Doctor explaining diagnosis to the patient

How is PCOS Diagnosed?

Wondering exactly how PCOS is diagnosed is only natural if you’re wondering if you have this condition. However, the process of figuring out whether or not you have polycystic ovary syndrome can soon feel overwhelming in light of the fact that there is no single, definitive test available that will give you a “yes” or “no” answer. Instead, there are a set of criteria and symptoms which one has to fit in order to be diagnosed with PCOS. 

But first of all, let’s briefly explain: what is PCOS?

What is polycystic ovary syndrome (PCOS)? 

In a nutshell, PCOS is a complex condition characterized by an imbalance of hormones in the body. Specifically, women with PCOS have higher-than-normal amounts of male hormones (known as androgens), which trigger symptoms like missed periods, acne, excess hair growth, weight gain, and other issues. Beyond these immediate effects, PCOS is also associated with long-term health implications like type 2 diabetes, inflammation, uterine cancers, and heart disease. 

Because of PCOS’ impact on a woman’s ability to ovulate, PCOS is associated with trouble getting pregnant as well. In fact, PCOS is understood to be the leading cause of infertility (as well as the most common endocrine disorder) among reproductive-age women. And this condition may be more common than you might think: according to the CDC, it affects between 6% and 12% of US women who are of reproductive age, while one study found that 70% of women with the condition didn’t even know they had it. 

What Causes PCOS?

In terms of what causes PCOS, there appears to be no one root issue. However, there is consensus that the condition has both hereditary and environmental contributing factors, which may be caused (at least in part) by a change or mutation to one or more genes. These are some of the same genes shared with T2DM (type 2 diabetes mellitus), and can be seen in higher prevalence among male family members. So why would these genes mutate in the first place? Well, one hypothesis posits that PCOS, from an evolutionary standpoint, could be advantageous for women affected by it. For instance, testosterone increases strength or bone density and women, facilitates weight gain, and improves the odds that women conceive fewer children: all these side effects work to ensure survival during conflict and famine, as well as increase the likelihood women can raise these fewer children past early childhood years. It’s important to note here that the CDC also proposes there is a genetic component to this condition, as PCOS appears to run in families

Whether this is the case or not, it appears that a driving force behind most PCOS symptoms is the presence of high levels of male hormones (androgens), which prevent the ovaries from producing hormones and ovulating normally. 

This issue goes hand in hand with another big driver of PCOS, which is insulin resistance. Insulin is a hormone which helps move sugar from the bloodstream to the body’s cells to use as energy. Women with PCOS seem to have reduced insulin sensitivity, by an average of  35-40%, compared to women without PCOS, according to one study. This means for women with PCOS that insulin levels need to increasingly rise in order to get sugar into their muscle cells, but as the body becomes more and more desensitised to insulin, the body needs to create more of it to get cells to open. This eventually leads to a build up of sugar (otherwise known as glucose) in the blood, which in turn leads to type 2 diabetes. This problem is then compounded by the fact that too much insulin also increases the production of androgens, and can lead to increased appetite and weight gain. 

Diagnosing PCOS Using The Rotterdam Criteria

PCOS is unique in that it holds health implications that are bound up in side effects that can provoke extreme psychological and emotional distress. As mentioned earlier, common symptoms of PCOS include acne, weight gain, excess body hair growth, mood disorders, chronic fatigue, and trouble sleeping, and all these problems are known to negatively impact patients’ confidence and self-esteem. 

As such, it is extremely important that if you suspect you may have PCOS, you pursue a diagnosis so you can work with a healthcare professional to manage symptoms and side effects. 

So what are the main PCOS diagnosis criteria? 

Well, the Rotterdam criteria require two out of the following symptoms: 

  • Irregular periods (also called oligomenorrea) or no periods (amenorrhea)
  • Higher levels of androgens present in the blood (hyperandrogenism)
  • Polycystic ovaries visible on an ultrasound 

Irregular or no periods 

Let’s first discuss irregular periods.

The menstrual cycle begins from the first day of your period to the first day of your next period, with the average menstrual cycle hovering around the 28 day mark. Menstrual flow occurring every 21 to every 35 days is considered normal, with a flow that lasts two to seven days. For the first few years after menstruation, longer cycles are common (as is irregularity), but tend to shorten and become more regular as one ages. If you get your period more often than every 21 days, or you go longer than 35 days between periods, then that is considered irregular. 

So how can you know if you’ve got an irregular period? Well, it’s a good idea to track your cycle. This way, you can see easily over the course of several months how regular or irregular your flow is. Women with PCOS often suffer from irregular periods because the ovaries produce higher-than-normal levels of androgens, and as such, don’t ovulate at all, or at least not as often as every month. So if you go frequently 35 days or more between periods, this could be a sign you have PCOS. Additionally, if you have ‘slightly irregular’ periods (between 32 and 35 days apart), your doctor may order a blood test mid-cycle to check your progesterone levels. 

Next, let’s talk about no periods altogether. This is another potential consequence of PCOS, and is a result of a lack of ovulation. If you’ve gone 6 or more weeks without bleeding, then this is considered a missed period. Though missed periods can also be triggered by stress, weight loss, and other environmental influences, if you have lighter than normal bleeding, or your periods have disappeared altogether, this is a cause for concern and should be discussed with a healthcare professional.  

Higher levels of androgens 

Your doctor can assess higher-than-normal levels of male hormones through a visual exam – looking for excess hair growth and acne – or through a blood test. 

If a blood test is ordered, then the following hormones may be measured when considering a PCOS diagnosis:

  • Lutenizing hormone (LH)
    • Women with PCOS have high levels of LH secretion, which can contribute to high levels of androgens. This, along with low FSH levels, can contribute to poor egg development and a consequent lack of ovulation 
  • Follicle-stimulating hormone (FSH) 
    • Your FSH levels may be checked to rule out the possibility of primary ovarian failure. In patients with PCOS, FSH levels are usually within normal range or low, and the LH-FSH ratio may be greater than 3. 
  • Total and free testosterone 
    • Women with PCOS are known to have raised levels of testosterone which is responsible for excess hair growth and acne, as your skin cells and hair follicles are extremely sensitive to increased levels of this hormone. 
  • Dehydroepiandrosterone sulfate (DHEAS) 
    • DHEAS is secreted by the adrenal glands and is converted into either estrogen or testosterone. In women, moderately high levels of DHEAS are associated with hyperandrogenism, and around 20-30% of women suffering from PCOS have elevated levels of DHEAS. 
  • Androstenedione 

When these blood tests are carried out, your glucose and cholesterol levels may also be evaluated (since insulin resistance is a common driver of PCOS). 

Polycystic ovaries (detected through ultrasound) 

Polycystic ovaries are characterized by ovaries that have a high number of follicles on them. These follicles are fluid-filled sacs, and they are not associated with any pain or discomfort. 

Normally, ovarian follicles contain egg cells, and these cells are then released during ovulation. Thanks to hormonal imbalances associated with PCOS, women with this condition don’t ovulate, or they ovulate irregularly, and so these follicles are prevented from being released (and subsequently developed), and so they accumulate in the ovaries. Women with PCOS can have 12 or more follicles on an ovary. 

To check the appearance of your ovaries (as well as the thickness of the lining of your uterus), a transducer is placed in the vagina to carry out a transvaginal ultrasound: this transducer then emits sound waves that are illustrated into images on a computer screen.

Keep in mind that if you’ve already ticked two of the three boxes above, a physician may forego an ultrasound, since you have already filled the criteria required to be diagnosed with PCOS. 

Big picture approach to diagnosing PCOS

Though being diagnosed with PCOS requires hitting two out of the three above criteria, it is important that any medical help you receive takes a holistic approach to treating polycystic ovary syndrome. 

As such, we recommend that when searching for providers to help manage your PCOS, you opt for healthcare expertise that: 

  • Takes a wide-angle lens to examining your medical history 
    • This means not just evaluating you along these three criteria, but truly listening to other reasons for why you suspect you may have PCOS. 
  • Practices a holistic approach to treating PCOS 
    • PCOS doesn’t have just one cause, and as such it doesn’t have one single solution.
    • It’s important to opt for a provider that places priority on your mental, emotional, and physical wellbeing by creating a treatment plan that takes into account medication, nutrition, and supplements, as well as your personal lifestyle and priorities. For that reason, it’s best to strive for a customized program when tackling PCOS symptoms. 
  • Gets you a prompt diagnosis 
    • Part of the stress PCOS patients’ face revolves around the time it takes to reach a diagnosis. From blood tests, to in-person doctor visits, to ultrasound results, it can be a long journey to finding a treatment plan that finally starts working for you. Allara’s expert-based program puts you on an expedited road to diagnosis and, if applicable, treatment. 

Though there is no known cure for PCOS, the first step to healing is to obtain a diagnosis

PCOS is a complex condition that can be effectively managed through a comprehensive, thoughtful approach that takes into account your lifestyle, medical history, and main concerns, and provides a clear pathway to minimizing the negative side effects, and taking back control of your health.