Bebe Rexha and PCOS: does a polycystic ovaries report settle the diagnosis?

By Ramon Martins Andrade, attorney (OAB/RJ 188.374)

English translation of an article first published in Portuguese: read the original.

In May 2023, in an interview on The Jennifer Hudson Show reported by Entertainment Tonight on 25 May, the singer Bebe Rexha said that, the year before, doctors had diagnosed her with polycystic ovary syndrome (PCOS), and added that many women have it and do not know it. She also spoke about the comments on her body that she had read online and summed up her view of them in a single remark: that we should not be talking about people’s weight. The public account stops there. Her criteria, tests and treatment have not been disclosed; nothing is known, and nothing is asserted here, about the doctors or the services that treated her, and nothing about the syndrome can be inferred from anyone’s appearance or weight.

The middle remark is the one that matters to the Brazilian reader. The syndrome often reaches the consulting room by a crooked path: an ultrasound ordered for some other reason, with “polycystic ovaries” in the report, and the hasty conclusion that the diagnosis has been made. It has not. This article examines what science knows, what the 2023 international guideline requires beyond the image, why the name of the condition changed in 2026, what the Sistema Único de Saúde (SUS, Brazil’s public health system) and private health plans must offer in the investigation and in the follow-up, and what the law says when the investigation stops at the report.

One woman in ten, and a name that misled

The 2023 international evidence-based guideline (Teede and colleagues, published simultaneously in the Journal of Clinical Endocrinology and Metabolism, Human Reproduction, Fertility and Sterility and the European Journal of Endocrinology) describes PCOS as the most common endocrinopathy among women of reproductive age, with a prevalence of between 10% and 13%, confirmed in the guideline’s own development process, and with impacts that run from adolescence to after the menopause. In Brazil, the reference study was carried out in primary care in Salvador: Gabrielli and Aquino (Reproductive Biology and Endocrinology, 2012) examined a probability sample of 859 women aged 18 to 45 attending the primary care network, 88.5% of them Black, and confirmed the syndrome under the Rotterdam criteria in 8.5%.

What these figures conceal is the time it takes to reach a diagnosis. In the largest study of patients’ experience, Gibson-Helm, Teede, Dunaif and Dokras (Journal of Clinical Endocrinology and Metabolism, 2017) surveyed 1,385 women with PCOS, most of them from North America and Europe: 33.6% took more than two years to be diagnosed and 47.1% saw three or more health professionals before the diagnosis. Only 35.2% said they were satisfied with the way they received it, and only 15.6% with the information that came with it. Seeing five or more professionals and waiting more than two years were associated with lower satisfaction (odds ratios of 0.5 and 0.4).

The syndrome is not an ovarian problem, and that is why the name has changed. In May 2026, The Lancet published the outcome of a global consensus process conducted with 56 academic, clinical and patient organisations and 14,360 responses from patients and professionals (Teede and colleagues): PCOS is to be called polyendocrine metabolic ovarian syndrome (PMOS). The paper states that the old name was inaccurate, because it suggested pathological ovarian cysts, concealed the endocrine and metabolic features and contributed to delayed diagnosis, fragmented care and stigma. A guidance article for gynaecologists published in the American Journal of Obstetrics and Gynecology in September 2026 (Bahri-Khomami and colleagues) explains that the characteristic ultrasound image corresponds to numerous arrested antral follicles, not to pathological cysts. The new name has not yet reached Brazilian official documents, and this article uses PCOS, the term found in the report and in the protocol (SOP, in Portuguese).

The metabolic burden is the reason the diagnosis matters beyond the menstrual cycle. In 462 women with PCOS followed at a tertiary outpatient clinic in the Southeast of Brazil, compared with other Brazilian cohorts, Maffazioli and colleagues (International Journal of Gynecology and Obstetrics, 2020) found insulin resistance in 39.6% to 55%, glucose intolerance in 7.2% to 28.1%, type 2 diabetes in 2% to 4.1% and metabolic syndrome in 27.4% to 38.3%, with no relevant difference between the regions. The 2025 joint position statement of Febrasgo, the Brazilian Society of Cardiology and the Brazilian Society of Endocrinology and Metabolism associates PCOS with a greater future risk of cardiovascular disease. Then there is mental health: the 2023 guideline tells professionals to be alert to the high prevalence of moderate to severe depressive and anxiety symptoms, and acknowledges that many women with PCOS experience weight stigma in health services.

What the 2023 guideline requires to settle the diagnosis

The 2023 guideline brought together 39 professional and patient organisations from 71 countries, reviewed the evidence in 52 systematic reviews and arrived at 254 recommendations and practice points; in Australia, where it was coordinated by Monash University, it was approved by the National Health and Medical Research Council (NHMRC). In adults, it keeps the adjusted Rotterdam criteria: two of three findings, namely irregular cycles or ovulatory dysfunction, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology, always after other causes have been excluded. And it states the essential point in so many words: when irregular cycles and hyperandrogenism are present, the diagnosis is simplified and neither ultrasound nor AMH is required. Hirsutism alone should already be considered predictive of biochemical hyperandrogenism; to measure the latter, the recommendation is total and free testosterone.

Imaging has become more demanding, not less. The threshold for polycystic morphology in adults is now 20 or more follicles in at least one ovary, with modern equipment. The novelty was anti-Müllerian hormone (AMH): it may replace ultrasound to define morphology, only in adults, only within the algorithm, never as a single test and never together with ultrasound, so as to limit overdiagnosis. In adolescents the rule is different: both irregular cycles and hyperandrogenism are required, and ultrasound and AMH are not recommended because of their low specificity; a girl who has signs without meeting the criteria may be considered at increased risk and reassessed up to eight years after her first period.

The diagnosis opens a follow-up that the guideline treats as permanent: the diagnosis may be regarded as lifelong. Glycaemic status should be assessed at diagnosis in all adults and adolescents and reassessed every one to three years, and the 75 g oral glucose tolerance test is the most accurate, regardless of BMI. A lipid profile should be done at diagnosis, regardless of age and BMI, and blood pressure measured every year. Depression should be screened for in all adults and adolescents, and anxiety in all adults, with validated instruments; eating disorders should be considered regardless of weight; patients should be asked about symptoms of sleep apnoea. None of this depends on the ultrasound report.

In the SUS: the 2019 protocol and what it guarantees

In the SUS, the yardstick is the Protocolo Clínico e Diretrizes Terapêuticas (PCDT, the Clinical Protocol and Therapeutic Guidelines) for Polycystic Ovary Syndrome, approved by Portaria Conjunta SAES/SCTIE nº 6 (a joint ordinance of the Ministry of Health) of 2 July 2019. It is still the one in force: in September 2026, the access pathway of the Bahia State Health Department for the syndrome’s medicines was still based on it. The protocol adopts Rotterdam, requires “at least two of the following criteria” (nine cycles or fewer in a year, clinical or biochemical hyperandrogenism, polycystic morphology on ultrasound) and states that the diagnosis “is confirmed after exclusion of other causes of hyperandrogenism”, with measurement of 17-hydroxyprogesterone, TSH, prolactin and FSH according to the suspicion. The Portaria provides that the protocol “is national in scope and must be used” by states and municipalities “in the regulation of access to care, authorisation, registration and reimbursement of the corresponding procedures” (art. 1, sole paragraph).

On three points the Brazilian protocol has fallen behind the 2023 guideline. The first is ultrasound: it still uses the threshold of more than 12 follicles per ovary, or a volume of 10 cm³, and concludes that “it is not yet possible to recommend” AMH in place of ultrasound. The second is adolescence: from two years after the first period until the age of 19, it requires all three Rotterdam components, ultrasound included, and allows the diagnosis to be postponed until after the age of 18, with the symptoms treated in the meantime. The third is metabolism: the oral glucose tolerance test appears only “for obese women or those with a family history of diabetes mellitus”, and the lipid profile only “for patients with suspected metabolic syndrome”, whereas the 2023 guideline calls for both in all patients.

The 2019 protocol, however, already guarantees a follow-up that many patients do not receive. It states that identifying the disease “at its early stage” gives primary care “an essential role”; it requires women using hormonal contraception to be reassessed three months after starting and every six months thereafter; it provides that the assessment of cardiometabolic risk factors, clinical and laboratory, “must be carried out annually”; and it requires referral to an endocrinologist of patients whose diagnosis has not been established or who have a metabolic comorbidity, severe hirsutism or signs of virilisation. It lists the SUS procedures for this, from testosterone measurement to the glucose curve, and the medicines: combined oral contraceptive, medroxyprogesterone, norethisterone, cyproterone and metformin; cyproterone is supplied through the Componente Especializado (the SUS specialised pharmaceutical care component), with a medical report renewed every six months, according to the Bahia pathway. Lei 8.080/1990 (the Organic Health Law, which governs the SUS) sets the measure of the duty: comprehensiveness, in art. 7, II, is the “articulated and continuous set of actions and services”. A diagnosis without the annual metabolic assessment that the protocol itself requires is interrupted care. Once Lei 15.493/2026 takes effect, expected 180 days after its publication on 3 September 2026, every woman will also be entitled to a full medical assessment in the SUS at least once a year, “with the guarantee that the relevant routine and screening tests are carried out” (art. 3); the scope of the law is discussed in annual assessment of women’s health in the SUS.

In the health plan: what the rol covers and what it leaves out

For the full investigation, the plan has little to refuse. Annex I of the rol da ANS (the ANS list of mandatory coverage; the ANS is Brazil’s health plan regulator), set out in Resolução Normativa (RN) 465/2021 as updated by RN 678/2026, lists total and free testosterone, sex hormone-binding globulin (SHBG), androstenedione, DHEA sulphate, 17-alpha-hydroxyprogesterone, prolactin, TSH, FSH, glucose, the oral glucose tolerance test, glycated haemoglobin, total cholesterol and fractions, transvaginal ultrasound and polysomnography. RN 465 guarantees “medical consultations in unlimited number” in the specialties recognised by the Conselho Federal de Medicina (CFM, the Federal Council of Medicine) (art. 18, I), which includes the annual return visit that metabolic follow-up presupposes, and RN 541/2022 abolished the limit on sessions with psychologists, speech therapists, occupational therapists and physiotherapists, for any condition. RN 566/2022 sets the time limits: up to seven business days for a gynaecology appointment (art. 3, I), up to 14 for the other specialties, such as endocrinology (art. 3, II), up to three for laboratory tests (art. 3, X) and up to ten for other outpatient tests, such as ultrasound (art. 3, XI).

AMH is not in Annex I. If it is requested, the way in is art. 10, § 13, of Lei 9.656/1998 (the Health Plans Act), added by Lei 14.454/2022: coverage of a procedure outside the rol must be authorised provided that “there is proof of efficacy, in the light of the health sciences, based on scientific evidence and a therapeutic plan”, or that there is a recommendation from Conitec (the SUS health technology assessment committee) or from an internationally renowned health technology assessment body. The Supremo Tribunal Federal (STF, Brazil’s Supreme Federal Court), in ADI 7.265 (decided on 18 September 2025), laid down cumulative requirements for such coverage: a prescription from the attending physician, no express refusal by the ANS and no pending ANS review, no adequate alternative on the rol, scientific proof of efficacy and safety, and registration with Anvisa (the health regulatory agency). For PCOS, the third requirement weighs heavily: the 2023 guideline treats AMH as an alternative to ultrasound, which is on the rol, and dispenses with it when irregular cycles and hyperandrogenism are already enough. The discussion only makes sense where ultrasound is not feasible or does not resolve the question, and the medical report must say so. If coverage is refused, ask for the answer in writing, with the name of the procedure and the rule invoked, as explained in the guide to coverage denials; where the plan requires patients to go through a family doctor before seeing a specialist, the limits discussed in gatekeeping and referral to a specialist apply.

Three countries, the same design: clinical diagnosis and continuous care

Australia made the guideline a matter of state policy. A summary published in the Medical Journal of Australia in September 2024 (Teede and colleagues) records that the guideline was approved by the NHMRC in July 2023, after meeting the national standard for clinical guidelines, that its recommendations apply to the Australian health system and that its implementation is prioritised and funded. For mental health, the paper refers to the Better Access programme, which entitles patients to up to ten individual and ten group sessions reimbursed by Medicare, the public insurance scheme. And it acknowledges the limit: there are few dedicated models of care.

The United Kingdom took the change to the front door of the public system. The official NHS page, reviewed on 30 June 2026, already uses the new name and describes the pathway: if the GP suspects the syndrome, they may refer the patient to a gynaecologist or an endocrinologist for blood tests and imaging, and an ultrasound will only be done if the patient is over 18. The long-term advice is regular check-ups to reduce the risk of type 2 diabetes, high blood pressure and cardiovascular disease.

France, through its public health insurance, has already brought the 2023 guideline into its patient information. The Assurance Maladie page, updated on 12 January 2026, says that “the clinical and biological symptoms alone make it possible to establish the diagnosis”, that AMH “may be requested in adult women (not in adolescents)”, that in adolescence one waits at least eight years after puberty before interpreting the ultrasound, and that, in the assessment, “symptoms of anxiety, depression and low self-esteem are looked for”. It calls PCOS a “chronic disease”. The routes differ (a guideline approved by the government in Australia, the GP as the front door in the United Kingdom, information from the public insurer in France), but in all three the diagnosis is clinical before it is a matter of imaging, and care does not end with the report.

When the investigation stops at the report: duties and liability

There are two possible errors, in opposite directions. One is overdiagnosis: settling on PCOS on the strength of an isolated ultrasound, without irregular cycles or hyperandrogenism and without ruling out thyroid disorders, prolactin disorders or adrenal hyperplasia, and giving an adolescent a label she does not have. The other is diagnosis without follow-up: recorded without blood glucose, without a lipid profile and without a return visit, until diabetes appears during a pregnancy. In both, the legal question is the same: what should have been done at that consultation, and was it done?

The Código de Ética Médica (the Code of Medical Ethics, CFM Resolution 2.217/2018) forbids doctors to “fail to use all available means of health promotion and of prevention, diagnosis and treatment of diseases, scientifically recognised and within their reach” (art. 32) and to “fail to inform the patient of the diagnosis, the prognosis, the risks and the objectives of treatment” (art. 34), and requires a legible medical record, with dated entries, to which the patient has access (arts. 87 and 88). The Estatuto dos Direitos do Paciente (the Patients’ Rights Statute), Lei 15.378/2026, guarantees information that is “accessible, up to date and sufficient” for decision-making (art. 12, § 1), participation in the treatment plan (art. 11), a second opinion “at any stage of treatment” (art. 18) and access to the medical record “without needing to give any justification” (art. 19); in the SUS, Lei 13.460/2017 (the law on the rights of users of public services), art. 6, III, already ensured access to one’s own information. Anyone who has received the diagnosis is entitled to know, in writing, which criteria support it and which causes were ruled out.

In civil liability, the hospital, the clinic and the health plan operator are strictly liable for the services that are their own (Código de Defesa do Consumidor, the Consumer Protection Code, art. 14), such as the wrongful refusal of a test on the rol or a laboratory failure; when the problem lies in the doctor’s own act, proof of the doctor’s fault is required (art. 14, § 4), and that question is decided by comparing the medical record with the protocol in force. The standard of the time counts: between 2019 and today, the Brazilian protocol required less metabolic screening than the 2023 guideline, and those who followed the PCDT followed the rule of the system. But the PCDT itself requires cardiometabolic risk to be assessed every year, and failing to do so departs from the written rule. If the omission took away a serious and real possibility of avoiding the harm, the Superior Tribunal de Justiça (STJ, the Superior Court of Justice) allows compensation for loss of a chance; the leading precedent is REsp 1.254.141/PR (Third Panel, Justice Nancy Andrighi reporting, decided on 4 December 2012), a case of inadequate treatment of breast cancer, not of PCOS, whose headnote sets the limit that applies to all: “The chance, however, can never reach the value of the asset lost”. In each case, the proof depends on expert evidence.

Before deciding

In my view, the lesson of Bebe Rexha’s account lies not in anyone’s body but in her remark that many women have the syndrome and do not know it. An ultrasound report does not diagnose PCOS, and the lack of one does not prevent the diagnosis either. In the SUS, the 2019 protocol is the yardstick for access, even where science has moved on, and it already guarantees the annual metabolic assessment and referral to a specialist. In the health plan, almost all the tests are on the rol, and what is missing, such as AMH, depends on Lei 9.656 and ADI 7.265, not on the name of the disease. Before taking any step, ask for the diagnostic criteria and the causes ruled out to be written down in the medical record, and keep the requests, the results and the answers. If a test was refused, if metabolic follow-up never began or if the diagnosis stopped at the imaging report, get in touch with the firm, with the medical request and the written answer in hand.

About the author

Ramon Martins Andrade (OAB/RJ 188.374) is a lawyer who graduated from UFRJ in 2011, with master’s degrees from Université Sorbonne Nouvelle and from the Naval War College (EGN, Brazilian Navy). He is currently a researcher in Human Rights and Health at ENSP/Fiocruz.

This content is for information and education only. It does not constitute legal advice, advertising of results or any guarantee of outcome, under Rule 205/2021 of the Brazilian Bar Association (OAB).