PCOS: signs, diagnosis, and what actually helps

PCOS is the most common hormonal condition in women of reproductive age, affecting up to 1 in 10. It is also one of the most under- and mis-diagnosed. Signs cluster: irregular or absent periods, excess facial or body hair, weight gain especially around the middle, acne (especially jawline and chin), thinning scalp hair, difficulty getting pregnant, dark velvety skin patches in folds.

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The Rotterdam criteria

PCOS diagnosis requires 2 of 3: irregular or absent ovulation; signs of high androgens (clinical or labs); polycystic-appearing ovaries on ultrasound. Other causes of these signs must be ruled out first (thyroid, prolactin, congenital adrenal hyperplasia).

What labs to ask for

Total and free testosterone, DHEA-S, AMH, fasting insulin and glucose (or HOMA-IR), TSH, prolactin, 17-hydroxyprogesterone. A pelvic ultrasound. Lipid panel if you have weight or family history concerns.

What actually moves the needle

Regular movement (20+ minutes most days). Lower glycemic-load eating (not extreme low-carb necessarily). Sleep. Stress management. Metformin if labs show insulin resistance. Inositol (myo + d-chiro 40:1, 4 grams per day) - real evidence for ovulation and insulin sensitivity. Combined hormonal contraception for acne and hirsutism. Spironolactone for stubborn skin and hair.

When trying to conceive

Letrozole is the first-line ovulation induction medication, more effective than clomid in PCOS. Talk to a reproductive endocrinologist if cycles do not return within a few months of lifestyle changes.

Common questions

Can you have PCOS without cysts on your ovaries? +

Yes. The Rotterdam criteria require only 2 of 3 features. Many women diagnosed with PCOS have no cysts visible on ultrasound.

Does PCOS go away with weight loss? +

Weight loss improves symptoms substantially for many women but the underlying tendency stays. Lean PCOS exists too - it is not just a weight condition.

Is metformin safe long-term for PCOS? +

Yes, decades of data. Side effects (GI mostly) usually fade after the first month. Take with food, extended-release version is gentler.