Polycystic Ovary Syndrome (PCOS)

Basics

Polycystic ovary syndrome (PCOS) is a hormone imbalance that affects 1 in 10 women of reproductive age. It affects different aspects of health, including: 

• The skin

• Unwanted hair growth

• Chronic inflammation

• Metabolism 

Also, it’s a leading cause of infertility in women. 

People with PCOS usually have high levels of certain hormones called androgens. These are sometimes called “male hormones” since people with male-typical body parts make more of them. But it’s normal for female bodies to make small amounts of androgens. In PCOS, high levels of androgens interfere with a healthy reproductive cycle. 

Insulin is another hormone that’s usually too high in people with PCOS. Insulin helps control glucose (sugar) levels in the body. High insulin levels happen because many people with PCOS also have insulin resistance. This is a situation in which cells in the body don’t respond properly to insulin. When you have insulin resistance, your glucose levels rise, leading to prediabetes and Type 2 diabetes.

PCOS is linked with other serious health conditions too, like high blood pressure and high cholesterol.

Causes

We don’t know exactly what causes PCOS. It’s probably a combination of factors, including your genetics and environment.

PCOS can affect people of all races and ethnicities. You have a higher risk of PCOS if one of your first-degree relatives — like your mom or sister — has it. Some studies have shown that if your mother has PCOS, you are about eight times more likely to develop it. This risk increases if your mother smoked during pregnancy.

Symptoms

Most PCOS symptoms are caused by high levels of androgens and insulin. Some people may have one or two symptoms, while others could have many more. Everyone is different. 

These are some common symptoms people with PCOS experience:

• Irregular periods (including missed periods, no periods, or very heavy periods)

• Fertility problems

• Increased hair growth (called hirsutism) on the face, chest, stomach, or upper thighs

• Acne that can be severe and hard to treat

• Carrying excess weight (especially around the waist) or having trouble losing excess weight

• Pelvic (lower stomach) pain

• Oily skin

• Patches of thick, dark, velvety skin, usually around the neck, armpits, or genitals (called acanthosis nigricans)

Sometimes, it’s not clear someone has PCOS, because the symptoms don’t seem related. You may be seeing different healthcare professionals for your acne and irregular periods without you or your healthcare team realizing that they’re linked. 

If you think you could have PCOS, try to mention all your symptoms to your healthcare team — even if you’re not sure they could be related.

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Diagnosis

There isn’t a single test to diagnose PCOS. Your primary care provider will use a combination of your medical history and symptoms, changes on your physical exam, and (sometimes) blood work to diagnose PCOS. 

A few medical organizations have developed different guidelines for diagnosing PCOS. In its latest guidelines, the American Society for Reproductive Medicine (ASRM) says there’s a good chance you have PCOS if other possible diagnoses have been excluded and you have at least two of the following:

• Irregular periods (called ovulatory dysfunction): You have no periods, or you have infrequent periods. Typically, this means fewer than 8 cycles a year, or cycles more than 35 days apart.

• High levels of androgen hormone: You may show signs of this, like acne, male-pattern hair loss, hirsutism, and patches of thickened, dark skin. You may also have blood work to check for high androgen levels. 

• Small cysts on the ovaries: These are detected with an ultrasound scan (a handheld machine that uses sound waves to make images of internal organs). If you meet the first two criteria, an ultrasound isn’t needed.

The lack of a specific test for PCOS can make getting a diagnosis tricky. And the symptoms of PCOS can be similar to other conditions, like thyroid disease. 

This can mean women with PCOS often struggle with symptoms for several years before getting a correct diagnosis. A study of people’s experiences getting a PCOS diagnosis found that almost half had to see three or more healthcare professionals before getting a diagnosis. One-third had a delay of 2 or more years before being diagnosed. 

Complications

There’s a high risk of serious health problems linked to PCOS.

Without treatment, PCOS can increase the risk of: 

• Excess weight

• Insulin resistance

• Type 2 diabetes

• Metabolic syndrome

• Nonalcoholic fatty liver disease (NAFLD)

• Sleep apnea

• Unhealthy cholesterol levels (low levels of “good” cholesterol and high levels of “bad” cholesterol)

• High blood pressure

• Endometrial cancer (a type of uterine cancer)

Untreated PCOS can also increase your risk of:

• Depression

• Anxiety

• Eating disorders

Finally, people with PCOS who don’t get treatment are at-risk for death by suicide. If you or someone you know is struggling with self-harm, call the National Suicide Prevention Lifeline at 988, or text “HOME” to 741-741 to reach the Crisis Text Line.

Treatment

As a first step, your healthcare team will recommend lifestyle changes — for their effects on overall health, weight, and fertility. Lifestyle changes involve: 

• Eating a balanced and nourishing diet

• Exercising regularly

• Getting enough good-quality sleep

• Taking steps to minimize stress

But because of the health problems related to PCOS, treatment with medication is important. 

Medications to treat PCOS require a prescription from a healthcare professional. 

Most medications for PCOS work by regulating hormonal imbalances. Which treatment is best for you depends on your symptoms and whether you’re trying — or not trying — to get pregnant.

Hormonal birth control

Hormonal birth control is often used first because it can help with many symptoms of PCOS. It can: 

• Regulate menstrual periods 

• Improve acne

• Improve hair growth

• Lower the risk of endometrial cancer (cancer in the lining of the uterus)

There are many different birth control options. These include the combined oral contraceptive pill. There are also alternatives to the pill, like patches, vaginal rings, and intrauterine devices (IUDs). 

Medications that lower or block androgen levels 

These medications work by decreasing the amount of androgen your body makes and limiting androgen’s effects as well. They treat acne and hair growth associated with PCOS. Typically, these medications are taken alongside the contraceptive pill — if the pill alone hasn’t worked to improve symptoms. 

These are three commonly used anti-androgen medications used to treat PCOS: 

• Spironolactone (Aldactone)

• Finasteride (Propecia) 

• Dutasteride (Avodart)

Weight loss 

Weight loss can improve some PCOS symptoms in people with excess weight. In fact, the ASRM now recommends weight-loss medications for people with PCOS looking to lose weight and improve their symptoms. Even small amounts of weight loss (5% to 15%) can improve menstrual symptoms and fertility. 

Weight-loss medications typically fall into two categories:

• Weight-loss pills like Xenical (orlistat)

• Newer weight-loss injectables like semaglutide (Wegovy, Ozempic) and tirzepatide (Mounjaro, Zepbound)

Fertility medications

Many people with PCOS don’t ovulate normally, which makes it hard for them to become pregnant. 

The first step to improving fertility is making lifestyle changes to optimize health and losing weight (with medication).

The next step is fertility medications. These work by helping to restore normal ovulation, improving the chances of pregnancy. 

Here are some of the medications, combinations of medications, and treatments commonly used to improve fertility in PCOS. They’re listed in the order in which you’d try them. 

1. Letrozole: Letrozole is the preferred first-step treatment to increase ovulation. An alternative approach is a combination of Clomid (clomiphene) and metformin (Glucophage). 

2. Gonadotropin injections: These injections are the next step. They require office visits. They’re injections of reproductive hormones, specifically luteinizing hormone (LH) and follicle-stimulating hormone (FSH), to stimulate the ovaries to produce eggs. Examples include Follistim AQ (follitropin beta), Gonal-f RFF (follitropin alfa), and Menopur (menotropin).

3. In vitro fertilization (IVF): IVF or other assisted reproductive technologies are another treatment option if first- and second-step fertility medications don’t help you get pregnant. 

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