How to diagnose PCOS?

August 22, 2022

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

PCOS is one of the most common conditions that women face in terms of their hormonal and metabolic health. Unfortunately, it is not easy to accurately diagnose this condition. There are many questions associated with the diagnosis and even more buts that can rule out the condition. Therefore, today we will look at what specifically can be difficult when diagnosing PCOS and what to look out for - also from the patient's perspective.

What is PCOS?

Polycystic ovary syndrome (PCOS) is a metabolic and hormonal condition in which a woman's body produces excessive amounts of male hormones, androgens.

The most common observable symptoms include:

Irregular cycle
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 growths on the neck or armpits
Dark or thick skin patches on the back of the neck, in the armpits, and under the breasts

You can read about why androgens are actually unbalanced, what role metabolism plays, and which types of PCOS we distinguish in this article .

Diagnosis of PCOS

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

Irregular menstruation or anovulation

Higher androgen production due to :

Blood tests
Physical symptoms of PCOS

Polycystic ovaries visible on ultrasound

However, this condition may not always be enough for the diagnosis to be correct.

To reiterate – why isn't ultrasound enough?

If a woman is diagnosed with PCOS through an ultrasound, surprisingly, this does not necessarily mean that she actually has PCOS. It is common and quite normal for women to have a higher number of follicles at times. These are developing eggs. If ovulation does not occur, which happens from time to time even in otherwise healthy women, the egg will not have time to mature and leave the follicle to be fertilized in the uterus. It will remain in the follicle on the ovary.

However, 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 profile consistent with PCOS. ( 2 )

Causes of irregular menstruation

We already know why an ultrasound diagnosis is not enough. Since an increased number of immature follicles on the ovaries occurs as a result of anovulation (a cycle without ovulation) and an irregular cycle, the need to meet two conditions for a diagnosis is not entirely sufficient. An irregular cycle, an anovulatory cycle or the loss of menstruation does not automatically mean that it is PCOS, although it is one of its main signs. Other conditions can also be behind it, such as a thyroid disorder, excessive exercise or insufficient energy intake.

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

PCOS

Other possible causes of irregular cycles

What else could be causing an irregular cycle?

Hypothyroidism – the thyroid gland is involved in regulating the cycle 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 are often misdiagnosed because it can take up to 6 years after their first period for their cycle to stabilize and ovulation to occur regularly. ( 2 ) Additionally, a developing female body is still learning how to handle hormones, so it is somewhat normal to have higher androgen levels or even mild insulin resistance.

Hypothalamic amenorrhea

One common condition that PCOS is confused with is hypothalamic amenorrhea. This is a condition in which menstruation stops due to a disruption in the communication within the hypothalamic-pituitary-ovarian axis. This causes anovulation and loss of menstruation. Hypothalamic amenorrhea occurs as a result of insufficient energy intake , excessive exercise, or other forms of stress . ( 3 ) Due to anovulation, a larger number of follicles can then 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 usually lower or at the lower end of the range compared to the hormonal profile of PCOS. ( 4 )

After HAK withdrawal

Although this type is one of the four main types of PCOS, even this diagnosis can be somewhat misleading. Birth control pills (or other forms of hormonal contraception) suppress ovulation and suspend endogenous hormones . ( 5 ) Some women, due to previous use of birth control pills, do not ovulate for several months after stopping them. PCOS that occurs after stopping hormonal contraception is often temporary, until the cycle stabilizes and the woman begins to ovulate regularly again.

Reasons for irregular menstruation after withdrawal:

1. Hypothalamic amenorrhea

The same goes for the loss of your period if you have just stopped taking hormonal contraception. In this case, we don't have to blame PCOS right away, but it could be hypothalamic amenorrhea. In order for your hormones to "activate" again after stopping birth control, they need the right fuel and lots of extra nutrients that the pills have broken down in your body while you're taking them. A small amount of food, a lack of vitamins and essential minerals, and too much exercise will only prolong the return of your period.

2. PCOS induced by pills

Discontinuing androgen-suppressing hormonal contraception can cause a temporary increase in these “male hormones,” which can lead to a diagnosis of PCOS. In addition, birth control often worsens insulin resistance and disrupts hypothalamic-pituitary-ovarian axis signaling, which can make it difficult to resume ovulation after discontinuation. If your periods were regular before you started taking hormonal contraception, it is very likely that you do not have true PCOS and your hormones will return to balance with proper support. ( 6 )

3. Real PCOS

If you were already dealing with problems related to your menstrual cycle, insulin resistance, and other symptoms of PCOS before starting hormonal contraception, it is likely that you may still have real PCOS after stopping it.

4: Thyroid dysfunction

The last of the selected causes of irregular cycles that can often confuse us when diagnosing PCOS is hypothyroidism, or reduced thyroid function. 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 tell if it’s PCOS or hypothyroidism? Although these two seemingly very different conditions have a lot in common, they share a lot in common. For example, they have more follicles, a very similar hormonal profile, and a metabolic state. While in PCOS, follicles are unable to grow and mature properly due to high levels of androgens, in hypothyroidism, hormonal changes, specifically elevated prolactin levels, prevent ovulation , which can lead to polycystic ovaries. ( 8 ) Women with PCOS tend to have higher LH to FSH ratios, but a similar high ratio can also occur due to an autoimmune thyroid disease called Hashimoto’s. ( 9 )

Third, insulin and its production are also closely related to thyroid function. When thyroid dysfunction occurs, insulin resistance and high insulin levels can occur. ( 10 )

Sometimes the symptoms associated with PCOS can be the most telling. These include, for example, the aforementioned excessive hair growth, thinning hair, acne, or increased fat deposition in the abdominal area. In the case of reduced thyroid function, we will encounter significant fatigue, cold hands and feet, and an irregular heart rate.

As for the insulin resistance present, at that point it starts to get complicated because nothing in the body works completely separately . If insulin resistance results in high insulin levels, it can again affect the production of androgens and increase their production. And so we encounter a combination of hypothyroidism and PCOS .

The main intention of the article is not to confuse and scare you women even more about what is happening to you, but rather to show how complicated the diagnosis of PCOS can often be. And perhaps to convey a little optimism and hope that it may not actually be PCOS at all, and that hormonal contraception and medication may not be the only solution to get out of it all.

Do you want to know more about yourself and know 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, so you can rule out the possibility of hypothyroidism.

If you want a complete assessment of your health, 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 continuously support you to achieve results. Information on how the consultations work can be found here .

Was this article useful to you? Share it with your friends, maybe it will be useful to someone else.

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

*The consultation does not serve as a substitute for gynecological support and assistance. If you are experiencing any health problems, we recommend that you contact your doctor as soon as possible.

Sources used:

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