What is PCOS?
PCOS is a hormonal condition where the ovaries produce more androgens than usual. Despite the name, you don't need cysts to have PCOS — and many women with cysts on ultrasound don't have PCOS. PCOS is the most common hormonal disorder in women of reproductive age (8-13% of women globally).
Diagnosis: the Rotterdam criteria
Doctors diagnose PCOS using the Rotterdam criteria. You need 2 of 3:
- Irregular ovulation: cycles >35 days or missing periods.
- Hyperandrogenism: acne, hirsutism, hair loss, or elevated testosterone.
- Polycystic ovaries on ultrasound: 12+ follicles per ovary.
Other conditions (thyroid, prolactin, CAH) must be ruled out first.
Common symptoms
- Cycles >35 days, fewer than 8-9 periods per year
- Acne along the jawline and chin
- Excess hair on face, chest, abdomen
- Scalp hair thinning
- Difficulty losing weight, abdominal weight gain
- Skin tags, acanthosis nigricans (insulin resistance)
- Mood changes, anxiety, trouble conceiving
Insulin resistance: the underrated piece
Up to 70% of women with PCOS have insulin resistance, even at a normal weight. High insulin tells the ovaries to make more testosterone, worsening cycle irregularity. Lifestyle changes that lower insulin (whole foods, movement, strength training, protein) often improve cycles within 3-6 months.
Lifestyle: what actually works
Medications and supplements
Hormonal birth control regulates cycles, reduces acne. Metformin improves insulin sensitivity. Spironolactone blocks androgens. Inositol (40:1 myo:d-chiro) has the strongest evidence among supplements: 2g myo + 50mg d-chiro twice daily for 3+ months.
Fertility and PCOS
PCOS is the most common cause of anovulatory infertility — but with treatment, the vast majority of women conceive. First-line: letrozole (preferred) or clomiphene. Lifestyle changes restore ovulation in many women without medication.
Long-term health
PCOS increases risk for type 2 diabetes (4×), cardiovascular disease, sleep apnea, fatty liver, endometrial cancer, depression. Regular screening matters. Lifestyle + medication reduce all of these risks substantially.