Polycystic Ovary Syndrome (PCOS) – Why Diagnosis Isn’t Always Simple

Polycystic Ovary Syndrome or PCOS is a syndrome associated with irregular menstrual cycles, acne or excess hair growth, and, occasionally, difficulties with weight control. While PCOS is a broad diagnosis, many women with PCOS do not fit the stereotypical PCOS mold. So, how do I know if I have PCOS?

A diagnosis of PCOS requires 2 of the following 3 characteristics:

  1. Irregular menstrual cycles: Periods that occur in an unpredictable pattern or greater than 45 days apart. Women with lengthened cycles typically do not ovulate regularly.
  2. Elevated levels of male hormones: This can be visible clinical signs (e.g. excess hair growth or acne) or unseen lab signs including elevated testosterone levels.
  3. Polycystic-appearing ovaries on transvaginal ultrasound: On an ultrasound, there are many “antral follicles,” which contain small immature eggs. Although the syndrome is called “polycystic ovary syndrome” women with PCOS have a large number of immature eggs or follicles, rather than ovarian cysts. Another hormone, called Anti-Mullerian Hormone (AMH), is often elevated in women with PCOS but this is not part of the formal diagnosis.

Given that the criteria to be diagnosed with PCOS only requires two of the three above characteristics, women may have PCOS without the commonly noted symptoms of acne, excess hair growth, or irregular cycles. Although many women with PCOS struggle with weight, diagnosis is independent of weight or body mass index (BMI). In fact, 10-15% of women with PCOS have a normal BMI. These women often do not have acne or excess hair growth and often attribute infertility to irregular menstrual cycles.

Diagnosis of Exclusion

It’s important for patients to understand that the PCOS diagnosis is a diagnosis of exclusion. This means that other syndromes or diseases can present similar symptoms to PCOS, with irregular cycles. Changes in weight and cycle irregularity can be a result of other health occurrences, such as pregnancy, thyroid disease, and elevated prolactin levels. In fact, physicians will often recommend a pregnancy test (HCG), thyroid test (TSH), and prolactin test before diagnosing PCOS.

While there are rarer diseases that can be dangerous for a woman’s health and are important to exclude as the cause of PCOS-like symptoms, ruling out pregnancy, pituitary disease, and thyroid disease is a reasonable place to start. Lifestyle factors that may contribute to absent or irregular cycles are also important to rule out prior to initiating fertility treatment. Women who have a low BMI, a history of excessive exercising or a history of caloric restriction (or a mix of the above) may experience irregular cycles. Treatment often includes lifestyle changes and support, including counseling and a nutrition referral. Women with low ovarian reserve often ovulate irregularly and may have irregular cycles. A physician will check a woman’s ovarian reserve, often with tests such as AMH, FSH, and estradiol.

Treatment Options

Lifestyle counseling is warranted in women with a diagnosis of PCOS. For women who are overweight, a 5-10% weight loss has been associated with improvement in menstrual regularity and resumption of menses. Counseling regarding the heightened risk of diabetes and pre-diabetes compared to women without PCOS may also help guide dietary and exercise choices for patients with the syndrome. Screening for diabetes should be strongly considered in any women with PCOS. If pre-diabetes is diagnosed, medication may be prescribed to aid in insulin resistance and, in some women, results in weight loss.

For those not interested in pregnancy immediately, it is important to discuss protection of the uterine lining from overgrowth or cancer. This is often done with contraceptives or an intrauterine device. Oral contraceptives have the added benefit of improvement of acne in women with PCOS. If you are interested in pregnancy, a referral to a Gynecologist or Reproductive Endocrinologist is often necessary. Women will likely need medications to induce ovulation and intercourse is then timed at home to coincide with ovulation or the medications combined with intrauterine inseminations on the day of ovulation.

PCOS affects 10-15% of reproductive-aged women and, as a result, warrants the attention of not only obstetrician-gynecologists but also physicians in other specialties.

Emory Reproductive Center has fertility experts available to discuss your reproductive needs, schedule an appointment today by calling 404-778-3401 or learn more about our services by visiting our website.

About Dr. Jennifer Kawwass

Jennifer Kawwass, MD is the Medical Director of the Emory Reproductive Center and a Guest Researcher at the CDC. She is board certified in both reproductive endocrinology and infertility and in obstetrics and gynecology. Dr. Kawwass is a fellow of the American Congress of Obstetricians and Gynecologists and a member of the American Society of Reproductive Medicine. She received her undergraduate degree from Davidson College, her medical degree from the University Of Virginia School Of Medicine, and her Ob/Gyn and REI fellowship training from Emory.

About Dr. Heather Hipp

Heather Hipp, MD is a Reproductive Endocrinology and Infertility specialist who practices at the Emory Reproductive Center. She is a board-certified Obstetrician-Gynecologist and a fellow of the American Congress of Obstetricians and Gynecologists. She received her undergraduate degree from Duke University. She received her M.D. from Emory University School of Medicine and completed her OB/Gyn residency and REI fellowship at Emory as well.


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