ConditionWomen's & pregnancy health
Polycystic Ovarian Syndrome (PCOS): Diagnosis and Long-Term Care
Polycystic ovarian syndrome (PCOS) is a hormonal condition diagnosed when a woman has at least two of three features: irregular or absent ovulation, signs or blood tests showing excess androgens (male-type hormones), and polycystic-looking ovaries on ultrasound, after other causes are ruled out. It affects about 1 in 8 to 1 in 10 women. Beyond periods, acne and excess hair, PCOS raises lifelong risks of diabetes, heart disease, endometrial cancer and depression, so management focuses on symptoms and long-term health.
Also called: PCOS, polycystic ovary syndrome, Stein-Leventhal syndrome, polycystic ovarian disease (PCOD)
At a glance
- Diagnosis
- 2 of 3 Rotterdam features: irregular ovulation, excess androgens, polycystic ovaries (or high AMH in adults).
- How common
- About 10 to 13% of women of reproductive age.
- Long-term risks
- Type 2 diabetes, gestational diabetes, high cholesterol, sleep apnea, endometrial cancer, anxiety and depression.
- Management
- Lifestyle changes, combined hormonal contraception, metformin, anti-androgens, and letrozole for fertility.
- Screening
- Regular checks of blood sugar, blood pressure, cholesterol and mood.
When to get help
Call 911 or go to the ER
- Severe one-sided pelvic pain with vomiting (possible ovarian torsion) or pain with fainting or a positive pregnancy test
See a doctor within a day or two
- Very heavy bleeding after months without a period
- Rapid development of male-pattern features: deepening voice, marked hair growth, enlarging clitoris, over weeks to months (possible androgen-producing tumor)
Book a routine appointment
- Fewer than 8 periods a year, or cycles longer than 35 days
- Excess hair growth on the face, chest or back, persistent acne or scalp hair thinning
- Trying to conceive for 12 months (or 6 months if 35 or older), or sooner with irregular cycles
- Darkened, velvety skin in the neck or armpits, or excessive thirst and urination
- Snoring with daytime sleepiness, or low mood and anxiety
How PCOS is diagnosed
Most guidelines use the Rotterdam criteria. In adults, PCOS is diagnosed when at least 2 of these are present:
- Irregular or absent ovulation: cycles shorter than 21 or longer than 35 days, or fewer than 8 periods a year
- Hyperandrogenism: excess hair growth (hirsutism), acne or male-pattern hair loss, or raised testosterone on blood tests
- Polycystic ovarian morphology on ultrasound, or a raised anti-Müllerian hormone (AMH) level as an alternative in adults
Other conditions that mimic PCOS must be excluded: thyroid disease, high prolactin, non-classic congenital adrenal hyperplasia, Cushing syndrome, androgen-secreting tumors and pregnancy.
Diagnosis in teenagers
Irregular cycles and acne are common in the first years after the first period. In adolescents, PCOS requires both irregular cycles (persisting more than 1 to 3 years after the first period) and hyperandrogenism. Ultrasound and AMH are not used for diagnosis in teens.
PCOS phenotypes
| Phenotype | Features | Metabolic risk |
|---|---|---|
| A (classic) | Irregular ovulation + androgen excess + polycystic ovaries | Highest |
| B (classic) | Irregular ovulation + androgen excess | High |
| C (ovulatory) | Androgen excess + polycystic ovaries | Moderate |
| D (non-androgenic) | Irregular ovulation + polycystic ovaries | Lower |
What drives PCOS
PCOS results from a combination of genetics and environment. Key mechanisms:
- insulin resistance: present in most women with PCOS, including many who are not overweight. High insulin stimulates the ovaries to produce more androgens.
- hormonal signaling: increased LH relative to FSH from the pituitary, which favors androgen production
- follicle development arrest: many small follicles fail to mature, so ovulation does not occur regularly
Weight gain worsens symptoms, and modest weight loss of 5 to 10% often improves cycles and metabolic health. For an introduction to everyday symptoms, see PCOS symptoms and treatment.
Long-term health risks
| Area | Risk |
|---|---|
| Metabolic | Prediabetes and type 2 diabetes, metabolic syndrome, high triglycerides and low HDL |
| Pregnancy | Gestational diabetes, high blood pressure in pregnancy, preterm birth |
| Uterus | Endometrial hyperplasia and cancer when periods are infrequent, because the lining builds up without regular shedding |
| Sleep | Obstructive sleep apnea |
| Liver | Fatty liver disease |
| Mental health | Anxiety, depression, eating disorders and body image concerns |
| Heart | Higher cardiovascular risk factors |
Recommended screening
- blood pressure at each visit
- blood sugar (fasting glucose, HbA1c or an oral glucose tolerance test) every 1 to 3 years, and before or early in pregnancy
- cholesterol based on overall risk
- screening for depression, anxiety and eating disorders
- sleep apnea assessment if symptoms suggest it
Management
Lifestyle
- balanced, sustainable eating and regular physical activity
- 5 to 10% weight loss if overweight, which can restore ovulation in some women
- better sleep and stress management
Irregular periods and endometrial protection
- combined hormonal contraception (pill, patch or ring) regulates bleeding and lowers androgens
- cyclic progestin or a hormonal IUD protects the uterine lining if not using the combined pill
- women with fewer than 4 periods a year should have at least 4 progestin-induced withdrawal bleeds or continuous protection
Excess hair, acne and hair loss
- combined hormonal contraception as first-line treatment
- anti-androgens such as spironolactone, with reliable contraception because they can harm a developing male fetus
- laser hair removal, electrolysis and topical eflornithine
- acne treatments from a dermatologist
Metabolic health
- metformin improves insulin resistance and may help weight and cycles
- GLP-1 receptor agonists for weight management in suitable women not trying to conceive
- treatment of blood pressure and cholesterol as needed
Fertility
- letrozole is first-line to induce ovulation
- clomiphene and metformin are alternatives or additions
- gonadotropin injections, ovarian drilling (laparoscopic surgery) or IVF if needed
- preconception care: folic acid, glucose testing and weight optimization
Frequently asked questions
How is polycystic ovarian syndrome diagnosed?
PCOS is diagnosed using the Rotterdam criteria: at least two of irregular or absent ovulation, signs or blood tests showing excess androgens, and polycystic ovaries on ultrasound (or high AMH in adults), after ruling out other hormone conditions.
Can you have PCOS without cysts on your ovaries?
Yes. The "cysts" are actually many small follicles, and you do not need them for diagnosis. Irregular ovulation plus signs of excess androgens is enough. In teenagers, ultrasound is not used for diagnosis.
What are the long-term risks of PCOS?
PCOS increases the risk of type 2 diabetes, gestational diabetes, high cholesterol, sleep apnea, fatty liver disease, endometrial hyperplasia and cancer, and anxiety and depression. Regular screening and healthy habits reduce these risks.
Can I get pregnant with PCOS?
Yes. Many women with PCOS conceive naturally or with treatment. Letrozole is the first-line medicine to trigger ovulation and is effective for most. Weight loss, when appropriate, also improves fertility.
Does PCOS go away after menopause?
Irregular periods become irrelevant after menopause, and androgen levels decline with age. However, the metabolic risks, such as diabetes and heart disease, continue, so ongoing screening and healthy habits remain important.
Sources
This guide was written from current patient and clinical guidance, including:
- International evidence-based guideline for the assessment and management of polycystic ovary syndrome (Monash University/ESHRE/ASRM, 2023)
- ACOG: Polycystic ovary syndrome (Practice Bulletin and FAQ)
- Endocrine Society: Diagnosis and treatment of PCOS clinical practice guideline
- NICHD: Polycystic ovary syndrome
- Office on Women's Health: Polycystic ovary syndrome