What is PCOS and How Does it Affect Fertility?

PCOS (Polycystic Ovary Syndrome) is one of the most common problems I diagnose and treat (especially in patients in their 20s to early 30s). PCOS is associated with irregular menstrual cycles – due to irregular ovulation caused by the ovaries not responding reliably to signals from the pituitary gland in the brain. Irregular ovulation can make the process of trying to get pregnant challenging and less efficient. PCOS can also be associated with skin/hair changes, mental health issues (anxiety and depression), weight gain, and an increased risk of developing chronic conditions like diabetes/hypertension over time. 

PCOS is diagnosed through a combination of medical history assessment, physical examination, and specific tests. The diagnostic process typically involves the following steps:

1. Medical History Assessment: Your healthcare provider will ask about your menstrual cycle, symptoms (such as irregular periods, excess hair growth, acne, or weight gain), and any relevant family history.
2. Pelvic Ultrasound: May reveal ovaries with lots of follicles (polycystic) that are especially located at the periphery of the ovary.
3. Blood Tests: Elevated testosterone levels and a high LH to FSH ratio are common findings in PCOS. Having high LH levels throughout the cycle often leads to false positive ovulation predictor kits. This can make it very difficult to anticipate ovulation and often contributes to the infertility associated with PCOS. 
4. Exclusion of Other Conditions: It is important to rule out other causes of irregular cycles (adrenal/thyroid issues, high prolactin). 

To be diagnosed with PCOS, you typically need to meet specific diagnostic criteria outlined by medical guidelines. I use the Rotterdam Criteria (you have to have 2 out of 3 of the following): 

1. Irregular/absent ovulation
2. Polycystic appearing ovaries
3. Signs of excess testosterone (oily skin/acne/excessive hair growth) or labs showing elevated androgens (testosterone/DHEAS/androstenedione)

**Note: Having a high AMH or excessive weight gain or having a certain BMI is not part of the diagnostic criteria. You can have high AMH without having PCOS. You can have PCOS despite being lean/thin/underweight. 

If trying to conceive, there are medications such as letrozole which can be used to help make cycles regular. Using metformin to make the cells in the body more sensitive to insulin may also help to regulate cycles. 

If not trying to conceive, optimizing general health to reduce the risk of metabolic issues (diabetes) and making sure you are shedding your lining at least once every 90 days (with progesterone) or by using birth control pills to balance out the effect of estrogen on the uterine lining is the main focus. Unopposed estrogen (not balanced out by progesterone) can cause an unhealthy thickening of the uterine lining which can eventually transform into uterine cancer. 

Improving quality of life issues such acne and  excessive hair growth is another major goal. Birth control pills can help as they increase the amount of a protein, sex hormone binding globulin – which binds free testosterone and lowers the overall effect of testosterone on the body, including the skin. Medications like spironolactone can also help to lower the activity of testosterone in the skin and hair follicles, and lower overall levels of testosterone in general. You cannot take spironolactone if you are trying to conceive as it can cause birth defects in a male fetus. I always recommend my patients who take spironolactone to be on a form of birth control. I find the combo of spironolactone + birth control pills works great for PCOS related acne and hair growth. Using laser/electrolysis and other cosmetic methods to treat excessive hair growth is also another important tool to improve one’s confidence and quality of life.

It is well known that people with PCOS can suffer from a higher incidence of depression and anxiety. It is important to be aware of this and use interventions such as talk therapy as well as pharmacologic treatments (anti-depressants and anti-anxiety medications) where necessary. 

Being on longterm pill/IUD can make it hard to know if you have underlying irregular ovulation from PCOS. Many patients with PCOS come to me without knowing about it – the reason they are often seeing me is that their periods are absent or irregular after coming off of hormonal contraception. There tends to be a misconception that the pill ‘masked’ their PCOS and caused a delay in diagnosis. However- despite this negative connotation, I do not think of this as problematic at all, as hormonal contraception is actually a form of PCOS treatment anyway!

If you are dealing with irregular menstrual cycles and you aren’t sure why, It’s important to consult a healthcare professional for a comprehensive evaluation, accurate diagnosis, and appropriate management of possible PCOS.