Last modified on April 2022
With inputs from Dr. Sreelekha
What is PCOS?
Polycystic Ovarian Syndrome is a hormonal and endocrine disorder that causes enlarged ovaries with small cysts present on the outer edges. Experts don’t know what is the definitive cause of PCOS but a combination of genetic, lifestyle and environmental factors plays a significant role.
The lifestyle disorder causes hormonal problems that can affect the function of a woman’s ovaries. There is a rise of PCOS cases among women in India, and due to either misdiagnosis or lack of awareness, there is a lack of immediate treatment.
As of 2021, the prevalence of Polycystic Ovarian Syndrome in India is about 22.5% with one in five women suffering from the condition. A delayed diagnosis and treatment can lead to long-term complications. Diet and lifestyle modifications are the first-line treatment for PCOS. This ultimate guide to PCOS will cover the following subjects.
Chapter 1: Causes of PCOS
There is no single proven cause for hormonal disorder, but research has dictated the following contributing factors to the condition.
- Genetics and familial predisposition
- Insulin resistance
- Increased androgens or male hormones
PCOS, marked by the overproduction of androgens, or male hormones, affects women of reproductive ages of 15 – 44 years. The condition, which is becoming increasingly common in India, affects obese women more commonly. 80% of women diagnosed with the condition are either overweight or obese.
Due to the fact that PCOS often runs in families, experts believe that defects in more than one gene can cause the hormonal disorder. There is not much information or research on the genetic causation factor of the condition. But, a woman is at a higher risk of developing PCOS if someone in her family already has it.
70% of the women that have PCOS have insulin resistance. Insulin is a hormone produced by the Beta cells of the pancreas that maintains blood sugar levels. Insulin resistance occurs when the body’s cells don’t respond to the insulin produced by the pancreas. This causes the pancreas to produce more insulin which leads to increased body insulin levels.
How does this relate to PCOS? The increase in insulin levels leads to the ovaries producing more testosterone relatively and also there are increased levels of free androgens in the body – a male hormone that can lead to PCOS. One of the main causes of insulin resistance is obesity – this is the link between obesity as a risk factor for PCOS.
Studies have revealed that having an increased BMI level can cause increased inflammation in the body.
Chapter 2: Symptoms of PCOS
There are various symptoms or side effects of PCOS, and not all women experience all of them at the same time. Essentially, the time of onset and range of symptoms can differ from woman to woman.
The symptoms include:
- Irregular menstrual/period cycles: from as low as 6 periods/year to no periods at all
- Dysmenorrhea: painful period cramps
- Menorrhagia: heavy menstrual bleeding
- Oligomenorrhoea- menstrual flow is reduced significantly
- Hirsutism: excessive hair growth on face, chest, back, thighs
- Acne of all grades on face and body
- Oily skin
- Male pattern baldness
- Excessive weight gain or difficulty in losing weight
- Difficulty in getting pregnant or infertility
- Acanthosis Nigricans: darkening of skin folds in neck, groin and, under breasts
- Skin tags
- Mental health conditions such as depression
Periods are “normal” if they occur every 21-35 days. Polycystic Ovarian Syndrome, which causes delayed, absent or irregular periods can delay the menstrual cycle for up to 5-6 months in some women.
Some women also experience regular periods but experience abnormal scanty flow that only lasts for about 2 days or experience abdominal heavy bleeding for more than a week. Women who experience such abnormalities can also experience pain or dysmenorrhea and weakness.
Due to the fact that the hormonal condition causes abnormal levels of male hormones, women experience oily skin along with moderate to severe acne that can be unresponsive to regular acne treatment. Most women experience acne on their jawline along with increased facial and body hair growth and scalp hair thinning.
Chapter 3: Diagnosing & Tests of PCOS
There isn’t one test that can diagnose PCOS, but there is a procedure followed by gynecologists that help them diagnose the hormonal disorder. PCOS diagnosis test includes:
- Medical history taking
- Symptoms analyzing
- Physical examination
- Blood test for abnormal hormonal levels
- Pelvic US to check for follicles and/or cysts in ovaries
A diagnosis involves the presence of two of the three following criteria:
- Hyperandrogenism (increased levels of male androgens): this is what causes hirsutism or excessive hair growth on the face and below the umbilicus till pelvis, acne and pimples resistant to regular anti-acne treatment, baldness, and acanthosis nigricans.
- Menstrual irregularity: Anovulation leading to irregular periods or no periods and high LH hormone.
- Polycystic ovaries in ultrasound scan: more than 12 follicles or cysts between 2-9 mm occupying equal to or more than 10 ml of ovarian volume.
- Thyroid Profile (Thyroid Stimulating Hormone)
- Diabetes Profile (HbA1c)
- Testosterone Profile
- DHEA (DehydroepiAndrostenedione)
- Follicle-Stimulating Hormone (FSH)
- Luteinizing Hormone (LH)
Chapter 4: Types of PCOS
Based on the symptoms a woman presents with, there are four different phenotypes of Polycystic Ovarian Syndrome. The exact pathological mechanisms of the phenotypes are not clear.
- Frank or classic polycystic ovary:
Irregular periods, increased levels of androgens, and polycystic ovaries.
- Classic non-polycystic ovary:
Irregular periods, increased levels of androgens, and normal ovaries.
- Non-classic ovulatory:
Regular menstrual cycles, increased levels of androgens, and polycystic ovaries.
- Non-classic mild or normo-androgenic:
Irregular menstrual cycles, normal androgens, and polycystic ovaries.
Chapter 5: PCOS Treatment
There is no cure for Polycystic Ovarian Syndrome, but the symptoms that it causes can be effectively managed with diet and lifestyle changes which include:
- Healthy, well-balanced diet
- Regular exercise
- Weight loss management
- Stress and anxiety management
- Medications such as OCP’s, oral anti-diabetic metformin, and androgen blockers
All women don’t experience the same degree of severity when it comes to the symptoms of PCOS. So, a customized or tailored treatment plan created by a gynecologist is appropriate.
Diet and lifestyle modifications
A healthy diet, weight management, and exercise are the first-line treatment in managing Polycystic Ovarian Syndrome and its symptoms. A healthy diet helps in lowering BMI and helps maintain blood sugar levels which prevent insulin resistance. Even a 10% reduction in body weight will help in regulating a woman’s menstrual cycle.
Get a sample PCOS diet for Vegetarians and Non-Vegetarians.
Medications for PCOS treatment
- Combined OCP’s
Birth control pills or oral contraceptive pills containing estrogen and progesterone are prescribed to help stabilize the body’s hormone levels and regulate the menstrual cycle.OCP’s also help in relieving symptoms caused by hormonal imbalance such as hirsutism, male pattern baldness, and treatment-resistant acne. This form of medication also offers the added protection of reducing the risk of endometrial cancer due to its progesterone content.
This is a form of progesterone, a hormone that plays a vital role in a women’s menstrual cycle and pregnancy. Progestin, when administered for 10-14 days every 1-2 months can help regulate hormone levels aiding in relieving symptoms caused by hormone imbalance.
If the hormonal condition isn’t responsive to the above treatment, surgical management is an option to help restore ovulation in women. Procedures such as ovarian drilling treat the condition – this involves the bursting of cysts that contain excess amounts of androgens laparoscopically.
Chapter 6: PCOS Risks & Complications
The diagnosis can pose several health complications such as:
- PCOS infertility
- Metabolic syndrome: high blood pressure, high blood sugar, and abnormal cholesterol or triglyceride levels that increase the risk of cardiovascular disease
- Cardiovascular disease
- Hypertension and high blood pressure
- An increase in the level of bad cholesterol in the blood
- Insulin resistance and type II diabetes
- Gestational diabetes or pregnancy-induced high blood pressure
- Increased risk of endometrial cancer
- Sleep Apnea secondary to obesity
- Endometrial cancer: cancer of the uterine lining
- Miscarriage or premature birth
- Nonalcoholic steatohepatitis caused by fat accumulation in the liver
- Abnormal uterine bleeding
Chapter 7: PCOS and Mental Health
The main symptoms of PCOS such as irregular menstruation, acne, weight gain, and hirsutism are widely known, but did you know that those diagnosed with PCOS are 3 times more likely diagnosed with mental health conditions such as depression and anxiety?
The cause behind PCOS posing an increased risk to these mental health conditions isn’t clearly known at this point in time. This may be due to the hormonal imbalance caused by the endocrine condition, or a combination of factors.
- Insulin resistance:
A theory suggests that due to the fact that insulin resistance alters the way the body makes certain hormones, it can lead to prolonged stress and depression.
PCOS results in increased inflammation, which if prolonged, can lead to high cortisol levels. This increases the risk of stress and depression.
Obesity in itself can cause depression, regardless of whether or not it’s related to PCOS. A significant amount of women suffering from PCOS are also obese – the connection may be mild but possible
PCOS and its associated symptoms can cause a high degree of stress to the body. The physical symptoms can be overwhelming and can lead to anxiety and depression.
Living a healthy lifestyle such as being physically active, eating a healthy nutritious diet, maintaining BMI, treating PCOS symptoms under the supervision of a professional, and managing stress can help reduce the risk of presenting with mental health conditions.
Chapter 8: PCOS & Pregnancy
A PCOS diagnosis can pose a significant challenge when it comes to pregnancy along with an increased risk of complications during pregnancy and birth-giving. This is due to the fact that PCOS results in a high level of male hormones in the body that prevent ovulation – the release of an egg. There are ways, however, to increase the chances of pregnancy.
- Consuming a healthy and nutritious diet
- Exercising regularly with straightening exercises
- Maintaining BMI: a 5-10% weight loss can effectively increase the chances of pregnancy
- Monitoring ovulation and timing sexual intercourse based on it
In cases where medications and lifestyle changes are unable to help increase the chances of pregnancy, professionals may suggest the following:
- Fertility medications to help in ovulation
- Surgical removal of ovarian tissues that produce male hormones in ovaries
- IVF (In vitro fertilisation)
It is however imperative to note that PCOS can increase the risk of the following complications during pregnancy:
- Gestational diabetes
- High blood pressure induced by the pregnant state
- Premature birth
- Clomiphene: induces ovulation
- Metformin: improves insulin sensitivity resulting in decreased glucose production
- Letrozole: induces ovulation by blocking estrogen production, leading to increases in follicle-stimulating hormone (FSH) release.
- Sensitizers: help decrease insulin resistance and help the body regulate metabolism and hormones along with improving ovulation rates
Women with PCOS most commonly undergo a C-section due to the larger birth weight of their child. Babies that are born to women with PCOS also pose a higher risk of fatality during delivery and are cared for in the NICU if it is a complicated birth.
Chapter 9: PCOS and COVID-19 Management
PCOS is a condition that causes physical, physiological, and emotional symptoms that can take a toll on a woman’s body and mind. In some ways, a woman diagnosed with PCOS has a higher risk of acquiring medical illnesses due to their constant vulnerable state. Following are tips to keep in mind for women diagnosed with PCOS to better manage their health.
- Ensure getting 8 hours of sleep
- Maintain a PCOS friendly diet
- Ensure physical activity and not a sedentary lifestyle
- Stay hydrated
- Don’t ignore medical symptoms
- Stay disciplined with your PCOS treatment
Chapter 10: PCOS vs PCOD: What is the difference?
There is no difference between PCOD and PCOS. Both are used interchangeably. Symptoms of PCOD/PCOS include irregular periods, acne, increased weight, abnormal hair growth on body. Along with these physical symptoms there can be cysts in the ovaries.
Chapter 11: Frequently Asked Questions on PCOS
Q: What is the main cause of PCOS?
A: PCOS affects 1 in 5 women during the childbearing age. The main cause behind the endocrinological condition is not clear, but experts have suggested that genetics, excess androgens, and insulin resistance are some of the causative factors.
Q: How do I know I have PCOS?
A: There are various symptoms that attribute to the possibility of a woman experiencing PCOS. Some of the common symptoms include irregular menstrual/period cycles, acne, and heavy menstrual bleeding. Speaking to a gynecologist can confirm a PCOS diagnosis. This is done through blood testing and physical examination
Q: At what age do PCOS symptoms start?
A: PCOS, marked by the overproduction of androgens, or male hormones, affects women of reproductive ages – 15 – 44 years. The condition, which is becoming increasingly common in India, affects obese women more commonly. 80% of women diagnosed with PCOS are either overweight or obese.
Q: Does PCOS have a cure?
A: There is no cure for PCOS, but the symptoms that it causes can be effectively managed with diet and lifestyle changes such as a balanced diet, weight loss management, and if needed, medications such as OCP’s.
Q: How are PCOS cysts removed?
A: If the hormonal condition isn’t responsive to the above treatment, surgical management is an option to help restore ovulation in women. Ovarian drilling may be one of the options suggested.
Q: What foods should I avoid in PCOS?
A: Avoid processed and fried foods, refined flour, and sugary beverages when diagnosed with PCOS. PCOS patients should eat foods that have a low glycaemic index i.e foods that are low in natural sugars and that are anti-inflammatory.
Q: Is PCOS dangerous and/or life-threatening?
A: PCOS is not a life-threatening condition and is managed effectively with lifestyle and diet modifications. However, the condition does pose a risk to other health conditions such as PCOS infertility,heart diseases, and type II diabetes.
Q: What are the best exercises for PCOS patients?
A: Strengthening exercises such as swimming, cycling, and yoga are great exercises for PCOS patients. They can help in core strength, improve bone density and help maintain a healthy heart rate. Another option is high-intensity interval training(HIIT) that involves a combination of outdoor and indoor activities with intervals of rest.
Q: Can I get pregnant with PCOS? Why is it difficult?
A: A diagnosis can pose a significant challenge when it comes to pregnancy along with an increased risk of complications during pregnancy and birth-giving. This is due to the fact that PCOS results in a high level of male hormones in the body that prevent ovulation – the release of an egg. There are ways, however, to increase the chances of pregnancy by consuming a healthy and nutritious diet and a 5-10% weight loss.
Q: Is endometriosis and PCOS the same thing?
A: No. Endometriosis and PCOS are two different conditions that pose similar problems of hormonal imbalance and infertility. Endometriosis causes the tissue that lines your uterus to grow outside the organ. This can cause severe pelvic pain, dysmenorrhea, painful sex, and infertility.
Q: How are PCOS and diabetes connected?
A: Insulin resistance occurs when the body’s cells do not respond to the insulin produced by the pancreas. This causes the pancreas to produce more insulin which leads to increased body insulin levels which leads to the ovaries producing more testosterone.
One of the main causes of insulin resistance is obesity – this is the link between obesity as a risk factor for PCOS. Too much insulin, a peptide hormone, can lead to type 2 diabetes if not treated appropriately.
Q: Can PCOS cause depression?
A: The main symptoms of PCOS such as irregular menstruation, acne, weight gain, and hirsutism are widely known, but women diagnosed with PCOS are 3 times more likely diagnosed with mental health conditions such as depression and anxiety.
The cause behind PCOS posing an increased risk to these mental health conditions isn’t clearly known at this point in time. This may be due to the hormonal imbalance caused by the endocrine condition, self-esteem issues or a combination of factors.
Q: How is PCOS diagnosed?
A: There isn’t one test that can diagnose PCOS, but there is a procedure followed by gynecologists that help them diagnose the hormonal disorder. The diagnosis procedure involves physical examination, ultrasound, and blood testing.
The presence of two of the following criteria will confirm a PCOS diagnosis
- Increased levels of male androgens
- Irregular periods
- Polycystic ovaries
Q: How is PCOS treated? What are the common medications used for PCOS?
A: Medications for PCOS treatment include combined OCP’s which contain estrogen and progesterone prescribed to stabilize the body’s hormone levels and regulate the menstrual cycle and progestin which when administered for 10-14 days every 1-2 months can help regulate hormone levels aiding in relieving symptoms of PCOS caused by hormone imbalance.
Q: What are some safe dairy alternatives for women with PCOS?
A: Lactaid, a type of dairy milk that has lactose removed, is a safe alternative for women diagnosed with PCOS.
Q: What does a PCOS belly look like?
A: There is no distinct way a PCOS belly would look, those diagnosed with the condition have a higher BMI. PCOS affects the way the body utilizes glucose and converts it into fats that are most commonly deposited around the belly area.
Women often experience what’s commonly known as “muffin top” or excess fat deposited in the lower belly, closer to the waist area.
Q: Is PCOS sexually transmitted?
A: No, PCOS isn’t a sexually transmitted disease. Experts have dictated that there are contributing factors that cause the condition: genetics, insulin resistance, excess androgens and low-grade inflammation
Q: Is PCOS painful?
A: PCOS is a hormonal disorder that doesn’t commonly cause pain in the pelvic area for all women. However, the condition does cause a hormonal imbalance that affects a woman’s menstrual cycle. Women can experience heavy menstrual bleeding and bloating which can cause painful cramps.
Q: Is soya chunks good for PCOS?
A: There is certain evidence that soy products will help prevent Diabetes and heart disease. Though the exact reason is not known, they have found that consuming soy products may help improve metabolic health and Insulin resistance.
Q: Is chicken good for PCOS?
A: Yes, lean meats or protein such as chicken, tofu, and fish are healthy dietary options for women that have PCOS. However, fried chicken should not be an option as fried and processed foods can cause inflammation in the body and exacerbate PCOS symptoms.
Q: Is egg good for PCOS?
A: Yes. Foods that are rich in protein such as beans, nuts, tofu, eggs, chicken, and fish are safe for those with PCOS. In fact, combining protein-rich foods with foods that contain fat or carbs, can help reduce the absorption of carbs in the body which will maintain insulin levels as well.
Q: Is Ghee good for PCOS?
A: Yes. Ghee is a good fat and in moderate amounts good for those diagnosed with PCOS. We say moderation because even though it is a healthy fat, it is still a fat. Women diagnosed with PCOS tend to gain weight quickly, and have a challenging time reducing it – therefore, monitoring of fat consumption is imperative.
There is no cure for Polycystic Ovarian Syndrome, and it is a lifelong condition with no definitive cure or treatment. However, lifestyle and diet modifications are effective first-line treatments for the hormonal condition, even though it is highly ignored.
The symptoms and the severity of the symptoms can vary from woman to woman diagnosed with, and therefore self-diagnosis and self-medication should not be the norm. The condition itself poses several health risks and complications; self-medicating can worsen the symptoms and can cause worse complications.
If you experience an irregular menstrual cycle, have treatment-resistant acne, increased hair growth, etc, see a gynecologist. A gynecologist will use your medical history, blood testing, and an ultrasound to confirm a PCOS diagnosis – or possibly another hormonal or endocrinology disorder.
A one size fits all approach isn’t the answer when treating Polycystic Ovarian Syndrome, rather prioritizing a healthy diet and lifestyle and following a treatment plan set up by a gynecologist should be the goal.