How is the diagnosis made?
At least two of three criteria must be present for the diagnosis — and it is essential that other conditions producing similar symptoms be ruled out:
- Excess male hormone — on examination findings or on a blood test
- Disturbance of ovulation — irregular menstrual cycles
- The appearance of the ovaries on ultrasound or a raised AMH level in the blood
A question people often ask: is an ultrasound essential? No. In an adult woman with both irregular periods and excess male hormone, two of the criteria are already met — there is no need for an ultrasound or an AMH test. An ultrasound is needed only if just one of these two findings is present, in order to assess the third criterion.
The diagnosis is different in young girls
In young girls within the first 8 years after their first period, both excess male hormone and irregular periods together must be present for the diagnosis.
In this age group the use of ultrasound and AMH is not recommended. The reason matters: having many small follicles in the ovaries can be normal at this stage; looking at an ultrasound leads to unnecessary diagnoses.
Which conditions are ruled out?
Conditions that can produce similar symptoms are always excluded: thyroid disease, a raised level of the milk hormone (prolactin) and a hormonal disorder arising from the adrenal gland. If there is doubt, other causes are looked into as well.
Symptoms
- Skin and hair: excess hair growth, severe acne, male-pattern hair loss, darkening of the skin.
- Periods and reproduction: infrequent periods or none at all, infertility due to disturbance of ovulation, thickening of the lining of the womb, increased risk in pregnancy.
- Metabolism: insulin resistance, rapid weight gain or difficulty losing weight, fat around the waist.
- Mental health: anxiety, low mood, sleep disturbance and eating disorders are markedly more common in PCOS. This is a heading that should not be overlooked.
The foundation of treatment: lifestyle
The guideline states plainly: there is no single diet or exercise programme specific to PCOS. The general principles of healthy eating apply, and the form you can keep up and prefer yourself should be chosen. Approaches claiming that "this diet solves PCOS" have no counterpart in the guideline.
The aim is to prevent weight gain and to manage weight where necessary; this is effective in improving both reproductive and metabolic outcomes. Behavioural methods such as goal setting, self-monitoring and problem solving are used to build lasting habits.
The guideline also reminds health professionals of this: bias on the basis of weight should be avoided, and permission should be asked before weighing someone.
Drug treatments
Medicines are generally directed at symptoms and the decision is made together:
- Contraceptive pills: the first step in treating irregular periods and findings such as excess hair growth and acne. No pill is superior to another; options with a lower dose of oestrogen and a lower risk of side effects are preferred.
- Metformin: recommended primarily in those with insulin resistance, a disturbance of sugar metabolism or a risk of diabetes, in order to improve the metabolic situation and support weight management. Long-term use is safe, but the person should be monitored for vitamin B12 deficiency.
- Anti-androgen medicines: considered when an adequate response has not been obtained from a contraceptive pill or cosmetic methods for at least 6 months. An important warning: because they can cause a developmental problem in a male baby, these medicines must always be used together with a highly effective method of contraception.
- Medicines used in weight treatment: may be considered in addition to lifestyle change. Because weight is likely to be regained when they are stopped, they should be planned for the long term.
- Inositol: may be tried according to personal preference; its benefit is limited and it is less effective than metformin.
- For unwanted hair, laser and light-based treatments are effective.
Long-term risks and the screening that needs to be done
PCOS is a condition that needs to be followed lifelong.
Heart and vascular health
Women with PCOS are in the high-risk group for cardiovascular disease and stroke.
- Fasting blood lipids should be checked in everyone at diagnosis — regardless of age and weight; depending on the result this is repeated every 1–3 years.
- Blood pressure should be measured every year, and also when a pregnancy is being planned.
Diabetes
The risk of diabetes is increased independently of weight and age.
- The blood sugar situation should be assessed in everyone at diagnosis.
- If there are additional risk factors (excess weight, diabetes in the family, high blood pressure) it is repeated every 1–3 years.
- The most sensitive test is the glucose tolerance test.
Cancer of the lining of the womb
In premenopausal women with PCOS the risk is increased 2- to 6-fold — but the actual risk is still low. The risk increases with long-untreated absence of periods, excess weight, diabetes and thickening of the lining of the womb.
Routine screening of thickness by ultrasound is not recommended. On the other hand, the threshold for investigation is kept low in those with risk factors or abnormal bleeding. The way to protect against it: weight management, establishing a regular menstrual cycle and regular progesterone treatment.
Sleep apnoea
Sleep apnoea is markedly more common in PCOS. If there is snoring and excessive daytime sleepiness, it should be assessed.
Pregnancy
PCOS is regarded as high risk in pregnancy. When planning a pregnancy, blood pressure should be measured and a glucose tolerance test done. If this was not done beforehand it is done at the first antenatal visit and then repeated at weeks 24–28.
Family members
Metabolic syndrome, type 2 diabetes and high blood pressure are also more common in the fathers and brothers of women with PCOS.
Frequently Asked Questions
Is an ultrasound essential for a diagnosis of PCOS?
No. In an adult woman with both irregular periods and excess male hormone, two of the three criteria are already met — there is no need for an ultrasound or an AMH test. An ultrasound is needed only if just one of these two findings is present, in order to assess the third criterion.
My daughter was told she has PCOS and had an ultrasound — is that right?
In young girls within the first 8 years after their first period, the use of ultrasound and AMH is not recommended. The reason is this: having many small follicles in the ovaries can be normal at this stage, and looking at an ultrasound leads to unnecessary diagnoses. In this age group, excess male hormone and irregular periods must be present together for the diagnosis.
Is there a special diet for PCOS?
The guideline states plainly: there is no single diet or exercise programme specific to PCOS. The general principles of healthy eating apply, and the form you can keep up and prefer yourself should be chosen. Approaches claiming that "this diet solves PCOS" have no counterpart in the guideline.
What treatment is used for my excess hair growth?
The first step is contraceptive pills; they are also the first option for irregular periods and acne. If an adequate response is not obtained from these or from cosmetic methods for at least 6 months, anti-androgen medicines are considered. Laser and light-based treatments are also effective in reducing unwanted hair.
What should I be careful about while taking an anti-androgen medicine?
You must use a highly effective method of contraception. These medicines can cause a developmental problem in a male baby. For this reason contraception must not be neglected during treatment.
Which screening tests should I have?
Everyone at diagnosis — regardless of age and weight — should have fasting blood lipids checked and their blood sugar situation assessed. Blood pressure is measured every year. Lipid and sugar screening is repeated every 1–3 years if there are risk factors. The most sensitive test for sugar is the glucose tolerance test.
Am I at risk of cancer of the womb, should I be screened by ultrasound?
In premenopausal women with PCOS the risk is increased 2- to 6-fold, but the actual risk is still low. Routine screening of thickness by ultrasound is not recommended. However, if you have not had periods for a long time, have abnormal bleeding or have risk factors such as excess weight, the threshold for investigation is kept low. The way to protect against it: weight management, establishing a regular menstrual cycle and regular progesterone treatment.
I am planning a pregnancy — what should I do?
PCOS is regarded as high risk in pregnancy. When planning a pregnancy, blood pressure should be measured and a glucose tolerance test done. If this was not done beforehand it is done at the first antenatal visit and then repeated at weeks 24–28.
Does PCOS affect my mood?
Yes, and this should not be overlooked. Anxiety, low mood, sleep disturbance and eating disorders are markedly more common in PCOS. Sleep apnoea is also more common; if there is snoring and excessive daytime sleepiness, it should be assessed.
Who else in my family is at risk?
Metabolic syndrome, type 2 diabetes and high blood pressure are more common in the fathers and brothers of women with PCOS. This means family members should not neglect their own check-ups either.
Sources
- 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Diagnostic criteria, the difference in diagnosis in adolescents, the place of ultrasound and AMH, lifestyle and drug treatments, long-term risks and screening intervals.
The information on this page is based on the national and international guidelines listed above. The page is reviewed whenever those guidelines are updated.
Practice and Contact Details
The information on this page is general. Please speak to your doctor about your own situation.
- DoctorOp. Dr. Murat Alpay — Specialist in Obstetrics and Gynaecology
- AddressOp. Dr. Murat Alpay Practice, Tekelioğlu Cd. No:51 B Kat:2, Filo Apt., 07160 Muratpaşa / Antalya
- Telephone0505 351 77 88
- HoursMonday – Saturday 09:00 – 18:00 · Closed on Sunday