Signs and Symptoms

Polycystic Ovarian Syndrome or PCOS is a chronic condition that’s defined as having excess androgens and/or chronic anovulation (absence or lack of menstruation) in the absence of adrenal and/or pituitary disease. It is sometimes known as PCO (polycystic ovaries) or POCD (polycystic ovarian disease).

Diagnosing PCOS requires a comprehensive set of bloodwork, physical evaluation, and imaging. Additionally, lifestyle choices such as diet, physical activity, and gut health are crucial in understanding how this condition uniquely manifests for you.

Because the symptoms are many from mental health issues, to weight gain, and infertility, they impact the full body and person. Therefore, treatment plans should be holistic and lifestyle-oriented.

Some baseline PCOS labs help in diagnosing the condition. But to get a personalized treatment plan, you must first know what’s happening in your body in a 360 way. To get this full system analysis, more comprehensive labs will help you identify your unique root cause patterns.

If you were recently diagnosed with PCOS or have already started your recovery journey, ensuring that you’re getting a comprehensive set of bloodwork is essential in finding the right set of treatments for you.

Diagnosis criteria

The diagnosis of polycystic ovarian syndrome (PCOS) requires the exclusion of all other disorders that can result in menstrual irregularity and hyperandrogenism.

Since the 1900s there have been several diagnosis criteria for PCOS. But it’s the 2003 Rotterdam Criteria continues to be the standard for a proper assessment.

Based on the criteria, 2 out of 3 of the following must be present for a final diagnosis:

• Clinical or biochemical signs of androgen excess (excess male pattern hair growth, acne)
• Oligoovulation (irregular or infrequent periods)
• Polycystic ovaries by ultrasound

The table below explains special considerations based on things like ethnicity and standard threshold levels for diagnosis:

How Doctors Diagnose PCOS (Procedure)

The majority of hormones involved in this metabolic and hormonal disorder include:

• Androgens (ie. testosterone)
• Estrogens
• Insulin
• Luteinizing Hormone (LH)
• Follicle-stimulating hormone (FSH)
• Anti-Müllerian Hormone (AMH)
• Prolactin

The Royal College of Obstetricians and Gynaecologists (RCOG) recommends a set of bloodwork to be done (see baseline labs below) alongside a physical exam and/or ultrasound to diagnose someone suspected of PCOS.

But, as research evolves so will our understanding of the mind-body connection, hormonal pathogenesis, and the connection between the gut, emotions, and PCOS, comprehensive labs should be considered for root cause diagnosis and creation of a holistic treatment plan.

1) Diagnosing PCOS using a Pelvic Exam

During a pelvic exam, the doctor will check for reproductive organs for masses, growths, and signs of androgen excess, such as hirsutism (excessive hair growth) or acne.

A physical pelvic exam isn’t enough to diagnose PCOS.

2) Diagnosing PCOS using Ultrasound

Ovarian ultrasonography is done through transvaginal ultrasound (TVUS) or pelvic ultrasound

While ultrasound alone cannot definitively diagnose PCOS, it is a valuable tool used to visualize the ovaries and other dimensions such as:

• Ovarian Morphology: in PCOS, the ovaries may appear enlarged and have an increased number of small follicles (follicles are fluid-filled sacs containing immature eggs).
• Endometrial Thickness: the endometrium may be thinner than expected during certain phases of the menstrual cycle when there is an absence or lack of periods.
• Follicle Count: a higher number of small follicles within the ovaries may be observed in women with PCO. A standard threshold is 20 or more follicles in at least 1 ovary, measuring 2-9 mm in diameter, or a total ovarian volume greater than 10 cm3.
• Ovarian Volume: ovaries may have increased volume due to the presence of multiple small follicles

3) Diagnosing PCOS with Baseline Labs

The Royal College of Obstetricians and Gynaecologists (RCOG) recommends using the below labs for getting an assessment of someone’s metabolic and hormone function as it's related to PCOS.

Thyroid Function Tests

Blood tests that measure the levels of thyroid-stimulating hormone (TSH), thyroxine (T4), and triiodothyronine (T3) in the blood.

Serum prolactin levels

Elevated prolactin levels can occur in conditions such as hyperprolactinemia, which can cause symptoms similar to PCOS, including irregular menstrual cycles, infertility, and galactorrhea

A significant proportion of PCOS patients (around 30-37% according to the studies) have elevated prolactin levels.

Free Androgen Index

Assesses the relative amount of bioavailable or "free" androgens in the bloodstream

It takes into account 1) the total amount of Testosterone circulating in the bloodstream, both bound to proteins such as SHBG and albumin, as well as free (unbound) testosterone and 2) Sex Hormone-Binding Globulin (SHBG), a protein produced by the liver that binds to sex hormones such as testosterone and estradiol, regulating their availability and activity in the body.

What is tested: Total Testosterone, Sex Hormone-Binding Globulin (SHBG)

Female Hormones Panel

PCOS is a hormonal and metabolic disorder that involves imbalances in several key hormones. To baseline your hormone levels, a doctor will typically do a blood test for estrogen, progesterone, LH, FSH, and testosterone among others.

The key hormones involved in the orchestration of ovulation every month are shown below.

What is tested: estrogen, progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, Sex Hormone-Binding Globulin (SHBG), Human Chorionic Gonadotropin, Dehydroepiandrosterone sulfate, DHEAS, 17-OH progesterone, 17 hydroxyprogesterone, 17 OHP, estradiol

Insulin Resistance Testing

Insulin resistance testing is performed to assess how effectively the body's cells respond to insulin, a hormone produced by the pancreas that helps regulate blood sugar levels. The test also helps rule out other metabolic disorders.

Insulin resistance is considered one of the key underlying factors in the development and manifestation of PCOS. Elevated insulin levels can promote the accumulation of abdominal fat and contribute to weight gain, worsening metabolic disturbances

What is tested: glucose, insulin, HbA1C

Lipid Panel

PCOS is associated with an increased risk of cardiovascular disease (CVD) and metabolic disorders such as insulin resistance, dyslipidemia (abnormal lipid levels), and obesity.

A comprehensive lipid panel is a blood test used to measure various types of lipids (fats) and fatty substances in the bloodstream.

What is tested: Total cholesterol, LDL cholesterol (bad cholesterol), HDL cholesterol (good cholesterol), Triglycerides

4) Treating PCOS using Comprehensive PCOS Blood Work

Doctors typically perform a baseline set of labs (see above) to screen for PCOS and rule out adrenal and/or pituitary disease. This helps them diagnose PCOS if 2 out of the 3 signs from the 2003 Rotterdam criteria are met.

Once diagnosed, the doctor might recommend more tests to check for complications or do a root cause diagnosis. This will help to come up with a holistic treatment plan that’s unique to you.

Comprehensive Female Hormone Panel

A blood or serum test (mentioned in the baseline labs section) is only a snapshot of your hormones at a particular moment in time.

According to this NIH study, supplementary dried urine tests give a more comprehensive view of your hormones. The DUTCH cycle mapping test is a type of urine test that is known to be effective in estrogen and progesterone evaluation while also checking for estrogen metabolites. This metabolism pathway is important in understanding how these hormones are getting broken down and used up.

Further, a saliva test is also shown to provide a deeper look at estrogen, progesterone, and even cortisol levels (essential in a person’s daily stress response) across the menstrual cycle.

All in all, while blood tests have been the conventional way of assessing hormonal imbalances, urine and saliva tests may provide good non-invasive alternative pathways and complementary ways to understand the full pattern of hormone fluctuation throughout the menstrual cycle.

Homocysteine Test

A homocysteine test measures the level of homocysteine in the blood. Homocysteine is an amino acid produced in the body as part of normal metabolism, and it is typically broken down and eliminated.

Homocysteine is an amino acid. Vitamins B12, B6, and folate break down homocysteine to create other chemicals your body needs. Imbalanced Homocysteine is correlated to cardiovascular disorders and others. High Homocysteine is prevalent in women with PCOS.

It is a biomarker that can test for the deficiency of B12, B6, and Folic Acid in the body as well as indirectly assess inflammation.

Vitamin D Test

Identifying and addressing vitamin D deficiency may help mitigate some of the metabolic and reproductive complications associated with PCOS. Here are some ways it is relevant for PCOS.

Vitamin D plays a role in improving insulin sensitivity

Vitamin D plays a physiological role in reproduction, including ovarian follicular development and luteinization.

67-85% of women with PCOS have vitamin D deficiency. The research is still developing on the direct impact of Vitamin D with PCOS but healthy levels should be maintained as it is a crucial vitamin for regular body function.

Depression and Anxiety

Women with PCOS are at an increased risk of experiencing depression and anxiety compared to women without PCOS. Depression and anxiety may exacerbate PCOS symptoms and vice versa, creating a vicious cycle of distress.

Women who are experiencing depression or anxiety may be less likely to adhere to lifestyle modifications.

This can have a compounding negative impact on quality of life. Therefore, getting a proper screening and visiting a therapist early will help with the healthy management of the symptoms.

Comprehensive Stool Test

The research on the connection between the Gut and PCOS has been slow but studies continue to point to a strong correlation.

While a stool test isn’t the norm, it might be part of a more comprehensive review of PCOS especially when trying to understand gastrointestinal (GI) symptoms.

A 360 view of the gut will help the practitioner understand inflammation, hormonal balance, and insulin resistance.

Summary

There are more and more discoveries happening for PCOS every year which help doctors understand the role of hormones in the female reproductive cycle. For example, increasingly it's shown that hormone metabolites play a role in how hormones are used up in the body impacting the baseline levels.

Therefore, it’s important to be open to a holistic checkup that gives a multi-dimensional, full-body look inside a PCOS patient.

Risk of Delayed Diagnosis

There are multiple risks involved with the delayed diagnosis of PCOS. These are the major risks involved

Type-2 Diabetes

Due to increasing insulin resistance, dyslipidemia (abnormal lipid levels), obesity, and glucose intolerance

Endometrial Cancer

Without ovulation (regular periods), progesterone levels remain low, allowing estrogen to continue stimulating the endometrium, leading to endometrial hyperplasia (overgrowth of the endometrium) and potentially increasing the risk of endometrial cancer.

Infertility

Delayed diagnosis and treatment of PCOS may prolong the time to conception or increase the risk of infertility, particularly if ovulation dysfunction remains untreated.

Psychological Impact

Women with PCOS are at a higher risk of experiencing depression, anxiety, and other mental health issues. A delayed diagnosis means delayed access to support and treatment for these psychological symptoms.

Cardiovascular Disease

PCOS is associated with an increased risk of cardiovascular disease, including high blood pressure, high cholesterol, and heart disease. Specifically when there is an abnormal lipid profile, the risk of cardiovascular disease is higher.

Weight Gain, Obesity, and Metabolic Disorders

PCOS is a hormonal as well as a metabolic disorder, meaning it leads to and is exaggerated by insulin resistance which can lead to stubborn weight gain and type-2 diabetes. Hyperandrogenism can lead to abdominal fat accumulation and reduce fat breakdown. Hormonal fluctuations can also affect mood and stress levels, which may contribute to emotional eating and weight gain.

Treatment Options

The goal of PCOS treatment is to alleviate symptoms, restore hormonal balance, reduce inflammation, control insulin resistance, improve fertility if desired, and reduce the risk of long-term complications such as diabetes and cardiovascular disease through lifestyle modifications, medication, and management of specific symptoms.

Lifestyle Modifications for PCOS

The goal of lifestyle modifications for PCOS is to improve insulin sensitivity, promote weight loss if overweight, regulate menstrual cycles, and reduce symptoms such as hirsutism and acne through dietary changes, regular physical activity, and stress management.

Lifestyle modifications will be helpful and sometimes necessary for improving overall health and enhancing medication effectiveness, potentially reducing the need for medication in the long term.

Healthy Diet for PCOS

Adopting a balanced diet rich in fruits, vegetables, lean proteins, and whole grains can help manage weight and improve insulin sensitivity. For a more complete guide check out Eating for PCOS.

Regular Exercise

A study showed a minimum of 120 minutes of vigorous-intensity exercise per week is needed to provide favorable health outcomes for women with PCOS.

Specifically, these are some good exercises:

• High-Intensity Interval Training (HIIT)
• Cardiovascular steady-state exercises such as dancing, walking, and biking. Daily walking on a treadmill or outside should last 30 to 45 minutes.
• Mind-body exercises such as Yoga, Pilates, and Tai Chi
• Strength Training

The effects of exercise include but are not limited to increased endorphins, lower stress, enhanced insulin sensitivity, hormone regulation, and better sleep.

Weight Management

Reducing weight is important because excess weight exacerbates insulin resistance, hormonal imbalances, and metabolic dysfunction associated with PCOS. Achieving and maintaining a healthy weight can help reduce insulin resistance, regulate menstrual cycles, and improve fertility in overweight or obese women with PCOS.

Regular exercise and diet routine is an essential part of consistent weight management.

Medications for PCOS

Birth Control Pills

Oral contraceptives containing estrogen and progestin can regulate menstrual cycles, reduce androgen levels, and improve symptoms like excessive hair growth and acne. This can typically reduce the risk of endometrial cancer associated with absent or missed periods (more risk of growth and build-up in the endometrium).

Anti-Androgen Medications

Medications such as spironolactone can help reduce symptoms of excess hair growth (hirsutism) and acne by blocking the effects of androgens.

Metformin

A diabetes medication, can help with ovulation, regulate menstrual cycles, and improve insulin resistance in PCOS patients.

Fertility Treatments for PCOS

Ovulation Induction for PCOS

Medications such as Clomiphene Citrate, Letrozole, or gonadotropins may be used to stimulate ovulation in women with PCOS who are trying to conceive.

In vitro fertilization (IVF) for PCOS

In cases where other fertility treatments are unsuccessful, IVF may be recommended to help achieve pregnancy.

Functional Medicine Therapies for PCOS

Supplements for PCOS

Additional supplements specifically helpful for PCOS include Inositol, Vitamin D3, Berberine, and CoQ10 have shown effectiveness in clinical trials.

Certain herbal supplements such as spearmint tea, maca root, ashwagandha, curcumin, licorice root, and chaste berries have been used for PCOS symptoms. Further rigorous clinical trials have yet to establish their effectiveness.

Mind-Body Mindfulness Practices for PCOS

Practices like yoga, meditation, and mindfulness may help manage stress, which can exacerbate PCOS symptoms

Please know that some supplements and herbs may interact with medications or make sure to consult a doctor before trying any alternative treatments for PCOS.

This is only a generic list based on current research and more treatment options and medications may be available to you.

Follow Up Testing

Follow-ups are crucial in the treatment of Polycystic Ovary Syndrome (PCOS) for several reasons:

• Assessment of Treatment Efficacy
• Monitoring of Symptoms and Complications
• Medication Management
• Lifestyle Counseling and Support
• Fertility Monitoring and Support especially if actively trying to conceive soon.
• Psychological Support

Please know that multiple healthcare providers should be a part of your PCOS management team to treat the full body system. For example doctors, therapists, dietitians, and fitness coaches.

By having a comprehensive set of labs, not only will you become more literate in managing your condition but your care team can give you a personalized treatment plan depending on your evolving goals from regular menstruation to pregnancy.

Summary

PCOS is a complex condition that impacts 6–12% of women of reproductive age. It requires a comprehensive evaluation for accurate diagnosis which can then be translated into personalized treatment.

Holistic treatment through lifestyle modifications around diet and exercise, and supplements plays a vital role alongside medication to support optimal health outcomes.