What Is Polycystic Ovary Syndrome (PCOS)?

Polycystic ovary syndrome (PCOS) is a hormonal condition that affects the female reproductive organs. The condition occurs when the ovaries make more androgens (the male sex hormone) than it needs to. Researchers do not know the exact cause of PCOS. However, a combination of genetic factors, hormone levels, and insulin resistance may raise your risk of developing the condition.

In the United States, PCOS affects about 6% to 12% of people with ovaries. People with the condition can experience a host of symptoms including infertility, excess hair growth, severe acne, oily skin, and obesity. Unfortunately, there is no cure for PCOS yet. Therefore, the goal of treatment is to help reduce symptoms.

Types of PCOS

Researchers have identified several types of PCOS: insulin-resistant, adrenal, inflammatory, and post-pill PCOS. The type of PCOS you have will depend on which factors are causing the condition.

Insulin-Resistant PCOS

Insulin-resistant PCOS is one of the most common types of PCOS, affecting as many as 70% of people with the condition.

Insulin-resistant PCOS happens when your cells don’t respond to insulin. Insulin is a hormone that regulates glucose, or your blood sugar. When working properly, insulin helps turn the sugar from your food into energy or stores it for energy later. But with insulin resistance, your body isn't able to use the sugar as energy, so it builds up in your cells and causes high blood sugar. As a result, your insulin level can increase, causing PCOS-related symptoms.

Adrenal PCOS

Research has found that adrenal PCOS happens when the adrenal glands (which are located on top of your kidneys) make too many hormones. Typically, the adrenal glands make hormones like cortisol (the stress hormone) and norepinephrine (adrenaline). When your adrenal glands make too many hormones, you may be at risk for higher androgen levels, which can produce PCOS symptoms.

In one study published in the Journal of Clinical Endocrinology & Metabolism, researchers found that out of 38 women with PCOS, 15 women made more adrenal hormones than usual. Roughly 10% of all people with PCOS have the adrenal type.

Inflammatory PCOS

People with inflammatory PCOS have chronic low-grade inflammation. This means that people with this type have high blood levels of C-reactive protein, a protein your liver makes when there's inflammation in your body. Inflammation can raise both your androgen and insulin levels, causing PCOS symptoms to occur.

Post-Pill PCOS

Oral contraceptive pills (e.g., birth control) can cause post-pill PCOS. Specifically, oral contraceptive pills manipulate estrogen and progesterone hormones to prevent pregnancy. In some cases, when you stop taking those pills, your ovaries may make more androgen than usual. Those high androgen levels cause PCOS symptoms, like acne, irregular periods, and excess hair growth.

Symptoms

PCOS symptoms can sometimes be easy to miss. In fact, some people may not know they have PCOS until they regularly miss their periods or cannot become pregnant after one year of trying to conceive. With the condition, you may experience symptoms such as:

• Irregular menstrual bleeding: Normally, periods happen every 24–38 days. During this time, you lose two to three tablespoons of blood. But with PCOS, you may have heavy menstrual bleeding and need to change your pad or tampon every one or two hours. You might also experience anovulatory periods, which occur when you have menstrual bleeding without ovulating. In some PCOS cases, you might not have any periods at all, which is a condition known as amenorrhea.
• Infertility: PCOS is one of the most common causes of anovulatory infertility (a type of infertility that occurs when you don't release an egg during menstruation, which is supposed to happen during ovulation). In fact, as many as 80% of people with infertility have this type. Among people with PCOS who are able to become pregnant, the risk of complications (e.g., miscarriage) is higher than average.
• Pelvic pain: One study published in Health and Quality of Life Outcomes, which looked at 20 women with PCOS, found that 70% of women reported cramping. The researchers found that cramping may occur with or without menstrual bleeding.
• Hyperandrogenism: This happens when the body makes more androgens than it needs to. High androgen levels can cause hirsutism, or excess hair growth. You might notice hair growth on your face, chest, stomach, or thighs. It's possible to also experience severe acne and oily skin.
• Obesity: PCOS can cause weight gain, typically around the waist. You might also have trouble losing weight.
• Acanthosis nigricans: In some cases of PCOS, you might have this symptom which causes thick patches of skin that appear dark and velvety. Generally, these patches appear in areas where your skin folds, such as your neck, groin, armpits, or breasts.

Causes

PCOS occurs when the sex hormones are out of balance. Usually, the ovaries make both estrogen and androgen. However, people who are assigned female at birth need more estrogen and less androgens than those assigned male at birth. With PCOS, people with the condition instead have high androgen levels and low estrogen levels. 

High androgen levels can prevent ovulation from occurring. When ovulation does not happen, the ovarian follicles that grow and mature your eggs are unable to release the eggs. Instead, the eggs will grow inside the follicle, which can sometimes form an ovarian cyst.

Why this condition occurs is still a bit of a mystery to researchers—as experts have not yet understood the exact cause of PCOS. However, a combination of genetic and biological factors may raise your risk of developing the condition.

Risk Factors

You may be at an increased risk of PCOS if you have:

• A family history of the condition
• Obesity
• Insulin resistance
• High androgen levels

Diagnosis

If you have symptoms of PCOS or may be at a risk for developing the condition, it's a good idea to visit your provider to get tested. In particular, there are three symptoms that healthcare providers look for to diagnose PCOS. Those symptoms include:

• Anovulation (not ovulating)
• High androgen levels
• Cysts in the ovaries

Your provider may use several measures to learn about your symptoms and evaluate your condition during the diagnostic process. These tests may include:

• Learning about your medical history and current symptoms
• Performing a physical to evaluate symptoms
• Conducting a pelvic exam to examine the vagina and cervix to feel for any signs of a cyst
• Taking photos via ultrasound to take a closer look at your ovaries
• Ordering blood tests to check your androgen, insulin, and cholesterol levels

Treatment

Currently, there is no cure for PCOS. Instead, your provider can help you develop a treatment plan that works to reduce your symptoms and treat infertility. Your exact treatments will depend on the symptoms you have, your medical history, and the severity of your condition.

Lifestyle Changes

By some estimates, losing 5% of your body weight can improve PCOS symptoms. Therefore, your provider may recommend lifestyle changes such as:

• Eating a low-dairy, low-carb diet
• Getting regular exercise throughout the week
• Practicing stress management techniques that help you follow a new diet and exercise plan

Medications

Depending on the underlying cause of your PCOS, your provider can recommend one or more of the following medications:

• Oral contraceptive pills: Oral contraceptives (e.g., birth control) can help lower androgen levels, regulate periods, reduce acne, stop excess hair growth, and prevent pregnancy.
• Metformin: Metformin is an anti-diabetic medication that helps treat insulin resistance. This medicine can also reduce acne, improve periods, and regulate ovulation. Keep in mind: healthcare providers prescribe metformin for “off-label use.” As of 2023, the Food and Drug Administration has not approved metformin to treat PCOS.
• Anti-androgens: These medicines help stop your ovaries from producing androgens. They may also lower the effect of excess androgen hormone by reducing symptoms such as acne and hair growth. Similarly to metformin, healthcare providers prescribe anti-androgens for "off-label use." The FDA has not yet approved anti-androgens to treat PCOS.

Infertility Treatments

PCOS can cause infertility. If you are trying to get pregnant, your provider may first recommend lifestyle changes to treat infertility—such as eating certain foods or being physically active. However, if lifestyle changes don’t help, your provider may recommend:

• Serophene (clomiphene citrate): Helps the ovaries mature and release eggs during ovulation
• Glucophage (metformin): Restores ovulation after four to six months of use
• Femara (letrozole): Lowers estrogen levels and signals the brain to make follicle-stimulating hormone (FSH)—a hormone that plays a key role in ovulation
• Gonadotropins: A group of hormone drugs that can improve ovulation 
• Ovarian drilling: A surgical procedure that destroys the part of the ovary that produces excess androgens 
• In vitro fertilization (IVF): A fertility treatment that involves mixing an egg and sperm in a petri dish outside of the body and later implanting the fertilized egg into the uterus

How To Prevent PCOS

Since PCOS can be genetic and many cases of PCOS run in families, there's no surefire way to prevent the condition. However, you can make certain lifestyle changes that could reduce your risk of developing symptoms or experiencing complications such as obesity, insulin resistance, or infertility.

Your provider can help you implement the prevention techniques that are right for you. Generally, they may recommend lifestyle habits such as:

• Eating a nutritious diet
• Following an exercise plan
• Taking supplements or medications that manage other conditions, such as diabetes
• Maintaining a weight that is best suited for your body

Comorbid Conditions

Sometimes, PCOS can co-occur with other health conditions—which are known as comorbid conditions or comorbidities. With PCOS, you may be at an increased risk for:

• Type 2 diabetes
• Obesity
• Heart disease
• Metabolic syndromes, such as high blood sugar, high cholesterol, and high blood pressure
• Depression
• Endometrial cancer

Living With PCOS

While there are several treatments that can help reduce symptoms, PCOS can interfere with your daily life and mental health. It's important to note that it's OK to feel however you're feeling about your symptoms and condition.

Aside from medications and other treatment options, you may find the following suggestions helpful for you:

• Seeing a mental health professional: Cognitive behavioral therapy (CBT) is a common technique that therapists use to help you improve body positivity and self-esteem. Additionally, therapy can help you navigate anxious thoughts and depressive moods—and learn coping skills for your physical and emotional symptoms.
• Treating acne and hair growth: Medications aren't the only way to help reduce symptoms or the appearance of unwanted acne and hair growth. Keep in mind: cosmetic changes are personal preferences. If you're looking for other treatments to help manage symptoms, ask your provider about antibiotic creams and retinoids for acne or safe hair removal options for you.

While symptoms may feel hard to manage, it's important to keep in mind that with the right treatment and lifestyle plan, people with PCOS continue to live happy and healthy lives.