PCOS: what it is, how it affects fertility, and what treatment works

What PCOS is

Polycystic ovary syndrome is a hormonal condition diagnosed when at least two of three features are present: irregular or absent ovulation, signs of raised male hormones (acne, excess facial or body hair, hair thinning at the scalp, or blood tests), and polycystic-appearing ovaries on ultrasound.

The 'cysts' are not true cysts but small follicles that have not matured and released an egg — which is why ovulation becomes irregular and periods unpredictable.

Insulin resistance sits behind much of it. It is common in South Asian women even at lower body weights, and it explains the link with weight gain, dark velvety skin patches at the neck and armpits, and a raised long-term risk of type 2 diabetes.

Diagnosis and what to ask for

Tests usually include: hormone levels, thyroid function, prolactin, blood sugar and insulin or an oral glucose tolerance test, lipid profile, and a pelvic ultrasound. Other conditions that mimic PCOS — thyroid disease, high prolactin, and rarer adrenal conditions — are excluded first.

Ultrasound alone does not diagnose PCOS. Many women have polycystic-looking ovaries without the syndrome, and a scan report using that phrase is not a diagnosis by itself.

Ask specifically for a metabolic assessment — sugar, insulin and lipids — because PCOS management is as much about long-term health as about fertility.

Treatment: what actually works

Weight and activity: where weight is raised, losing even 5-10 per cent of body weight restores ovulation in a substantial proportion of women. Regular exercise improves insulin sensitivity independently of weight loss, which matters for women whose weight is already normal.

Diet: no special PCOS diet is required. What helps is the pattern — lower refined carbohydrate, more fibre, protein at each meal, and portion control of rice and refined flour. The changes are the same ones that manage insulin resistance generally.

Medicines: metformin improves insulin sensitivity and sometimes restores cycles; the combined pill regulates periods and controls acne and excess hair for women not trying to conceive; and for those who are, ovulation induction with letrozole (now first-line in most guidance) or clomiphene works well. IVF is used when those fail or other factors exist.

Protect the uterus: with very infrequent periods, the lining can thicken over years and raise the risk of endometrial problems. Even without fertility plans, a woman with PCOS should have a plan with her doctor to bleed regularly — usually with hormonal treatment.

Conceiving with PCOS

Most women with PCOS who want a baby conceive, often with simple ovulation induction. The main obstacle is unpredictable ovulation, not an inability to conceive.

Practical points: ovulation predictor kits are less reliable in PCOS because LH may be persistently high; tracking mucus and using regular sex every two to three days works better; and treatment is monitored with scans to avoid multiple pregnancy.

In pregnancy, PCOS raises the risk of gestational diabetes and high blood pressure — so early booking, the sugar test on schedule, and closer monitoring matter. Tell your obstetrician at the first visit.

When to see a doctor

Book an appointment for: periods that are irregular, absent for three months or more, or come fewer than eight times a year; new or worsening excess hair, acne or scalp hair loss; difficulty conceiving; or dark velvety skin patches at the neck or armpits.

Same-day: severe pelvic pain (an ovarian cyst can twist or rupture), heavy bleeding with dizziness, or symptoms of very high blood sugar such as excessive thirst, urination and weight loss.

This article is general information, not medical advice, and is no substitute for personal medical advice. For any decision about your or your child's health, please consult your doctor.

Frequently asked questions

Q: Does PCOS go away? — It is a long-term condition rather than an infection to be cured, but its symptoms are very manageable and often improve substantially with weight, activity and treatment. Many women find it much less troublesome after their thirties.

Q: Will I need IVF? — Most women with PCOS do not. Ovulation induction tablets are the usual first step and are inexpensive; IVF is reserved for those who do not respond or who have additional factors.

Q: Are the herbal PCOS cures advertised online useful? — Inositol has some evidence and is discussed by many doctors; most other products do not. None replaces treating insulin resistance and restoring ovulation. Ask your doctor before spending.

Q: I am not overweight — can I still have PCOS? — Yes. 'Lean PCOS' is common in South Asian women, and insulin resistance can be present at a normal weight. The diagnosis and the treatment both apply.