PCOS Complete Guide — Symptoms, Diagnosis, and Management

Polycystic Ovary Syndrome (PCOS) is a hormonal condition that affects approximately 8–13% of women of reproductive age worldwide, making it one of the most common endocrine disorders in women. Despite its prevalence, up to 70% of affected women remain undiagnosed.

The name is misleading in two important ways. First, not all women with PCOS have cysts on their ovaries — the "polycystic" appearance on ultrasound actually shows multiple small, immature follicles that haven't completed ovulation, not true cysts. Second, PCOS isn't just an ovarian problem — it's a systemic metabolic and hormonal condition that affects your entire body.

At its core, PCOS involves a disruption in the hormonal signals that regulate ovulation. Women with PCOS typically produce higher-than-normal levels of androgens (often called "male hormones," though all women produce them). This androgen excess, combined with insulin resistance that affects 50–80% of women with PCOS, interferes with the normal follicular development and ovulation process.

The downstream effects touch nearly every system: reproductive health (irregular periods, difficulty conceiving), metabolic health (insulin resistance, increased risk of type 2 diabetes), dermatological health (acne, excess hair growth, hair thinning), and mental health (higher rates of anxiety and depression). PCOS is a lifelong condition, but with proper management, most women live full, healthy lives.

PCOS presents differently in every woman, which is one reason it's so often missed or misdiagnosed. Symptoms can range from mild to severe and may change over time. The most common include irregular periods, androgen-related symptoms, and metabolic features.

Irregular periods are the hallmark symptom. This can mean cycles longer than 35 days, fewer than 8 periods per year, no periods at all (amenorrhea), or very heavy bleeding when periods do occur (because the uterine lining builds up over a longer-than-normal time without shedding).

Androgen excess produces visible symptoms that often cause significant distress: persistent acne (especially along the jawline and chin), hirsutism (excess hair growth on the face, chest, back, or abdomen — affecting up to 70% of women with PCOS), and androgenic alopecia (thinning hair on the scalp, particularly at the crown).

Metabolic symptoms include weight gain or difficulty losing weight (especially around the abdomen), insulin resistance (which may show as darkened skin patches called acanthosis nigricans, particularly on the neck, armpits, and groin), and fatigue.

Other associated symptoms include mood changes (anxiety, depression, and emotional volatility are significantly more common in PCOS), skin tags, and sleep disturbances including obstructive sleep apnea. Many women also experience chronic low-grade inflammation, which contributes to fatigue and may increase cardiovascular risk over time.

Importantly, you don't need every symptom to have PCOS — and lean women with PCOS may have few visible signs, making diagnosis particularly challenging.

PCOS is diagnosed using the Rotterdam Criteria, the most widely accepted international standard. You need to meet at least 2 of 3 criteria — and other conditions that mimic PCOS must be ruled out first.

The three criteria are: irregular or absent ovulation (evidenced by irregular or missing periods), clinical or biochemical signs of excess androgens (visible symptoms like acne and hirsutism, or elevated androgen levels on blood tests), and polycystic ovaries on ultrasound (12 or more follicles measuring 2–9mm in one ovary, or increased ovarian volume).

Your doctor will typically order blood tests including total and free testosterone, DHEA-S, sex hormone-binding globulin (SHBG), LH and FSH (the LH:FSH ratio is often elevated in PCOS), fasting glucose and insulin, HbA1c, thyroid function (TSH), and prolactin. These help both confirm PCOS and rule out thyroid disorders, hyperprolactinemia, congenital adrenal hyperplasia, and Cushing's syndrome — all of which can mimic PCOS.

A pelvic ultrasound may be performed, though it's not required for diagnosis if you meet the other two criteria. In adolescents, ultrasound is less reliable because polycystic-appearing ovaries are common during normal pubertal development.

Getting diagnosed can be frustrating — many women see multiple doctors before receiving an accurate diagnosis. If your concerns are dismissed, advocate for yourself. Bring a symptom diary, request specific blood work, and don't hesitate to seek a second opinion from an endocrinologist or reproductive specialist.

Lifestyle modification is considered the first-line treatment for PCOS by every major medical organization — and for good reason. Research consistently shows that diet and exercise improvements can reduce androgen levels, improve insulin sensitivity, restore ovulation, and improve mental health, often as effectively as medication.

The dietary approach with the most evidence for PCOS focuses on managing insulin resistance. This doesn't mean a specific branded diet — it means choosing foods that produce a lower glycemic response. Practical strategies include pairing carbohydrates with protein and healthy fats to slow glucose absorption, choosing whole grains over refined carbohydrates, emphasizing vegetables, legumes, and fiber-rich foods, and including anti-inflammatory fats from olive oil, nuts, avocados, and fatty fish.

Even modest weight loss (5–10% of body weight) in overweight women with PCOS can significantly improve symptoms and restore ovulation. However, PCOS makes weight loss harder due to insulin resistance and hormonal factors — so sustainable, gradual approaches work better than crash dieting, which can worsen hormonal imbalance.

Regular exercise improves insulin sensitivity independently of weight loss. Both aerobic exercise (brisk walking, cycling, swimming) and resistance training have been shown to benefit PCOS. Aim for 150 minutes of moderate activity per week, which can be broken into manageable daily sessions.

Stress management matters too. Chronic stress elevates cortisol, which worsens insulin resistance and androgen production. Adequate sleep (7–9 hours), mindfulness practices, and regular physical activity all help regulate the stress response. The goal isn't perfection — it's building consistent, sustainable habits that support your body's hormonal environment.

Medical management of PCOS is tailored to your specific symptoms and goals — there's no one-size-fits-all medication. The right approach depends on whether your primary concerns are irregular periods, androgen symptoms, insulin resistance, or fertility.

For cycle regulation, combined oral contraceptives (the pill) are the most commonly prescribed first-line treatment. They suppress androgen production, regulate periods, protect the endometrium from the thickening that can occur with prolonged anovulation, and often improve acne and hirsutism. Cyclical progesterone is an alternative for women who can't take estrogen.

For insulin resistance, metformin is widely used. Originally a diabetes medication, metformin improves insulin sensitivity, lowers androgen levels, and can help restore regular ovulation. It's particularly beneficial for women with PCOS who have prediabetes or type 2 diabetes. Inositol supplements (particularly myo-inositol and D-chiro-inositol in a 40:1 ratio) have also shown promising results for insulin sensitivity and ovulation in clinical trials.

For androgen symptoms, spironolactone is the most common anti-androgen medication. It reduces hirsutism and acne but takes 3–6 months to show full effects and must be used with reliable contraception due to its potential to affect fetal development. Topical treatments (prescription retinoids for acne, eflornithine cream for facial hair) can complement systemic therapy.

For fertility, letrozole has emerged as the first-line ovulation induction agent for PCOS, outperforming clomiphene in clinical trials. If oral medications don't achieve ovulation, injectable gonadotropins or IVF may be considered.

Regular monitoring is essential regardless of treatment — including periodic blood work, blood pressure checks, and endometrial assessment if periods remain irregular.

Yes — PCOS is the most common cause of anovulatory infertility, but the majority of women with PCOS can and do get pregnant, often with relatively straightforward interventions. The key challenge is that irregular or absent ovulation makes it harder to conceive naturally, but ovulation can usually be restored.

Lifestyle optimization is the first step. In overweight women with PCOS, losing even 5–10% of body weight can restore spontaneous ovulation in up to 50% of cases. Regular exercise, stress management, and an insulin-sensitizing diet support this process. Some women with mild PCOS find that these changes alone are enough to achieve pregnancy.

If lifestyle changes aren't sufficient after 3–6 months, ovulation induction medications are the next step. Letrozole is now the recommended first-line medication, with clinical trials showing higher live birth rates compared to clomiphene citrate, particularly in women with a BMI over 30. Metformin may be added as an adjunct to improve ovulation rates.

For women who don't respond to oral medications, injectable gonadotropins (FSH) can stimulate ovulation, though they require careful monitoring due to the risk of ovarian hyperstimulation syndrome (OHSS), which women with PCOS are more susceptible to.

IVF is typically reserved for cases where simpler treatments haven't worked or when there are additional fertility factors. Women with PCOS generally respond well to IVF, though protocols need to be carefully managed to minimize the OHSS risk.

Preconception care is important: ensure your blood sugar is well controlled, start prenatal vitamins (especially folate) at least 3 months before trying to conceive, and discuss any medications with your provider, as some PCOS treatments need to be stopped before pregnancy.

PCOS is more than a reproductive condition — it has significant long-term metabolic and cardiovascular implications that require ongoing attention throughout your life, even after your reproductive years.

The most well-established long-term risk is type 2 diabetes. Women with PCOS are 2–4 times more likely to develop type 2 diabetes compared to women without PCOS, and up to 40% develop prediabetes or diabetes by age 40. Regular screening (fasting glucose and HbA1c every 1–2 years) is recommended for all women with PCOS, regardless of weight.

Cardiovascular risk is elevated as well. PCOS is associated with higher rates of high blood pressure, elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides — a cluster known as metabolic syndrome. While PCOS hasn't been definitively proven to cause heart attacks and strokes independently, the cumulative risk factors increase lifetime cardiovascular risk.

Endometrial health requires monitoring. When you don't ovulate regularly, the uterine lining builds up without the progesterone-driven shedding that normally occurs. This prolonged estrogen exposure can lead to endometrial hyperplasia, which increases the risk of endometrial cancer. Regular periods (either natural or induced through medication) protect the endometrium.

Mental health is significantly affected. Women with PCOS have 3 times the risk of depression and anxiety compared to women without PCOS, driven by both the biological effects of hormonal imbalance and the psychosocial impact of symptoms like hirsutism, weight gain, and infertility.

The encouraging news: proactive management of PCOS — through lifestyle, medication, and regular screening — dramatically reduces these long-term risks. PCOS requires lifelong awareness, but not lifelong suffering.