PCOS: understanding diagnosis and modern management

For years you were told your acne came with your age, your erratic cycle with stress, and your weight with a bit of discipline. Only when someone laid the complaints side by side did the penny drop: maybe these all belong together. PCOS (polycystic ovary syndrome) is the most common hormonal condition in women of reproductive age. Roughly 1 in 10 women have it, and a large share do not know.

This is the overview article of our PCOS series. My take: no single symptom points to PCOS on its own, and that is precisely why it often stays unnoticed for years. A few blood values usually give a first direction. Below you read what PCOS is, which symptoms fit it, what the cause is, how the diagnosis is made and which hormones you can have tested.

What is PCOS?

PCOS is a hormonal condition in which ovulation often fails to happen and your body makes relatively many male hormones (androgens). Despite the name, not every woman with PCOS has visible cysts on the ovaries. It is about a combination of complaints, not one abnormality.

The name is actually misleading. Those small follicles on an ultrasound are not real cysts, but immature egg follicles that have stalled. In many women with PCOS you see them, in some you do not. That is why you can have PCOS with completely normal-looking ovaries.

What are the symptoms of PCOS?

The symptoms revolve around three themes: a disrupted cycle, signs of too many androgens, and metabolic complaints. Not every woman has everything. One mainly notices an irregular period, another mainly acne or hair growth.

• An irregular, long or absent period (fewer than 8 times a year)
• Acne or oily skin that does not respond to ordinary products
• Excess hair growth on the face, belly or chest (hirsutism)
• Thinning scalp hair, especially at the crown
• Weight gain or difficulty losing weight around the belly
• Difficulty conceiving

Many of these complaints also fit other causes. An irregular period can also belong to a thyroid problem or stress, for example. That is precisely why a symptom alone says little, and a blood value only gives direction. Also read our article on hormonal imbalance and the symptoms if you are unsure where your complaints come from.

What causes PCOS?

The precise cause is not known. But three things almost always play a part: a hereditary predisposition, an increased production of androgens, and insulin resistance. The latter, a reduced sensitivity to insulin, seems to be the engine behind many complaints.

Insulin resistance means your body has to make more insulin to keep your blood sugar stable. That high insulin can push the ovaries to make more testosterone, and that disrupts ovulation. So the hormones keep each other in a vicious circle. PCOS therefore occurs more often in women who are overweight, although slim women have it too.

Heredity plays a clear role. If your mother or sister has PCOS, or if early cardiovascular disease or type 2 diabetes runs in the family, your chance is greater. That explains why PCOS often announces itself as early as puberty.

How is PCOS diagnosed?

PCOS is diagnosed using the so-called Rotterdam criteria. You receive the diagnosis if you have at least two of these three points, and other causes are excluded:

1. Irregular or absent ovulation: an irregular or absent period.
2. Too many androgens: visible (acne, hirsutism) or measured in the blood (raised testosterone).
3. Polycystic ovaries on an ultrasound: many small follicles.

Because two of the three criteria are enough, you can have PCOS without cysts and without visible acne. The GP usually starts with your story, a blood test and, if needed, an ultrasound. An important part is excluding other causes, such as a thyroid problem or a raised prolactin. The NHG and Thuisarts.nl describe this approach for Dutch general practice too.

Not everyone wants or can go to the GP straight away. At Lunara you can also have the relevant hormones drawn yourself, without a referral, as a starting point for a conversation. You then discuss an abnormal result with your GP.

Which blood values fit PCOS?

No single blood value proves PCOS on its own. But a few hormones together show a pattern that fits it. The table below links each symptom or criterion to the value that usually says the most about it, and to what that value shows.

The best moment to draw blood is usually in the first days of your cycle (day 2 to 5). If you have no or a very irregular period, blood can be drawn at any time, because then there is no fixed cycle to align with. This table is a tool, not a diagnosis. Which combination is worthwhile for you depends on your complaints.

Want a targeted test? The Women's Hormones panel measures testosterone, SHBG, LH, FSH and prolactin, among others, in one draw, so you get the whole pattern into view rather than one isolated number. In our separate article you can read more deeply which hormones to test for PCOS. If you want a panel built around the PCOS picture, look at the PCOS screening. If excess hair growth is what you recognise most, read on about PCOS and excess hair growth in hirsutism.

PCOS and conceiving

PCOS is one of the most common causes of reduced fertility, but it does not mean you cannot conceive. Because ovulation is irregular, it is harder to time. Many women with PCOS do conceive, sometimes spontaneously and sometimes with help.

An erratic cycle makes predicting your fertile days difficult. So it can help to map your hormones before you start. The Fertility Assessment looks at AMH, FSH and LH, among others. Also read which blood test is worthwhile when trying to conceive.

A high AMH is common in PCOS and means something different than in women without PCOS. It then points to many small follicles, not automatically to better fertility. So always discuss a result with a doctor.

Not every PCOS is the same: the four pictures

PCOS is not a one-size condition. Based on the Rotterdam criteria, doctors distinguish four pictures, depending on which combination of features you have. That explains why one woman mainly has skin complaints and another mainly an absent cycle, while both receive the same diagnosis.

• Picture A: irregular cycle, too many androgens and polycystic ovaries. Often the most pronounced, with the greatest chance of insulin resistance.
• Picture B: irregular cycle and too many androgens, without visible cysts on the ultrasound.
• Picture C: too many androgens and polycystic ovaries, but a reasonably regular cycle.
• Picture D: irregular cycle and polycystic ovaries, without clear signs of too many androgens.

Which picture fits you often determines where attention goes: with one picture mainly the metabolism, with another mainly the cycle or fertility. This is a tool to understand your situation, not a classification you can make yourself. A doctor assesses which picture fits based on your symptoms, your blood values and, if needed, an ultrasound.

PCOS in the long term: why staying watchful pays off

PCOS does not disappear, but it does change with your age. In your twenties and thirties the cycle and fertility are often central. After that, attention shifts to your metabolism and your cardiovascular health, because PCOS goes together with a higher risk of type 2 diabetes and a less favourable cholesterol profile.

That is why it can be worthwhile to periodically look beyond just your hormones. Values that often recur in that broader picture:

• Fasting glucose and, if needed, insulin, for signs of insulin resistance
• Your cholesterol and triglycerides, for your cardiovascular health
• Your blood pressure and weight, which the Voedingscentrum and the GP weigh in the overall picture

How often and what exactly is worthwhile differs per person and per life stage. The international ESHRE guideline advises looking at the metabolism regularly with PCOS, certainly with overweight or a burdened family. What suits you, you decide together with your GP.

What can you do yourself with PCOS?

PCOS cannot be cured, but the complaints can be influenced well in many women. Lifestyle is the first step that recurs in virtually every guideline, including the international ESHRE guideline for PCOS. Improving insulin sensitivity in particular seems to make a difference.

• Regular exercise, with attention to strength and endurance
• Food that keeps your blood sugar steadier, with fewer fast sugars
• A small weight loss, where there is room for it, can already improve the cycle
• Attention to sleep and stress, which influence your hormones too

Important: these steps do not replace medical treatment. Some women also need medication, for example to regulate the cycle or support fertility. What suits you, you discuss with your GP or gynaecologist.

Alongside your cycle complaints, are you also bothered by hair loss? Then also read which hormones to test for hair loss, because with PCOS testosterone often plays a part in it.

Testing PCOS via Lunara: how it works

You do not need a referral from the GP for a hormone test. You order online, schedule an appointment at a draw location near you and have blood taken in the morning. You receive your result digitally, usually within a few working days.

Every result gets context from a BIG-registered doctor, per value. So you not only know what your testosterone or LH is, but also what that can mean in your situation and whether a next step is logical. Want to walk calmly through the symptoms first? Then read our article on the signs of PCOS.

Frequently asked questions

Can I have PCOS with a normal period?

You can. For the diagnosis, two of the three Rotterdam criteria are needed. If you have signs of too many androgens and polycystic ovaries, you can have PCOS while your period is reasonably regular.

Which hormones point to PCOS?

Often a raised testosterone, a low SHBG and a raised LH/FSH ratio, sometimes with a high AMH. No single value proves PCOS alone; it is about the pattern, together with your symptoms and, if needed, an ultrasound.

Does PCOS go away at menopause?

The cycle complaints can change around menopause, but the predisposition remains. Attention to your metabolism and cardiovascular health therefore stays worthwhile at a later age too. Discuss with your GP what suits you.

Is PCOS dangerous?

PCOS itself is not an acute disease, but it goes together with a higher risk of type 2 diabetes and cardiovascular disease. That is why it can be worthwhile to keep an eye on your blood sugar alongside the cycle. What you need, you decide together with a doctor.

Sources

• NHG and Thuisarts.nl, Polycystic ovary syndrome (PCOS), Dutch College of General Practitioners. Available via thuisarts.nl.
• International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome 2023, ESHRE and partners.
• NVOG (Dutch Society of Obstetrics and Gynaecology), patient information on PCOS and fertility. Available via degynaecoloog.nl.

Every blood test result via Lunara receives a professional review by a BIG-registered doctor. For treatment decisions, discuss your results with your GP.