Diagnosis, Treatment and Management of PCOS

Melissa Nichols
Oct 5
4 min read

Polycystic ovary syndrome (PCOS) is a hormonal disorder with complex and heterogeneous causes, often resulting in metabolic, reproductive, and psychological symptoms. It affects an estimated 6-13% of women of reproductive age worldwide, requiring clinical diagnosis based on established criteria. Management is through a combination of medical and lifestyle interventions, each with specific benefits and risks.

Causes of PCOS

The exact cause of PCOS is not fully understood, but multiple factors are involved:

Insulin resistance: Elevates insulin and androgen production such as testosterone and DHEA, leading to ovulatory dysfunction.
Low-grade inflammation: Triggers excess androgen production, influencing ovarian function.
Genetics: Family history increases risk due to various gene loci linked to hormone regulation and insulin sensitivity.
Excess androgen: Ovaries produce elevated levels of male hormones, interfering with regular ovulation.

Symptoms of PCOS

PCOS manifests with a range of symptoms, often starting around the first menstrual period but may arise later:

Irregular or infrequent periods (oligo-amenorrhea)
Excess facial/body hair (hirsutism)
Severe acne
Male-pattern baldness or hair thinning
Polycystic ovaries on ultrasound
Weight gain and insulin resistance
Skin darkening (especially neck, armpits, groin)
Infertility
Psychological issues such as depression and anxiety.

Diagnosis of PCOS

PCOS is clinically diagnosed using the modified Rotterdam criteria, requiring at least two of the following, after excluding other causes:
- Clinical or biochemical hyperandrogenism (elevated androgens, hirsutism)
- Evidence of ovulatory dysfunction (infrequent or absent periods)
- Polycystic ovarian morphology (≥20 follicles per ovary, increased ovarian volume) on ultrasound.
Blood tests:

Test	Lab Value
Blood Sugar markers	Glucose tolerance, fasting insulin, fasting glucose
Basic Hormone panel	Estradiol, testosterone, androstenedione
Blood serum test	FSH, LH, SHBG, prolactin, TSH
Adrenal stress index (ASI)	17-hydroxyprogesterone, DHEAs

Drug Treatment for PCOS: Benefits and Risks

Hormonal Contraceptives: Regulate menstrual cycles, reduce androgens (acne, hirsutism), and protect against endometrial cancer. Risks include potential side effects (weight gain, mood changes, rare thromboembolism).
Metformin: Improves insulin resistance and regularity of the menstrual cycle. Benefits include a reduced risk of diabetes; potential risks include gastrointestinal side effects, such as nausea and diarrhea.
Ovulation Induction (Letrozole, Clomiphene): Used for infertility—effective in inducing ovulation but may carry risks of multiple pregnancy, ovarian hyperstimulation.
Anti-androgen Therapy (spironolactone): Reduces hirsutism and acne, but is not used alone due to risks of congenital disabilities, so must be combined with contraception.
Weight Management Medications (Semaglutide, others): May reduce weight and improve symptoms; long-term safety and effectiveness are still under evaluation.

Diet and Lifestyle Changes for PCOS

Dietary Approaches: (See Workshop of Understanding Nutrition for a Healthier You)
- Focus on vegetables, whole grains, nuts, legumes, and healthy fats
- Protein 1-1.2g/kg in weight per day
- Diets higher in fiber (~25g per day)
- Eat meals with a low glycaemic index to regulate blood sugar
Physical Activity and Weight Loss:
- Regular exercise, at a minimum of 30 minutes a day, reduces insulin resistance, improves weight, and increases the chances of regular cycles and ovulation.
- Even modest weight loss is strongly linked to improved symptoms and a reduced risk of diabetes.
Behavioral modifications:
- Stress management: Meditation or breath work
- Sleep with blackout curtains and stay away from electronics 30 minutes before bed
- Get 10 minutes of sunlight each morning

Vitamins and Herbs for PCOS

Vitamins, minerals, and herbs should always be discussed with a healthcare provider before use.

Chromium- helps regulate glucose and insulin metabolism by enhancing insulin sensitivity and reducing inflammation. Risks: Long-term use may harm the kidneys and liver.
Berberine -(similar effects to Metformin) improves insulin sensitivity, lowers testosterone levels, and supports healthy lipids. Risks: GI upset (nausea and cramping), low blood pressure, potential interactions with other meds, such as diabetic meds. Safety in pregnancy and lactation is not thoroughly studied.
Saw palmetto- blocks conversion of testosterone to DHT (a more potent androgen), modulates hormone metabolism. May help balance testosterone. Risks: headache, nausea, dizziness, bleeding risk, and theoretical concerns for hormone-sensitive cancers like breast cancer. Not for pregnant/nursing women or people with hormone-related cancers.
Reishi- an adaptogen that modulates the immune system, reduces inflammation, and may support stress resilience. Risks: Allergic reactions, possible digestive upset, and rare liver toxicity with prolonged or excessive use. Drug interactions are possible.
Meadow root- mild anti-inflammatory and diuretic. Risks: Allergic reactions (esp. with aspirin allergy), stomach upset, bleeding risk (esp. with anticoagulants), not for pregnancy.
EPA/DHA combination- Omega-3 fatty acids reduce inflammation, improve lipid profile, and may lower androgen levels. Risks: stomach upset, bleeding risk at high doses, caution if allergic to fish/shellfish.
Vitamin D (tends to be low in PCOS)- improves insulin sensitivity and ovulation function. Risks: Toxicity at very high doses- possible kidney injury.
Magnesium – helps with sleep, mood, and inflammation. Supports energy metabolism, insulin action, and nervous system function. Risks: diarrhea at high doses, caution with renal dysfunction (risk of accumulation).
Myo-inositol is a natural sugar alcohol that plays a role in cellular signaling and metabolism. Helps improve insulin sensitivity and regulate menstrual cycles. Risks: few side effects at standard doses. Very high doses may cause mild GI discomfort. Do not take long-term.