By Jillian Foglesong Stabile MD, FAAFP, DABOM
Polycystic ovary syndrome (PCOS) is a hormonal disorder that mainly affects women of reproductive age, but some women can continue to have PCOS symptoms after menopause. It's characterized by an imbalance in hormones such as androgens (male hormones present in small amounts in women) and insulin, which can disrupt ovulation and lead to a variety of symptoms.
The condition is more common than you might think, affecting approximately 1 in 10 women globally [1]. PCOS is also a leading cause of infertility, though it can manifest in ways unrelated to fertility, such as acne or weight gain.
Understanding the symptoms early allows you to seek prompt diagnosis and management, improving your quality of life and reducing long-term health risks.
Common Symptoms of PCOS
1. Irregular Periods
One of the hallmark symptoms of PCOS is irregular menstrual cycles. You may experience periods that are very infrequent (fewer than eight a year), excessively heavy, or completely absent. Your cycle may also last longer than the normal 21-35 days. This is due to hormonal imbalances that disrupt ovulation, making it challenging to predict cycles. [2]
2. Excess Androgen Levels
Androgens are typically thought of as the male sex hormones, but are also present in women in small amounts. Elevated androgen levels can lead to symptoms such as:
- Hirsutism (excessive hair growth, typically on the face, chest, or back)
- Acne that is more stubborn than usual
- Androgenic alopecia (male-pattern baldness or hair thinning)
3. Polycystic Ovaries
Although "cysts" are part of the condition's name, not all women with PCOS have cysts. When present, these are actually immature follicles that haven’t developed enough to release eggs during ovulation. They appear as a "string of pearls" on an ultrasound. [3]
4. Weight Gain and Difficulty Losing Weight
Many women with PCOS experience metabolic issues such as insulin resistance, leading to weight gain, particularly around the abdomen. Losing weight can also feel disproportionately difficult, even with lifestyle adjustments. [4]
5. Other Symptoms
Some less commonly discussed but equally important symptoms include:
- Fatigue
- Skin tags (small growths on the skin, often around the neck or underarms)
- Darkened patches of skin (acanthosis nigricans), often found on the neck, groin, or under the breasts
If you notice any of these symptoms, they could also point toward PCOS.
How PCOS Affects Hormones and Metabolism
PCOS originates from disruptions in hormone production and regulation. It can impact your body in several ways, including:
Hormonal Imbalance
- Elevated Androgens disrupt ovulation and lead to symptoms like acne and hirsutism.
- Insulin Resistance occurs in many women with PCOS, where your cells don't respond well to insulin, leading to elevated blood sugar levels. Insulin resistance can worsen weight gain and increase the risk of type 2 diabetes. [5]
Fertility Challenges
PCOS and infertility are often linked because the lack of ovulation (the release of an egg) makes conception difficult. Many women with PCOS are still able to conceive, so it’s still important to use protection if you are not trying to get pregnant; and, if you are trying to get pregnant, it’s important to discuss any concerns about PCOS with your healthcare provider before you start trying to conceive.
Long-Term Health Risks
Untreated PCOS can lead to serious conditions, including:
- Type 2 diabetes
- High blood pressure
- Heart disease
- Endometrial cancer
How PCOS is Diagnosed
Recognizing the signs of PCOS is the first step toward understanding whether you might have the condition. However, confirming a diagnosis requires a thorough medical evaluation. The process of diagnosing PCOS is typically guided by criteria established by the American College of Obstetricians and Gynecologists (ACOG). To diagnose PCOS, a doctor will consider a combination of your medical history, symptoms, lab results, and imaging studies. Here's a detailed breakdown of the diagnostic steps:
1. Medical History and Symptoms
A comprehensive medical history is the foundation of the diagnostic process for PCOS. During your visit, your doctor will ask detailed questions about various aspects of your health and menstrual history. These questions help your doctor get a better understanding of your symptoms, lifestyle, and any possible risk factors. The goal is to identify any signs or patterns that might suggest PCOS.
Menstrual Cycle:
One of the first things your doctor will ask about is the regularity and frequency of your menstrual periods. Women with PCOS often have irregular periods, which can be one of the main indicators of the condition. You may experience infrequent periods, missed periods, or periods that are abnormally heavy or light.
A history of amenorrhea (no periods) or oligomenorrhea (infrequent periods, such as fewer than 8 cycles per year) is commonly seen in women with PCOS.
Weight and Metabolic Issues:
PCOS is often linked to weight gain or difficulty losing weight. Your doctor may ask if you've noticed any sudden weight changes or if you have trouble maintaining a healthy weight despite efforts like diet and exercise.
Obesity, especially abdominal obesity, is a common feature of PCOS, and it often contributes to issues with insulin resistance, which is common in women with PCOS.
Signs of Excess Androgens (Male Hormones):
PCOS often involves an imbalance in androgen hormones, which are considered "male hormones" but are present in small amounts in women. Elevated levels of androgens can lead to visible symptoms such as:
- Excess hair growth (hirsutism) on the face, chest, abdomen, or back.
- Acne and oily skin, particularly in areas where men tend to develop acne (chin, jawline, chest).
- Scalp hair thinning or male-pattern baldness (androgenic alopecia).
Your doctor will inquire if you've noticed these changes in your skin or hair, as they can be key indicators of PCOS.
Fertility Concerns:
If you are trying to conceive and have had difficulty getting pregnant, your doctor will want to know. One of the hallmarks of PCOS is anovulation (lack of ovulation), which can result in infertility. Difficulty with ovulation is a common cause of irregular cycles and makes conception more challenging (though not impossible).
2. Physical Examination
After taking your medical history, the next step is a physical examination. This exam allows your doctor to check for visible signs of PCOS that are often related to hormonal imbalances. These physical signs are often helpful in guiding further tests or confirming suspected PCOS.
Excess Hair Growth (Hirsutism):
Your doctor may examine areas such as your face, upper lip, chest, back, and abdomen to look for excessive hair growth. Women with PCOS often experience hair growth in areas typically associated with male patterns, which is linked to higher levels of androgens (male hormones).
Acne and Oily Skin:
PCOS is associated with hormonal acne, which often appears in the lower face (jawline, chin) or on the chest and back. Your doctor may check for these types of acne, as well as general skin texture, which can also be affected by elevated androgen levels.
Darkening of the Skin (Acanthosis Nigricans):
This is a skin condition characterized by dark, thickened patches of skin, usually found on the neck, armpits, or groin. It is commonly seen in individuals with insulin resistance, a condition often associated with PCOS. The presence of acanthosis nigricans can be an important diagnostic clue.
Pelvic Exam:
During the physical examination, your doctor may perform a pelvic exam to check for any physical abnormalities in the reproductive organs, such as enlarged ovaries or signs of cysts.
3. Blood Tests
Blood tests are essential in confirming the diagnosis of PCOS, particularly when it comes to measuring hormone levels and assessing other factors related to the condition.
Testosterone Levels:
Testosterone is one of the primary androgens (male hormones) that is elevated in women with PCOS. High testosterone levels can contribute to symptoms like hirsutism, acne, and hair thinning.
Luteinizing Hormone (LH) and Follicle-Stimulating Hormone (FSH):
Your doctor will likely test the levels of LH and FSH, which are two hormones involved in regulating ovulation. In women with PCOS, the ratio of LH to FSH is often elevated, with higher than normal LH levels and lower than normal FSH levels. Since these hormones are what signal your body to ovulate, this imbalance can affect the normal process of ovulation, leading to irregular periods.
Insulin Resistance:
Many women with PCOS also experience insulin resistance, where the body doesn't use insulin effectively. Insulin resistance can lead to higher levels of insulin in the bloodstream, which can worsen PCOS symptoms, including weight gain and infertility.
Blood tests may include fasting blood glucose and insulin levels to assess how well your body is handling glucose. If these levels are abnormal, it may suggest the presence of insulin resistance, which is common in PCOS.
Thyroid Function Tests:
Since hypothyroidism (underactive thyroid) can mimic some of the symptoms of PCOS, your doctor may also perform thyroid function tests to rule out thyroid problems as a cause of your symptoms.
4. Pelvic Ultrasound
A pelvic ultrasound is often used to further evaluate the ovaries and check for cysts, one of the hallmark features of PCOS.
Ovarian Appearance:
During an ultrasound, the doctor will look for polycystic ovaries—which appear as multiple small cysts around the edges of the ovaries. However, not all women with PCOS have visible cysts, and having cysts alone is not sufficient for a diagnosis.
Ovary Size:
The doctor will also assess whether the ovaries are enlarged, as enlarged ovaries are a common finding in women with PCOS.
Rule Out Other Conditions:
The ultrasound is also useful in ruling out other conditions, such as ovarian tumors or endometriosis, that might cause similar symptoms.
5. Exclusion of Other Conditions
PCOS shares several symptoms with other medical conditions, so it's crucial to exclude other potential causes before confirming the diagnosis. This is done through a process of elimination.
Thyroid Disorders:
As mentioned earlier, an underactive thyroid (hypothyroidism) can cause symptoms like weight gain, fatigue, and irregular periods, which are also common in PCOS. Thyroid function tests help rule out thyroid dysfunction.
Hyperprolactinemia:
Hyperprolactinemia, an elevated level of prolactin (a hormone that helps with milk production), can also cause irregular periods and infertility. A blood test for prolactin levels can help determine if excess prolactin is the cause of your symptoms.
Congenital Adrenal Hyperplasia (CAH):
CAH is a genetic disorder that affects the adrenal glands and can lead to symptoms like hirsutism, acne, and irregular periods. It's important to test for CAH if there's any suspicion that it could be causing your symptoms.
Managing and Treating PCOS
While there’s no cure for PCOS, it is a manageable condition. Here’s how to take control of your symptoms and overall health.
Lifestyle Changes
Adopting a healthy lifestyle can significantly improve PCOS symptoms:
- Diet – Focus on low glycemic index (GI) foods that stabilize blood sugar.
- Exercise – Regular activity improves insulin sensitivity and helps maintain a healthy weight.
Medications
Depending on your symptoms, your doctor may recommend:
- Birth Control Pills to regulate menstrual cycles and reduce androgen levels.
- Metformin to improve insulin resistance.
- Anti-Androgens to reduce hair growth and acne.
Fertility Treatments
For women trying to conceive, medications like Clomid or treatments like intrauterine insemination (IUI) and in vitro fertilization (IVF) are options to help increase your chances. If you think you may have PCOS, it’s important to discuss fertility options with your OB/GYN before trying to conceive.
Mental Health Support
Living with PCOS can impact your emotional well-being. Counseling or joining support groups can help you manage any mental health challenges.
When to See a Doctor
Wondering when it’s time to seek medical advice? Here are some situations that warrant a visit to your healthcare provider:
- Irregular or absent periods
- Excessive hair growth, acne, or unexplained hair loss
- Difficulty conceiving after trying for six months to a year
The earlier you seek diagnosis, the sooner you can manage symptoms and minimize long-term health risks.
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