PCOS Management
Symptoms, Causes & Treatment
Everything you need to know about polycystic ovary syndrome (PCOS): what causes it, how it is diagnosed, and the effective lifestyle and medical treatments available.
What Is PCOS?
Polycystic ovary syndrome (PCOS) is a common hormonal condition affecting women of reproductive age. It is characterised by a combination of irregular or absent periods, signs of excess androgen (male hormones), and polycystic ovaries on ultrasound. It is the most common endocrine disorder in women, affecting an estimated 1 in 10 women in the UK, though many are undiagnosed.
Despite its name, PCOS is not primarily a condition of the ovaries. It is a metabolic and hormonal disorder with wide-ranging effects on menstrual regularity, fertility, skin and hair, weight, and long-term health. The "cysts" seen on ultrasound are actually immature follicles (small fluid-filled sacs containing eggs that have not developed fully) rather than true cysts.
PCOS is diagnosed using the Rotterdam criteria, which require at least two of the following three features:
- Irregular or absent ovulation (usually manifesting as irregular, infrequent, or absent periods).
- Clinical or biochemical signs of excess androgens (acne, hirsutism, raised testosterone on blood test).
- Polycystic ovaries on ultrasound (12 or more follicles in one ovary, or ovarian volume greater than 10ml).
Other causes of irregular periods and excess androgens (such as thyroid disease, congenital adrenal hyperplasia, and Cushing's syndrome) must be excluded before a diagnosis of PCOS is made.
PCOS is a lifelong condition, but its symptoms can be managed effectively with a combination of lifestyle modification and, where appropriate, medication.
What Are the Symptoms of PCOS?
PCOS symptoms vary widely in type and severity between individuals. Not all women have all features. Some women are diagnosed incidentally during investigations for infertility or irregular periods.
Irregular, infrequent, or absent periods · Difficulty conceiving · Excess facial or body hair (hirsutism) · Acne · Oily skin · Thinning hair or hair loss on the scalp · Weight gain, particularly around the abdomen · Skin darkening in skin folds (acanthosis nigricans) · Mood changes, depression, or anxiety
Severe pelvic pain with a known ovarian cyst — possible cyst rupture or torsion (emergency) · Significant difficulty conceiving after 12 months of trying · Symptoms of diabetes developing alongside PCOS (excessive thirst, urination, fatigue)
Seek urgent attention if you develop sudden severe pelvic pain with a known ovarian cyst (possible torsion or rupture). If you have PCOS and are not trying to conceive, ensure your womb lining is regularly protected with the pill, progestogen therapy, or Mirena IUS — absent periods increase endometrial cancer risk over time.
What Causes PCOS?
PCOS results from a complex interplay of hormonal, metabolic, and genetic factors. Insulin resistance is central to its pathophysiology and explains why lifestyle modification is so effective.
The exact cause is unknown, but PCOS involves excess androgen production, insulin resistance, and disrupted LH/FSH signalling from the pituitary. These interact to prevent regular ovulation.
PCOS runs in families. If a close female relative has PCOS, your risk is significantly higher. Specific genetic variants affecting androgen and insulin signalling have been identified.
Excess body fat worsens insulin resistance, which raises insulin levels, which in turn stimulates more androgen production — creating a cycle that worsens PCOS symptoms.
Women with PCOS have a 5–7 times higher lifetime risk of developing type 2 diabetes. This is driven by insulin resistance and beta-cell dysfunction, independent of obesity. Annual HbA1c screening is recommended from diagnosis.
Women with PCOS are at increased risk of endometrial hyperplasia and endometrial cancer due to chronic anovulation causing unopposed oestrogen stimulation of the uterine lining. Regular endometrial protection is essential.
Up to 50% of women with PCOS experience anxiety, depression, or reduced quality of life related to symptoms including weight gain, acne, hirsutism, fertility difficulties, and chronic health management burden.
Key Risk Factors
How Is PCOS Diagnosed?
PCOS is diagnosed using the Rotterdam criteria — at least two of three features are required: irregular or absent ovulation, clinical or biochemical evidence of excess androgens, and polycystic ovaries on ultrasound. Blood tests and pelvic ultrasound are the main investigations.
How Is PCOS Treated?
Treatment is tailored to the individual’s primary concerns and goals: menstrual regulation, fertility, androgen symptoms (acne, hair growth), or metabolic health. There is no one-size-fits-all treatment for PCOS.
Supportive Measures
Lifestyle modification is the most important intervention in PCOS, especially in overweight women. Even 5–10% weight loss improves ovulation rates, reduces androgen levels, and lowers long-term metabolic risk. A low glycaemic index diet reduces insulin resistance. Regular exercise improves insulin sensitivity and supports weight management. Stress management and adequate sleep are also important — both affect cortisol and insulin levels.
Long-Term Management of PCOS
PCOS is a lifelong condition. Long-term health monitoring is essential: annual HbA1c and lipid checks, blood pressure monitoring, and endometrial protection for women with absent or very infrequent periods (via the combined pill, progestogen, or Mirena IUS). Fertility treatments have high success rates in PCOS. Psychological support for body image, self-esteem, and the impact of symptoms on relationships and mental health should be offered routinely.
When Should You Seek Medical Advice?
Sudden severe pelvic pain with a known ovarian cyst — possible cyst torsion or rupture, which is a surgical emergency. Call 999 or attend A&E immediately.
You have irregular periods and have been struggling to conceive · You have signs of androgen excess (hirsutism, acne, hair loss) affecting your quality of life · You have a family history of PCOS or type 2 diabetes and have not been tested · You are gaining weight and have irregular cycles.
Managing PCOS for the Long Term
PCOS cannot be prevented, but its long-term health risks can be significantly reduced through lifestyle management and regular monitoring.
Even modest weight loss of 5–10% significantly improves menstrual regularity, ovulation, and metabolic health in overweight women with PCOS. Regular exercise also reduces insulin resistance independently of weight.
Women with PCOS have higher lifetime risk of type 2 diabetes and cardiovascular disease. Annual HbA1c, blood pressure, and lipid checks are recommended from diagnosis.
Women with PCOS should have an annual HbA1c, fasting lipid profile, and blood pressure check. Those with elevated risk should be considered for metformin even without diabetes to reduce progression.
Inositol supplements (particularly myo-inositol) improve insulin sensitivity and ovulation rates in PCOS. Evidence supports their use as an adjunct to lifestyle modification, particularly in women preferring to avoid metformin.
Psychological support — including CBT, body image therapy, and peer support groups — significantly improves quality of life in women with PCOS. Self-compassion approaches have emerging evidence in PCOS.
Maintain a healthy weight through Mediterranean or low-GI dietary patterns. Reducing refined carbohydrates lowers insulin and testosterone. Even small amounts of weight loss (5%) produce significant hormonal improvements.
Speak to a Clinician About PCOS
Through The GP Service, a licensed clinician can assess your symptoms, request appropriate investigations, and discuss management options for PCOS — from lifestyle advice to medication and fertility referrals — in a confidential online consultation.
Expert clinical advice, when you need it.
PCOS FAQs
Yes. PCOS is a leading cause of ovulatory infertility, but many women with PCOS do conceive with the right support. First-line treatment is lifestyle modification — even modest weight loss improves ovulation significantly. If periods remain irregular, ovulation induction with letrozole (first-line, NICE-recommended) or clomifene can be used. If ovulation induction fails, gonadotrophin injections or laparoscopic ovarian drilling (LOD) are options. IVF is effective for PCOS-related infertility. The prognosis is generally positive with appropriate management.
PCOS cannot be cured, but its symptoms and long-term risks can be effectively managed. The combined pill regulates periods and reduces androgen-related symptoms. Metformin improves insulin sensitivity and metabolic health. Lifestyle modification is fundamental — it improves hormonal balance, reduces insulin resistance, and lowers long-term diabetes and cardiovascular risk. With appropriate management, most women with PCOS lead full and healthy lives including successful pregnancies.
PCOS carries several long-term health risks that require monitoring. The most significant are type 2 diabetes (5–7x increased risk), cardiovascular disease, and endometrial cancer. Insulin resistance — present in 70–80% of women with PCOS — is the central driver of metabolic risk. The good news is that all of these risks are significantly modifiable through lifestyle intervention, appropriate medication, and regular monitoring. Women with PCOS should not view their diagnosis as a fixed sentence but as an opportunity to take proactive control of long-term health.
Yes. Women with PCOS and absent or very infrequent periods (fewer than 4 per year) are at increased risk of endometrial hyperplasia — and, over time, endometrial cancer — because oestrogen is not being opposed by progesterone from ovulation. To protect the womb lining, these women should take either the combined pill, progestogen-only pill, Mirena IUS, or a withdrawal bleed induced with progesterone at least every 3 months. This endometrial protection should continue until menopause, regardless of whether pregnancy is desired.
Lichen sclerosus is a chronic inflammatory skin condition affecting the vulva, causing white, thinning, fragile skin with intense itch, soreness, and changes in vulval architecture. It can be mistaken for recurrent thrush or atrophic vaginitis. It is not infectious or sexually transmitted. It is diagnosed by clinical examination and sometimes biopsy. Treatment is with potent topical corticosteroids (typically clobetasol propionate 0.05%). It requires long-term monitoring as it carries a small increased risk of vulval cancer if untreated. Any woman with persistent vulval symptoms should be examined rather than treated empirically.
Irregular periods have many causes including PCOS, thyroid disorders, hyperprolactinaemia, perimenopause, significant weight loss, excessive exercise, eating disorders, and stress. A single irregular period is rarely cause for concern. Consistently irregular cycles — longer than 35 days or shorter than 21 days — warrant investigation with a blood test (FSH, LH, thyroid, prolactin) and a pelvic ultrasound. A missed period in a woman of reproductive age should always prompt a pregnancy test before other investigations.
Pericarditis is inflammation of the sac surrounding the heart, typically caused by a viral infection. It produces a sharp, stabbing chest pain that is typically worse when lying flat and relieved by leaning forward. It may be associated with fever and a pericardial friction rub on examination. Treatment is with NSAIDs (ibuprofen or aspirin) and colchicine for 3 months. Rest and avoidance of strenuous exercise during treatment are important. Pericarditis must be distinguished from myocarditis and aortic dissection, both of which are more serious.
Cardiac syndrome X (also called microvascular angina) causes typical angina symptoms — chest tightness on exertion — with a normal coronary angiogram, in the absence of coronary artery narrowing. It is caused by dysfunction of small coronary blood vessels. It is more common in women, particularly postmenopausal women. Treatment includes nitrates, beta-blockers, and sometimes hormone therapy. It is often undertreated because the normal angiogram can lead to symptoms being dismissed. Referral to a cardiologist is appropriate if symptoms persist despite standard measures.