Polycystic Ovarian Syndrome (PCOS) is a hormonal issue that affects 10 to 47 percent of American women (depending on region, with a higher prevalence in the southern United States). PCOS affects how the ovaries work, which can ultimately lead to issues conceiving. Those with PCOS often have irregular menstrual cycles and aside from affecting your fertility, it can also cause other unwanted side effects including excess hair growth, acne and weight gain.
PCOS is a complicated condition, with many moving parts—meaning that there doesn’t seem to be one clear expression of it with recognizable and predictable signs and symptoms. Instead, there are many things that we know can contribute to PCOS—but understanding the how and the why is more complicated (more on that below).
How do I know if I have PCOS?
Medically, PCOS is diagnosed by having any two of the following (commonly referred to as the Rotterdam Criteria):
High androgens (the “male” hormones): This can be documented by bloodwork (for example, testing testosterone and androstenedione) or clinically (with the presence of acne or thinning hair).
Irregular or absent cycles: Longer and irregular cycles indicate you might be infrequently and inconsistently ovulating (oligo-ovulation) and the absence of cycles for months at a time is suggestive of not ovulating at all (anovulation). (Read more about how to track ovulation if you have PCOS.)
Having ovaries with an abnormally high number of antral follicles (one of the youngest stages of egg growth): Clinically if an ovary has more than 12 antral follicles it is referred to as PCO (polycystic ovary). (PCO is a term that refers to an ovary with more than twelve antral follicles and doesn’t mean those follicles are cysts—it is not the same as a PCOS diagnosis. Confusing, we know.)
If you suspect you have PCOS, your next step is to talk to your doctor who can send you for blood tests and an ultrasound.
What does a menstrual cycle and ovulation look like with PCOS?
A common side effect of PCOS is inconsistent or absent ovulation. If your period is long or highly irregular (or absent for long stretches) this could be a clue, but you can confirm with at-home LH tests which can help determine if you are ovulating (by registering—or not—the LH peak that happens just prior to ovulation and the onset of your period two weeks later). This lack of ovulation can be a key factor in infertility; without ovulation, the egg doesn’t have the opportunity to reach the fallopian tube to be fertilized.
How exactly PCOS impacts your ovulation is complex and might involve many interconnected variables such as having high AMH, an elevated LH level, elevated androgen production and increased insulin resistance.
Each of these can interfere with your ability to properly ovulate and therefore to get pregnant, which is why it’s important for those with PCOS to seek help from an experienced healthcare professional.
How is PCOS treated?
Since PCOS is heavily linked (and exacerbated by) insulin resistance and high insulin levels, treatment may include medications and supplements in addition to dietary and lifestyle guidelines to improve insulin sensitivity. Although weight loss, exercise, nutrition and supplements or medications focused on improving insulin sensitivity are considered the first line of treatment, it’s important to know there are subtypes of PCOS. For example, lean PCOS is a term used for patients with a normal or low BMI that experience the same PCOS condition, though they may not benefit the same way from weight loss and dietary changes the same way someone with a higher BMI might.
If dietary changes and supplementation isn’t enough to regulate your cycle, the next step is typically starting medications to induce ovulation. These are oral medications (Letrozole or Clomid) that increase FSH levels to recruit a follicle. This is usually done with cycle monitoring (tracking with bloodwork and ultrasound) to see the response to the medications and confirm ovulation.
PCOS is complicated and many people with PCOS will have completely different symptoms and issues from one another. If you suspect this is you, seek out medical evaluation.