What Should You Do If You Suspect You Have PCOS?
See your gynecologist or endocrinologist for evaluation. Diagnosis involves blood tests for androgens, insulin, and other hormones, along with pelvic ultrasound. If diagnosed, start with lifestyle modifications — even 5-10% weight loss can significantly improve symptoms. Your doctor will recommend medications based on your primary concerns: fertility, irregular periods, acne, or metabolic health.
The diagnostic workup for PCOS includes serum total and free testosterone, dehydroepiandrosterone sulfate (DHEA-S), 17-hydroxyprogesterone (to exclude late-onset congenital adrenal hyperplasia), thyroid-stimulating hormone (to exclude thyroid disease), prolactin, fasting glucose, insulin, hemoglobin A1c, and a lipid panel. Pelvic ultrasound evaluates ovarian morphology — polycystic ovaries are defined as 12 or more follicles per ovary or ovarian volume exceeding 10 mL, though the 2023 International Evidence-Based PCOS Guideline recommends using anti-Müllerian hormone (AMH) as an alternative to ultrasound.
Treatment should be individualized based on the patient's primary concerns and reproductive goals. For women not seeking pregnancy, combined oral contraceptives are first-line for menstrual regulation and androgen suppression. Spironolactone (25-200 mg daily) is added for persistent hirsutism and acne. For women seeking pregnancy, letrozole is the recommended first-line ovulation induction agent based on the NICHD Reproductive Medicine Network trial. Metformin may be added for its insulin-sensitizing effects, particularly in women with BMI above 25.
The 2023 International Evidence-Based PCOS Guideline provides comprehensive diagnostic and treatment recommendations
What Are the Symptoms of PCOS?
Common symptoms include irregular or absent menstrual periods, excess hair growth on the face and body (hirsutism), acne, thinning hair on the scalp, weight gain particularly around the abdomen, difficulty getting pregnant, and skin darkening in body folds (acanthosis nigricans). Symptoms typically begin around puberty but may not be recognized until adulthood.
Menstrual irregularity is the most common presenting symptom, affecting 75-85% of PCOS patients. This ranges from oligomenorrhea (cycles longer than 35 days) to amenorrhea (absence of periods for 3 or more months). Irregular periods reflect anovulation — failure to release an egg — which also explains the fertility difficulties. Chronic anovulation leads to unopposed estrogen stimulation of the endometrium, increasing the risk of endometrial hyperplasia and endometrial cancer, which is 2-6 times higher in women with PCOS.
Hyperandrogenism — excess male hormones — drives many visible symptoms. Hirsutism (excess terminal hair in male-pattern distribution) affects 60-70% of PCOS patients. Acne, particularly along the jawline and chin, affects 15-30%. Androgenic alopecia (female-pattern hair thinning) occurs in 5-10%. Metabolic features including insulin resistance, dyslipidemia, and central obesity are integral to the syndrome and significantly increase long-term cardiovascular and diabetes risk.
How Is PCOS Treated?
Treatment depends on primary goals. For menstrual regulation: combined oral contraceptives. For fertility: letrozole (first-line), clomiphene, or gonadotropins. For hirsutism/acne: spironolactone plus COCs. For insulin resistance: metformin and lifestyle modifications. Weight loss of 5-10% through diet and exercise improves all aspects of PCOS.
Lifestyle modification is the foundation of PCOS management regardless of BMI. A structured exercise program of at least 150 minutes per week of moderate-intensity aerobic activity, combined with a balanced diet emphasizing low-glycemic-index foods, has been shown to improve insulin sensitivity, reduce androgen levels, and restore ovulatory cycles. The PCOS Lifestyle Randomized Controlled Trial demonstrated that lifestyle intervention was comparable to oral contraceptives for improving metabolic and reproductive outcomes at 12 months.
For fertility, letrozole (an aromatase inhibitor) replaced clomiphene citrate as the recommended first-line ovulation induction agent following the landmark NICHD trial, which showed letrozole had higher live birth rates (27.5% vs 19.1%) and ovulation rates (61.7% vs 48.3%) compared to clomiphene. Metformin (1500-2000 mg daily) can be used alone or combined with letrozole to enhance ovulation rates, particularly in obese patients. Ovarian drilling and IVF are reserved for medication-resistant cases.
The NICHD trial showed letrozole had higher live birth rates (27.5% vs 19.1%) compared to clomiphene
What Are the Long-Term Health Risks of PCOS?
PCOS significantly increases lifetime risk of type 2 diabetes (4-8 fold), metabolic syndrome (up to 3 fold), cardiovascular disease, endometrial cancer (2-6 fold), gestational diabetes, preeclampsia, sleep apnea, depression, and anxiety. Regular screening and proactive management of metabolic risk factors are essential for long-term health.
Type 2 diabetes is the most significant metabolic complication. A meta-analysis found women with PCOS have a 4-fold increased risk of type 2 diabetes, with up to 40% developing impaired glucose tolerance or diabetes by age 40. The 2023 PCOS guideline recommends screening with an oral glucose tolerance test (OGTT) at diagnosis and every 1-3 years thereafter, as HbA1c alone may miss early glucose abnormalities in younger women.
Cardiovascular risk is elevated through clustering of metabolic risk factors: insulin resistance, dyslipidemia (low HDL, high triglycerides), central obesity, and chronic low-grade inflammation. While younger women with PCOS have more subclinical atherosclerosis (increased carotid intima-media thickness), whether this translates to higher rates of cardiovascular events in later life is still being studied. Mental health screening is also recommended — depression affects 28-64% and anxiety affects 34-57% of women with PCOS.
