PCOS goes undiagnosed in 70% of women who have it, and it often misunderstood by health professionals. A clear understanding of the drivers is key to identifying the types of PCOS and makign a successful treatment plan. Whether you’re newly diagnosed or simply looking to learn more, knowing how PCOS manifests and the factors that contribute to it can help you make informed decisions about your health. 

What is PCOS?

PCOS stands for Polycystic Ovary Syndrome. Cysts are small sacs in your ovaries that contain immature eggs that were not released, usually due to a hormonal imbalance. You don’t have to have ovarian cysts to have PCOS, but it is a common sign. There are different types of PCOS based on the cause of your symptoms, so testing is usually needed to determine what type of PCOS you have. 

PCOS is most often diagnosed in those assigned female at birth (AFAB) in their 20s or 30s, but it can show up as soon as menstruation begins. 

Signs and Symptoms of most types of PCOS 

There are several ways to diagnose and classify PCOS. Many doctors use the “Rotterdam Criteria,” which stipulates that you must have two of these three symptoms to be diagnosed with PCOS: 

1. High levels of androgen hormones like testosterone
2. Disturbances in the length of your menstrual cycle and/or missed periods
3. Ovarian cysts that can be seen with an ultrasound

While this can be helpful for initial diagnosis, it fails to answer the question of why you are experiencing symptoms and how they can be treated.

There are lots of ways that PCOS can manifest, so it’s important to collect as much information as possible to make an accurate diagnosis and start treating the root cause of your symptoms. 

Long or Irregular Cycles 

The most common indicator of PCOS is irregularity in the length and schedule of your period cycles. About 85-90% of people with long cycles (35+ days from the start of your period to the start of the next) have PCOS. This is highly influenced by your hormonal balance.  

People with PCOS also tend to have more severe PMS symptoms leading up to their period, like severe cramping, breast tenderness, heightened appetite, fatigue, and significant mood swings.

We would assess things like; how long menstruation usually lasts, the amount of time between periods, if your periods come at regular intervals, and what symptoms you experience leading up to your period. 

Imbalanced Hormone Levels

Our bodies maintain a delicate balance of hormones that shifts throughout the stages of menstruation, but disruptions in non-cyclical hormones like cortisol or TSH can also contribute to imbalances that can indicate PCOS. 

Cyclical Hormones fluctuate as you move through the stages of your menstrual cycle.

• Androgens are the male sex hormones, including testosterone, DHEA, and its precursors. Androgens tend to be high in individuals with PCOS. 
• Estrogen to Progesterone Ratio – The level of estrogen or progesterone alone is not typically a problem; it’s the ratio of estrogen to progesterone. Too little progesterone compared to estrogen can produce a condition called Estrogen Dominance, which mimics symptoms of menopause or PMS. 
• Luteinizing Hormone to Follicle Stimulating Hormone Ratio – These hormones are produced by the pituitary gland. Too much Leutinizing Hormone compared to Follicle Stimulating Hormone can prevent ovulation in people with PCOS. 

Non-Cyclical Hormones

• Thyroid Stimulating Hormone is what causes your thyroid gland to produce hormones, which help regulate your metabolism. Individuals with PCOS may have high TSH levels, indicating an underactive thyroid. 
• Insulin is the hormone your body uses to convert sugar from your blood to sugar usable by your tissues. People with PCOS often have high levels of insulin without the body reacting appropriately, resulting in insulin resistance. High levels of insulin also increase testosterone levels. 
• Cortisol is your stress hormone. While it’s sometimes portrayed negatively on social media, cortisol is a necessary hormone, and too much or too little can affect your metabolism, skin, digestion, and more. People with PCOS tend to have alterations in their levels of cortisol.
  • Altered cortisol levels can cause chronic inflammation, a driver of other negative symptoms and disease manifestations in the body. 

We assess levels of the above hormones using blood tests and metabolic panels to establish what imbalances may be causing your PCOS. 

Physical Signs of most types of PCOS

Hormonal imbalances can manifest as physical signs on our bodies as well. Excess androgenic hormones are often associated with severe acne, coarse hair growth on the face, chest, or back, darkened skin in body creases (like the armpits), hair loss, and unexplained weight gain. 

Obesity and unexplained weight gain are bidirectionally related to PCOS. Weight gain can be a cause of PCOS because it creates insulin resistance and hormonal imbalances, increasing symptom severity and androgen levels. On the other side of the equation, PCOS itself can lead to weight gain that is caused by hormonal imbalances, so it’s a self-perpetuating cycle. 

Be sure to tell your provider if you’re experiencing any of the above symptoms, which will help inform your diagnosis.

Health and History

Other indicators of PCOS can be harder to detect, because hormones influence nearly every system in your body. These imbalances can lead to various symptoms that aren’t immediately obvious.

While hormonal imbalances can cause or worsen inflammation, inflammation itself can also be a huge contributor to the development of PCOS. Chronically increased levels of inflammatory markers–called cytokines–disturb regular ovarian activity, leading the the dysfunctions that define PCOS. This shows us that chronic inflammation is a factor in the development of PCOS, and it should be taken into account when developing a treatment strategy. 

Some signs of chronic inflammation are persistent fatigue, body pain or joint stiffness, digestive issues like bloating or diarrhea, skin conditions such as rashes or acne, and frequent infections due to a weakened immune response. Inflammation can also lead to mental symptoms like brain fog, mood disturbances, or depression.

Independent of inflammation, many individuals with PCOS experience mental health symptoms like depression, anxiety, fatigue, sleep disturbances, and brain fog. This may be linked to your hormonal imbalances or underlying causes of your symptoms, like obesity. Insulin resistance and higher androgen hormone levels–both symptoms of PCOS–can heavily influence your mood and cognitive function. 

Knowing what medications you take regularly can influence the way your PCOS presents. If you are on or have been on any of these medications, let your provider know. 

• Hormonal Birth Control
• Steroid Medications 
• Anti-Sezure Medications 

PCOS can also be influenced by your genes, so if a close relative has PCOS, you may be genetically predisposed to developing the condition. With a full picture of your health, history, and lifestyle, we can begin to understand what type of PCOS you are affected by and how it should be treated.

Types of PCOS

There are a couple of PCOS classification systems used by different types of health and wellness professionals, but we will focus on the functional medicine classification system. This includes: 

Insulin-Resistant PCOS is the most common type of PCOS and is usually accompanied by diabetes or high body weight.

Treatment priorities are: Re-establish healthy insulin sensitivity with diet modifications, supplements, and herbs. 

Post-Pill PCOS is usually a temporary state as your body readjusts your hormonal balance without the help of birth control.

Treatment priorities include: Reduce the body’s production of luteinizing hormone with a custom herbal formula. 

Inflammatory PCOS is caused by a compromised immune response due to stress, poor gut health, or environmental toxins.

Treatment priorities: Assess your diet and lifestyle to reduce exposure to toxins and inflammatory substances, reduce immune activation, improve gut permeability, and rebalance hormones. 

Adrenal PCOS is driven by alterations in androgen hormones coming from the adrenal glads that disrupt ovulation.

Treatment priorities: Focus on lowering cortisol levels through adequate sleep and stress management. We would also work to reduce the androgen DHEA—produced by the adrenal glands—using herbs, nutraceuticals, and, when necessary, pharmaceuticals.

Your experience of ovulatory dysfunction may comprise of a mixture of the above drivers. Based on what endocrine patterns you have, we can construct a tailored treatment plan that addresses the underlying cause of your symptoms. 

Taking all of the risk factors and indicators into account, it always comes back to the idea of homeostasis–bringing your body into balance. Whether it’s your hormones, inflammation levels, or underlying conditions, the goal is to restore equilibrium so your body can function optimally. By understanding the risk factors, symptoms, and root causes of your PCOS, we can take meaningful steps toward addressing imbalances and improving your health.

References

1. Andrisani, Alessandro, Maria Cristina Nesci, Ludovico Muzii, Giacomo Corrado, Francesco Palla, and Gabriele Saccone. “Polycystic Ovary Syndrome and Insulin Resistance: A Risk for Pregnancy and the Reproductive Period.” Diagnostics 12, no. 8 (2022): 1922. https://www.mdpi.com/2075-4418/12/8/1922.
2. Zhang, Fan, et al. “Recent Advances in Pathogenesis and Emerging Therapeutic Targets of Polycystic Ovary Syndrome.” Journal of Clinical Endocrinology and Metabolism 2022 (2022): 9240569. https://onlinelibrary.wiley.com/doi/full/10.1155/2022/9240569.
3. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. “Revised 2003 Consensus on Diagnostic Criteria and Long-Term Health Risks Related to Polycystic Ovary Syndrome (PCOS).” Archives of Gynecology and Obstetrics 302, no. 6 (2020): 1197–1204. https://link.springer.com/article/10.1007/s00404-020-05951-2.
4. Teede, Helena, et al. “The International Evidence-Based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (PCOS).” Gynecological Endocrinology 37, no. 6 (2021): 495–504. https://www.tandfonline.com/doi/abs/10.1080/09513590.2021.1908254.
5. Centers for Disease Control and Prevention. “PCOS (Polycystic Ovary Syndrome) and Diabetes.” CDC. Accessed October 11, 2024. https://www.cdc.gov/diabetes/risk-factors/pcos-polycystic-ovary-syndrome.html
6. Ibrahim, Ayah E., et al. “Microbiome in Polycystic Ovary Syndrome: Pathophysiology and Therapeutic Insights.” Frontiers in Endocrinology 13 (2022): 1017468. https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2022.1017468/full.
7. World Health Organization. “Polycystic Ovary Syndrome.” WHO. Accessed October 11, 2024. https://www.who.int/news-room/fact-sheets/detail/polycystic-ovary-syndrome
8. Palomba, Stefano, et al. “PCOS: A Syndrome of Misunderstood Endocrinology.” Journal of Clinical Endocrinology and Metabolism 102, no. 3 (2017): 785–800. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5542050/.
9. Azziz, Ricardo, et al. “PCOS, Infertility, and Insulin Resistance.” Journal of Clinical Investigation 131, no. 1 (2021): e141785. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11191327/