Polycystic ovary syndrome (PCOS) is a complex, diabetes-like metabolic and endocrine condition.

It’s becoming increasingly common in women and around 8 to 13% percent of women currently live with it.

PCOS is considered a syndrome because it presents differently between individuals. Because of the symptom criteria, there are 4 forms of PCOS. To be diagnosed with PCOS, you must have at least 2 out of 3 symptoms as stated by the Rotterdam criteria:

1. Delayed ovulation or irregular menstrual cycles (anovulation)

2. High androgenic hormones (ie. free testosterone)

3. Polycystic ovaries on ultrasound

Just because your period-tracking app tells you that ovulation happens every month, doesn’t mean it’s true.

Your body sends you messages throughout your cycle giving you a heads up that ovulation is set to happen (by way of changing cervical fluid), and that it’s happened (via your slightly increased basal body temperature). Testing your progesterone levels (via blood work) 7 days after you ovulate will indicate if you’ve ovulated.

Irregular menstrual cycles can be defined as:

• Normal in the first year of having your period

• In the first 1-3 years of having your period: Less than 21 or greater than 45 days

• After having your period for 3 years: Less than 21or greater than 35 days

• After having your period for 3 years: Less than 8 menstrual cycles per year

High androgens

It’s normal for women to have a specific amount of male hormones (i.e. testosterone). High levels of male hormones can be problematic in women, and may contribute to acne along the jawline or back, growth of facial and body hair, or alopecia (hair loss) in specific patterns.

The Ferrimen Gallway score is a great tool you can use to determine if you are experiencing changes in hair growth. While the Ludwig visual score helps to assess the degree of alopecia.

Nevertheless, it’s still a good idea to get your hormones assessed (even if you don’t have signs of hair growth) to determine if you have high androgens. Here’s what you should be asking your provider to test:

• Free testosterone

• Total testosterone

• Sex Hormone Binding Globulin

• DHEAS

Polycystic Ovaries

Although this syndrome has cysts in the name, you don’t need to have ovarian cysts to have PCOS. Nonetheless, to determine if you have cysts, a transvaginal ultrasound needs to be done. Although criteria continues to evolve as technology advances, you need 12+ follicles that are between 2-9mm or an ovarian volume bigger than 10cm in a single ovary.

An ultrasound should not be used for the diagnosis of PCOS in people who have only had their periods for less than 8 years. During this life stage, you may have many follicles in your ovaries. 

Earlier I talked about the PCOS types – here’s how they differ based on which criteria you may have: 

Type A Classified as:

• Hyperandrogenism

• Anovulation/irregular periods

• Polycystic ovaries

Signs and symptoms include: increased BMI and weight circumference, highest androgen values, polycystic ovaries, increased LH/FSH, AMH, low progesterone, and menstrual irregularity. The Type A person may also be insulin resistant, potentially leading to an increased risk of diabetes and heart disease. 

Type B Classified as:

• Hyperandrogenism

• Anovulation/irregular periods

Signs and symptoms include: increased BMI, abdominal weight gain, menstrual irregularity, physical signs of high androgens (ex. hirsutism, acne, and alopecia). Insulin resistance is also a factor.  

Type C Classified as:

• Hyperandrogenism

• Polycystic ovaries

Signs and symptoms include: medium BMI score, abdominal weight again, increased androgens (ex. testosterone), and polycystic ovaries. While periods may be regular, ovulation may not be occurring.  

Type D Classified as:

• Anovulation/irregular periods

• Polycystic ovaries

Signs and symptoms include: menstrual irregularities, polycystic ovaries, androgen levels are normal (no physical signs of androgen excess), normal BMI, normal waist circumference, may be signs of insulin resistance. This type is thought of as ‘lean’ PCOS.

Additional Helpful Information

Type 2 diabetes/impaired glucose tolerance/gestational diabetes is increased in women with PCOS. This means you should also be asking your doctor to test:

• Fasting insulin

• Fasting glucose

These above tests will determine if you have insulin resistance, a key feature of PCOS.

In addition, generally all women with PCOS are at higher risk for cardiovascular disease. Screening should include:

• Fasting lipid profile

• Blood pressure measurement

• Weight, height, and waist circumference

Moving Forward

Knowing the PCOS criteria and types will help you determine if you are living with PCOS. Although first line treatment is usually the birth control pill, there are dietary and lifestyle interventions that can make a difference.

Nevertheless, getting more information is key in understanding how to approach your specific PCOS type.

Here are some ideas on how to move ahead:

• Track your period

• Find out if your body is ovulating (use your period app as a suggestion)

• Get your blood work done (other providers than your PCP can order blood work, too).

• Talk to your medical doctor about an ultrasound if either the first 2 criteria may not be an issue (ie. blood work is optimal).

Reference

Teede, H., Misso, M., Costello, M., Dokras, A. et al. (2018). Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertility and Sterility, 110(3), 364-379.

Dr. Alexsia Priolo is a Naturopathic Doctor in Toronto, Canada with a strong focus on hormonal health, especially as it relates to the menstrual cycle and fertility. She knows that hormones can be complicated and affect periods and the skin, and everything in between.

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