PCOS: Symptoms, Causes & Treatment Guide

What Is PCOS and What Causes It?

PCOS (Polycystic Ovary Syndrome) is a hormonal disorder where the ovaries produce too much testosterone. This hormone imbalance prevents eggs from maturing properly, disrupts ovulation, and causes symptoms like irregular periods, excess hair growth, and difficulty conceiving. It affects 8-13% of women of reproductive age and is one of the most common endocrine disorders in women.

Polycystic Ovary Syndrome, commonly known as PCOS, is a complex hormonal condition that affects women during their reproductive years. The term "polycystic" refers to the multiple small follicles (fluid-filled sacs) that may develop on the ovaries, though not all women with PCOS have visible cysts. Understanding the underlying mechanisms of PCOS is essential for effective management and treatment.

At its core, PCOS is characterized by an overproduction of androgens, particularly testosterone, by the ovaries. While all women produce small amounts of androgens, women with PCOS produce higher levels than normal. This hormonal imbalance interferes with the normal development and release of eggs during ovulation. Instead of maturing fully and being released, the eggs often remain in the ovaries as small, immature follicles, which can appear as "cysts" on ultrasound imaging.

The irregular or absent menstruation experienced by women with PCOS is not due to a lack of eggs, but rather because the eggs don't mature sufficiently to trigger ovulation. This is why PCOS is one of the leading causes of infertility, yet also one of the most treatable. The ovaries typically contain plenty of eggs; they simply need help maturing and being released.

The Role of Insulin Resistance

Research has shown that 70-80% of women with PCOS have insulin resistance, meaning their bodies don't respond effectively to insulin. This leads to elevated insulin levels in the blood, which in turn stimulates the ovaries to produce more androgens. This creates a problematic cycle: insulin resistance leads to high insulin, high insulin triggers excess androgen production, and excess androgens worsen PCOS symptoms.

Insulin resistance also explains why many women with PCOS struggle with weight management. High insulin levels promote fat storage, particularly around the abdomen, and increase appetite, especially for carbohydrate-rich foods. However, the relationship works both ways - losing weight can improve insulin sensitivity and reduce androgen production, which is why lifestyle modifications are often the first-line treatment for PCOS.

Genetic and Environmental Factors

PCOS tends to run in families, suggesting a strong genetic component. If your mother or sister has PCOS, your risk of developing the condition is significantly higher. However, PCOS is not determined by a single gene but rather by multiple genetic factors that interact with environmental influences.

Environmental factors that may contribute to or worsen PCOS include obesity, sedentary lifestyle, and exposure to certain endocrine-disrupting chemicals. While you cannot change your genetic predisposition, understanding these environmental factors provides opportunities for prevention and management through lifestyle modifications.

What Are the Symptoms of PCOS?

The main symptoms of PCOS include irregular or absent periods, excess hair growth on the face and body (hirsutism), acne, weight gain, difficulty getting pregnant, thinning hair on the scalp, and mood changes including depression. Symptoms can vary widely between individuals, and some women have PCOS without obvious symptoms.

PCOS manifests differently in each woman, with symptoms ranging from mild to severe. The condition affects multiple body systems due to the widespread effects of hormonal imbalance. Understanding these symptoms is crucial for early recognition and timely treatment. Many women experience symptoms starting in adolescence around their first menstrual period, while others don't notice issues until they try to become pregnant.

The three hallmark features of PCOS, known as the Rotterdam criteria, include menstrual irregularities, signs of excess androgens (either clinical or biochemical), and polycystic ovaries on ultrasound. A diagnosis typically requires at least two of these three features, along with exclusion of other conditions that can cause similar symptoms.

Menstrual Irregularities

One of the most common symptoms of PCOS is irregular menstruation. Women with PCOS may experience:

• Oligomenorrhea: Having fewer than 8 periods per year, or cycles longer than 35 days
• Amenorrhea: Complete absence of menstruation for 3 or more consecutive months
• Unpredictable periods: Cycles that vary significantly in length from month to month
• Heavy or prolonged bleeding: When periods do occur, they may be unusually heavy or last longer than normal

These menstrual irregularities occur because without regular ovulation, the uterine lining builds up longer than normal. When bleeding does occur, it may be heavier and more prolonged. Importantly, irregular periods are not just an inconvenience - prolonged periods without menstruation can increase the risk of endometrial hyperplasia and potentially endometrial cancer.

Signs of Excess Androgens

The elevated testosterone levels in PCOS cause several visible and distressing symptoms:

• Hirsutism: Excess hair growth in a male-pattern distribution, including the face (chin, upper lip), chest, abdomen, back, and thighs. This affects approximately 70% of women with PCOS.
• Acne: Persistent, often severe acne that typically doesn't respond well to standard treatments and may continue well into adulthood
• Male-pattern hair loss: Thinning hair on the scalp, particularly at the crown and temples (androgenic alopecia)
• Oily skin: Increased sebum production leading to persistently oily skin

Metabolic and Reproductive Symptoms

Beyond the visible symptoms, PCOS affects metabolism and reproduction in significant ways:

• Weight gain: Many women with PCOS struggle with weight management, particularly around the abdomen. The high testosterone can increase appetite and cravings for carbohydrates.
• Difficulty losing weight: Even with diet and exercise, weight loss can be more challenging for women with PCOS
• Infertility: Due to irregular or absent ovulation, many women with PCOS have difficulty conceiving naturally
• Fatigue: Often related to insulin resistance and blood sugar fluctuations

Psychological and Emotional Symptoms

The hormonal imbalances and visible symptoms of PCOS can significantly impact mental health:

• Depression: Women with PCOS have higher rates of depression than the general population
• Anxiety: Concerns about symptoms, fertility, and long-term health can contribute to anxiety
• Decreased libido: Despite higher testosterone levels, many women with PCOS experience reduced sexual desire
• Body image concerns: Weight gain, acne, and excess hair growth can significantly affect self-esteem

When Should You See a Doctor for PCOS?

See a doctor if you have fewer than 8 periods per year, notice increased facial or body hair, have persistent acne, are struggling to get pregnant, or experience unexplained weight gain. Early diagnosis and treatment can help manage symptoms and reduce long-term health risks associated with PCOS.

Many women live with PCOS symptoms for years before seeking medical attention, often because they assume their irregular periods or other symptoms are normal. However, early diagnosis and treatment are important not only for managing current symptoms but also for preventing long-term complications. The sooner PCOS is identified and managed, the better the outcomes for both symptom control and overall health.

You should consider making an appointment with a healthcare provider, such as a gynecologist or endocrinologist, if you experience any of the following:

• Infrequent periods: Having your period fewer than 4 times per year (fewer than every 3 months)
• Absent periods: Missing 3 or more consecutive periods when you're not pregnant
• New or worsening hair growth: Noticing more hair than usual on your face, chest, or other areas
• Persistent acne: Acne that doesn't respond to over-the-counter treatments, especially if it persists past your teenage years
• Difficulty conceiving: If you've been trying to get pregnant for 12 months (or 6 months if over 35) without success
• Rapid or unexplained weight gain: Particularly if concentrated around the abdomen

If you're young and experiencing symptoms, you can also visit a youth health clinic or speak with your general practitioner, who can provide initial evaluation and referrals if needed. Don't hesitate to seek care - PCOS is common, well-understood, and highly treatable.

How Is PCOS Diagnosed?

PCOS is diagnosed using the Rotterdam Criteria, which require at least 2 of 3 features: irregular/absent periods, clinical or biochemical signs of high androgens, and polycystic ovaries on ultrasound. Diagnosis involves a physical exam, blood tests to measure hormone levels (testosterone, LH, FSH), and often a pelvic ultrasound. Other conditions must be ruled out first.

Diagnosing PCOS involves a comprehensive evaluation because no single test can confirm the condition. Healthcare providers must gather information from multiple sources and rule out other conditions that can cause similar symptoms. The diagnostic process typically involves several steps and may require multiple appointments to complete fully.

When you visit a gynecologist or endocrinologist for suspected PCOS, the evaluation will typically include:

Medical History and Physical Examination

Your doctor will ask detailed questions about your menstrual history, including the age of your first period, cycle regularity, and any changes over time. They'll also inquire about symptoms like hair growth, acne, and weight changes. Family history is important since PCOS runs in families. The physical examination includes checking for signs of excess androgens (hirsutism, acne), measuring your body mass index (BMI) and waist circumference, and assessing for other related conditions.

Blood Tests

Blood tests are essential for measuring hormone levels and ruling out other conditions. Common tests include:

• Testosterone: Total and free testosterone levels are typically elevated in PCOS
• LH and FSH: The ratio of luteinizing hormone to follicle-stimulating hormone is often elevated in PCOS
• Anti-Mullerian hormone (AMH): Often elevated in PCOS due to the increased number of follicles
• Thyroid function tests: To rule out thyroid disorders that can cause similar symptoms
• Prolactin: To rule out prolactinoma
• Fasting glucose and insulin: To assess for insulin resistance and diabetes risk
• Lipid panel: To evaluate cardiovascular risk factors

Pelvic Ultrasound

An ultrasound examination of the ovaries is often performed to look for the characteristic appearance of polycystic ovaries. According to current diagnostic criteria, polycystic ovaries are defined as having 20 or more follicles per ovary (using modern high-resolution ultrasound) or an ovarian volume greater than 10 ml. However, it's important to note that having polycystic-appearing ovaries on ultrasound alone is not sufficient for a PCOS diagnosis - many women without PCOS can have this finding, and some women with PCOS have normal-appearing ovaries.

The Rotterdam Criteria

The most widely used diagnostic criteria for PCOS are the Rotterdam Criteria, established in 2003 and updated in 2023. To be diagnosed with PCOS, you must have at least two of the following three features:

1. Oligo-ovulation or anovulation: Irregular or absent ovulation, typically manifesting as irregular or absent periods
2. Clinical and/or biochemical signs of hyperandrogenism: Either visible signs (hirsutism, acne) or elevated androgen levels on blood tests
3. Polycystic ovaries on ultrasound: Meeting the criteria described above

Additionally, other conditions that can cause similar symptoms must be excluded, including thyroid disorders, hyperprolactinemia, congenital adrenal hyperplasia, Cushing's syndrome, and androgen-secreting tumors.

What Can You Do to Manage PCOS?

Lifestyle modifications are the first-line treatment for PCOS. Regular physical activity and weight loss of just 5-10% can significantly improve all PCOS symptoms, restore ovulation, and reduce long-term health risks. Focus on low glycemic index foods, increase fiber intake, engage in both aerobic exercise and strength training, and maintain consistent sleep patterns.

While medication plays an important role in PCOS management, lifestyle modifications are universally recommended as the foundation of treatment, regardless of weight status. Research consistently shows that changes in diet, exercise, and other lifestyle factors can significantly improve hormonal profiles, metabolic markers, and symptoms - often with results comparable to or better than medication alone.

The impact of lifestyle changes on PCOS can be profound. Studies have shown that weight loss of just 5-10% of body weight can restore regular menstrual cycles, improve fertility, reduce androgen levels, improve insulin sensitivity, and decrease the risk of long-term complications like diabetes and heart disease. Even women who are not overweight can benefit from dietary improvements and increased physical activity.

Dietary Recommendations

There is no single "PCOS diet," but certain dietary patterns have been shown to be beneficial:

• Low glycemic index (GI) foods: Choose foods that don't cause rapid spikes in blood sugar, such as whole grains, legumes, non-starchy vegetables, and most fruits
• Adequate protein: Include lean protein with meals to help stabilize blood sugar and increase satiety
• Healthy fats: Focus on omega-3 fatty acids from fish, nuts, and seeds; limit saturated and trans fats
• High fiber: Aim for 25-30 grams of fiber daily from vegetables, whole grains, and legumes
• Limit refined carbohydrates: Reduce intake of white bread, pasta, rice, sugary foods, and sweetened beverages
• Regular meal timing: Eating at consistent times can help regulate blood sugar and hormones

It can be challenging to lose weight with PCOS because testosterone increases appetite, particularly for quick-energy carbohydrates like sugar, bread, pasta, and rice. However, testosterone also makes it easier to build muscle and improve fitness, which can be used to your advantage. Support from a registered dietitian who understands PCOS can be invaluable in developing a sustainable eating plan.

Exercise Recommendations

Regular physical activity improves insulin sensitivity, helps with weight management, reduces androgen levels, and improves mood - all important for PCOS management. Recommendations include:

• Aerobic exercise: At least 150 minutes of moderate-intensity activity (brisk walking, cycling, swimming) or 75 minutes of vigorous activity per week
• Strength training: 2-3 sessions per week targeting all major muscle groups - building muscle improves insulin sensitivity
• Reduce sedentary time: Take breaks from sitting, aim for movement throughout the day
• Consistency over intensity: Regular, moderate exercise is more beneficial than occasional intense workouts

The type of exercise matters less than doing it consistently. Choose activities you enjoy and can maintain long-term. Even modest increases in physical activity provide benefits, so start where you are and gradually increase.

Other Lifestyle Factors

• Sleep: Aim for 7-9 hours of quality sleep. Poor sleep worsens insulin resistance and can increase hunger hormones.
• Stress management: Chronic stress elevates cortisol, which can worsen insulin resistance and PCOS symptoms. Consider meditation, yoga, or other stress-reduction techniques.
• Avoid smoking: Smoking worsens cardiovascular risk, which is already elevated in PCOS
• Limit alcohol: Excessive alcohol can affect hormone levels and contribute to weight gain

How Is PCOS Treated with Medication?

PCOS treatment depends on your symptoms and goals. Combined birth control pills regulate periods and reduce acne and hair growth. Metformin improves insulin sensitivity. For fertility, letrozole or clomiphene citrate induce ovulation. Progesterone-only medications can regulate periods without contraceptive effect. Treatment is personalized based on individual symptoms, whether you want to conceive, and other health factors.

Medical treatment for PCOS is tailored to each woman's specific symptoms, health concerns, and reproductive goals. There is no one-size-fits-all approach, and treatment may change over time as your circumstances evolve. The primary goals of medication therapy include regulating menstrual cycles, reducing androgen-related symptoms, improving fertility when desired, and preventing long-term complications.

Medications for Menstrual Regulation and Symptom Control

Combined oral contraceptives (birth control pills) containing both estrogen and progestin are often the first-line treatment for women who don't want to become pregnant. These medications work by:

• Regulating menstrual cycles and ensuring regular withdrawal bleeds
• Reducing androgen production and blocking androgen effects on skin and hair
• Improving acne and reducing excess hair growth
• Protecting against endometrial hyperplasia and cancer

Progestin-only medications can be used if estrogen is contraindicated. Options include progestin-only pills, hormonal IUDs, or cyclical progestin therapy for 10-12 days each month to induce regular withdrawal bleeds. These protect the endometrium but don't address androgen-related symptoms and don't prevent pregnancy.

Medications for Insulin Resistance

Metformin is a diabetes medication that improves insulin sensitivity and is commonly used in PCOS management. Benefits include:

• Improving insulin sensitivity and lowering insulin levels
• May help with weight loss or prevent weight gain
• Can improve menstrual regularity in some women
• May enhance ovulation, especially when combined with lifestyle changes
• Reduces the risk of developing type 2 diabetes

Metformin is often used alongside other treatments and may be continued during pregnancy in some cases to reduce the risk of gestational diabetes and miscarriage, though this should be discussed with your doctor.

Treatments for Excess Hair Growth

In addition to birth control pills, other treatments for hirsutism include:

• Anti-androgens: Medications like spironolactone can block the effects of testosterone on hair follicles (must not be used during pregnancy)
• Topical treatments: Eflornithine cream can slow facial hair growth
• Physical hair removal: Laser hair removal or electrolysis provide more permanent solutions. Some healthcare systems provide financial assistance for these treatments for women with documented PCOS.

Fertility Treatments

For women with PCOS who want to become pregnant, several effective options exist:

Letrozole is now considered the first-line medication for ovulation induction in PCOS. It works by stimulating the pituitary gland to produce more FSH, which triggers follicle development and ovulation. Typically taken for 5 days early in the cycle, ovulation often occurs 5-10 days later.

Clomiphene citrate is another ovulation-inducing medication that has been used for decades. It works similarly to letrozole but through a different mechanism.

Metformin may be used for a few months before starting ovulation-inducing medications to improve their effectiveness, particularly in women with significant insulin resistance.

Gonadotropins (injectable hormones) may be used when oral medications don't work, though they require careful monitoring due to the higher risk of multiple pregnancies.

In vitro fertilization (IVF) is an option when other treatments haven't succeeded. Women with PCOS often respond well to IVF because they typically have a good ovarian reserve with many follicles available for stimulation. However, careful medication dosing is needed to prevent ovarian hyperstimulation syndrome.

Can You Get Pregnant with PCOS?

Yes, many women with PCOS successfully become pregnant, either naturally or with medical assistance. PCOS is one of the most treatable causes of infertility. Weight loss of 5-10% can restore ovulation in many women. Ovulation-inducing medications are highly effective. Women with PCOS often have higher success rates with IVF due to having more eggs available.

One of the most common concerns for women diagnosed with PCOS is whether they will be able to have children. The good news is that PCOS, while a leading cause of infertility, is also one of the most treatable causes. With appropriate management, the majority of women with PCOS can conceive and have healthy pregnancies.

The fertility challenges in PCOS stem primarily from irregular or absent ovulation - without ovulation, there's no egg available to fertilize. However, the underlying problem is not a lack of eggs. In fact, women with PCOS typically have a higher ovarian reserve (more eggs) than average, which can be an advantage when seeking fertility treatment. The challenge is getting those eggs to mature and release properly.

Natural Conception

Some women with PCOS do ovulate occasionally and can conceive naturally, though it may take longer than for women without PCOS. Lifestyle modifications, particularly weight loss if overweight, can dramatically improve the chances of natural conception by restoring regular ovulation. Studies show that losing just 5-10% of body weight can restore ovulatory cycles in many women.

Interestingly, fertility in women with PCOS often improves naturally as they approach their late 30s and early 40s. As androgen levels decline with age, many women find their cycles become more regular and conceiving becomes easier. However, since egg quality does decline with age, it's generally advisable not to delay pregnancy attempts too long.

Medical Assistance

For women who don't conceive naturally, several effective treatments are available:

• Ovulation induction: Medications like letrozole or clomiphene citrate successfully induce ovulation in approximately 80% of women with PCOS
• Metformin: Can be used alone or in combination with ovulation-inducing drugs to improve effectiveness
• Injectable gonadotropins: Used when oral medications don't work
• Ovarian drilling: A surgical procedure that can restore ovulation in some cases
• IVF: Highly effective, with women with PCOS often achieving above-average success rates due to their higher egg numbers

Pregnancy Considerations

Once pregnant, women with PCOS have a higher risk of certain complications, including gestational diabetes, preeclampsia, preterm birth, and cesarean delivery. These risks can be minimized through careful monitoring, maintaining a healthy weight before and during pregnancy, and appropriate medical management. Many healthcare providers continue metformin during pregnancy to reduce some of these risks.

What Are the Long-Term Health Risks of PCOS?

PCOS increases the risk for type 2 diabetes (50-70% develop prediabetes or diabetes), cardiovascular disease, endometrial cancer (if periods are absent for extended periods), sleep apnea, nonalcoholic fatty liver disease, and mental health conditions including depression and anxiety. Regular monitoring and proactive management can significantly reduce these risks.

PCOS is not just a reproductive disorder - it's a metabolic condition with implications for long-term health. Understanding these risks is important not to cause alarm, but to empower women to take proactive steps to protect their health. The good news is that lifestyle modifications and appropriate medical management can significantly reduce most of these risks.

Type 2 Diabetes

The risk of developing type 2 diabetes is significantly elevated in women with PCOS, with studies suggesting that 50-70% will develop prediabetes or diabetes by age 40. This risk is related to the insulin resistance that underlies much of PCOS pathology. Regular screening with fasting glucose or glucose tolerance tests is recommended, typically every 1-3 years depending on other risk factors. Lifestyle modifications, particularly maintaining a healthy weight, can dramatically reduce this risk.

Cardiovascular Disease

Women with PCOS have higher rates of cardiovascular risk factors including high blood pressure, elevated cholesterol, and higher inflammatory markers. These factors, combined with insulin resistance and often central obesity, increase the risk of heart disease and stroke. Regular monitoring of blood pressure and lipids, along with lifestyle modifications and treatment when needed, can mitigate this risk.

Endometrial Cancer

When ovulation doesn't occur, the uterine lining (endometrium) isn't shed regularly through menstruation. Instead, it continues to build up under the influence of estrogen without the protective effect of progesterone. Over time, this can lead to endometrial hyperplasia and potentially cancer. This is why ensuring regular periods - at least 4 times per year - is medically important, not just for convenience. Birth control pills, progesterone therapy, or hormonal IUDs all provide this protection.

Other Health Concerns

• Sleep apnea: Women with PCOS have higher rates of obstructive sleep apnea, independent of weight. Symptoms include loud snoring, pauses in breathing during sleep, and daytime fatigue.
• Nonalcoholic fatty liver disease (NAFLD): Related to insulin resistance, NAFLD is more common in women with PCOS
• Depression and anxiety: Rates are significantly higher in women with PCOS, related both to hormonal factors and the psychological impact of symptoms
• Gestational complications: As mentioned, pregnancy complications are more common in women with PCOS

How Can You Live Well with PCOS?

Living well with PCOS involves a combination of medical treatment, lifestyle management, emotional support, and regular health monitoring. Understanding your condition empowers you to make informed decisions. Connect with healthcare providers who understand PCOS, seek mental health support when needed, and join support communities. Many women with PCOS lead full, healthy lives with proper management.

A PCOS diagnosis can feel overwhelming, but with the right approach and support, most women with PCOS can effectively manage their symptoms and live healthy, fulfilling lives. The key is taking an active role in your health care, understanding your condition, and building a support network of healthcare providers and others who understand what you're going through.

Building Your Healthcare Team

PCOS affects multiple body systems, so you may benefit from working with several healthcare providers:

• Gynecologist or reproductive endocrinologist: For menstrual management and fertility concerns
• Endocrinologist: For metabolic aspects and diabetes prevention
• Registered dietitian: For nutrition guidance tailored to PCOS
• Mental health professional: For managing the emotional aspects of PCOS
• Dermatologist: For skin and hair concerns

Mental Health and Self-Care

The visible symptoms of PCOS and concerns about fertility can take a significant toll on mental health. It's important to:

• Acknowledge that your feelings about PCOS are valid
• Seek professional mental health support if you're struggling with depression, anxiety, or body image issues
• Connect with others who have PCOS through support groups or online communities
• Practice self-compassion and avoid self-blame - PCOS is a medical condition, not a personal failing
• Celebrate your successes, no matter how small they may seem

Staying Informed and Advocating for Yourself

Medical understanding of PCOS continues to evolve. Stay informed about new research and treatment options, but rely on reputable medical sources. Don't hesitate to ask questions at medical appointments or seek second opinions if you feel your concerns aren't being addressed. You know your body best, and your input is valuable in developing an effective treatment plan.

Remember that PCOS management is a marathon, not a sprint. There will be setbacks and challenges, but with persistence and the right support, most women with PCOS achieve their health and life goals. Many women find that managing PCOS actually leads them to develop healthier habits that benefit their overall well-being far beyond just addressing PCOS symptoms.