Comparison of normal ovary and polycystic ovary.
The Flex guide to polycystic ovary syndrome (PCOS)
What is PCOS? Everything you need to know
TL/DR: PCOS stands for polycystic ovary syndrome. It’s one of the causes of irregular periods and can also lead to problems with fertility. Fortunately, it is treatable and there are an array of medical options, as well as lifestyle modifications, that can help with symptoms.
Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders among people with uteruses, with an estimated prevalence (i.e. proportion of the population that is affected) that ranges from six to ten percent.1
PCOS is a complex condition that is thought to be due to a combination of genetic and environmental factors. Hence, the name: PCOS is a “syndrome,” which means that it’s characterized by a constellation of signs and symptoms that will vary from one person to another.
Of course, being a “syndrome” doesn’t mean PCOS is any less difficult or painful to deal with than other diseases of the reproductive system. And, for some, it can be frustratingly difficult to treat (and even more annoying to live with, especially during your period).
Maybe you’re curious about what PCOS really entails – or maybe you’ve even received a diagnosis of PCOS from your provider. Either way, you’re in the right place. Read on to learn more about how PCOS is diagnosed, its most common symptoms, and how it affects your period.
How is PCOS diagnosed?
PCOS is diagnosed based on having two out of three criteria, which are:
- Infrequent or absent ovulation,
- and/or the appearance of polycystic ovaries on ultrasound.2
The first of the three criteria – infrequent or absent ovulation – is especially characteristic of PCOS, and it’s often one of the symptoms patients notice earlier on thanks to irregular or missing periods. In someone with a regular menstrual cycle, ovulation will take place roughly halfway between the beginning of one menstrual period and the beginning of the next.
If you aren’t ovulating regularly, you won’t get regular periods – and if you aren’t ovulating at all, well, you may miss your period altogether. For those with PCOS, there are a few things going on at the molecular level that contribute to this failure to ovulate:
During ovulation, the ovary responds to hormonal stimulation and releases an ovum, or egg, which is ready to be fertilized by a sperm if present. Follicles usually house the developing eggs, preparing them for release. However, for people with PCOS, there is hormonal dysregulation present that impedes follicular development. No (fully developed) follicle, no egg, no period.
Moving on to the second criterion when diagnosing PCOS: hyperandrogenism. This long, scary-looking word isn’t as complex as it appears. It basically refers to the hormonal dysregulation we mentioned above – a.k.a. the reason your body isn’t able to properly develop an egg follicle.
So, what throws off the hormonal balance? Individuals with PCOS tend to have excess androgens in their bloodstream, the result of higher levels of ovarian androgen secretion. Androgens are steroid hormones that are present in biological males and, to a much lesser extent, in females (they’re commonly referred to as “male hormones”). The main circulating androgen is testosterone.
Androgens are thought to be the culprit to certain other symptoms of PCOS, such as excess hair growth. As such, many physicians will run tests to check androgen levels (and hormone levels more generally) as one of their first steps in diagnosing PCOS.
And the third criterion? This is the one that gives PCOS its name: the actual “polycystic-ness” of your ovaries. In simpler terms, it’s figuring out whether or not your ovaries have cysts – sac-like pockets of tissue – dotting their surface.
When follicular development is impaired, the dominant follicle that usually emerges to produce and release an egg may not be “selected” by your body to do the job. This means that, instead of one dominant follicle, there may be several smaller follicles that end up partly forming and then fusing together, creating a cyst.
Ultrasound is usually the simplest way for your provider to get a visual of your ovaries. This imaging modality is painless and widely accessible, offered at many outpatient practices and clinics.
According to the Rotterdam criteria, you need two out of the three “pieces of evidence” we touch on above (infrequent or absent ovulation, hyperandrogenism, and/or the appearance of polycystic ovaries) to be diagnosed with PCOS. Keep in mind that these guidelines may differ depending on your healthcare institution, practice, or provider.
Polycystic ovary syndrome symptoms & how to deal
What are the symptoms of PCOS? There are quite a few, including the period irregularities we mentioned above and other symptoms related to excess androgens in the bloodstream. Here are some of the most common:3
- Menstrual irregularities, including infrequent or absent menstrual periods
- Menorrhagia, or heavy menstrual bleeding when there is a period
- Excess hair growth on regions such as the face, chest, and arms
- Hair loss and/or male-pattern baldness
- Weight gain
- Insulin resistance
- Sleep apnea
- Difficulties becoming pregnant or infertility
People with PCOS often notice the changes in their period early on, especially if they had a normal period prior. Changes in the number or length of the period, multiple skipped periods without a pregnancy, or heavy menstrual bleeding can all indicate that there is an issue with ovulation, which could be part of PCOS.
A quick but important reminder: You should always listen to your body and feel comfortable contacting your healthcare provider whenever you notice a change in your menstrual cycle – especially when this change becomes a pattern.
If you have noticed that you do have some of the other symptoms listed above, such as a recent increase in the severity of your acne or hair growth in areas where you previously had none, take note of them! Jot down dates in your phone or keep a journal; that way, you’ll be armed with specifics when you bring it up to your provider.
Coping with PCOS symptoms: Diet, exercise, & lifestyle adjustments
Dealing with PCOS can be difficult, especially as many of the symptoms are all-encompassing. The missed or irregular periods are stressful and the pain can be overwhelming when a period finally does arrive – not to mention the super-heavy bleeding and constant fear of leakage, even on “light” days.
Thankfully, and despite the fact that there is no single “cure,” PCOS is treatable. There are a number of medication therapies available to manage the condition and minimize symptoms, including certain hormonal contraceptives, fertility-boosting interventions for individuals struggling to conceive, and metformin, a drug that helps those with insulin resistance (which commonly occurs alongside PCOS).4
Lifestyle changes can also make a huge difference in mitigating PCOS symptoms. PCOS is more common in overweight individuals; excess weight may be partially hereditary or attributable to lifestyle factors.
Optimizing your diet and exercise routine around your body’s unique needs, especially when it comes to balancing hormones, can have a big impact on the severity of PCOS. A nutritious diet that is high in lean protein, low in fat, and minimizes your intake of “empty” carbohydrates (like white bread, french fries, candy, soda, and sweets) is a good place to start.
Remember: You don’t need to completely overhaul your diet or workout routine overnight. Take little steps, practice them consistently, and reward yourself for the progress you make. Even efforts as simple as swapping out your daily caramel latte for a black coffee or doubling your portion of leafy greens at dinner will pay off hugely in the long run.
The same goes for exercise: Start by parking your car at the back of the grocery store lot so you get some extra steps in, go on a walk with your partner or a friend instead of watching TV, or find a 10-minute YouTube workout class and tackle it during your lunch break.
Some nutritionists recommend the DASH Diet for people with PCOS, which provides specific recommendations for the portions of various food groups to eat per day to maximize cardiovascular health.5 However, finding a diet that works for you as an individual is key. A diet or weight loss plan that worked for a close friend – or even your parent or sibling – might not work for you, and vice versa.
You can also take a sort of reverse-engineered approach, keeping a symptom diary to identify the lifestyle triggers that make your PCOS feel worse. Each day, log your meals, exercise, sleep, and symptoms. Over time, you’ll start to pick up on certain patterns: Maybe your acne goes into overdrive when you eat too much cheese, or red meat seems to trigger unbearable cramps around your period. Having a record of these things in writing will make it easier to create (and stick to) new, healthier habits.
Gradual, sustained weight loss may help with the metabolic components of PCOS, like insulin resistance. It may also improve other symptoms, like stubborn acne. If you have the resources to do so, try to work closely with a healthcare provider or nutritionist when creating a weight loss plan. Having someone else there to monitor your progress, customize your routine, and offer support will make it easier to maintain your results long-term.
PCOS & periods
Let’s recap: Polycystic ovary syndrome, a.k.a. PCOS is thought to be caused by a hormonal imbalance that results in higher levels of androgens (“male hormones”) in the bloodstream. This androgen-heightened state, through a series of chemical reactions that are a bit too complex to explain in detail here, ends up impairing follicular development.1
This means that, instead of one dominant follicle that develops and supports the growth of an ovum, or egg, your body tries to develop multiple follicles that never quite get there. These multiple follicles clump together in the ovary, forming polycystic ovaries. In PCOS, there can be more than 20 follicles found in the ovary at any given time.2 This decreased or even absent ovulation can eventually progress to infertility.
In the early stages of PCOS, people will often notice changes in their menstrual cycle. Specifically, they may not have a period or may skip periods with no apparent rhyme or reason. The periods themselves may also be shorter or longer than that person’s “norm,” and the first period after a skip may also be heavier, as the endometrium has more to shed. Any irregularity in your menstrual cycle should be brought up with your healthcare provider ASAP.
If you’re struggling with heavy periods as a result of PCOS, it may be helpful to switch up your period product. Tampons and pads can only hold a maximum of 12-15 mL of fluid. Menstrual cups and discs, on the other hand, can hold up to 30 mL (about 6 teaspoons) of period blood, meaning less-frequent changes and fewer leaks to contend with.
If cramps are a problem, menstrual discs like Flex Disc may also offer some relief. Since discs sit in the widest part of the vaginal canal – the vaginal fornix – and collect (rather than absorb) blood, they don’t apply the same constant pressure to your vaginal walls that a tampon does. Flex Disc is also super flexible, moving with your body as it contracts and therefore easing cramps.
If you’re concerned you might have PCOS but don’t yet have a diagnosis, make an appointment with your provider. And before you jump to any conclusions, check in with yourself: Has your diet or exercise routine changed drastically? Did you switch your birth control method? Are you in the middle of a stressful time? Each of these factors (among many others) can affect your menstrual cycle, so any deviation from your norm doesn’t necessarily point to PCOS.
PCOS & fertility
Now that you know how PCOS can impact the menstrual cycle, it’s not surprising to learn that the condition can also impact fertility. Recalling your high school biology class… in a healthy individual, ovulation takes place when the mature ovum is released from the ovary and is able to be fertilized by a sperm cell that has made it upstream. This results in fertilization, the creation of a zygote, and thus a pregnancy.
However, with PCOS, ovulation is irregular or, at times, completely dysfunctional (meaning there is no egg released from the ovary). Even when an egg is released, the reproductive milieu is impacted such that miscarriage rates are higher among people with PCOS as compared to the general public.3 The miscarriage and infertility risks that come with PCOS are a heavy emotional burden and can make living with this disease very difficult for patients.
Fortunately, there are treatments that may help to regulate the menstrual symptoms of PCOS and thus regulate ovulation. These will usually take the form of combined estrogen-progestin oral contraceptives, although other options may be presented by your provider depending on your health history.6 Consistent contraceptive therapy can help to re-regulate the hormonal balance, leading to a more regular cycle.
Along with that, if you are interested in becoming pregnant, there are ways for providers to support that decision with additional ovulation induction-type therapies. It is absolutely possible to become pregnant with PCOS: An early diagnosis and commitment to treatment, alongside compassionate providers, are perhaps the best ways to boost your odds.
PCOS & mental health
It’s so important to mention that many symptoms of PCOS not only impact your physical health but also your mental health. It can be difficult to go through a painful and unpredictable menstrual cycle, and coupled with other symptoms – like acne, sleep apnea, and unexpected hair growth – it’s not surprising that PCOS brings with it a psychological burden.
Knowing this, if you are struggling with PCOS and its symptoms, you may benefit from a treatment approach that addresses both the mental and physical effects of the condition. Consider joining a PCOS peer support community: These serve as a safe space to discuss symptoms, thoughts, and feelings with others who know exactly what you’re going through. There are many online forums and communities; you can also ask your provider for recommendations.
If you have the resources to do so, it may also be helpful to work with a therapist who specializes in chronic illness. The Psychology Today website has a fantastic search feature that allows you to look up therapists in your region – plus, you can filter by specialty, accepted insurance, gender, and type of therapy. Many therapists accept sliding-scale pay or less expensive group sessions, both in-person and online.
On a different-but-related note, journaling is an excellent tool for navigating chronic illness, especially if you are unable to work with a therapist (but try it in addition to therapy, if you can!). Use it to track your symptoms and vent about them, write about how you got through a particularly painful period, or jot down tricks or strategies that made an immediate positive impact on your day.
PCOS can be very difficult to live with, but its symptoms are, fortunately, treatable. By recognizing the signs and symptoms early and linking with a provider who can partner with you on your care journey, you’ll set yourself up for the best possible outcome.
- PCOS is an endocrine-metabolic condition that is characterized by a hyperandrogenic state, irregular or absent ovulation, and the presence of polycystic ovaries on imaging
- The symptoms of PCOS are menstrual changes, including irregular periods, along with an array of symptoms that include excess hair growth, male pattern baldness, acne, and metabolic changes
- Fortunately, PCOS is completely treatable with hormonal medications otherwise known as oral contraceptives, certain treatments for insulin resistance, as well as supportive care
- Lifestyle changes like diet and exercise modifications can also help with the severity of symptoms
- Changing up your period product may be helpful for those with PCOS struggling with especially heavy or painful periods – menstrual cups and menstrual discs hold up to 3x as much blood as pads or tampons
- Focusing on whole-body wellness is key for people experiencing PCOS