How to diagnose PCOS?

Author: Eliška Hosnedlová, IHP (Certified Integrative Health Practitioner and Femvie expert)

PCOS is one of the most common conditions women face regarding their hormonal and metabolic health. Unfortunately, it is not at all easy to determine this condition flawlessly. A diagnosis is accompanied by many questions and even more "buts" that can rule out the condition. Therefore, today we will look at what specifically can be problematic in diagnosing PCOS and what to watch out for - even from the patient's perspective.

What is PCOS?

Polycystic ovary syndrome (PCOS) is a metabolic and hormonal condition where the female body produces an excessive amount of so-called male hormones, androgens.

The most common observable symptoms include:

• Irregular periods
• Excessive hair growth
• Acne or oily skin
• Infertility or difficulty conceiving
• Polycystic ovaries on ultrasound
• Increased fat storage, especially in the abdominal area
• Excessive hair loss
• Small skin tags on the neck or armpits
• Dark or thick skin patches on the back of the neck, armpits, and under the breasts

You can read about why androgens are out of balance, the role of metabolism, and the types of PCOS we distinguish in this article.

PCOS Diagnosis

For a woman to be diagnosed with PCOS, at least two of the following three criteria must apply (1):

1. Higher androgen production based on:

• Blood tests
• Physical symptoms of PCOS

However, this condition may not always be enough for an accurate diagnosis.

To recap - why is an ultrasound not enough?

If a woman receives a diagnosis based on an ultrasound finding, it surprisingly doesn't immediately mean it's genuinely PCOS. It's common and quite normal for women to occasionally have a larger number of follicles. These are developing eggs. If ovulation doesn't occur, which happens sometimes even to otherwise healthy women, the egg doesn't mature and doesn't leave the follicle to be fertilized in the uterus. It remains in the follicle on the ovary.

At the same time, without the presence of an increased number of follicles, PCOS cannot be ruled out. A woman can have completely normal-looking ovaries and still have a hormonal condition consistent with the PCOS profile. (2)

Causes of irregular menstruation

We already know why a diagnosis based on ultrasound isn't enough. Since an increased number of undeveloped follicles on the ovaries occurs due to anovulation (a cycle without ovulation) and irregular cycles, meeting two conditions for diagnosis is not entirely sufficient. An irregular cycle, an anovulatory cycle, or loss of menstruation does not automatically indicate PCOS, even though it is one of its main signs. Other conditions, such as thyroid dysfunction, excessive exercise, or insufficient energy intake, can also be responsible.

For this reason, it is necessary to gather more information and understand the woman's lifestyle, eating habits, assess current energy intake and amount of physical activity to rule out other possibilities.

Other possible causes of irregular cycles

What else can cause an irregular cycle?

• Hypothyroidism – the thyroid gland is involved in cycle regulation, and its slowed function can impact ovulation and lead to irregular cycles
• Stress – stress hormones, especially cortisol, can affect the menstrual cycle
• Adolescence – adolescent girls often receive a wrong diagnosis, as it can take up to 6 years after the first menstruation for the cycle to stabilize and ovulation to occur regularly. (2) Moreover, the developing female body is still learning to work with hormones, so it is somewhat normal to have higher androgen levels or even mild insulin resistance.

Hypothalamic amenorrhea

One of the common conditions for which PCOS is mistaken is hypothalamic amenorrhea. This is a condition where menstruation stops due to a disruption in communication within the hypothalamus-pituitary-ovarian axis. This causes anovulation and loss of menstruation. Hypothalamic amenorrhea occurs due to insufficient energy intake, excessive exercise, or other forms of stress. (3) Due to anovulation, a larger number of follicles may form on the ovaries, so the main difference between loss of menstruation and PCOS is hormone levels. Because stress factors lead to an overall lower production of reproductive hormones, androgens, as well as LH and FSH, are generally lower or at the lower end of the range compared to the PCOS hormonal profile. (4)

After stopping hormonal birth control

Although this type is classified among the four main types of PCOS, this diagnosis can also be somewhat misleading. Birth control pills (or other forms of hormonal contraception) suppress ovulation and halt endogenous hormones. (5) Some women, due to their previous use, do not ovulate for several months even after stopping. PCOS manifesting after discontinuing hormonal contraception is often temporary, until the cycle stabilizes and the woman starts ovulating regularly again.

Reasons for irregular menstruation after discontinuation:

1. Hypothalamic amenorrhea

The loss of menstruation is similar even if you have just stopped hormonal birth control. Even in this case, we don't necessarily have to blame PCOS; it could be hypothalamic amenorrhea. For hormones to "reactivate" after discontinuing birth control, they need proper fuel and many extra nutrients that the pills depleted from the body during use. Insufficient diet, lack of vitamins and essential minerals, and excessive exercise will only prolong the return of menstruation.

2. Pill-induced PCOS

Discontinuation of androgen-suppressing hormonal contraception can cause a temporary increase in these "male hormones," which can lead to a PCOS diagnosis. Additionally, contraceptive use often worsens insulin resistance and disrupts the signaling of the hypothalamus-pituitary-ovarian axis, which can make it harder for ovulation to resume after discontinuation. If menstruation was regular before starting hormonal contraception, it is highly likely that it is not true PCOS, and hormones will balance out again with proper support.(6)

3. True PCOS

If you were already dealing with menstrual cycle issues, insulin resistance, and other symptoms of PCOS before starting hormonal contraception, it is likely that even after stopping it, you may still have true PCOS.

4: Thyroid dysfunction

The last of the selected causes of irregular cycles, which can often confuse us when diagnosing PCOS, is hypothyroidism, or an underactive thyroid. The thyroid gland is an important element in regulating the menstrual cycle. (7) Its hormones are involved in the development of follicles on the ovary, but also in the signaling of brain hormones to the ovary.

Is it PCOS or hypothyroidism?

Why is it so difficult to determine whether it is PCOS or an underactive thyroid? Although at first glance we encounter two diametrically different conditions, they have a lot in common. For example, increased follicle formation, a very similar hormonal profile, and metabolic state. While in PCOS, follicles cannot grow and mature properly due to high androgen levels, in hypothyroidism, hormonal changes, specifically increased prolactin levels, prevent ovulation, which can lead to polycystic ovaries. (8) Women with PCOS tend to have a higher LH to FSH ratio, but a similarly high ratio can also occur due to an autoimmune thyroid disease, known as Hashimoto's. (9)

Thirdly, insulin and its production are also significantly related to thyroid function. If thyroid dysfunction occurs, insulin resistance and high insulin levels can result.(10)

Sometimes, symptoms associated with PCOS can tell us the most. These include, for example, excessive hair growth, hair thinning, acne, or increased fat storage in the abdominal area. In the case of an underactive thyroid, we are more likely to encounter significant fatigue, cold hands and feet, and an irregular heart rate.

When it comes to existing insulin resistance, at that point, things start to get complicated, because nothing in the body works in complete isolation. If high insulin levels result from insulin resistance, this can again affect androgen production and increase their formation. And so we encounter a combination of hypothyroidism and PCOS.

The main aim of the article is not to confuse and scare women even more about what is happening to them, but rather to show how complicated a PCOS diagnosis can often be. And perhaps to convey some optimism and hope that it may not be PCOS at all, and that hormonal contraception and medication do not have to be the only solution to all of this.

Do you want to know more about yourself and your health status as accurately as possible? Instead of speculating, get blood tests. Be sure to choose a complete hormonal profile including prolactin and androgen hormones. Other important tests include a glucose test, fasting insulin, and lipid profile, which can reveal possible insulin resistance and metabolic syndrome. And last but not least, don't forget a thyroid profile with all hormones, including antibodies, to rule out the possibility of hypothyroidism.

If you wish to have a complete evaluation of your health status, you can also contact our Femvie experts, who will create an individual plan based on your medical history, laboratory results, symptom monitoring, cycle analysis, and a 90-minute initial consultation. Our experts will support you throughout the process to help you achieve results. Information on how consultations work can be found here.

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If you have any questions about women's health, do not hesitate to contact our experts at Femvie advice center. They will be happy to answer all your questions for free.*

*The advice center is not a substitute for gynecological support and assistance. If you are experiencing any health problems, we recommend contacting your doctor as soon as possible.

Sources used:

1. https://nyulangone.org/conditions/polycystic-ovary-syndrome-in-adults/diagnosis
2. https://www.larabriden.com/you-might-not-have-pcos/
3. https://www.shadygrovefertility.com/infertility-causes/hypothalamic-amenorrhea/
4. https://www.researchgate.net/figure/Typical-hormone-pattern-in-functional-hypothalamic-amenorrhea_tbl1_339097174
5. https://modernfertility.com/blog/birth-control-ovulate/
6. https://verilymag.com/2017/04/temporary-pcos-symptoms-treatment-expert
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5980701/
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4287775/
9. https://www.verywellhealth.com/hypothyroidism-pcos-link-2616554
10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3356957/

Femvie products that can help you

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• 💊 Magnesium — supports insulin sensitivity and hormonal health
• 💊 Magnesium-Zinc-B6 — key minerals for hormonal balance in PCOS

Frequently asked questions

What is PCOS and how does it manifest?

Polycystic ovary syndrome (PCOS) is a hormonal disorder causing irregular cycles, excessive hair growth, acne, or fertility problems. It affects up to 10% of women of reproductive age.

Can PCOS be treated naturally?

PCOS symptoms can be naturally alleviated with a low-glycemic diet, regular exercise, stress reduction, and targeted dietary supplements. Natural treatment does not replace medical care.

Does PCOS affect fertility?

PCOS is one of the most common causes of infertility, but many women with PCOS do get pregnant—either naturally or with the help of treatment. The key is proper diagnosis and an individualized approach.