Polycystic Ovary Syndrome (PCOS): Causes, Symptoms and Modern Management

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Zappelphilipp Marx•
Ultrasound scan of the ovaries for suspected PCOS

Irregular cycles, persistent acne, increased body hair, weight gain and a desire to conceive that does not take off: these can all be caused by Polycystic Ovary Syndrome (PCOS). It is one of the most common hormonal disorders during the reproductive years worldwide and a leading cause of cycle problems and anovulatory infertility. This guide explains in plain language what PCOS is, how to recognise common signs, how diagnosis is made according to current guidance, and which elements of treatment are considered helpful today.

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 different in each person. Typical is a combination of:

  • elevated 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 undeveloped follicles that do not mature to ovulation. PCOS is therefore a chronic dysfunction of hormonal regulation and metabolism, rather than an irreversible defect of the ovaries.

How common is PCOS worldwide?

Large reviews and international organisations estimate that about 8–13 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 attention focuses mainly on contraception.

Current fact sheets from the World Health Organization (WHO), for example the WHO PCOS factsheet, and international guidelines emphasise that PCOS affects more than fertility: it can affect blood sugar, blood pressure, heart health and mental wellbeing. For region-specific information, national health authorities and professional bodies in India, such as the Ministry of Health and Family Welfare (MoHFW), Indian Council of Medical Research (ICMR) and leading public hospitals, also provide locally relevant guidance.

Recognising typical PCOS symptoms early

PCOS usually becomes apparent in late puberty or early adulthood, but sometimes only when fertility problems arise. Common PCOS symptoms include:

  • irregular menstruation, cycles longer than 35 days or absent periods
  • very heavy or very light bleeding without an obvious reason
  • increased hair growth on the face, chin, chest, abdomen or back
  • persistent acne or very oily skin beyond adolescence
  • thinning hair or hair loss on the forehead or crown
  • weight gain, particularly central abdominal weight, often despite unchanged eating habits
  • fatigue, strong cravings and large day-to-day energy fluctuations
  • difficulty conceiving because ovulation is absent or hard to predict

No one has all the features. Even single signs such as cycles regularly longer than 35 days or pronounced hirsutism are a clear reason to discuss PCOS with a clinician.

Causes and mechanisms — why PCOS develops

The exact cause of PCOS is not fully understood. Research points to an interaction of genetic predisposition, hormonal regulatory systems and environmental factors. Studies from major research centres describe the syndrome as a cluster of symptoms around a hormonal core of androgen excess and insulin resistance.

  • Genetic predisposition: PCOS runs in some families. First-degree relatives have a considerably higher risk of developing PCOS-typical features.
  • Insulin resistance: Many people with PCOS are less sensitive 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 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 influence how strongly a genetic predisposition becomes manifest, but they do not fully explain PCOS on their own.

An important take-away: PCOS is not a “punishment” for wrong choices but a biological predisposition whose effects you can influence with appropriate measures.

Diagnosis by guidelines — Rotterdam criteria and more

PCOS is a diagnosis of exclusion. Before making the diagnosis, clinicians check whether other conditions could explain the symptoms, for example thyroid disorders, elevated prolactin levels or rare genetic causes. Only after these alternatives are ruled out 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 blood
  • polycystic ovaries on ultrasound with many small follicles

Usually at least two of these three features must be present to consider PCOS. A large international evidence-based guideline on PCOS summarises these criteria and concrete diagnostic pathways; such guidance is useful for clinicians worldwide and should be considered alongside national recommendations from authorities such as MoHFW, ICMR and specialist bodies within India.

Public health portals and patient-facing resources — for example international sites like the NHS and WHO — explain in everyday language how diagnosis is made and what practical measures can help. For Indian readers, materials from MoHFW, ICMR and major public hospitals can provide locally relevant advice.

Special considerations apply for adolescents: pubertal features such as acne and cycle irregularities are common even without PCOS. Guidelines therefore recommend caution in labelling young people and favour monitoring the course over time rather than making a premature diagnosis.

Long-term risks — PCOS affects the whole body

PCOS is not only about fertility. Without appropriate care 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, particularly 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 hypertensive disorders

For these reasons, international guidelines recommend regular checks of blood pressure, blood sugar, lipids and weight, regardless of whether there is currently a fertility desire. Endocrinology and gynaecology reviews stress 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 management

Lifestyle is the first recommendation in almost all PCOS guidelines. It does not replace medical treatment but significantly enhances its effects. A moderate, sustained weight loss of five to ten percent can visibly improve cycle regularity, hormones and metabolism in people who are overweight.

  • Blood-glucose-friendly diet: Plenty of vegetables, legumes, whole grains, nuts and healthy fats help to stabilise blood sugar and insulin. Sugary drinks, sweets and highly processed snacks should be the exception.
  • Regular physical activity: At least 150 minutes of moderate aerobic activity per week plus one to two sessions of resistance training are recommended. This improves insulin sensitivity independent of weight and benefits 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 investigation. Patient information from national and international child health and reproductive health institutes indicates they may support cycle and metabolism in 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 give sustainable benefit and can worsen binge eating, weight fluctuation and frustration.

Medical treatment — what options are available

Which medications are appropriate depends on your goals, laboratory results and life stage. Modern guidelines emphasise a stepwise approach with active involvement of the person affected.

  • Hormonal contraception: Combined pills, patches or vaginal rings can regulate cycles and bleeding, reduce menstrual discomfort and improve acne or hirsutism. They are mainly used when there is no current desire for pregnancy.
  • Metformin: This drug 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 the cycle.
  • Antiandrogens: Agents such as spironolactone or specific progestins can reduce excessive hair growth and acne. They must always be used with reliable contraception because they can harm an unborn child.
  • Ovulation induction: For those trying to conceive, international guidelines often recommend letrozole as first-line treatment to trigger ovulation. Clomiphene is an alternative but is increasingly being replaced by letrozole in many settings.
  • Gonadotropins: Hormone injections are used when oral medications are insufficient. They require close ultrasound monitoring to avoid ovarian hyperstimulation and multiple pregnancies.
  • Weight-management medications: In some countries, medications to reduce weight and improve metabolism are used for marked obesity. Their use should be individualised and based on evidence within specialised multidisciplinary teams.

Good patient-friendly overviews of diagnosis and treatment can be found in materials from reproductive medicine societies and national health institutes; international examples include ASRM and NICHD, while Indian clinicians and patients can also refer to guidance from MoHFW, ICMR and tertiary care centres for locally relevant recommendations on lifestyle, medications and fertility treatment.

PCOS and fertility — a systematic approach

1. Optimise the basics

Before any medical fertility treatment it is worth reviewing the basics. A blood-glucose-friendly diet, weight reduction if overweight, stopping smoking, moderating alcohol intake and increasing physical activity improve spontaneous ovulation rates and the chances of success for any subsequent treatment.

2. Make ovulation visible

Many people with PCOS ovulate irregularly or not at all. Cycle tracking with temperature charts, ovulation tests, observation of cervical mucus and, if needed, ultrasound help to better time ovulation. At the same time, other factors such as sperm quality and fallopian tube patency should be checked.

3. Ovulation induction and insemination

If spontaneous ovulation is absent, letrozole or clomiphene can be used to stimulate egg maturation. Depending on the situation, intrauterine insemination (IUI) with prepared sperm may be helpful, where sperm are placed directly into the uterus.

4. IVF and ICSI

If pregnancy does not occur despite ovulation induction or additional factors are present, procedures such as in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) may be considered. People with PCOS have a higher risk of ovarian hyperstimulation syndrome, so stimulation protocols and the trigger for ovulation must be planned carefully.

5. Information from reliable sources

National and international institutes provide detailed explanations about hormonal stimulation, ovulation induction, IUI, IVF and ICSI. Such resources are useful starting points to prepare for consultations with your care team; in India, information from MoHFW, ICMR and recognised fertility centres can be particularly relevant.

PCOS across the life course — from puberty to menopause

PCOS can accompany people for decades, but its impact varies. In adolescence acne, cycle irregularities and body image are often prominent. Later, fertility, weight, blood pressure and blood sugar become central. In perimenopause hormones change again—some symptoms may ease while long-term cardiovascular risks may become more important.

Good PCOS management is therefore dynamic. The goal is not to follow a rigid protocol for life but to find a sensible mix of lifestyle measures, medical treatment and psychological support appropriate for each life stage.

Mental health — PCOS is also a psychological challenge

PCOS is not limited to laboratory values. Studies show higher rates of depressive symptoms, anxiety disorders, eating disorders and body dissatisfaction. Visible changes such as acne, increased hair growth or weight gain collide 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 circle, good clinician–patient communication, psychological therapy, dietetic guidance, exercise coaching and support groups can help to view PCOS not as personal failure but as a manageable condition. A stable psychological foundation increases the likelihood of successfully implementing medical and day-to-day measures in the long term.

When should you see a doctor for suspected PCOS?

You should seek medical advice if your cycle is clearly 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 already after six months for people in their mid-30s and older) are warning signs.

Acute problems such as severe lower abdominal pain, sudden one-sided pain, fever, circulatory symptoms or very heavy bleeding require immediate medical assessment. PCOS cannot be reliably diagnosed by self-assessment. A structured work-up with medical history, blood tests and ultrasound is the key step to gain clarity and develop an appropriate plan.

Conclusion — understand PCOS and manage it with confidence

PCOS is common and complex and still under-recognised, but today there are better data, modern guidelines and a wider range of treatment options than ever before. With a combination of a blood-glucose-friendly diet, regular exercise, individually selected medications and long-term follow-up, cycle regularity, skin condition, metabolism and fertility can be significantly improved for many people. It is important to take time to understand your body, use information from reliable sources and choose a care team that listens to you and makes decisions together with you. PCOS is a chronic but manageable predisposition — the better you know it and the more closely treatment and daily life are tailored to you, the more control you regain over health, family planning and quality of life.

Disclaimer: Content on RattleStork is provided for general informational and educational purposes only. It does not constitute medical, legal, or other professional advice; no specific outcome is guaranteed. Use of this information is at your own risk. See our full Disclaimer.

Frequently Asked Questions (FAQ)

PCOS is a hormonal and metabolic predisposition in which the ovaries often do not have regular ovulation, produce more male-type hormones and show many small follicles on ultrasound, which can affect the cycle, fertility and the risk of certain long-term conditions.

Signs of PCOS include very irregular or absent periods, increased body hair on the face or chest and abdomen, persistent acne, unexplained weight gain, hair thinning on the scalp or difficulty conceiving despite trying for a long time without contraception.

PCOS is considered a lifelong predisposition; it usually does not disappear completely but can be influenced so that many symptoms lessen and risks decrease through a combination of diet, exercise, medication and good medical care.

Yes, many people with PCOS have normal or low weight, because genetic and hormonal factors play a major role, so a normal body mass index does not exclude PCOS and lean people can also have cycle disturbances and metabolic risks.

Not everyone with PCOS is overweight and not every treatment starts with weight loss, but if weight is significantly elevated, a moderate, sustainable weight reduction of a few percent of initial weight can markedly improve metabolism, cycles and hormone levels without extreme diets.

A predominantly plant-based, fibre-rich diet with plenty of vegetables, legumes, whole grains, nuts and healthy fats is recommended, while sugary drinks, sweets and highly processed convenience foods should be eaten only rarely.

Regular physical activity can improve insulin sensitivity, stabilise weight and blood sugar, lift mood and positively influence the cycle and hormonal balance, which is why it is a core component of PCOS treatment regardless of starting weight.

Many people with PCOS conceive spontaneously or with support, because lifestyle measures, medications to trigger ovulation and, if needed, assisted reproductive treatments can significantly improve the chances of pregnancy in many cases.

Common medications include hormonal contraceptives to control cycles and symptoms, metformin for insulin resistance, antiandrogens for hirsutism and acne, as well as letrozole, clomiphene or gonadotropins to trigger ovulation for those seeking pregnancy, each tailored to your situation.

If PCOS remains untreated for a long time, cycle problems and visible symptoms may persist and the risk of type 2 diabetes, high blood pressure, lipid disorders, cardiovascular disease and changes of the uterine lining may increase, which is why regular follow-up is advisable.

Many people report mood swings, depressive episodes, anxiety and stress related to body image and fertility, so it is important to take psychological strain seriously and seek help early through counselling, support groups or psychotherapy if needed.

Even though cycles and ovulation no longer occur after menopause, the PCOS predisposition remains and can influence the risk of cardiovascular disease, blood sugar problems and weight gain, so a healthy lifestyle and regular checks remain important.