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Is PCOS always a clear-cut diagnosis?
This is a question we women’s health specialists ask ourselves on a regular basis! The current gold standard (Rotterdam) diagnostic criteria for Polycystic Ovarian Syndrome require 2 out of 3 of these markers:
- Ovulation disorders: You ovulate late or less often, resulting in irregular or infrequent menstrual cycles. This could mean your menstrual cycles are 35 days or longer, or you could have eight or fewer menstrual cycles per year. Approximately 95% of women with PCOS have ovulation disorders.
- Symptoms or labs that show elevated levels of androgen hormones: These are high lab levels of testosterone or DHEA. Or, symptoms such as “male pattern hair growth” (unwanted hair growth on your face, chest, abdomen, or back), scalp hair thinning, boils in your groin or armpits, dark skin patches, acne, skin tags, and a super high or insatiable libido. Approximately 60% of women with PCOS have high androgens.
- Polycystic ovaries on ultrasound: Specifically, 12 or more enlarged follicles in one ovary or both ovaries, measuring 2-9 m in diameter, and/or increased ovarian volume of > 10 ml) These can cause a swollen feeling, or severe pain if a cyst ruptures, but often no obvious symptoms. Only 17-33% of women with PCOS actually have ovarian cysts.
However, we often have patients that don’t exactly fit these diagnostic criteria. Yet they have enough symptoms to warrant a workup. One major concern with using only the Rotterdam criteria is that insulin resistance is a VERY common issue with PCOS, yet is not even considered in the Rotterdam markers.
The diagnostic criteria does not include insulin resistance?
Nope. Even though at least 70% of women with PCOS have insulin resistance! Based on our clinical experience, we suspect that even more than 70% of women with PCOS have issues with blood sugar and insulin.
Insulin resistance often comes with excess abdominal weight, but not always. You can be thin or of normal weight and still have signs of sugar and insulin problems. You may feel hypoglycemic symptoms when you go too long without eating. Perhaps you have sugar cravings. Or maybe when you eat sugar or refined carbohydrates you get an energy spike and then crash.
You may also have no obvious symptoms but have signs of early sugar and insulin problems on lab markers. These markers include fasting insulin (the most informative), glucose, hemoglobinA1C, and triglycerides.
When we suspect PCOS, we automatically test for these metabolic abnormalities. When these markers are off, combined with just 1 of the 3 Rotterdam criteria, it’s a clear signal that hormone imbalance is in play.
So, we count insulin resistance and blood sugar dysregulation as a fourth criterion for PCOS diagnosis – as many PCOS practitioners do. However, insulin resistance by itself, with no other signs of hormone imbalance, is not enough for a PCOS diagnosis.
What about infertility, isn’t that a THING?
Yes, PCOS is currently the leading cause of female fertility problems. This is primarily because of the ovulation disruption. This fertility aspect is a big part of why we are more commonly identifying PCOS nowadays. More women are screened for PCOS, because of seeking help for not being able to conceive. PCOS is now on most gynecologists’ and all reproductive endocrinologists’ radar.
But infertility is not always an issue with PCOS. Only some women have this problem. Infertility by itself does not mean PCOS; it’s a result, but not a diagnostic criterion. Think of it as a red flag that PCOS should be investigated.
How to view PCOS as a spectrum
The PCOS spectrum can range from mild to severe, with many variations. We used to think of most PCOS cases as severe types, with all three Rotterdam criteria plus insulin resistance. This classic type could be a woman with excess abdominal weight, sweet cravings, difficulty losing weight, irregular periods, and male pattern hair growth.
However, now we know that many moderate and mild, or atypical types exist, with only two criteria. A woman may have irregular periods and infertility but be thin and show no signs of high androgen hormones. Another atypical mild case could be a woman of normal weight, with sweet cravings and a slightly high fasting blood sugar, but with regular periods. By the way, these cases get diagnosed far less often!
PCOS has a reputation of being “hard to diagnose,” probably because the Rotterdam criteria are not inclusive enough. If your conventional doctor is only using the Rotterdam criteria, then it’s true, your mild PCOS may not be caught.
As functional practitioners we have hormone imbalance and PCOS on our radar even if you only have 1 of these signs. The more you have, the stronger the case for female hormone imbalance – which may meet the Rotterdam criteria for classic PCOS, may categorize you as “on the spectrum” with a mild version, or may mean you have a hormone imbalance that is not manifesting as PCOS . . . at least not now.
Don’t treat mild PCOS lightly
A mild version of PCOS is not something to take lightly. The drivers that got you there are not going to steer you to health unless you do something about them. PCOS is a hormone and metabolic disorder that, left untreated, has long term health risks.
The most effective means to healthily regulate your hormones and heal from PCOS is through lifestyle interventions. Depending on your particular case, this includes adjustments in stress, sleep, food, exercise, detoxification, digestion, and even gut bacteria! You can do the bulk of this yourself.
Often simply applying these interventions steers your hormones back on track, and then symptoms go away and lab markers normalize. By the way, this is true with mild hormone imbalance all the way to full-blown classic PCOS.
But, it’s hard to know which lifestyle interventions to make, and how to make them. This is exactly why we created our program. Instead of reading this blog or a book on PCOS and fixing it on your own, you can take this program and be gently guided through this process.