PCOS Symptoms and Diagnosis: What You Need to Know

What is PCOS?

PCOS is a complex hormonal condition characterized by disrupted ovulation, elevated androgens (male-type hormones), and often — though not always — a distinctive appearance of the ovaries on ultrasound. It is estimated to affect 6–13% of reproductive-aged women worldwide, making it one of the most common endocrine disorders in this group 2Ref 2Teede HJ, Tay CT, Laven JJE, Dokras A, et al. (2023).Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome.Current international consensus on PCOS assessment, diagnosis, and management. It is a leading cause of irregular periods and fertility challenges. Despite its name, having cysts on the ovaries is neither required for diagnosis nor specific to PCOS [1, 2, 3].

What are the symptoms of PCOS?

PCOS presents differently from person to person. Common features include:

Menstrual irregularity — cycles that are infrequent (fewer than 8 to 9 per year), very long (longer than 35 days), or absent. This reflects infrequent or absent ovulation.

Signs of androgen excess — higher-than-typical levels of testosterone and related hormones can cause: - Acne that tends to be hormonal in pattern (jawline, chin, neck) - Excess hair growth on the face, chest, or abdomen (hirsutism) - Hair thinning or male-pattern hair loss on the scalp (androgenetic alopecia)

Polycystic ovarian morphology on ultrasound — multiple small follicles arranged around the periphery of one or both ovaries, though this finding alone does not establish a diagnosis.

Weight changes — while not a diagnostic criterion, many people with PCOS experience difficulty maintaining weight or have central (abdominal) fat distribution.

Metabolic effects — insulin resistance is common in PCOS and can raise the risk of blood sugar abnormalities, elevated cholesterol, and cardiovascular risk factors. Not everyone with PCOS is overweight; people of normal weight can also have significant insulin resistance [1, 2, 3].

How is PCOS diagnosed?

The most widely used diagnostic framework is the Rotterdam criteria, which require meeting at least two of three features 4Ref 4Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group (2004).Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS).The Rotterdam criteria — the two-of-three framework used for PCOS diagnosis:

1. Irregular or absent ovulation (reflected in irregular or absent periods) 2. Clinical or biochemical signs of androgen excess — either visible signs (acne, excess hair growth) or elevated androgen levels on blood tests 3. Polycystic ovarian morphology on ultrasound

Because at least two of three criteria must be met, PCOS can look quite different across individuals. Someone can have PCOS without obvious acne or without a positive ultrasound finding.

Diagnosis also requires ruling out other conditions that can produce similar symptoms — including thyroid disorders, elevated prolactin, congenital adrenal hyperplasia, and Cushing syndrome. A clinician will typically order labs before confirming a PCOS diagnosis [1, 3].

What tests are typically ordered?

There is no single definitive blood test for PCOS. Common workup includes:

• TSH to rule out thyroid dysfunction
• Prolactin to rule out hyperprolactinemia
• Testosterone (total and free) and DHEAS to assess androgen levels
• Fasting glucose and insulin or HbA1c to screen for insulin resistance and prediabetes
• Lipid panel for cardiovascular risk assessment
• LH and FSH may be ordered in some evaluations

A pelvic ultrasound may be used to assess ovarian appearance, though it is not always required for diagnosis. In adolescents, the diagnostic criteria differ somewhat, as irregular cycles are common in the years after the first period [1, 3].

What are the long-term health implications?

PCOS is not only a reproductive condition. The metabolic features — particularly insulin resistance — are associated with a higher risk of:

• Type 2 diabetes
• Prediabetes
• Cardiovascular disease
• Endometrial changes from prolonged lack of ovulation (irregular shedding of the uterine lining)

Regular monitoring of blood sugar, blood pressure, and lipids is part of ongoing PCOS management. This is why a gynecologist managing PCOS often coordinates with a primary care physician or endocrinologist [1, 2].

How is PCOS managed?

PCOS management is tailored to the person's primary concerns and goals — whether that is regulating periods, managing acne or hair growth, supporting fertility, or addressing metabolic health.

Lifestyle measures including regular exercise and a balanced diet can improve insulin sensitivity and partially restore ovulatory regularity in many people 2Ref 2Teede HJ, Tay CT, Laven JJE, Dokras A, et al. (2023).Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome.Current international consensus on PCOS assessment, diagnosis, and management.

Hormonal contraceptives are often used to regulate cycles and manage androgen-related symptoms (acne, hair growth) in people not trying to conceive.

Metformin may be used to address insulin resistance, particularly when metabolic risk factors are present.

Ovulation induction is available for those trying to conceive; current evidence favors letrozole over clomiphene for this purpose in PCOS 5Ref 5Legro RS, Brzyski RG, Diamond MP, Coutifaris C, Schlaff WD, Casson P, Christman GM, Huang H, Yan Q, Alvero R, Haisenleder DJ, Barnhart KT, Bates GW, Usadi R, Lucidi S, Baker V, Trussell JC, Krawetz SA, Snyder P, Ohl D, Santoro N, Eisenberg E, Zhang H (2014).Letrozole versus clomiphene for infertility in the polycystic ovary syndrome.Evidence that letrozole is preferred over clomiphene for ovulation induction in PCOS.

A gynecologist or reproductive endocrinologist is the right clinician to guide PCOS management, often in collaboration with a primary care physician for the metabolic aspects.