PCOS 360

6 Mar 2023

6 Mar 2023

by Dr. Oybek Rustamov in Fertl Edu

This is not another run-of-the-mill blog on PCOS. It is a comprehensive article which explains the cause of PCOS, how each symptom develops, and how you can diagnose it.

More importantly, the article equips you with the knowledge of how to prevent the symptoms from developing into stressful problems. If you already have PCOS-related issues, you can address them using the solutions I recommend in the article and obtaining medical help.

You can bookmark this as your guide for dealing with PCOS. If you do not find an answer to your questions, please ask using the Contact Us form and I will try to answer promptly.

What is PCOS?

Polycystic ovary syndrome, or PCOS, is a common reproductive health problem that affects 1 in 10 women.

As the name suggests, women with PCOS have an excess amount of small fluid-filled sacs in their ovaries, which look like small cysts. In fact, these “cysts” are growing follicles containing eggs, called antral follicles.

Normally, all women have antral follicles during reproductive ages. However, women with PCOS have an excess amount. These follicles can be counted using an ultrasound, a method called Antral Follicle Count (AFC). This count should be less than 20 in each ovary, or less than 40 in total.

Women with PCOS usually have a higher AFC. It appears that the high number of antral follicles is responsible for the other symptoms of PCOS, which include irregular menstrual cycles and high levels of male hormones.

Antral follicles produce the Anti-Mullerian Hormone (AMH), a hormone responsible for regulating ovulation. At any given time, there are many antral follicles in the ovaries. However, in each menstrual cycle, only one (1) follicle should grow larger and ovulate. This means that the remaining antral follicles should be kept suppressed, which is the role of AMH.

In PCOS, the amount of AMH is so high that it keeps all of the follicles suppressed. Even one (1) leading follicle cannot escape the suppression of AMH and hence, ovulation does not occur.

For the menstrual period to occur, women should produce estrogen in the first 14 days of the menstrual cycle and produce progesterone after ovulation. Since ovulation does not occur every month in PCOS, women do not produce progesterone and do not have their monthly menstrual period.

Ovulation may occur once every 2 to 3 months, which means that women with PCOS often have their menstrual period once every few months. Similarly, due to lack of regular ovulation, they do not release an egg every month – leading to infertility.

IMAGE 1. In PCOS, women have more than 20 follicles in each ovary.

Cause of PCOS

The official cause of PCOS is unknown. However, we know the following things about the condition.

Based on the facts above, we can assume that women with PCOS are born with high egg reserves. They have an excessive number of growing follicles that produce too much male hormones. This causes high levels of androgens in the blood. In addition, due to the high levels of the Anti-Mullerian Hormone, growing follicles are suppressed and cannot ovulate. Finally, the lack of ovulation causes irregular menstrual cycles and infertility.


IMAGE 2. Women with PCOS are born with very high Egg Reserves. Hence, they have very high Antral Follicle Counts (AFC), very high Anti-Mullerian Hormone (AMH) levels, and late menopause.


If you have two or all of these symptoms, you can be diagnosed with PCOS. PCOS diagnosis is based on the three (3) following symptoms:

  1. Symptoms of excess androgens
  2. Signs of no ovulation, or “anovulation”.
  3. Polycystic ovaries seen on ultrasound.

There are four types of PCOS:

  1. Type A: All three symptoms present, known as Classic PCOS.
  2. Type B: Excess androgen and anovulation.
  3. Type C: Excess androgen and polycystic ovaries seen on ultrasound.
  4. Type D: Anovulation and polycystic ovaries seen on ultrasound.

How do you diagnose excess androgen?

Excess androgen can be diagnosed based on symptoms or a blood test for male hormones. For the diagnosis of PCOS, either is fine. To diagnose on the basis of symptoms, you should look for signs of high amounts of male hormones. This usually manifests as excess hair growth, acne, and the loss of scalp hair.

Hirsutism is the excess growth of body and facial hair. The best diagnostic tool for hirsutism is the Modified Ferriman-Gallwey Score (mFG Score). An mFG score of 6 or more is considered as an indication of excess androgen in PCOS. For the severity of hirsutism, an mFG score of 6 to 15 is mild, 16 to 24 is moderate, and more than 25 is severe.

You can check your mFG Score using the PCOS Quiz on this page!

Excess androgen can also be diagnosed using a blood test that measures the amount of the following male and steroid hormones: free testosterone, androstenedione, and Sex Hormone Binding Globulin (SHBG).

To obtain a full hormonal profile, this blood test is often performed with the Female Hormone Profile which includes FSH, LH, Oestradiol, Prolactin, and AMH. Since male hormone levels normally vary in the blood, women with symptoms of excess androgen may have normal male hormone levels. In this situation, clinical assessment based on the symptoms can be used for a diagnosis.

The Female Hormone Profile can be done any day of the menstrual period. Blood samples should be taken in the morning and does not require fasting. The normal levels are:

Active androgen levels are measured by the Free Androgen Index (FAI). This can be calculated by comparing the Total Testosterone (TT) and Sex Hormone Binding Globulin (SHBG) levels.


IMAGE 4. Modified Ferriman Score (mFG Score).

How do you diagnose anovulation?

Anovulation can be diagnosed using symptoms or performing a blood test. A regular menstrual cycle occurring approximately every 28 to 35 days is a very reliable sign of ovulation. Irregular menstrual cycles lasting longer than 35 days indicate that ovulation is not taking place every month.

We can reliably diagnose anovulation in women with irregular periods. Not having periods for longer than 6 months, known as amenorrhea, also confirms anovulation. Anovulation can also be diagnosed using LH kits, though, they may give false readings.

Progesterone level is a very accurate test for ovulation.

Since the only source of progesterone is an ovulated follicle, high levels of progesterone confirm ovulation. Progesterone gradually increases to its peak on the 7th day after ovulation. With that, it is important to time progesterone correctly. In 28-day cycles, ovulation occurs around the 14th day of the menstrual cycle and progesterone level should be measured on the 21st day. In 35-day cycles, progesterone is measured on Day 28 of the cycle. Also, progesterone levels higher than 30 nmol/L confirms ovulation.

How do you diagnose Polycystic Ovaries?

Polycystic ovaries are diagnosed using an internal pelvic ultrasound scan. The sonographer counts the antral follicles, measures the volume of the ovaries, and looks for specific features of polycystic ovaries. If any of the features below are present, a sonographer can diagnose polycystic ovaries:

  1. Antral Follicle Count more than 20 in each ovary or more than 40 in total.
  2. Volume of either or both ovaries larger than 10 cm^3.
  3. “String of pearls” sign. Due to the hardening of the ovaries’ outer layer, the follicles are arranged around the surface of ovaries. In the ultrasound, this looks like a string of pearls.

Screening for PCOS

You can check if you have symptoms of PCOS using symptom checker questionnaires. Since women with PCOS have very high levels of AMH, the AMH test can be used as a reliable tool for screening.

Categories of Related Problems

Polycystic ovary syndrome causes three different categories of problems:
  1. Metabolic
  2. Skin
  3. Reproductive
IMAGE 5. Categories of PCOS Problems.

Metabolic Problems

In PCOS, for unknown reasons, the body cells become resistant to insulin.

Insulin, a hormone produced from the pancreas, transports blood glucose into the muscle, fat, and liver cells where it will be used for energy. With insulin resistance, the cells do not take up glucose easily, leaving a high amount of sugar in the bloodstream. In response, the pancreas produces more insulin to push the glucose into the cells.

Provided that the pancreas keeps up with the insulin production, the level of glucose in blood remains normal. Gradually, the pancreas can fail to provide enough insulin. Resulting in blood sugar, it can lead to prediabetes and later, type II diabetes.

High amounts of circulating sugar can enter visceral fat cells in excess amounts and cause a cascade of metabolic changes. The fat surrounding the internal organs in the abdomen and around the tummy is called visceral fat. This has different properties than fat in other parts of the body.

Visceral fat, or belly fat, produces hormones and various substances that cause generalised inflammation. Chronic generalised inflammation worsens insulin resistance and leads to further weight gain, high blood pressure, and heart diseases. Additionally, insulin resistance can cause a specific skin feature, like brown skin tags. Some areas of the skin, such as the armpit or the back and sides of the neck, can also darken which is called acanthosis nigricans.

In severe forms of insulin resistance, women develop metabolic syndrome which has the following symptoms:

  1. Elevated waist circumference: >80 cm
  2. Elevated blood pressure: Systolic BP >130 or Diastolic >85
  3. Elevated fasting glucose level: > 5.6 mmol/L
  4. Elevated triglycerides: >1.7 mmol/L
  5. Reduced High-Density Lipoprotein Cholesterol (HDL-C): <1.3 mmol/L

Metabolic syndrome can be diagnosed in women with three or more of the above symptoms.

Skin Problems

PCOS-related skin problems are caused by high levels of male hormones or androgens.

Normally, women produce a small amount of male hormones, like testosterone, dihydrotestosterone (DHT), androstenedione, and dehydroepiandrosterone sulphate (DHEAS). These hormones are necessary to maintain reproductive function, provide energy, and maintain metabolism.

To understand the cause of hormonal problems in PCOS, we should review how these hormones are produced. For this, we should look into ovarian follicles, the main source of production of the male hormones.

Sleeping eggs and their surrounding nursing cells together are called primordial follicles.

Women are typically born with around half a million primordial follicles in their ovaries, known as egg reserve. However, women with PCOS genes are born with three to four times more eggs in their ovaries. This is a starting point that determines who will have PCOS.

Almost all primordial follicles rest in a non-active state until their activation. Hence, they are called “sleeping eggs”. Once the time for each egg comes, they activate and start growing.

The time from activation to full growth, or follicle development, takes approximately three months. Towards the end, activated eggs and their surrounding nursing cells, called granulosa cells, undergo rapid changes.

The size and number of granulosa cells increase and start producing hormones such as estrogen and AMH. This stage is called the Pre-Antral Follicle stage. Later, the fluid-filled cavity or “Antrum” in Latin, accumulates between the layers of the egg and its surrounding granulosa cells. Hence “Antrum”, we call this the Antral Follicle stage.

During this period, the follicles measure 2 to 10 mm in size and are visible on an ultrasound scan. One of the antral follicles is selected to become a dominant follicle when it grows to 17 to 20 mm in size and ovulates the egg. The remaining preantral and antral follicles stop developing, are broken down by immune cells, and taken away from the ovaries.

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Having discussed the structures of the ovaries which produce female and male hormones, we can now discuss the actual production of these hormones. More importantly, we will try to understand why women with PCOS produce both female and male hormones in excess amounts and what we can do about it.

The main female hormone is called estrogen and the male hormone is called testosterone. They are also called sex hormones.

Both female and male hormones are mainly produced from the sac of growing antral follicles in the ovaries. Women without PCOS have approximately 15 to 20 antral follicles in their ovaries. Given this is an average number, they produce a normal amount of sex hormones. However, women with PCOS have an antral follicle count (AFC) of more than 40, meaning they have 2 to 3 times more follicles. A large number of growing follicles in ovaries produce a much higher amount of male hormones than necessary.

There are two more sources of male hormone production in women.

Adrenal glands produce different types of male hormones called DHEAS and androstenedione. The role of these hormones is not significant in women of reproductive age as they play important roles after the menopause.

The other important source of production of male hormones is fat tissue. The enzymes produced from the fat cells can convert estrogen into testosterone. So, fat transforms a male hormone from a female hormone, especially belly fat.

PCOS increases the activity of an enzyme called 5-alpha reductase which converts testosterone to a more potent form of a male hormone, dihydrotestosterone (DHT). High levels of androgens stimulate skin glands to produce more sebaceous fluid which can increase oiliness of skin and cause acne.

With regards to hair growth, testosterone and DHT affect different parts of the body differently. To understand it, we should explore normal hair growth in women. Generally, there are two different types of hair in the body: vellus and terminal hair.

In women of reproductive age, the scalp, armpit, and pubic area are covered with thick terminal hair. The rest of the body is covered with fine vellus hair.  Prolonged exposure to high amounts of androgens turns follicular into terminal hair in all parts of the body. It has the opposite effect on the scalp’s terminal hair, making the scalp hair thinner and finer, turning into vellus hair. Later, vellus hair starts falling off which causes alopecia.

IMAGE 7. Frequency of problems in women diagnosed with PCOS.

Reproductive Problems

PCOS-related problems of the reproductive system are linked to not ovulating regularly. In fact, women with PCOS have high egg reserves and long fertility.

For instance, women with normal egg reserves run out of eggs at the age of 40 to 47 and stop having menstrual periods at the age of 45 to 52. Women with PCOS run out at the age of 48 to 55 and become menopausal at age 53 to 60 years. They can release eggs in their mid to even late forties. However, with age, the quality of eggs become poorer which reduces the odds of conception.

If women with PCOS have high egg reserves and long fertility, why do they struggle to conceive? Good question.

This is something to do, again, with the amount of antral follicles they have in their ovaries. To understand this, we need to take a journey into the follicles and eggs in the ovaries. If it is too technical, you can skip this section.

As we discussed, growing antral follicles produce the AMH hormone. One of the roles of AMH is to prevent all antral follicles from becoming dominant and ovulating. This is nature’s way of preventing ovulation of multiple follicles at once. This ensures that only a single follicle can ovulate to prevent twins, triplets or even higher order pregnancies.

The amount of AMH in ovaries and blood determines how much suppression takes place.

Women with normal egg reserves and normal amounts of antral follicles produce an average amount of AMH. This is just enough to keep all follicles suppressed, except the one leading follicle. Once the leading follicle enters the dominant stage, it starts producing hormones, like estrogen and inhibin which send a signal to the pituitary gland.

Subsequently, the pituitary gland slows down FSH production and stops stimulating the remaining follicles. So, in concert with other ovarian and pituitary hormones, AMH plays the role of suppressing antral follicles and ensuring only one follicle ovulates. In other words, AMH is the gatekeeper of follicles.

Women with PCOS have a large number of antral follicles and produce very high levels of AMH. High AMH concentration in the ovaries suppresses more follicles than necessary. As a result, none of the follicles manage to escape the suppression and cannot grow into the dominant stage. Unless follicles grow into their dominant phase, they cannot ovulate.

As a result, we have a paradox of PCOS.

Women have lots of follicles but do not release them. In this strange situation, women have very high fertility as they have a high number of eggs, but are temporarily infertile. Why temporarily? Because they become fertile later. How come? Because as PCOS women age, their egg reserve declines, their antral follicle count reduces, and their AMH becomes normal.

The normal AMH does not suppress the growing follicles as much and women start ovulating. So paradoxically, women with PCOS are infertile in their twenties to early thirties and become fertile in their late thirties and early forties.

The time they start ovulating and become fertile depends on the severity of PCOS. Women with mild PCOS start having normal AMH in their late twenties to mid-thirties and start ovulating. AMH levels of women with severe PCOS become normal in their late thirties to mid-forties and ovulating.

However, ovulation does not necessarily mean they have normal fertility. As age affects the quality of eggs, their overall fertility declines with age. Hence, women with PCOS should not wait until their ovaries start ovulating. They should start trying to conceive when they are ready. Though, they may need fertility treatment, which we will discuss later.

Treatment of PCOS

There are two types of treatment for problems caused by PCOS: General Treatment and Targeted Treatment.

General treatment includes weight loss, metformin, and the hormonal pill. These treatments help correct the underlying metabolic and hormone changes caused by PCOS. Targeted treatment is directed to relieving symptoms of each individual PCOS-related problem. Both treatments are important to improve the overall symptoms of PCOS and achieve the desired effect.

General Treatment

Weight Loss

When it comes to weight, PCOS women pulled the short straw. It is not easy to keep their weight down.

This is because of how the metabolism works. For women with PCOS, it is easy to gain weight. Even if they eat an average amount of food, they can easily put weight on. But it is very hard to shed any weight. Due to insulin resistance, they always have higher levels of blood sugar.

Instead of distributing sugar to cells as an energy source, they convert most of the sugar into fat. In addition, they disproportionately transport higher amounts of sugar into visceral fat which is notoriously difficult to lose. While other parts of the body convert sugar into predominantly healthy High-Density Lipoproteins (HDL), visceral fat stores it as unhealthy cholesterol, triglyceride (TGL).

Excess amount of body weight, particularly increase in tummy fat, creates metabolic changes in the body and triggers other symptoms of PCOS. An increase in the level of unhealthy triglycerides can cause collection of fatty cells inside the blood vessels, called atherosclerosis. If weight loss is not achieved, this can lead to heart diseases in later life.

The conversion of estrogen to testosterone in fat tissue can increase the amount of male hormones in the bloodstream. This can cause skin symptoms, such as excess hair growth and acne.

There is a link between body fat and ovarian function, but the mechanism is not fully understood. However, it is likely to be related to insulin resistance and the production of enzymes and androgens from fat cells. This mechanism is responsible for the change in ovarian function when body weight is increased or reduced.

Women with PCOS stop ovulating once their body weight increases. Similarly, once they lose weight, they start ovulating again. Studies show when PCOS women with obesity lose 10 percent of their body weight, they start ovulating. For instance, a 10-kg weight loss is sufficient for a woman of 100 kg to start ovulating. This regulates their periods, restores fertility, and improves metabolic and skin problems.

So, we all agree gaining weight is easy for women with PCOS and often, it is not their fault. Increased weight causes multiple PCOS symptoms. Losing weight is very important in dealing with PCOS. Now, we know why we should focus on weight loss and know that there is no way around it. I know it is harder for women with PCOS, but it is achievable and the reward is immense.

It will transform all aspects of your health and wellbeing – it is worth the effort.


Earlier, we explored how insulin resistance causes a cascade of metabolic changes which results in increased blood sugar, weight gain, hormonal changes, blood pressure, and heart disease.

Metformin is a drug that counteracts these pathological processes by making cells more sensitive to insulin. As a result, circulating sugar in the bloodstream can easily enter the cells to be used as an energy source.

Due to the generalised effect of metformin on one’s whole metabolism, it improves all symptoms of PCOS. However, metabolic changes are slow processes and the benefits are gained through long-term use.

You can start metformin tablets in lower doses and gradually increase the number of tablets you take. Initially, you take a 500 mg tablet once a day for a week. Next week, a 500 mg tablet twice a day for a week. Then, you can increase it to three to four times a day.

Metformin side effects include feeling sick, vomiting, diarrhea, stomach pain, loss of appetite, and a metallic taste in the mouth. Usually, side effects gradually settle. Taking metformin can cause Vitamin B12 deficiency, which can cause tiredness, mouth ulcers, and problems with vision. If you have these symptoms, you should check the Vitamin B12 levels in your blood.

Hormonal Pill

The pituitary gland and ovarian hormones govern the reproductive system.

FSH and LH hormones produced from the pituitary stimulate ovaries to grow antral follicles into dominant follicles and ovulate the egg. Growing antral follicles produce estrogen and testosterone. In return, estrogen levels regulate FSH and LH production by sending feedback signals. This chain of feedback interactions can be broken by administering artificial estrogen hormone.

Combined Oral Contraceptive Pills (COCP) contain artificial estrogen and progesterone hormones. Administration of COCP blocks the pituitary gland from producing FSH and LH. With low levels of FSH and LH, antral follicles are not stimulated and prevent the growth of a dominant follicle and ovulation. Further, the production of estrogen, and more importantly testosterone, from the follicles remain very low.

Like we discussed earlier, some PCOS symptoms are fuelled by the production of estrogen and testosterone in high levels. Reducing estrogen and testosterone levels improve most PCOS symptoms, including skin problems.

In PCOS, high and prolonged estrogen production causes the uterine lining to continuously grow. Since ovulation does not take place regularly, women with PCOS do not produce progesterone. To have menstrual period, the uterine lining should get progesterone. An increase and subsequent reduction in progesterone levels causes menstrual period.

In PCOS, the lack of progesterone causes the uterine lining to build up, causing unscheduled and prolonged bleeding. As COCP contains both artificial estrogen and progesterone, despite not having ovulation, women have regular menstrual periods. This allows the regular renewal of uterine lining which is important in preventing unexpected heavy and prolonged menstrual periods.

Since hormonal pills stop ovulation and have contraceptive effects, this treatment is not ideal for women trying to conceive.

IMAGE 8. General Treatment.

Targeted Treatment

In targeted treatment, we will discuss how you can manage each symptom of PCOS.

Excess Weight

We can assess body weight by measuring Body Mass Index (BMI) and waist circumference.

Waist circumference is obtained by placing a tape measure halfway between your lowest rib and the top of your hip bone. This is roughly in line with your belly button. You can breathe normally while measuring. Waist circumference is used to estimate tummy fat to assess your risk of metabolic diseases, like diabetes, blood pressure, and heart diseases. The risk can be calculated in three categories:

Women with PCOS should try to keep their weight within a normal BMI and waist circumference of less than 80 cm. Given they are at risk of metabolic and hormonal changes, an increase in body weight and tummy fat triggers the development and worsening of PCOS symptoms. So, keeping weight in the normal range should be the priority.

There are five ways to lose weight and keep it under control:

Healthy diet and regular physical exercise are the necessary parts of your weight loss project.

A healthy diet provides necessary amounts of nutrients that are essential for your overall well being. Regular physical exercise increases your metabolic rate and helps you lose weight faster and improve your physical as well as mental well being.

Medical treatment of weight loss includes tablets and injections (Summarized on Image 9). These treatments are available for women with a BMI over 30. The treatment can be prescribed to women with a BMI over 27 if they have one of the following: diabetes, high blood pressure or dyslipidemia.

Dyslipidemia is diagnosed using a blood test for a fasting lipid profile. High levels of unhealthy cholesterol (LDL cholesterol >  3.3 mmol/L or triglycerides > 1.7 mmol/L) or low levels (HDL cholesterol < 1.5 mmol/L) is the diagnosis of dyslipidemia.

Using diet, physical exercise, and medications, most women achieve target weight. If these interventions are not successful, bariatric surgery can be considered in women with a BMI over 35. The common forms of weight loss surgeries are intragastric balloon (Orbera), sleeve gastrectomy, single anastomosis gastric bypass, and RY gastric bypass.

Bariatric surgery may provide significant weight loss and improvement of health. Since it involves a significant surgical intervention, bariatric treatment is recommended only when other treatments have not been successful.

Unwanted Hair

To diagnose excess hair, we should use objective tools for assessment. The Modified Ferriman Gallwey (mFG) Score is the best tool for diagnosis and monitoring the effects of the treatment.

Unwanted hair is directly linked to abnormal metabolism, increased weight, and excess androgen. Hence, general treatment to improve insulin resistance, weight loss, and reduction in androgen production is essential. In addition to these, treatments that reduce the effect of androgens and local treatment of excess hair are recommended.

The first line treatment to improve insulin resistance is metformin. The effect of metformin can be monitored using blood tests for fasting sugar levels. If the fasting blood sugar level is more than 5.6 mmol/L, the glucose tolerance test (GTT) gives a more accurate assessment of insulin resistance and development of pre-diabetes and diabetes.

If metformin is not effective, a more potent treatment, such as Ozempic and Saxenda, can be prescribed.

Since increased body fat contributes to excess androgen production, achieving and maintaining normal weight is essential. Weight loss also improves metabolism and insulin resistance which reduces unwanted hair.

Hormonal Treatment

Androgen production in the ovaries is stimulated by a cyclical change in FSH and LH hormone, which is produced during the menstrual cycle by the pituitary gland. Combined Oral Contraceptive Pills (COCP) contain estrogen and progesterone that suppress FSH and LH production.

In addition, COCP increases the protein in blood called the Sex Hormone Binding Globulin (SHBG). This protein binds sex hormones and reduces the amount of free androgen hormones in the blood. Therefore, COCP can reduce the amount of androgens in the blood and improve symptoms of unwanted hair.

The effect of COCP on hirsutism can be seen after taking it at least for 6 months or longer.


Cyproterone Acetate (CA) is commonly used as an anti-androgen for hirsutism. It blocks the binding of testosterone and DHT to androgen receptors of the hair follicles. Essentially, hair follicles do not fully “sense” androgens in the blood when you take CA.

Cyproterone acetate can be used in doses of 50 to 100 mg daily. Also, you can take it as part of the Diane-35 tablet containing COCP and Cyproterone Acetate. Side effects include headache, weight gain, breast tenderness, and depression. It can have a toxic effect on the liver in some patients, therefore women should have the liver function test (LFT) periodically while on CA. Cyproterone acetate can also be used for treatment of alopecia.

Spironolactone is the most effective anti-androgen for treating hirsutism, acne, and alopecia. It blocks androgen receptors, so testosterone and DHT cannot stimulate the growth of body and facial hair. Spironolactone can be started with a 25 mg tablet a day and progressively increase to 100 mg per day over a week. It can cause the following side effects: tiredness, dizziness, and low blood pressure.

Flutamide reduces androgen production and blocks androgen receptors. The daily dose of flutamide is 250 to 750 mg. It is effective for hirsutism, acne, and alopecia. However, it can have hepatotoxic effects in some women. Therefore, monitoring of liver function is necessary.

Finasteride blocks the conversion of testosterone to a more active androgen DHT. Due to the reduction of DHT levels, it can improve symptoms of hirsutism significantly.

Using anti-androgens strictly contraindicates pregnancy. Anti-androgens can cause serious abnormalities in the fetus. With that, women on anti-androgens must use very effective contraception, like COCP or long-acting reversible contraceptives.

Local Treatment

Local treatment of hirsutism includes waxing, bleaching, laser removal, and anti-androgen cream (Vaniqa).

Effective treatment of unwanted hair can be achieved through weight loss, improving insulin resistance, COCP, anti-androgens, and local skin treatments.


In PCOS, infertility is mainly caused by anovulation. However, conceiving requires optimal functioning of both female and male reproduction. Therefore, it is important to conduct a full assessment of fertility. If all other causes of infertility, such as male factor, tubal disease, severe endometriosis, and uterine pathologies, are excluded, treatment of anovulation can be started.

Women with PCOS have plenty of follicles in their ovaries. Due to high levels of AMH and other ovarian hormones, they do not ovulate regularly. To achieve ovulation, you need a higher level of FSH and LH hormones.

This can be achieved in two different ways.
  1. Clomid or Letrozole tablets. Increases your own FSH and LH production from your pituitary gland.
  2. FSH and LH Injections. These treatments are called Ovulation Induction (OI). Its effectiveness is approximately 10 percent per month. Provided ovulation is achieved, it is recommended to continue OI for 4 to 6 months, giving approximately 35 percent chance of a successful pregnancy. If OI is not effective, it is assumed there may be other causes of infertility. Then, IVF Treatment is recommended.

Long-Term Health Problems

Due to metabolic changes, PCOS increases your risk of developing diabetes, high blood pressure, and heart disease. Therefore, you should undergo a PCOS Annual Check-up which includes the following:

If necessary, your doctor will provide you with advice on lifestyle modifications and treatment for metabolic problems. The main objective of the annual check-up is identifying risk factors, early detection of metabolic syndrome symptoms and prevention of diabetes and cardiovascular diseases.

In PCOS, continuous estrogen production without progesterone can cause excessive growth of the uterine lining, called unopposed estrogen. Long-term unopposed estrogen for years can cause changes in the uterine lining and increase the risk of endometrial cancer.

During the menstrual cycle, women shed old uterine lining. The renewal of the uterine lining reduces the risk of endometrial lining. Therefore, women with PCOS should try to achieve a menstrual period at least once every 3 to 4 months. This can be achieved using COCP or Progesterone tablets, such as Provera.


Polycystic Ovary Syndrome (PCOS) is a common condition that is linked to ovarian function, excess androgen production, increased insulin resistance, and metabolic abnormalities. PCOS causes metabolic, skin, and reproductive problems which can be very distressing.

PCOS can be diagnosed if women have two or all three of these symptoms: irregular period, excess androgens, and polycystic ovaries. Effective treatment of PCOS has two strategies: generalised and targeted treatment. Most women benefit from generalised treatment which includes maintaining body weight in normal range, metformin to improve insulin resistance, and taking COCP.

Specific symptoms, such as unwanted hair, acne, and infertility, can also be treated using effective targeted treatment.

To prevent diabetes, blood pressure, heart disease, and endometrial cancer, women should have an annual check-up.


International evidence-based guideline for the assessment and management of polycystic ovary syndrome,
ESHRE, CREPCOS, ASRM, Monash University 2018.


Wołczyński S, Zgliczyński W.
Abnormalities of the menstrual cycle. In: Large Interna – Endocrinology. 2nd edition. Medical Tribune Poland, Warsaw 2012


Fica S, Albu A, Constantin M, Dobri GA, Davila C.
Insulin resistance and fertility in polycystic ovary syndrome. J Med Life. 2008;1(4):415– 422.


The Rotterdam ESHRE/ASRM-sponsored PCOS consensus work- shop group.
Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004


Sunita J. Ramanand, Balasaheb B. Ghongane, Jaiprakash B. Rama- nand, et al.
Clinical characteristics of polycystic ovary syndrome in Indian women. Indian J Endocrinol Metab. 2013;17(1):138–145.


Shalini Gainder, Bharti Sharma
Update on Management of Polycystic Ovarian Syndrome for Dermatologists. Indian Dermatology Online Journal, V10, Issue 2


Sylwia Bednarska, Agnieszka Siejka.
The pathogenesis and treatment of polycystic ovary syndrome: What’s new? Adv Clin Exp Med. 2017;26(2):359–367


Bode et al.
Hirsutism in Women American Family Physician. Volume 85, Number 4, February 15, 2012

About the Contributor/Author & Reference


Chief Medical Officer, Fertl

Fertility Specialist, Obstetrician & Gynaecologist,
Clinical Director, Adora Fertility Brisbane, Australia

Sub-Specialty Training in Reproductive Medicine & Surgery
Cambridge University Hospitals, 2013-2015

Doctor of Medicine (MD)
University of Manchester, 2011-2014
Thesis: The Role of Anti-Müllerian Hormone in Assisted Reproduction in Women

Scientific Work in Women’s Health
High Impact Journal Articles: 11
Textbook Chapters: 3
International Conference Presentations: 21

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Adenomyosis 360 This is a comprehensive blog written for women diagnosed with adenomyosis. I cover each and every aspect of the disease. You can safely

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Endo 360

Endometriosis 360 Guide This is a comprehensive blog article written for patients suffering from endometriosis. I will touch up on each and every aspect of

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