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For incidence estimation, the rate was computed as the total number of new PCOS cases recorded between 20 divided by the total number of person-years of follow-up.Person-time for the denominator was estimated by summing each woman's follow-up from the latest among (1) their 15th birthday, (2) 1 year after registration, (3) the date at which their practice met minimum quality criteria and (4) the 1 January 2004, to the earliest of the date among (1) their first incident diagnosis, (2) their date of death, (3) the date they left the practice, (4) the date data were last collected from their practice and (5) the 31 December 2014.In our study, data were included from each practice that met minimum quality criteria, for example, acceptable computer usage (a time point when a practice is considered to use their computer system adequately, ie, at least one medical record, one additional health data record such as body mass index, laboratory test results and two therapy records are computerised annually for a practice) and acceptable mortality reporting (a time point which the observed death rates for a practice reach the standard predicted numbers of deaths derived from National statistics given the practice's demographics).12–14Women aged 15–45 years, who were permanently registered for at least 1 year, were included in the study population.Women with conditions that can cause similar symptoms to PCOS were identified and excluded.Among the women with a diagnosis of PCOS, we calculated the number and proportion with a prescription for one of the drugs of interest at any point prior to their PCOS index date.Among the women without prescription for each drug of interest prior to the index date, we then calculated the proportion of women with a prescription for that drug within 2 years after the PCOS index date.We used cumulative incidence plots to describe how the proportion initiating different drugs increased over the 2 years following the PCOS index date for the time period 2004–2012.All analyses were performed using STATA V.13.0 and were carried out for all PCOS cases and stratified by case definition (diagnosed PCOS vs probable PCOS).

The denominator for the prevalence calculation consisted of any women with at least 1 year of postregistration follow-up, of which at least 6 months must have occurred in 2014.Acne-related treatments were more commonly used to treat probable (28.3%) than diagnosed (12.3%) cases, while metformin was prescribed much more commonly in diagnosed cases.Conclusions In conclusion, compared to rates estimated in community samples, the incidence and prevalence of women presenting in primary care with PCOS diagnoses and features are low, indicating that PCOS is an under-recognised condition.The prevalence of PCOS was also estimated within 5-year age bands.Secondary analysis was carried out to assess the sensitivity of the prevalence estimate to the length of the postregistration period (ie, 1 year, 2 years) and the minimum period registered within 2014 (ie, 3, 6 and 9 months).

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A full list of the codes used to define cases is provided in online supplementary table SI.

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