PCOS: Diagnosis, Symptoms, and Treatment Options

Your periods have never been regular. You may also have acne, extra hair on your face or body, or trouble getting pregnant. Someone mentions PCOS, and you want to know what it means, how it is diagnosed, and what can help.

This guide explains polycystic ovary syndrome (PCOS) in plain terms. It uses the 2023 international guideline that clinicians in Canada, the US, and many other countries follow.

What PCOS is

PCOS is a common hormone condition. The WHO estimates it affects about 10% to 13% of women of reproductive age, and many are not diagnosed.[2]

In PCOS, the ovaries often do not release an egg each month. The body may also make more androgens (hormones such as testosterone that are present in everyone, usually at lower levels in women). Many people with PCOS also have insulin resistance, where the body needs more insulin to keep blood sugar normal.[3]

Common signs include:[3][5]

• Irregular, infrequent, or missing periods.
• Acne.
• Hirsutism (coarse hair growth on the face, chest, or back).
• Thinning scalp hair.
• Trouble getting pregnant.
• Weight gain, although PCOS occurs at all body sizes.

What your doctor looks at

The diagnostic criteria

The 2023 international guideline uses the Rotterdam criteria. Adults need 2 of these 3 features, after other causes are ruled out:[1]

• Irregular cycles or ovulation problems. More than 1 year after periods start, this usually means cycles shorter than 21 days or longer than 35 days, or fewer than 8 periods a year.
• Hyperandrogenism: clinical signs such as hirsutism or acne, or high androgen levels on a blood test.
• Polycystic ovaries on ultrasound, or a high AMH (anti-Mullerian hormone) blood level. The 2023 guideline added AMH as an option for adults.

If you have irregular cycles and signs of high androgens, you do not need an ultrasound or AMH test to make the diagnosis.[1]

For teenagers, the rules are stricter. They need both irregular cycles and high androgens. Ultrasound and AMH are not recommended within 8 years of the first period, because normal teenage ovaries can look polycystic.[1]

Ruling out other causes

Other conditions can look like PCOS. Clinicians usually check:[1]

• A pregnancy test.
• Thyroid function (TSH).
• Prolactin, a hormone that can stop periods when it is high.
• 17-hydroxyprogesterone, to check for a gene-related adrenal condition.
• In some cases, other tests if androgen levels are very high or symptoms started suddenly.

Screening for related health risks

The guideline recommends regular checks because PCOS raises some long-term risks:[1]

• Blood sugar, preferably with an oral glucose tolerance test, because type 2 diabetes and gestational diabetes are more common.
• Blood pressure, cholesterol, and weight.
• Mood, including depression and anxiety, and eating concerns.
• Sleep apnea symptoms, such as loud snoring and daytime sleepiness.
• The lining of the uterus, because very infrequent periods can raise the risk of endometrial cancer over time.

Treatment options

Treatment depends on your symptoms and goals. Many people use more than one option.

Lifestyle

Healthy eating and regular physical activity are recommended for everyone with PCOS. In people with higher body weight, even modest weight loss can improve cycles and metabolic health.[1]

Irregular periods, acne, and hair growth

• Combined hormonal birth control pills are the first-line treatment. They regulate bleeding, protect the uterine lining, and reduce acne and hair growth.[1]
• Metformin, a diabetes drug, can help with weight and metabolic risk, alone or with the pill.[1]
• Anti-androgen drugs, such as spironolactone, can reduce hair growth. They must be used with reliable birth control because they can harm a developing baby.
• Cosmetic hair removal, such as laser treatment, can help.

Fertility

Letrozole is the first-line medicine to trigger ovulation in PCOS.[1] In a large US trial, letrozole led to more live births than clomiphene, the older standard: about 27.5% compared with 19.1%.[4] Metformin, injectable fertility drugs, surgery on the ovaries, and IVF are other options.

Canada and the US

Canadian and US clinicians use the same international guideline. Coverage differs. For example, coverage of fertility drugs and IVF varies a lot by province, state, and insurance plan.

PCOS and pregnancy

People with PCOS have a higher chance of gestational diabetes and high blood pressure in pregnancy. The 2023 guideline recommends checking blood sugar with a glucose tolerance test before pregnancy or early in pregnancy, and again later in pregnancy.[1] It also supports folic acid and a healthy lifestyle before conception. If you have PCOS and are planning a pregnancy, ask your clinician to review your blood sugar, blood pressure, and medicines first. Some medicines, such as spironolactone, should be stopped before trying to conceive.

Questions to ask your clinician

• Which of the diagnostic criteria do I meet?
• What tests have ruled out other causes?
• How often should my blood sugar, blood pressure, and cholesterol be checked?
• Which treatment fits my main goal right now?
• If I want to get pregnant, when should I see a fertility specialist?
• How do I protect the lining of my uterus if my periods are rare?

When to get care quickly

PCOS itself is not an emergency. Go to the emergency department if you have heavy bleeding that soaks a pad every hour for several hours, fainting, sudden severe pelvic pain, or a positive pregnancy test with pain or bleeding. See a clinician soon if you have very rapid hair growth or voice deepening, which can point to a different cause.

Bottom line

PCOS is common and treatable. Diagnosis in adults needs 2 of 3 features, after other causes are ruled out. Care includes treating symptoms, supporting fertility when you want it, and checking for diabetes and heart risk over time.

Primary AI can show you the guideline and study sources behind this topic in plain language, so you can bring better questions to your appointment.