PCOS (Polycystic Ovary Syndrome): Symptoms, Diagnosis, Diet and Treatment

Polycystic ovary syndrome (PCOS) is one of the most common hormonal conditions in women of reproductive age, affecting roughly 1 in 10, and it is probably even more frequent in South Asian women. It involves irregular ovulation, higher levels of "male" hormones (androgens) and often insulin resistance. It is a lifelong condition, but good management improves symptoms and reduces long-term risks.

Symptoms

• Irregular, infrequent or absent periods (fewer than 8-9 periods a year, or cycles longer than 35 days)
• Excess hair growth on the face, chest, abdomen or back (hirsutism)
• Acne and oily skin
• Scalp hair thinning (female pattern hair loss)
• Weight gain, especially around the abdomen, or difficulty losing weight
• Dark, velvety skin patches on the neck, armpits or groin (acanthosis nigricans) and skin tags
• Difficulty getting pregnant
• Mood changes, anxiety, depression, tiredness and poor sleep

Symptoms usually begin around puberty, but may be noticed later after weight gain or stopping the pill.

What causes PCOS?

The exact cause is unknown. Contributing factors include:

• Insulin resistance: high insulin levels stimulate the ovaries to make more androgens and prevent normal ovulation. This occurs in many women with PCOS, even those who are slim.
• Genetics: it often runs in families.
• Hormone imbalance involving LH, FSH and androgens.
• Excess weight can worsen insulin resistance and symptoms but does not cause PCOS by itself.

How PCOS is diagnosed

Doctors usually use the Rotterdam criteria: at least two of three features, after excluding other causes:

1. Irregular or absent ovulation (irregular periods)
2. Signs of high androgens, either clinical (hirsutism, acne) or on blood tests
3. Polycystic-appearing ovaries on ultrasound, or a high anti-Müllerian hormone (AMH) level in adults

Tests may include:

• Blood tests: testosterone, sex hormone binding globulin, LH and FSH, thyroid hormone (TSH), prolactin and 17-hydroxyprogesterone, to exclude thyroid disease, high prolactin and congenital adrenal hyperplasia
• Blood sugar, HbA1c and cholesterol. See HbA1c explained
• Pregnancy test if periods are absent
• Pelvic ultrasound. In teenagers, ultrasound is not used in the first eight years after the first period.
• Blood pressure, BMI and waist measurement. Use our BMI calculator.

Health risks linked to PCOS

• Type 2 diabetes and prediabetes (several times higher risk), and gestational diabetes. See early symptoms of diabetes
• High blood pressure and high cholesterol, and increased heart disease risk
• Fatty liver
• Sleep apnoea
• Endometrial hyperplasia and cancer, if periods are very infrequent and the lining of the womb builds up
• Infertility, pregnancy complications such as miscarriage and pre-eclampsia
• Depression and anxiety

Lifestyle: the foundation of treatment

• Weight management: losing 5-10% of body weight improves ovulation, hormones and metabolism. If you are lean, focus on healthy habits instead.
• Diet: choose a balanced, lower glycaemic load diet: vegetables, pulses, whole grains, fish, eggs, nuts. Reduce sugary drinks, sweets, white rice and bread, and fried food. See our diabetes diet for South Asians for practical ideas.
• Exercise: at least 150 minutes of moderate activity weekly, plus strength training.
• Sleep and stress: aim for 7-8 hours of sleep, and ask for help if you feel low or anxious.
• Stop smoking.

Medical treatment

Treatment depends on your goals:

• Regulating periods and protecting the womb: combined oral contraceptive pills, or progestogen given for some days every few months, or a hormonal IUS.
• Excess hair and acne: combined pills, anti-androgen medicines (such as spironolactone, with effective contraception because it can harm a pregnancy), topical acne treatments, laser or electrolysis, hair removal and cosmetic treatments.
• Insulin resistance and weight: metformin may help in some women, especially with prediabetes or a high BMI. GLP-1 medicines may be considered in obesity under specialist care.
• Fertility: letrozole is the first-line medicine for inducing ovulation, then clomifene, gonadotrophins, laparoscopic ovarian drilling or IVF if needed.
• Mental health support and screening for depression.

Do not stop treatment or start supplements without medical advice. Inositol and vitamin D are popular, but the evidence is still limited.

PCOS and pregnancy

Women with PCOS can have healthy pregnancies. Plan ahead: take folic acid, optimise weight and blood sugar, and review medicines. During pregnancy, screening for gestational diabetes and high blood pressure is important. Read about gestational diabetes and use our ovulation calculator, though cycle prediction is unreliable with irregular periods.

Long-term monitoring

• Yearly blood pressure, weight, waist, and blood sugar or HbA1c
• Cholesterol every one to three years
• Regular periods or hormonal protection of the womb
• Mental health review

When to see a doctor

See a doctor if your periods are irregular for more than three months, absent for more than 3 months and you are not pregnant, if you have excess hair growth or severe acne, if you are struggling to conceive after 6-12 months, or if you have symptoms of diabetes. Seek urgent care for very heavy bleeding or severe pelvic pain. See also irregular periods.

References

• International evidence-based guideline for the assessment and management of polycystic ovary syndrome, 2023
• American College of Obstetricians and Gynecologists: PCOS
• World Health Organization: polycystic ovary syndrome fact sheet
• Endocrine Society: clinical practice guideline on PCOS