCOS management were the National Institute of Child Health and Human Development criteria from 1990 [8] and the Rotterdam Criteria from 2003 [9], established by the European Society of Human Reproduction and Embryology (ESHRE)/American Society for Reproductive Medicine (ASRM)-sponsored Consensus Group. Both documents emphasized hyperandrogenism and chronic anovulation as diagnostic markers, with the latter expanding the criteria to include PCOM, thereby significantly broadening the definition of the syndrome. However, these recommendations remained adult-focused and did not address the diagnostic and therapeutic nuances specific to adolescents. Over the years, guideline development has evolved in methodology and scope. Key frameworks such as Grading of Recommendations, Assessment, Development, and Evaluation [10], the Appraisal of Guidelines for Research and Evaluation tool [11] and its updated version [12] were adopted to ensure consistency, transparency, and rigor. Between 1990 and 2025, only 3 official guidelines specifically address the diagnosis and management of PCOS in adolescents [13, 14, 15]. The other general guidelines include chapters and distinctions in recommendations based on the patient’s age. However, variability in the assessment of PCOS by pediatric specialists remains evident and has a significant impact on the final diagnosis in patients in this age group [16].

Aim of the study

Our study aimed to examine the changing approaches to the diagnosis and management of PCOS in adolescents by systematically comparing the most recent international and regional guidelines on the diagnosis and management of PCOS in adolescents with the recommendations and position statements published over the last ten years. The objective was to identify the major shifts in diagnostic criteria, therapeutic strategies, and understanding of adolescent PCOS, as well as to highlight areas of ongoing controversy and emerging consensus among leading scientific societies.

Material and methods

This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement [17] to ensure transparency in identifying, selecting, and synthesizing relevant studies. Systematic searches were conducted in PubMed/Medline, Embase, and Web of Science databases, complemented by manual searches of organizational websites, including the European Society of Endocrinology, Endocrine Society, ESHRE, ASRM, American College of Obstetricians and Gynecologists, American Association of Clinical Endocrinologists and Royal College of Obstetricians and Gynaecologists. Reference lists of key documents were reviewed to identify additional relevant documents.

The search extended to March 2025, using a combination of terms such as “PCOS,” “guidelines,” “recommendations,” “consensus statement,” “position statement,” “diagnosis,” and “treatment.” Boolean operators (e.g., “AND/OR”), and a publication year filter (2015–2025) were applied to refine the results. The search included English written guidelines with a global, international, national, or local scope, which were either general or specific to adolescents. Document types included were guidelines, practice guidelines, recommendations or consensus statements that provided explicit diagnostic or therapeutic recommendations for adolescents. The exclusion criteria included papers classified as systematic reviews, clinical studies, observational studies, interventional studies, longitudinal studies, registry-based studies, epidemiological studies, case reports, or meta-analyses. We also excluded documents that did not mention the adolescent group anywhere in the text.

The general guidelines aimed primarily at adults were also reviewed to extract adolescent-specific information, ensuring a comprehensive analysis of adolescent content. To assess the adolescent specificity in each guideline, we performed a keyword search for “adolescents” (including all grammatical variations) using the text search function. Based on the frequency of this keyword, we categorized the strength of focus as follows: 0 occurrences: no adolescent-oriented recommendations (exclusion criteria), 1–10 occurrences: low focus on adolescents, 11–50 occurrences: moderate focus on adolescents, 51–99 occurrences: high focus on adolescents, 100+ occurrences or entire document targeted at adolescents: very high focus on adolescents. We acknowledge that the frequency of keyword occurrences represents only a proxy measure of adolescent-specific focus and may not fully reflect the depth or quality of recommendations within each guideline. A PRISMA 2020 flow diagram (Figure 1) is presented to illustrate the study selection process, including the number of records identified, screened, excluded, and included.

Figure 1.

PRISMA flow diagram

Results

The database searched 268 records, with an additional 21 identified through organizational websites and citation tracking. After removing 107 duplicates from the database search and 19 from websites of organizations and citation searching against databases, 163 unique records were screened at the abstract level. Thirteen full-text screened studies were assessed for eligibility from the databases search and 2 studies from other methods, with exclusions made for reasons such as not mentioning the adolescent group in the publication (2 studies from the database search and 1 study from other methods). Ultimately, 11 studies met the inclusion criteria and were included from the review of databases, and 1 study from the review of websites of organizations and citation. The included studies were synthesized into a comparative table, capturing their publication year, first author, range (global versus national), adolescent focus (assessed by searching for the phrase “adolescent/adolescence” in the whole text), description of recommendations, and frameworks used (Table I).

Table I.

Characteristics of included evidence-based guidelines, recommendations, and consensus statements on polycystic ovary syndrome (PCOS) in adolescents

No.	Year of publication	Author	Range	Number of occurrences of term “adolescents” in whole text*	Focus on adolescents	Description
1	2015	Moghetti et al.[18]	National (Italy)	6	Low	It contains one short section about adolescents, highlighting difficulty of diagnosing, careful follow-up and evaluation in suspected cases
2	2015	Witchel et al.[13]	Global	Addressed to adolescents	Very high	Guideline for management of PCOS in adolescents, diagnostic challenges; emphasizing physiological changes during puberty
3	2015	Goodman et al.[19]	Global	50	Moderate	It contains brief section about adolescents, diagnostic criteria, treatment strategies
4	2017	Ibáñez et al.[14]	Global	Addressed to adolescents	Very high	Guideline for management of PCOS in adolescents, discusses hormonal, metabolic, and reproductive aspects, evidence-based recommendations
5	2018	The 2018 International Evidence-Based Guideline [20]	Global	129	Very high	International evidence-based guideline combining the highest-quality available evidence with insights from a multidisciplinary team of experts
6	2018	Milewicz et al.[21]	National (Poland)	19	Moderate	It includes national perspectives on PCOS diagnosis and management across different age groups
7	2020	Malik et al.[22]	National (India)	90	High	Guideline for diagnosis and management of PCOS in the Indian population; most recommendations are presented separately for adult women and adolescents
8	2020	Peña et al.[15]	Global	Addressed to adolescents	Very high	The guideline focuses entirely on adolescent PCOS, discussing diagnostic criteria and treatment approaches
9	2020	Moran et al.[23]	Global	13	Moderate	It focuses on lifestyle management for PCOS, including recommendations for adolescents
10	2023	The 2023 International Evidence-Based Guideline [24]	Global	192	Very high	An updated general guideline with further refinement of diagnostic and therapeutic approaches for adolescents
11	2024	Teede et al.[25]	National (Australia)	16	Moderate	An Australian adaptation of the 2023 International Evidence-Based Guideline [24]
12	2025	Peña et al.[26]	Global	Addressed to adolescents	Very high	Prepared by the same group as the 2023 International Evidence-Based Guideline [24]; this document extracts and presents the adolescent-specific recommendations

^*The frequency of the word “adolescents” appearing in a document was used to assess its focus on adolescent-specific content: 0 occurrences: no reference to adolescents; excluded from analysis; 1–10 occurrences: low focus on adolescents; 11–50 occurrences: moderate focus on adolescents; 51–99 occurrences: high focus on adolescents; 100+ occurrences or the entire document dedicated to adolescents: very high focus on adolescent-specific recommendations

Each guideline was systematically analyzed to extract key information on the diagnosis criteria, associated health risks, and methods of the PCOS treatment in adolescents, following the structure of the guideline chapters. The results of this study are presented in three tables, each summarizing key findings related to different aspects of PCOS. In the table, within the columns referring to Biochemical Criteria of Hyperandrogenism, PCOM and Pelvic ultrasonography, anti-Müllerian hormone (AMH), and impaired glucose risk, we indicated in parentheses the strength of each recommendation whenever it was explicitly provided by the original authors.

Diagnostic criteria include data on menstrual irregularities, ovulatory dysfunction, biochemical and clinical hyperandrogenism, PCOM, and AMH. Broader factors such as the influence of ethnic background and identification of adolescents at risk are also considered (Table II).

Table II.

(Part 1). Diagnostic criteria for polycystic ovary syndrome (PCOS) in adolescents based on included evidence-based guidelines, recommendations, and consensus statements

Aspect	Diagnostic criteria	Menstrual irregularities and ovulatory dysfunction	Biochemical criteria of hyperandrogenism	Clinical hyperandrogenism
Moghetti et al. (2015) [18]	No unambiguous criteria to diagnose PCOS during adolescence exist; evaluate persistent oligomenorrhea as a potential early sign of PCOS, especially if it lasts > 2 years PM or is linked to hyperandrogenism	Persistent oligoamenorrhea as a potential early indicator of PCOS, particularly if it continues beyond 2 years PM and/or is accompanied by hyperandrogenism	Not mentioned	Not mentioned
Witchel et al. (2015) [13]	Diagnostic features: clinical hyperandrogenism (moderate to severe hirsutism), biochemical hyperandrogenism (elevation of serum total and/or free T levels), oligo-anovulation, PCOM (no compelling criteria for adolescents)	Physiology:menstrual interval of 20–45 days within the first 2 years PM or > 90 days in 1 year PM; Evidence of oligo-anovulation: menstrual intervals < 20 days or > 45 days 2 or more years PM; Menstrual irregularity regardless of years PM:menstrual intervals > 90 days; diagnosis consideration: lack of menses by age 15 years or by more than 2–3 years after thelarche	Defined by reliable total/free T assays; advise against relying on a single elevated value (> 2 SD above the mean) for diagnosis in asymptomatic adolescents	Mild hirsutism in early PM years is often developmental and not diagnostic, moderate-severe hirsutism is diagnostic
Goodman et al. (2015) [19]	Diagnostic features: menstrual irregularities; hyperandrogenism (clinical or biochemical); PCOM (enlarged ovaries > 12 cm3 on TVUS, follicle counts are not reliable); hyperinsulinemia; IR; persistent symptoms (e.g. acne)	Persistent oligomenorrhea > 2–3 years PM predicts ovulatory dysfunction; immaturity of the axis is a common cause in early adolescence; persistent oligomenorrhea with biochemical hyperandrogenism is more indicative of PCOS than acne or alopecia	Stress the lack of normal T ranges for adolescent group; free T levels typically range between 1.0 and 1.3 ng/dl; total T median 35–40 ng/dl by Tanner stage 5	mFG score less reliable in adolescents; persistent oligomenorrhea with biochemical evidence are diagnostic; severe acne suggests hyperandrogenism; hirsutism less diagnostic in younger populations due to pubertal changes
Ibáñez et al. (2017) [14]	Diagnostic features: clinical hyperandrogenism (moderate to severe hirsutism, oligomenorrhea and secondary amenorrhea [beyond 2 years PM] or primary amenorrhea), biochemical hyperandrogenism	Oligomenorrhea or secondary amenorrhea > 2 years PM may indicate androgen excess; primary amenorrhea defined as absence of menstruation by the age of 15 or 3 years PM, warrants further evaluation	Elevated total/free T necessary for confirmation	Moderate-to-severe hirsutism and severe acne as evidence of androgen excess; mild hirsutism can also indicate hyperandrogenism when paired with irregular cycles; isolated acne or alopecia is insufficient for diagnosis
The 2018 International Evidence-Based Guideline	Step 1: Irregular cycles + clinical hyperandrogenism (exclude other causes)* = PCOS diagnosis; Step 2: If clinical hyperandrogenism is absent, assess biochemical hyperandrogenism (after excluding other causes) = PCOS diagnosis; Step 3: If ONLY irregular cycles OR hyperandrogenism is present, ultrasonography is not indicated in adolescents = classify as at risk of PCOS and reassess later	Cycles are normal in the first year PM. Irregular cycles defined as: • > 1 to < 3 years PM: < 21 or > 45 days; • > 1 year PM: > 90 days for any one cycle; • primary amenorrhea by age 15 or > 3 years post thelarche	Calculated free T, free androgen index, or calculated bioavailable T should be used. Interpretation must be guided by age and pubertal specific reference ranges. Assessment is key when clinical hyperandrogenism is unclear or absent	Exam for symptoms: acne, alopecia and hirsutism, and, in adolescents, severe acne and hirsutism; mild acne and alopecia are not recommended as diagnostic criteria for adolescents
Milewicz et al. (2018) [21]	Diagnosis: both symptoms for at least 2 years: 1. irregular menstruation (oligomenorrhea, primary or secondary amenorrhea); 2. hyperandrogenism (biochemical [elevated androgens] or clinical [hirsutism, severe acne, androgenic alopecia]); PCOM on TVUS or cystic acne may support the diagnosis, but not required; risk factors: early menarche, early pubarche, low birth weight, and obesity	Physiology: cycles should be normal within 2 years PM; Abnormalities that require evaluation: > 45 days or < 20 days during 1 year PM; Diagnostic: oligomenorrhea, primary or secondary amenorrhea	No age- or ethnicity-specific standards for free and total T levels; T > 0.55 ng/ml suggests androgen excess; total T and SHBG are used to calculate FAI (FAI = total T [nmol/l] × 100/SHBG [nmol/l]), with FAI > 5 indicating hyperandrogenemia	mFG score with ethnicity-specific thresholds ( > 7 for Caucasians, 9–10 for Mediterranean populations, and 2 for Asians); hirsutism is a reliable clinical marker
Malik et al. (2020) [22]	Diagnosis: each symptom: 1. androgen excess (biochemical: serum total testosterone; clinical: acne, hirsutism, FPHL); 2. ovulatory dysfunction; 3. PCO with strict interpretation of TVUS findings; Minimum diagnostic work-up: 5 tests: 1. serum total testosterone (cut-off 60 ng/dl); 2. OGTT (at 0 and 2 hours after 75 g glucose load); 3. serum 17-OHP (assessed at 8 am); 4. serum TSH; 5. serum prolactin levels	Oligomenorrhea or amenorrhea > 2 years PM signals PCOS; it should be evaluated using the adult Rotterdam criteria (evidence of androgen excess, ovulatory dysfunction, and PCOM on ultrasonography interpretations); menstrual regularity defined as 4 cycles/year for adolescents aged 12–16 years	Serum total T cutoff 60 ng/dl as a primary marker; OGTT, 17-OHP, TSH, and prolactin for diagnostic workup	Acne, hirsutism, FPHL as one of early signs of PCOS
Peña et al. (2020) [15]	Diagnosis: both symptoms required: 1. irregular menstrual cycles and ovulatory dysfunction; 2. hyperandrogenism (biochemical and clinical)	Aligns with the 2018 International Evidence-Based Guideline	Free T and FAI; LC-MS/MS assays preferred; androstenedione and DHEAS lack diagnostic specificity but aid in adrenal tumor or CAH detection; discontinue contraception for 3 months; interpret results using age-and puberty-specific reference ranges	mFG score 4–6 for hirsutism detection (> 3 in White and Black women, > 5 in Mongoloid Asian women); acne (≥10 lesions) or hirsutism as strong indicators of hyperandrogenism; mild hirsutism + menstrual irregularities suggest hyperandrogenism
Moran et al. (2020) [23]	Not mentioned	Not mentioned	Not mentioned	Not mentioned
The 2023 International Evidence-Based Guideline [24]	Step 1: irregular cycles + clinical hyperandrogenism (after excluding other causes) = PCOS diagnosis; Step 2: if no clinical hyperandrogenism, test for biochemical hyperandrogenism (exclude other causes) = PCOS diagnosis; Step 3: if only irregular cycles or hyperandrogenism; classify as at risk and reassess later; TVUS or AMH are not indicated	Physiology: menstrual irregularities during 1 year PM; Menstrual irregularity: • cycles < 21 ays or > 45 days from > 1 to < 3 years PM, • cycles < 21 days or > 35 days from > 3 years PM, • <8 cycles per year, • cycles >90 days after 1 year PM; Primary amenorrhea: lack of menstruation by age 15 or within 3 years PM after thelarche (breast development)	Total and free T, and FAI to assess biochemical hyperandrogenism (if not elevated: measuring androstenedione and DHEAS); LC-MS/MS assays for measuring total T and if needed, for androstenedione and DHEAS; androstenedione and DHEAS are secondary markers avoid testing on contraception; androgen levels reach adult ranges at 12–15 years of age	mFG score 4–6 for hirsutism detection; persistent acne or hirsutism to evaluate hyperandrogenemia; mFG less reliable in younger, perimenarcheal populations
Teede et al. (2024) [25]	Both hyperandrogenism and ovulatory dysfunction are necessary for a PCOS diagnosis; avoid using nonspecific features common in adolescence (defining PCOM by ultrasonography or by AMH level); individuals with only one diagnostic criterion (hyperandrogenism or irregular cycles) as being “at risk of PCOS”	Not mentioned	Not mentioned	Not mentioned
Peña et al. (2025) [26]	As in the 2023 International Evidence-Based Guideline [24]: specified menstrual cycle abnormalities and hyperandrogenism (biochemical/ clinical) constitute the two essential diagnostic criteria for PCOS in adolescents	As in the 2023 International Evidence-Based Guideline [24]	The 2023 International Evidence-Based Guideline [24]: calculated free T level and FAI – the best sensitivity (80.3%, 80.2%) and specificity (93.3%, 86.4%) for the diagnosis of hyperandrogenism	The 2023 International Evidence-Based Guideline [24]: mFG score cut-offs were based on adult studies; severe acne during perimenarcheal years is uncommon and is more likely to indicate hyperandrogenism

AMH – anti-Müllerian hormone; CAH – congenital adrenal hyperplasia; DHEAS – dehydroepiandrosterone sulfate; FAI – free androgen index; FPHL – female pattern hair loss; IR – insulin resistance; LC-MS/MS – liquid chromatography–tandem mass spectrometry; mFG – Ferriman-Gallwey score; OGTT – oral glucose tolerance test; PCOM – polycystic ovarian morphology; PM – postmenarche; SD – standard deviation; T – testosterone; TSH – thyroid-stimulating hormone; TVUS – transvaginal ultrasonography; 17-OHP – 17-hydroxyprogesterone

Table II.

(Part 2). Diagnostic criteria for polycystic ovary syndrome (PCOS) in adolescents based on included evidence-based guidelines, recommendations, and consensus statements

Aspect	PCOM and pelvic ultrasonography	Anti-Müllerian hormone (AMH)	Ethnic background in adolescents	Adolescents at risk of PCOS
Moghetti et al.	Not mentioned	Elevated AMH reflects disordered	Not mentioned	Not mentioned
(2015) [18]		folliculogenesis; not involved
		in dominant follicle selection
Witchel et al.	No standardized criteria for	AMH not validated; data	Developmental hirsutism	Re-evaluations in adolescent girls
(2015) [13]	PCOM in adolescents; an ovarian	inconclusive for adolescents;	in early adolescence varies	with clinical features of androgen
	volume > 12 cm3 may indicate	unreliable for the diagnosis	by ethnicity	excess such as hirsutism and
	enlargement but should not			biochemical hyperandrogenism
	be used for diagnosis; ovarian			if oligomenorrhea has not persisted
	imaging can be deferred, as			for more than 2 years
	abdominal ultrasonography may
	provide inadequate information,
	especially in obese
Goodman et al.	Large multicystic ovaries are	Not mentioned	Not mentioned	Metformin may help prevent or
(2015) [19]	common in girls < 17 years			delay PCOS progression in high-
	of age; TVUS not a first-line			risk prepubertal girls by addressing
	diagnostic tool; advise focusing on			hyperandrogenemia, insulin
	hyperandrogenism and menstrual			resistance, and metabolic risks
	irregularities
Ibáñez et al.	PCOM alone not diagnostic;	Elevated in adults with PCOS; not	Severity varies by ethnicity;	In adolescents at risk for PCOS,
(2017) [14]	use only for specific conditions;	validated in adolescents; unreliable	mFG thresholds not	normal ovulatory function may exist
	advise focusing on clinical	for the diagnosis	adolescent-specific	or emerge with time and present
	and biochemical markers like			with ovulatory adolescent PCOS
	hyperandrogenism and menstrual
	irregularities
The 2018	TVUS should not be used for	Serum AMH levels should not yet	Adolescent and ethnicity-	Adolescents with PCOS features but
International	diagnosis in those < 8 years after	be used as an alternative for PCOM	specific BMI and waist	not meeting diagnostic criteria (e.g.,
Evidence-	menarche, due to high prevalence	detection or as a single test	circumference categories	irregular cycles or hyperandrogenism
Based	of multi-follicular ovaries at this	for PCOS diagnosis; assays are	need to be considered	only) could be considered “at
Guideline [20]	stage of development	unreliable during pubertal transition	when optimizing lifestyle	increased risk”; reassessment
			and weight	advised at or before full reproductive
				maturity (8 years PM)
Milewicz et al.	PCOM in TVUS and/or cystic acne	AMH not recommended due to	Not mentioned	Not mentioned
(2018) [21]	may support diagnosis but are not	lack of standardization and reliable
	required	cut-off values
Malik et al.	PCOM assessed with strict	Not mentioned	Not mentioned	Not mentioned
(2020) [22]	ultrasonographic criteria; ovarian volume > 10 ml considered
	abnormal, per Rotterdam criteria
Peña et al.	Multi-follicular ovaries common;	AMH thresholds undefined,	Hypertrichosis common	Adolescents who have features
(2020) [15]	avoid ultrasonography < 8 years	unreliable for the diagnosis	in Mediterranean	of PCOS but do not meet the
	PM; allow using TVUS for other		and Middle Eastern	diagnostic criteria; reassessment
	conditions		adolescents, may mimic	3 years PM for menstrual irregularity
			hirsutism; cultural factors	and 8 years PM for PCOM;
			influence evaluation	COCPs are used for irregular
				menstrual cycles and/or
				hyperandrogenism, metformin alone
				or with COCPs to manage weight
				and metabolic comorbidities
Moran et al.	Not mentioned	Not mentioned	Ethnic-specific BMI	Not mentioned
(2020) [23]			and waist circumference categories need to be considered when
			optimizing lifestyle and weight
The 2023	Avoid ultrasonography	Not recommended for diagnosis	Consider ethnic variations	Irregular cycles or clinical
International	for < 8 years PM; focus on	in adolescents; levels unreliable	and use tailored diagnostic	hyperandrogenism but not meeting
Evidence-	biochemical and clinical markers;	due to pubertal development	approaches	full PCOS criteria; metformin alone
Based	allow using TVUS for other			or education + lifestyle + COCPs
Guideline [24]	conditions			(lowest effective estrogen dose
				[20–30 μg EE or equivalent]
				or consider natural estrogen
				preparations); reassessment advised
				at or before full reproductive maturity,
				8 years PM
Teede et al.	PCOM should not be used	Unreliable for the diagnosis; focus	Not mentioned	COCPs or metformin recommended
(2024) [25]	diagnostically; advise focusing	on clinical hyperandrogenism		for adolescents at risk of PCOS
	on clinical and biochemical	and ovulatory dysfunction instead		to manage irregular cycles
	markers like hyperandrogenism	of AMH testing during the pubertal		or hirsutism
	and menstrual irregularities	transition
Peña et al.	As in the 2023 International	As in the 2023 International	As in the 2023 International	As in the 2023 International
(2025) [26]	Evidence-Based Guideline [24]:	Evidence-Based Guideline [24]:	Evidence-Based Guideline	Evidence-Based Guideline [24]:
	ovarian morphology in	AMH value in adolescents is	[24]	one of the two features required
	adolescence is physiologically	variable and available data is		for adolescent PCOS diagnosis
	elevated and undergoes dynamic	limited (small sample sizes, older		(menstrual irregularities/ovulatory
	changes, applying adult criteria	adolescents)		dysfunction or hyperandrogenism)
	for PCOM is inappropriate at this stage of development

BMI – body mass index; COCP – combined oral contraceptive pill; mFG – Ferriman-Gallwey score; PCOM – polycystic ovarian morphology; PM – postmenarche; TVUS – transvaginal ultrasonography

Health risks associated with PCOS outline cardiovascular risk, impaired glucose tolerance, and mental health risks observed in affected individuals (Table III).

Table III.

Health risks associated with polycystic ovary syndrome (PCOS) in adolescents based on included evidence-based guidelines, recommendations, and consensus statements

Aspect	Cardiovascular (CV) risk	Impaired glucose tolerance (IGT) risk	Mental health risk
Moghetti et al.	Not mentioned	Not mentioned	Not mentioned
(2015) [18]
Goodman et al.	Not mentioned	High prevalence of metabolic syndrome	Hirsutism and acne affect self-esteem
(2015) [19]		in adolescents with PCOS; IR is a major	and quality of life and contribute to
		therapeutic target; metformin improves	psychosocial morbidity
		hyperinsulinemia, lipid profiles, and menstrual
		regularity
Witchel et al.	Timely diagnosis provides an opportunity	IR is not diagnostic; IR and hyperinsulinemia	Depressive symptoms warrant psychological
(2015) [13]	for lifestyle counseling, assessment	can signal related health risks; adolescents	evaluation
	of comorbidities, and initiation of treatment	with polydipsia, polyuria, acanthosis nigricans,
	when indicated	or obesity may be assessed for glucose
		tolerance using an OGTT
Ibáñez et al.	Weight loss and exercise are first-line	IR and glucose intolerance are clinically	Not mentioned
(2017) [14]	interventions for overweight adolescents,	relevant and should not be considered
	improving cardiometabolic health,	as diagnostic criteria
	androgen levels, and menstrual cycles
The 2018	CVD risk factors should be assessed: use	Glycemic status should be assessed	Likely increased prevalence of moderate to
International	BMI categories and waist circumference,	at baseline, then every 1–3 years;	severe anxiety and depressive symptoms,
Evidence-Based	overweight/obese adolescents should	OGTT recommended in high-risk patients	which should be routinely screened in all
Guideline [20]	have fasting lipid profile at diagnosis,		adolescents at diagnosis; psychological
	BP measured annually		therapy and/or pharmacological treatment
			should be offered when indicated
Milewicz et al.	Early diagnosis is critical for managing	IR is common in adolescents with PCOS;	Not mentioned
(2018) [21]	CV risks and oxidative stress; normal	abnormal fat distribution is associated with
	fasting glucose 3.9–5.5 mmol/l	IGT and T2D
	and insulin < 25.0 mIU/l used as
	benchmarks
Malik et al.	Lack of adolescent-specific	OGTT preferred for screening impaired	Routine screening for depression and anxiety
(2020) [22]	recommendations; highlights importance	glucose tolerance and T2D; HbA1ctesting only	recommended; counseling or treatment
	of CV screening, though only in adults	if OGTT not feasible; early referral to specialist	based on severity suggested
	with PCOS	care recommended
Peña et al.	Not mentioned	Highlight high prevalence of glucose	Routine depression/anxiety screening
(2020) [15]		intolerance in adolescents with PCOS	at diagnosis, further evaluation if the screen
			is positive; the use of psychiatric agents may
			worsen risk of obesity; risk is associated
			with PCOS symptoms
Moran et al.	Not mentioned	Not mentioned	Psychological support needed to address
(2020) [23]			anxiety, depression, and body image issues
The 2023	Routine assessments: lipid profiling,	Increased risks of IFG, IGT, and T2D; glycemic	Risk is associated with PCOS symptoms;
International	BP annually; age-specific variations in risk	status should be assessed at diagnosis in all	screen for anxiety/depression at diagnosis;
Evidence-Based	factors should guide personalized care	adolescents with PCOS	CBT and lifestyle modifications
Guideline [24]			recommended
Teede et al.	Not mentioned	Not mentioned	High prevalence of depressive symptoms
(2024) [25]			with dissatisfaction with emotional support;
			recommend validated psychological
			instruments for screening and tailored
			counseling or treatment
Peña et al.	As in the 2023 International Evidence-	As in the 2023 International Evidence-	As in the 2023 International Evidence-Based
(2025) [26]	Based Guideline [24]	Based Guideline [24]: no recommendation	Guideline [24] + generic online screening
		of any specific test to assess dysglycemia	resources may be used for screening and
		in adolescents (the absence of evidence)	rescreening for depression

BMI – body mass index; BP – blood pressure; CBT – cognitive behavioral therapy; CVD – cardiovascular disease; HbA1c – glycated hemoglobin; IFG – impaired fasting glucose; IR – insulin resistance; OGTT – oral glucose tolerance test; T2D – type 2 diabetes

Lifestyle and treatment approaches provide an overview of various interventions, including lifestyle modifications, combined oral contraceptive pills (COCPs), metformin, combination treatments, anti-androgen agents, inositol, and topical treatments (Table IV).

Table IV.

(Part 1). Lifestyle and treatment approaches for polycystic ovary syndrome (PCOS) management in adolescents based on included evidence-based guidelines, recommendations, and consensus statements

Aspect	Lifestyle aspect	Combined oral contraceptive pills (COCPs)	Metformin	Combination treatments
Moghetti et al.	Not mentioned	Not mentioned	Not mentioned	Not mentioned
(2015) [18]
Goodman et al.	Lifestyle changes combined	COCPs suppress ovarian androgen	Metformin may help manage	Metformin as first-line
(2015) [19]	with metformin improve	production and increase SHBG; they may	symptoms in adolescents who	monotherapy or in
	metabolic parameters, including	be used in combination with metformin	avoid COCPs; monotherapy	combination with COCPs
	hyperinsulinemia, lipid profiles,	and/or anti-androgen agents	effective for symptoms in lean	and antiandrogenic agents
	and menstrual irregularity, even		and overweight adolescents;
	in lean adolescents		doses of 850 mg daily for lean
			and 1.5–2.5 g daily for obese
			girls
Witchel et al.	No specific guidance	Not mentioned	Improves insulin sensitivity and	Not mentioned
(2015) [13]			reduction of hyperandrogenemia
Ibáñez et al.	Exercise as first-line therapy;	No specific formulation can be	Improves ovulation and	Insulin-sensitizing agents,
(2017) [14]	calorie-restricted diets	recommended over another	testosterone levels; beneficial	anti-androgens, and COCP
			effects in overweight or obese	combinations superior for
			adolescents with PCOS	cardiometabolic outcomes
The 2018	Healthy lifestyle behaviors	COCP alone should be considered	Metformin in addition to	Metformin combined
International	(healthy eating and physical	in adolescents with a clear diagnosis	lifestyle could be considered	with COCP could be
Evidence-	activity) should be recommended	of PCOS and in adolescents deemed	in adolescents with a clear	considered in adolescents
Based	for all with PCOS across the life	“at risk”; use the lowest effective estrogen	diagnosis or with symptoms	with PCOS and BMI
Guideline [20]	course; prevention of weight	dose (20–30 μg EE or equivalent)	before diagnosis; starting	≥ 25kg/m2 where COCP
	gain and monitoring is important		at a low dose (500 mg	and lifestyle fail to achieve
	particularly from adolescence		increments every 1–2 weeks)	goals
Milewicz et al.	Not mentioned	Low-dose estrogen formulations reduce	Recommended for biochemical	Metformin with low-dose
(2018) [21]		metabolic risks; avoid COCPs in venous	hyperandrogenism if lifestyle	COCPs is effective for
		thrombosis, migraines, and early pubertal	changes insufficient	metabolic phenotype with
		stages; use in Tanner stages 4–5		clinical hyperandrogenism
Malik et al.	Lifestyle modification is first-line	Low-dose COCPs (with or without anti-	Considered after 6 months	COCPs and metformin
(2020) [22]	therapy for at least 6 months,	androgenic progestins like drospirenone	of lifestyle changes as	recommended for IGT
	then metformin as a second-	and desogestrel) for menstrual	a second-line therapy;	or T2D; if menstrual
	line; for BMI > 97.5thpercentile	irregularities and hirsutism, between	wait 2 years PM; calorie-	irregularity and hirsutism
	for age, it is recommended to	12 and 16 years of age for short period	restricted diet recommended	are diagnosed, low-dose
	follow lifestyle modifications in	(up to 7 days) and after the age	first; in adolescents with	COCPs with anti-
	combination with calorie-restricted	of 16 routinely	hyperandrogenism, metformin	androgenic activity (CPA,
	meals (low carbohydrate and fat,		should not be initiated unless	drospirenone, desogestrel)
	high protein); routinely screen		glucose intolerance is confirmed	are suggested
	for BMI and waist circumference		by OGTT
Peña et al.	Weight gain is the primary priority;	COCPs alone in adolescents with a clear	In addition to lifestyle	COCPs with metformin,
(2020) [15]	regular weighing; early intervention	PCOS diagnosis or those “at risk”; first-line	interventions in adolescents	may be considered if BMI
	to prevent obesity; behavioral	for hyperandrogenism and irregular cycles:	with a diagnosis or at risk	> 25 kg/m2 or COCPs
	intervention combined with dietary	low-risk COCPs; specific types or doses	of PCOS; 1500–1700 mg/day;	and lifestyle changes fail
	intervention	of progestins, oestrogens or combinations	beneficial effects of metformin
		of COCPs cannot currently	on BMI, waist-to-hip ratio
		be recommended	and triglycerides
Moran et al.	Regular monitoring for weight	Not mentioned	Not mentioned	Not mentioned
(2020) [23]	changes; 60 min of exercise daily
	with 3 muscle-strengthening
	sessions per week; general healthy
	eating principles; encouraging
	evidence-based and socio-culturally
	appropriate healthy lifestyle
The 2023	60 min of moderate to vigorous	In adolescents at risk of or with	In adolescents at risk of	No combination treatment
International	exercise daily and muscle-	a clear diagnosis for management	or with PCOS for cycle	recommended (no data
Evidence-	strengthening exercises three	of hirsutism and/or irregular menstrual	regulation; use for metabolic	in adolescents); COCPs
Based	times a week; tailored goals; avoid	cycles; lower-risk preparations preferred;	indications or intolerance to	are preferred over
Guideline [24]	weight-related stigma	no COCP preparation is superior; first line:	COCPs; starting with 500	metformin for hirsutism
		lowest effective estrogen dose	mg increments 1–2 weekly;	management; metformin
		20–30 μg EE or equivalent or consider	maximum 2 g/day	over COCPs for metabolic
		natural estrogen preparations; general		indications
		population guidelines should
		be considered when prescribing COCPs
		in adolescents as specific types or doses
Teede et al.	Early lifestyle interventions critical to	Not mentioned	Metformin alone	Hirsutism: after 6 months
(2024) [25]	improve metabolic outcomes		in adolescents at risk	of suboptimal response
			or diagnosed with PCOS	to topical treatment and/
				or COCPs, COCPs with
				anti-androgens
				are recommended
Peña et al.	As in the 2023 International	As in the 2023 International Evidence-	As in the 2023 International	As in the 2023
(2025) [26]	Evidence-Based Guideline [24]:	Based Guideline [24]	Evidence-Based	International Evidence-
	no specific diet or exercise over another is recommended		Guideline [24]	Based Guideline [24]

BMI – body mass index; CPA – cyproterone acetate; EE – ethinylestradiol; IGT – impaired glucose tolerance; OGTT – oral glucose tolerance test; PM – postmenarche; SHBG – sex hormone-binding globulin; T2D – type 2 diabetes

Table IV.

(Part 2). Lifestyle and treatment approaches for polycystic ovary syndrome (PCOS) management in adolescents based on included evidence-based guidelines, recommendations, and consensus statements

Aspect	Anti-androgen agents	Inositol	Topical treatments
Moghetti et al.	Flutamide: may have favorable effects on	Limited evidence; potential	Not mentioned
(2015) [18]	ovulation, risk of hepatotoxicity even at low doses,	metabolic benefits
	potential embryotoxicity (therefore inappropriate
	for management of reproductive abnormalities)
Goodman et al.	Antiandrogenic therapy may affect bone mass	Not mentioned	Recommends eflornithine for facial hirsutism;
(2015) [19]	in adolescents but no short-term bone loss evidence		slows hair growth but regrowth occurs after
			discontinuation
Witchel et al.	Not mentioned	Not mentioned	Not mentioned
(2015) [13]
Ibáñez et al.	More effective than metformin monotherapy	Not mentioned	Localized hirsutism: diode/alexandrite lasers
(2017) [14]	in reducing features of androgen excess when		preferred; facial hirsutism: eflornithine as an
	effective forms of contraception are used		adjuvant to photoepilation for laser-resistant
			facial hirsutism in girls aged 16 and older or as
			monotherapy when photoepilation is not indicated
The 2018	Where COCPs are contraindicated/poorly	Inositol (in any form) should	Not mentioned
International	tolerated, anti-androgens could be considered	currently be considered
Evidence-	to treat hirsutism and androgen-related alopecia,	an experimental therapy in PCOS
Based	in presence of other effective contraception
Guideline [20]	(to avoid male fetal undervirilization)
Milewicz et al.	Spironolactone effective starting at 25 mg daily;	Acknowledges potential benefits	Laser, photoepilation, and eflornithine are
(2018) [21]	flutamide discouraged; contraception required	but lacks reliable evidence	contraindicated in adolescents; laser in teenage
	with antiandrogens	for routine use; high costs restrict	patients requires parental consent
		the availability of this therapy
		in Poland
Malik et al.	Spironolactone or finasteride: if there is no	Inositol is not recommended for the	Recommends laser and IPL with pharmacologic
(2020) [22]	improvement with COCPs or COCPs are not	management of hyperandrogenism	therapy; direct hair removal methods are
	tolerated; spironolactone is not recommended		recommended along with COCPs as first-line
	for menstrual irregularity		therapy
Peña et al.	To treat hirsutism or androgen-related alopecia	Not mentioned	Not mentioned
(2020) [15]	if COCPs are contraindicated or intolerable;
	in the presence of effective forms of contraception
Moran et al.	Not mentioned	Not mentioned	Not mentioned
(2020) [23]
The 2023	Use if hirsutism persists despite 6 months of COCP	Data for adults; metformin over	Adult data indicate that these are first-line
International	therapy; contraception critical; spironolactone: dose of	inositol for hirsutism and central	treatments for hirsutism; combine with other
Evidence-	25–100 mg/day has lower risks of adverse effects; CPA:	adiposity; specific types, doses	treatments if needed
Based	dose of ≥10 mg is not advised due to an increased risk	or combinations of inositol cannot
Guideline [24]	(e.g. meningioma); finasteride: an increased risk of liver	currently be recommended
	toxicity; flutamide and bicalutamide: an increased risk	for adolescents
	of severe liver toxicity
Teede et al.	Not mentioned	Not mentioned	Not mentioned
(2024) [25]
Peña et al.	As in the 2023 International Evidence-Based	As in the 2023 International	As in the 2023 International Evidence-Based
(2025) [26]	Guideline [24]: the role of antiandrogens is limited	Evidence-Based Guideline [24]:	Guideline [24]: no data exist in adolescents
	(2 studies in adolescents)	no data exist in adolescents and	and laser and light-based therapies are
		only biochemical efficacy has	effective treatments for hirsutism and related
		been demonstrated in adults	psychological features in adults

COCP – combined oral contraceptive pill; CPA – cyproterone acetate; IPL – intense pulsed light

These tables collectively illustrate the diagnostic framework, associated health complications, and management strategies for PCOS from the included guidelines.

Discussion

Over the last decade, the diagnosis and management of adolescent PCOS have undergone a notable evolution, reflecting both the maturation of evidence synthesis methodologies and a growing recognition of the developmental specificity of adolescence. Rather than relying strictly on the Rotterdam criteria [9], current perspectives underscore a shift toward more individualized, physiology-aware, and age-appropriate diagnostic standards. Core diagnostic features, clinical hyperandrogenism, and menstrual irregularities remain central to all contemporary frameworks, whereas markers such as PCOM and AMH have been increasingly excluded from adolescent diagnostic algorithms [15, 21, 24, 25, 26]. Despite AMH being significantly higher in girls with PCOS, it was not recommended as a diagnostic marker because of low diagnostic accuracy (sensitivity 0.66, specificity 0.78), substantial overlap with healthy adolescents, and absence of validated cut-off values, leading to a high risk of overdiagnosis [25]. Consequently, the most recent guidelines emphasize a comprehensive clinical assessment integrating the patient’s pubertal stage and hormonal context.

The significant change in the approach to diagnosing the syndrome over the last ten years has given clinicians a new tool: the “at risk” status. Just ten years ago, the same authors who wrote the current guidelines stated that PCOS should be diagnosed with caution, especially in young patients without a full picture of signs of PCOS, in order to avoid stigmatizing adolescents experiencing symptoms of hyperandrogenism or irregular menstruation [13]. This is because these symptoms may indicate puberty, but they may also lead to the overuse of metformin and COCPs. At the same time, these recommendations by Witchel et al. [13], from 2015, included the first recommendations to reevaluate these young patients frequently so as not to overlook developing PCOS. As this approach has evolved, the latest recommendations, which synthesize sources at both qualitative and quantitative levels, now provide us with a tool known as “at risk” for PCOS. This category includes adolescents who experience one of the two symptoms required for a full diagnosis. The latest recommendations concerning teenagers, published in 2023, and the latest synthesis, published in 2025, emphasize the importance of detecting the risk of PCOS as early as possible [24, 26]. This is because PCOS carries the risk of glucose intolerance, as well as an increased risk of cardiovascular disease and endometrial hyperplasia in adulthood. Classifying patients as ‘at risk’ enables regular monitoring and early treatment, which is essential for controlling the development of the disease and associated risks.

Treatment paradigms have evolved in parallel: lifestyle optimization now constitutes the universal first-line intervention, while COCPs, metformin, and anti-androgenic agents are introduced according to dominant symptomatology. This trajectory reflects a transition from therapy adopted from adults’ models toward a holistic model that integrates physiological maturation, psychological well-being, and cardiometabolic status.

Over time, the body of evidence forming the foundation for guideline development in adolescent PCOS has gradually expanded, although the number of high-quality studies available for certain aspects of care remains limited. Earlier national publications, such as those by Moghetti et al. (2015) [18] and Milewicz et al. (2018) [21], reflected the scientific landscape of their time: these documents included only brief sections concerning adolescents and relied primarily on expert consensus, as few empirical data were then available. In contrast, more recent frameworks, particularly the 2018 and 2023 International Evidence-Based Guidelines [20, 24], demonstrate a growing research base and a clearer methodological distinction between adult and adolescent recommendations. This progression highlights an encouraging trend toward greater representation of the adolescent population in clinical and translational research.

The 2018 International Evidence-Based Guideline [20] represented a pivotal step in this process, as it was the first large-scale consensus involving 40 organizations in its development. It introduced a unified, multidisciplinary approach that integrated endocrine, metabolic, and psychological perspectives, providing clinicians with clear diagnostic and management principles applicable separately across the adult and adolescent spectrum. In this sense, the 2018 document laid the groundwork for subsequent refinement.

Building on that foundation, the 2023 International Guideline [24] further expanded the scope and methodological precision of evidence synthesis. Only research meeting stringent methodological standards was included in the final synthesis. Within its hierarchy of evidence, the number of eligible studies varied across topics: for instance, recommendations defining ovulatory dysfunction timing were formulated in the absence of dedicated trials, while 4 studies supported metformin use in adolescents, 17 informed biochemical hyperandrogenism thresholds, and 47 addressed mental health screening. These figures reflect the differential pace at which particular research domains have evolved. It is worth noting that in areas where dedicated clinical trials were not included, the decision to create recommendations was made based on the natural history or consensus decisions, or was maintained from the previous edition of the recommendations from 2018 [20], as in the case of menstrual irregularities [24, 26].

The diagnostic calibration of hyperandrogenism and menstrual dysfunction in adolescents remains one of the most dynamic yet contested areas. Many adolescent-specific statements within the latest 2023 International Evidence-Based Guideline [24] are derived from adult frameworks, particularly testosterone thresholds and Modified Ferriman-Gallwey cut-offs. The 2018 International Evidence-Based Guideline had already stated that “Normal (androgen) values are ideally based on levels from a well phenotyped healthy control population or by cluster analysis of a large general population considering age and pubertal specific stages,” though it refrained from defining numerical values [20]. Nevertheless, by 2023, consensus authors acknowledged that adult-based cut-offs remain the most pragmatic standard [24, 26].

This adaptation is justified by developmental endocrinology: “In most adolescents, androgen levels reach adult ranges at 12–15 years of age” [24]. Therefore, applying adult reference thresholds during this stage is considered a reasonable and clinically pragmatic approach.

Recent studies, however, have begun to construct genuine adolescent norms. Zhao et al. [28] employed cluster analysis to define normative cut-offs for children from birth to 19 years, identifying hormonal clusters that more accurately distinguish physiological from pathological changes. Complementarily, Adriaansen et al. [29] applied quantile regression to establish continuous pediatric reference intervals for serum 11-oxygenated androgens in children with clinical symptoms of hyperandrogenism. These efforts indicate a transition toward age- and maturation-adjusted reference frameworks, yet their translation into guideline policy remains a matter for future guidelines.

Approaches to fertility counseling have also evolved from highlighting the problem to structured recommendations. Earlier documents, including Witchel et al. [13] and Ibáñez et al. [14] consensus, discussed reproductive outcomes by highlighting the mechanisms and heterogeneity in this topic. The 2023 International Evidence-Based Guideline [24] diverges from this approach by incorporating fertility education and shared decision-making with parents as integral components of comprehensive adolescent management. It also mentions inositol as a low-risk adjunct with potential metabolic benefits, although consistent clinical advantages in ovulatory function, hirsutism reduction, or weight management have not been demonstrated. The current guideline [24] allows its use based on patient preference but emphasizes that no specific form, dose, or regimen can be recommended, as high-quality studies in this age group are lacking.

Taken together, the synthesis of guidelines published between 2015 and 2025 reveals a decade-long evolution from fragmentary, adult-centered recommendations toward a coherent, evidence-based, and developmentally nuanced framework for adolescent PCOS. The 2023 International Evidence-Based Guideline [24] represents the culmination of these efforts to produce a transparent and comprehensive consensus. Its authorship, uniting many contributors to preceding national and specialty guidelines, allowed prior fragmented insights to be consolidated into a unified, globally accepted model.

Notably, no current guideline explicitly delineates management strategies for lean adolescents with PCOS, despite the increasing prevalence of this phenotype and research in this area [30]. Similarly, the evidence base remains insufficient to formulate specific recommendations concerning bariatric interventions and cosmetic or dermatologic procedures, although these topics bear significant clinical relevance in this population. Addressing these omissions should be prioritized in forthcoming consensus revisions.

Another promising direction involves refining phenotype-based classification systems. Given the syndrome’s heterogeneity, future research could identify phenotypes (e.g., obese/lean/insulin-resistant/hyperandrogenic subtypes) and develop management algorithms. As this aspect remains transformative – only 1 longitudinal qualitative study was incorporated into the 2023 International Evidence-Based Guideline [24] – Young et al. [27] demonstrated that collaborative programs engaging both parents and adolescents facilitate better symptom control, treatment adherence, and psychosocial adjustment. Such an approach would align with precision-medicine principles and improve prognostic accuracy. As understanding of PCOS pathophysiology deepens, integrating metabolic markers, insulin-resistance indices, and inflammatory profiles into phenotype definitions may enable targeted interventions at earlier developmental stages.

Conclusions

This systematic review aimed to examine the changing approach of diagnostic and therapeutic recommendations for PCOS in adolescents over the past decade, identifying areas of consensus and divergence among international and national guidelines. The analysis demonstrates a clear shift from adult-derived criteria toward a more structured, developmentally informed, and multidisciplinary approach tailored to adolescent physiology. Current evidence-based frameworks emphasize clinical hyperandrogenism and menstrual irregularities as the core diagnostic features, while excluding PCOM and AMH concentration due to their poor specificity in this age group. Lifestyle modification has emerged as the universal first-line intervention, complemented by individualized pharmacologic management based on predominant symptoms. Furthermore, contemporary guidelines increasingly recognize the psychosocial dimension of PCOS, underscoring the importance of mental health assessment and patient-centered counseling. Future directions include exploring the distinct features of lean phenotypes and integrating longitudinal, multidisciplinary approaches to optimize adolescent PCOS management.

Conflict of interest

None declared.

Funding

None.

Ethics approval

Not applicable.