PCOS: Diagnosis, Myths and Evidence-Based Management
Polycystic ovary syndrome is one of the most common endocrine conditions in women of reproductive age, and one of the most misdiagnosed in both directions – labelled on the basis of an ultrasound alone in women who do not have it, and missed in women who do.
What the diagnosis actually requires
The widely used Rotterdam criteria require two out of three:
- Irregular or absent ovulation – cycles longer than 35 days, fewer than eight periods a year, or absent periods
- Clinical or biochemical hyperandrogenism – excess hair growth on the face, chest or abdomen, persistent acne, male-pattern hair thinning, or raised testosterone on a blood test
- Polycystic ovarian morphology on ultrasound – many small follicles or increased ovarian volume
Two points follow from this, and they undo a lot of confusion.
First, polycystic-looking ovaries alone are not PCOS. Up to a quarter of healthy young women have this appearance without the syndrome. An ultrasound report is not a diagnosis.
Second, ultrasound is not required at all if the first two criteria are met, and guidelines specifically advise against using it within eight years of the first period, because multifollicular ovaries are normal in adolescence.
Other causes must be excluded first: thyroid disease, raised prolactin, non-classical congenital adrenal hyperplasia, and, where features are severe or rapid in onset, androgen-secreting tumours and Cushing’s syndrome.
Why it matters beyond periods
PCOS is a metabolic condition as much as a reproductive one. Insulin resistance is present in a majority of women with it, independent of weight, and Indian women tend to show it at lower BMIs than European populations.
Associated risks include type 2 diabetes, gestational diabetes, dyslipidaemia, fatty liver, hypertension, obstructive sleep apnoea, and, because of prolonged unopposed oestrogen when periods are absent, endometrial hyperplasia over the long term. Anxiety and depression are substantially more common and should be asked about routinely rather than treated as a side issue.
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Myths worth dropping
- You have cysts that need removing. The follicles are not cysts and are not removed.
- PCOS means you cannot conceive. Many women with PCOS conceive naturally; most others respond to ovulation induction.
- You must avoid all carbohydrates. Total energy balance and food quality matter more than eliminating a macronutrient.
- Birth control pills cause infertility. They do not. They mask the underlying pattern while taken and it returns after stopping.
- It will go away after marriage or after a baby. It will not; it is a lifelong metabolic pattern that can be well managed.
What actually works
Weight and lifestyle
Where there is excess weight, a 5-10% reduction frequently restores ovulation, improves cycle regularity and reduces androgen levels. This is first-line in every major guideline. Both aerobic and resistance training improve insulin sensitivity independently of weight change, which matters for lean women with PCOS.
Combined oral contraceptives
First-line for cycle regulation, acne and excess hair, and they protect the endometrium. They do not treat insulin resistance.
Metformin
Useful where there is impaired glucose tolerance or insulin resistance, and it modestly improves cycle regularity. It is not a weight-loss drug, though a small reduction is common.
Ovulation induction for fertility
Letrozole is now first-line and outperforms clomiphene for live birth rates in PCOS. Gonadotropins and laparoscopic ovarian drilling are second-line options, with IVF where these fail.
Hair and skin
Anti-androgens such as spironolactone reduce excess hair growth but must be combined with reliable contraception. Topical treatment, laser hair reduction and standard acne therapy help and take months, not weeks; realistic timelines prevent a great deal of frustration.
Inositol and supplements
Myo-inositol has reasonable evidence for improving insulin sensitivity and ovulation and is generally well tolerated. Most other supplements marketed for PCOS have little or no evidence.
Long-term follow-up
- Glucose tolerance test or HbA1c every one to three years, more often in pregnancy planning
- Blood pressure and lipids periodically
- At least four periods a year, either naturally or induced, to protect the endometrium
- Screening for depression and anxiety
- Early screening for gestational diabetes in pregnancy
When to see a doctor
- Fewer than eight periods a year, or cycles longer than 35 days
- Rapidly worsening excess hair, voice deepening or clitoral enlargement, which need urgent assessment
- Absent periods for more than three months when not pregnant
- Difficulty conceiving after 12 months, or after 6 months if over 35
- Very heavy or prolonged bleeding after a long gap
This article is general health information. PCOS management should be individualised with a gynaecologist or endocrinologist.