Polycystic ovary syndrome (PCOS)
PCOS is the commonest hormonal disorder in women of reproductive age. The ovaries release an egg rarely and unpredictably, and the body makes more male…
On this page
- Three features, of which two are enough
- Why ovulation goes wrong
- Which tests are needed, and when
- What else produces the same picture
- What changes the course apart from medicines
- Medicines and what to expect from them
- Pregnancy: when it is wanted and when it is not
- What is worth watching over the years
- Online consultation
Medicines commonly prescribed for Polycystic ovary syndrome (PCOS)
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 850 mgActive substance: metforminManufacturer: Sandoz Farmaceutica S.A.Prescription requiredDosage form: TABLET, 850 mgActive substance: metforminManufacturer: Uxa Farma S.A.Prescription requiredDosage form: TABLET, 1000 mgActive substance: metforminManufacturer: Galenicum Health S.L.U.Prescription required
PCOS is the commonest hormonal disorder in women of reproductive age. The ovaries release an egg rarely and unpredictably, and the body makes more male hormone than usual. That is where the disturbed cycle, the unwanted hair, the spots and the trouble conceiving come from. The name misleads: there are no cysts in the ovaries at all, but a crowd of small immature follicles, each holding an egg that never finished ripening. PCOS cannot be cured outright, yet almost every part of it can be managed, pregnancy included.
Three features, of which two are enough
The diagnosis is made when at least two of the three conditions below are met and other causes of the same picture have been excluded.
- Infrequent or absent periods. This is the outward sign that ovulation is not happening every cycle, or is not happening at all. Cycles longer than about six weeks, or fewer than eight or nine periods a year, are already worth investigating.
- Excess male hormone. It shows either in a blood test or in the woman herself: hair where there usually is none — above the lip, on the chin, around the nipples, down the midline of the abdomen, on the back; stubborn spots that do not settle by the end of adolescence; thinning of the hair along the parting and at the temples.
- A polycystic appearance of the ovaries on ultrasound — many small follicles and an increased ovarian volume. The follicle count that counts as the threshold depends on the resolution of the scanner, so the report is worth reading through with a doctor rather than off a single line.
Two consequences of this rule are often forgotten. First, the scan is not obligatory: if a disturbed cycle sits alongside signs of excess androgen, the diagnosis is already made. Second, the ultrasound picture on its own, with a normal cycle and no androgen signs, is not a diagnosis — such ovaries turn up in perfectly healthy women too.
Why ovulation goes wrong
PCOS has no single cause, but the mechanism is understood well enough to show what can be influenced.
The central link is the tissues' loss of sensitivity to insulin. To push glucose into the cells, the pancreas releases more and more insulin, and the excess drives the ovaries to make extra testosterone. Testosterone in turn stops the follicle maturing and releasing its egg: it halts halfway, stays in the ovary as a small sac, and such sacs build up.
From there a circle closes. Insulin also lowers the blood level of the protein that binds testosterone and holds it inactive, so more of the hormone circulates free even when the total is unchanged. At the same time the rhythm of signals from the pituitary is disturbed: disproportionately much luteinising hormone is released, spurring the ovary further.
Excess weight worsens all of this, because fat tissue sustains insulin resistance on its own. But PCOS also occurs at an entirely ordinary weight, and blaming everything on extra kilograms is wrong. Heredity matters too: if a mother or sister has the same complaints, the likelihood is higher. No single PCOS gene has been found; it is a sum of many weak influences.
Which tests are needed, and when
Testing has two jobs: to confirm the excess of androgens, and to rule out other illnesses that look the same.
- Hormone bloods — total testosterone and the protein that binds it, thyroid hormones, prolactin, and 17-hydroxyprogesterone. Best taken in the morning and in the first half of the cycle; if there are no periods, any day will do, but the doctor should be told.
- Pelvic ultrasound, when indicated rather than automatically. In girls during the first years after their first period, ultrasound is not used for the diagnosis: immature ovaries look polycystic without any disease at all, and irregular cycles at that stage are normal.
- Metabolic tests — fasting blood glucose in mmol/L or a glucose tolerance test, the three-month average glucose figure, cholesterol and its fractions, blood pressure and waist measurement.
One caveat matters. A normal testosterone result does not rule the diagnosis out: if a woman has clearly excessive male-pattern hair growth, that is enough as a feature even when the numbers on the form sit inside the reference range. The reverse holds as well — combined contraceptives lower the result, so a doctor will usually ask for a break before the test.
What else produces the same picture
PCOS is a diagnosis of exclusion. Before settling on it, a doctor rules out conditions treated in an entirely different way:
- thyroid disease — a disturbed cycle, weight gain, hair loss, tiredness;
- raised prolactin, including from a pituitary tumour — periods that stop, sometimes discharge from the breast and headaches;
- non-classical congenital adrenal hyperplasia — outwardly almost indistinguishable from PCOS, separated by the 17-hydroxyprogesterone level, and that changes both the treatment and the conversation about planning a pregnancy;
- Cushing's syndrome — purple stretch marks, a rounded face, weakness of the thigh muscles, bruising at the slightest knock, high blood pressure;
- premature ovarian insufficiency — flushes, dryness, a high follicle-stimulating hormone level;
- functional hypothalamic amenorrhoea — the cycle disappears against a background of severe food restriction, heavy training or intense stress; here androgens are not raised, and the treatment is restoring nutrition and reducing the load rather than giving hormones.
One rare but dangerous cause stands apart. If excess hair has appeared suddenly and is worsening over months, and along with it the voice deepens, muscle bulk increases, the clitoris enlarges and the hair thins in a male pattern, this is not PCOS. That is how a hormone-producing tumour of the ovary or adrenal gland behaves, and investigation cannot be put off. In PCOS the features build slowly, over years, usually starting back in adolescence.
What changes the course apart from medicines
This is not the generic advice to live healthily but the single most effective thing in PCOS, because it works on the cause rather than on one symptom.
Where there is excess weight, losing five to ten per cent restores ovulation and periods in many women, reduces hair growth and improves glucose readings. That is not much: at eighty kilograms it means four to eight. Chasing an ideal figure is unnecessary; what matters is that the result holds.
- Eating with less sugar and fewer refined flour products, and more vegetables, pulses, whole grains, fish and vegetable oils. There are no strict prohibitions and no separate PCOS diet.
- Regular movement, both endurance and strength work: muscle takes glucose out of the blood without needing insulin, which makes strength training particularly valuable here.
- Enough sleep — short sleep by itself worsens insulin sensitivity.
- Stopping smoking, which adds to a vascular risk that is already raised.
- Hair removal by whatever method suits you; for persistent hirsutism laser gives a longer-lasting result than shaving or waxing.
If weight loss does not come, this is not a dead end: part of the improvement comes from regular movement alone, even with no change on the scales.
Medicines and what to expect from them
Drugs are chosen for a purpose, not against PCOS in the abstract: one woman is treating spots, another needs her cycle back, a third is planning a pregnancy.
- Combined hormonal contraceptives are the mainstay when pregnancy is not being sought. They regulate the cycle, protect the lining of the womb, lower free testosterone and over time reduce spots and hair growth. The effect on hair is not visible before about six months.
- Cyclical progestogens or a hormone-releasing intrauterine system are the alternative when combined preparations do not suit. The aim is the same: not to let the womb lining build up for years without shedding.
- Metformin improves insulin sensitivity and helps the metabolic picture, especially when glucose is already disturbed. It does not act instantly and does not replace food and movement; nausea and loose stools are eased by building the dose up slowly.
- Anti-androgens — spironolactone, cyproterone acetate — are used for marked hair growth when contraceptives alone are not enough. They are dangerous to a male fetus, so they are only given alongside reliable contraception. Flutamide, which used to appear in this list, is now barely used because of severe liver damage.
- Topical treatments — a cream that slows facial hair growth (first changes at about six weeks; it does not remove hair), minoxidil solution for thinning scalp hair, and the usual acne treatments. None is used in pregnancy or while trying to conceive.
None of these cures PCOS — they hold the situation while they are being taken. After stopping, the earlier picture usually returns, and that does not mean the treatment was wrong.
Pregnancy: when it is wanted and when it is not
PCOS is among the commonest causes of difficulty conceiving and at the same time among the most treatable. Most women with the diagnosis do become pregnant, many without any stimulation at all.
When pregnancy is planned, the starting point is weight and metabolism, after which drugs are used to bring an egg to maturity and release it: letrozole is the current first choice, clomifene the second, and metformin is sometimes added. If tablets do not work, the next steps are injectable gonadotrophins under ultrasound monitoring and then in vitro fertilisation. The surgical option is laparoscopic ovarian drilling, spot cautery of the tissue that makes androgens, now used only rarely.
Stimulation carries its own danger — ovarian hyperstimulation syndrome. Seek emergency care if, after stimulation or egg collection, there is severe abdominal pain and bloating, unstoppable vomiting, rapid weight gain over a couple of days, a sharp drop in the amount of urine, or breathlessness. The other feature of stimulation is multiple pregnancy, which runs a harder course.
Pregnancy with PCOS needs attentive care: high blood pressure and pre-eclampsia, gestational diabetes, miscarriage and preterm birth are all more likely, which is why diabetes screening is arranged earlier than usual.
And the flip side, forgotten most often of all: ovulating rarely is not the same as being infertile. An egg can be released at any unpredictable moment, so if pregnancy is not wanted now, contraception is as necessary as it is for anyone else.
What is worth watching over the years
PCOS is not only about the cycle and the skin. It raises the likelihood of several conditions that develop slowly and give nothing away early on, yet respond well to early action.
- The lining of the womb. If periods are absent for years, the endometrium thickens without shedding, and over time that raises the risk of it turning malignant. Hence the rule: bleeding should happen at least every few months, either on its own or brought on with medication. See a gynaecologist if there have been no periods for more than three or four months, if bleeding has become very heavy or prolonged, if there is bleeding between periods or after sex, and always after any bleeding once the menopause has passed.
- Type 2 diabetes. Glucose is checked regularly, with the interval set by a doctor according to age, weight and previous results.
- Blood pressure and cholesterol. They are measured not because they cause trouble but because they stay silent until late.
- Breathing during sleep. Snoring with pauses, waking unrefreshed and daytime sleepiness are reason to be assessed for sleep apnoea, which is commoner in PCOS.
- Mood and the relationship with food. Anxiety, low mood and eating disorders are appreciably more common in PCOS than average. This is not a matter of character or a consequence of appearance; it is part of the picture, and worth raising with a doctor plainly.
With age, cycles settle for many women and hair growth becomes less obvious, but the metabolic risks do not go away by themselves, so follow-up is still worth continuing after the menopause.
Online consultation
An online appointment suits most PCOS questions: examination is rarely needed here, interpretation almost always is. A consultation can go through the blood results and the scan report and explain what they actually mean; set out a plan of investigation when the cycle has gone awry and the cause is unclear; work out which contraception fits your situation and over what timescale it acts; map the steps before trying to conceive; sort out side effects of treatment already prescribed; and give a clear answer on what in the vast literature about diet and PCOS has any basis.
A face-to-face visit is needed for the scan and examination, and signs of ovarian hyperstimulation or heavy bleeding call for emergency care rather than a message.
This material is for information only and does not replace medical advice.
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