What is PCOS? More than just “cysts on the ovaries”
PCOS is not a single symptom but a syndrome. It describes a recurring pattern of hormonal and metabolic features that can look slightly different in each person. Typical is a combination of:
- increased androgens such as testosterone or visible signs of androgen excess like hirsutism and acne
- disturbances of ovulation and the cycle with infrequent or absent bleeding
- many small, immature follicles in the ovaries that appear like cysts on ultrasound
Important clarification: these follicles are usually not “true” cysts but developing follicles that do not mature to ovulation. PCOS is therefore a chronic dysfunction of hormonal regulation and metabolism, not an irreversible defect of the ovaries.
How common is PCOS worldwide?
Large reviews and international organisations estimate that about 8 to 13 percent of people with ovaries of reproductive age meet criteria for PCOS, depending on the definition and the population studied. Many people are diagnosed late because cycle irregularities, acne or body hair are often dismissed as “normal” for a long time or the focus is only on contraception.
Current fact sheets from the World Health Organization, for example the PCOS factsheet from the WHO, and international guidelines emphasise that PCOS affects more than fertility: it can impact blood sugar and blood pressure as well as cardiovascular risk and mental health.
Typical PCOS symptoms — recognise them early
PCOS usually becomes apparent in late puberty or young adulthood, but sometimes only when fertility is an issue. Common PCOS symptoms include:
- irregular menstruation, cycles longer than 35 days or absent bleeding
- very heavy or very light bleeding without an obvious cause
- increased hair growth on the face, chin, chest, abdomen or back
- persistent acne or very oily skin after adolescence
- thinning of scalp hair or hair loss at the front or crown
- weight gain, especially central abdominal weight, often despite unchanged eating habits
- fatigue, food cravings and strong day-to-day energy fluctuations
- difficulty becoming pregnant because ovulation is absent or hard to predict
No one shows all features. Even single signs such as cycles regularly longer than 35 days or pronounced hirsutism are a clear reason to raise the issue of PCOS with a health professional.
Causes and mechanisms — why PCOS develops
The exact cause of PCOS is not fully understood. Research points to an interplay of genetic predisposition, hormonal feedback systems and environmental factors. Studies from a large US research institute describe the syndrome as a cluster of symptoms centred on hormonal features of androgen excess and insulin resistance.
- Genetic predisposition: PCOS occurs more frequently in some families. First-degree relatives have a clearly increased risk of developing PCOS-typical features.
- Insulin resistance: Many affected people respond less well to insulin. The body produces more insulin, which stimulates androgen production in the ovaries and disrupts egg maturation.
- Weight and body composition: Overweight can worsen pre-existing insulin resistance, but it is not a prerequisite. There are many lean people with PCOS.
- Environment and lifestyle: Diet, stress, sleep and physical activity modify how strongly genetic predisposition becomes apparent, but they do not explain PCOS on their own.
An important take-away: PCOS is not a “punishment” for poor choices but a biological predisposition whose effects you can influence with appropriate measures.
Diagnosis according to guidelines — Rotterdam criteria and more
PCOS is a diagnosis of exclusion. Before diagnosing PCOS, clinicians check whether other conditions could explain the symptoms, for example thyroid disorders, elevated prolactin levels or rare genetic causes. Only when these alternatives are excluded is PCOS considered.
Many professional societies use three core criteria commonly referred to as the Rotterdam criteria:
- infrequent or absent ovulation with irregular or missing bleeding
- clinical signs of androgen excess such as hirsutism or acne, or elevated androgen levels in the blood
- polycystic ovaries on ultrasound with many small follicles
Usually at least two of these three features must be present to consider a diagnosis of PCOS. A large international evidence-based guideline on PCOS diagnosis and management, accessible through organisations such as the Royal College of Obstetricians and Gynaecologists, summarises these criteria and concrete diagnostic pathways and stresses the importance of a shared, informative conversation with the person affected.
Public health portals such as the British NHS NHS and international organisations like the World Health Organization explain in plain language how diagnosis is made and which everyday measures can help.
Special considerations apply for adolescents: puberty-related symptoms such as acne and cycle irregularities are common without PCOS. Guidelines therefore recommend being cautious with the diagnosis in young people and favour monitoring the course rather than labelling too early.
Long-term risks — PCOS affects the whole body
PCOS is not only a fertility issue. Without appropriate management it can increase the risk of several physical conditions:
- impaired glucose tolerance, prediabetes and type 2 diabetes
- high blood pressure, unfavourable blood lipids and metabolic syndrome
- cardiovascular disease later in life
- sleep apnoea, especially with higher body weight
- thickening of the uterine lining with increased risk of endometrial cancer if bleeding is very infrequent or absent
- pregnancy complications such as gestational diabetes or high blood pressure
For this reason, international guidelines recommend regular monitoring of blood pressure, blood sugar, lipids and weight, regardless of whether there is a current desire to conceive. A major review from an endocrinology society emphasises the importance of viewing PCOS as a lifelong health factor, not just a problem of the twenties and thirties.
Diet and exercise — the foundation of PCOS care
Lifestyle is the first-line recommendation in almost all PCOS guidelines. It does not replace medical therapy but substantially enhances its effects. A moderate, sustained weight loss of five to ten percent can noticeably improve cycle regularity, hormone levels and metabolism in people with overweight.
- Blood sugar–friendly diet: Plenty of vegetables, legumes, whole grains, nuts and high-quality fats stabilise blood sugar and insulin. Sugary drinks, sweets and highly processed snacks should be occasional.
- Regular exercise: At least 150 minutes of moderate aerobic activity per week plus one to two sessions of strength training are recommended. This improves insulin sensitivity regardless of weight and has positive effects on mood and sleep.
- Stable routines: Adequate sleep, regular meals and stress-reduction strategies help buffer hormonal fluctuations.
- Supplements: Substances such as myo-inositol or D-chiro-inositol are under active study. information from the National Institute of Child Health and Human Development on PCOS indicates they may support cycle and metabolic health for some people, but they should always be part of a comprehensive plan.
More important than a perfect scheme is that the plan fits your daily life. Extreme diets, quick fixes and strict bans rarely lead to lasting benefits and can worsen binge eating, weight fluctuations and frustration.
Medications — which options are available
Which medications are appropriate depends on your goals, lab values and life stage. Modern guidelines emphasise a stepwise approach with active involvement of the person affected.
- Hormonal contraception: Combined oral contraceptives, patches or vaginal rings can regulate cycles and bleeding, reduce menstrual pain and improve acne or hirsutism. They are mainly used when there is no current desire to conceive.
- Metformin: This medication improves insulin sensitivity and is commonly used for insulin resistance, prediabetes or elevated diabetes risk. It can have positive effects on weight, blood sugar, androgen levels and cycle regularity.
- Antiandrogens: Agents such as spironolactone or certain progestins can reduce excessive hair growth and acne. They must always be combined with reliable contraception because they can harm a developing fetus.
- Ovulation induction: For active fertility goals, international guidelines often recommend letrozole as first-line treatment to induce ovulation. Clomiphene is an alternative but is increasingly being replaced by letrozole.
- Gonadotropins: Injectable hormones are used when tablets are insufficient. They require close ultrasound monitoring to avoid ovarian hyperstimulation and multiple pregnancies.
- Weight-management medications: In some countries, medications that reduce weight and improve metabolism are used for significant overweight. Their use should be individualised and evidence-based within specialist teams.
Accessible overviews of diagnosis and treatment can be found in patient information from organisations such as the American Society for Reproductive Medicine ASRM and on the PCOS pages of the US National Institute of Child Health and Human Development NICHD, which explain lifestyle, medications and fertility treatments in detail.
PCOS and fertility — proceed systematically
1. Optimizing the basics
Before any medical fertility treatment it is worthwhile to review the basics. A blood sugar–friendly diet, weight reduction if overweight, smoking cessation, moderate alcohol use and increased physical activity improve spontaneous ovulation rates and the chances of success for any further therapy.
2. Making ovulation visible
Many people with PCOS ovulate irregularly or not at all. Cycle tracking with temperature charts, ovulation tests, observing cervical mucus and, when needed, ultrasound helps to better identify ovulation. At the same time, other factors such as sperm quality and fallopian tube patency should be checked.
3. Ovulation induction and intrauterine insemination
If spontaneous ovulation does not occur, letrozole or clomiphene are used to stimulate egg maturation. Depending on the situation, intrauterine insemination may be added, where prepared sperm are placed directly into the uterus.
4. IVF and ICSI
If pregnancy does not occur despite ovulation induction or if additional factors are present, procedures such as in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) are considered. People with PCOS have an increased risk of ovarian hyperstimulation syndrome, so stimulation protocols and ovulation trigger must be planned carefully.
5. Reliable information sources
The National Institute of Child Health and Human Development provides dedicated pages on PCOS and fertility with detailed explanations of hormonal stimulation, ovulation induction, IUI, IVF and ICSI. Such portals are good starting points to prepare for medical appointments.
PCOS across the life course — from puberty to menopause
PCOS accompanies people over decades but not always with the same intensity. In adolescence, acne, cycle irregularities and body image often dominate. Later, fertility, weight, blood pressure and blood sugar become central. In perimenopause hormones change again; some symptoms may lessen while others, like cardiovascular risk, may come more into focus.
Good PCOS management is therefore dynamic. The goal is not to follow a rigid protocol for life but to find an appropriate mix of lifestyle, medical treatment and psychological support for each life stage.
Mental health — PCOS is also a psychological challenge
PCOS is more than lab results. Studies show increased rates of depressive symptoms, anxiety disorders, eating disorders and body dissatisfaction. Visible changes such as acne, increased hair growth or weight gain intersect with societal ideals and can strongly affect self-esteem and relationships.
It is worthwhile to consider mental health from the start. Open conversations in your personal network, good clinician–patient communication, psychological support, nutrition counselling, exercise coaching and peer support groups can help to view PCOS not as personal failure but as a manageable challenge. A stable psychological foundation increases the likelihood of implementing medical and practical measures long term.
When should you see a doctor for suspected PCOS?
You should seek medical advice if your cycle is noticeably irregular for several months, your period is absent for more than three months or you have very infrequent bleeding. New-onset hirsutism, persistent acne, unexplained rapid weight gain, severe fatigue or an unfulfilled desire to conceive for twelve months — often after six months for people in their mid-30s — are warning signs.
Acute problems such as severe lower abdominal pain, sudden one-sided pain, fever, circulatory problems or very heavy bleeding require immediate medical assessment. PCOS cannot be reliably self-diagnosed. A structured evaluation with medical history, blood tests and ultrasound is the most important step to get clarity and develop a sensible plan.
Conclusion — understand PCOS and manage it with agency
PCOS is common, complex and still under-recognised, yet better data, modern guidelines and a wide range of treatment options are available today. With a combination of blood sugar–friendly diet, regular exercise, individually chosen medication and long-term follow-up, cycle, skin, metabolism and fertility can be significantly improved for many people. It is important to take the time to understand your body, use information from reliable sources and build a care team that takes you seriously and makes decisions with you. PCOS is a chronic but manageable predisposition — the better you know it and the more closely treatment and daily life fit you, the more room you regain for health, family planning and quality of life.
