PCOS: Causes, Symptoms and the Integrative Path
PCOS is not a single defect of the ovaries. It is an interplay of hormones and metabolism, in which insulin resistance often pulls the strings in the background. Once you understand that, you see behind acne, cycle disorder and cravings not a single diagnosis, but a system with many points of entry.
Many women with PCOS have a long road behind them before the diagnosis finally lands. Years of irregular cycles, of acne that will not go away, of cravings that cannot be explained. And then they often hear just one sentence: Take the pill or lose weight. I see it differently. PCOS is not a single switch that is stuck. It is a connected process of hormones, insulin, inflammation and genes. That is exactly what makes it workable, because a net can be addressed in several places.
Perhaps you know this. Your cycle comes when it pleases, or not at all. The skin on your chin stays inflamed, even though you left sixteen behind long ago. Hairs grow in places where you would rather they did not. And the afternoon craving feels like a pull that discipline can do little against. Perhaps you have also been told you simply have PCOS and should learn to live with it. That is not enough.
This article looks more closely. We clarify what PCOS actually is and why the small follicles on ultrasound are not true cysts. We understand the four PCOS phenotypes and why insulin resistance is so often the driver in the background. We talk about diagnosis and about evidence-based levers, from diet to inositol. And again and again it comes back to the three-step rhythm: feel what is going on, understand why, and then act.
What PCOS really is
The name is a little misleading. Polycystic ovary syndrome sounds like cysts in the ovaries. In fact the many small follicles you can see on ultrasound are not true cysts but immature egg follicles that have stalled. And not every woman with PCOS even has this picture. PCOS is therefore not the finding of a single organ but a syndrome, that is, a pattern of several features.
Three building blocks span this pattern. First, elevated male hormones, hyperandrogenism, which can show on skin and hair. Second, a disturbed or absent ovulation, which appears as irregular or infrequent cycles. Third, the typical ultrasound appearance with many small follicles. How these three building blocks come together differs from woman to woman. That is exactly what makes PCOS so varied.
PCOS as the most common hormonal and metabolic disorder
Review According to PubMed, Ricardo Azziz described PCOS in 2018 in Obstetrics and Gynecology as by far the most common hormonal and metabolic disorder in women of reproductive age. He classes PCOS as a highly heritable, multifactorial disorder and names four recognised phenotypes with different long-term metabolic implications. Abnormalities of insulin action are among the described core mechanisms. Notably, his conclusion is that despite great progress, PCOS remains often underdiagnosed and misunderstood.
Azziz R. Obstet Gynecol. 2018;132(2):321-336. doi:10.1097/AOG.0000000000002698 · PMID: 29995717
How common PCOS is depends strongly on which criteria you apply. A review by Daria Lizneva and colleagues in 2016 in Fertility and Sterility places the various estimates in context and describes how the frequency changes by definition and by the group studied (according to PubMed, doi:10.1016/j.fertnstert.2016.05.003, PMID: 27233760). Across the studies, the figure is put at around five to twenty percent of women of reproductive age. And now you know why PCOS is not a rare diagnosis but affects many women.
PCOS is not your failure and not a sign that you simply need to try harder. It is a strongly heritable disorder in which hormones and metabolism interact differently. That takes nothing away from your agency, but it does take away the shame. And it shifts the focus: away from the question of blame, toward the places in the system where something can move.
The four PCOS phenotypes: why PCOS is not always PCOS
When two women receive the diagnosis PCOS, they can be very different. One struggles mainly with acne and hair, the other almost only with absent cycles. This is because PCOS, according to the internationally used Rotterdam criteria, is divided into four phenotypes, depending on which of the three building blocks are present.
Phenotype A is the full form with all three features: elevated male hormones, disturbed ovulation and the typical ultrasound appearance. Phenotype B has elevated male hormones and disturbed ovulation but an unremarkable ultrasound. Phenotype C combines elevated male hormones with the ultrasound appearance but has regular ovulation. Phenotype D shows disturbed ovulation and the ultrasound appearance, yet without elevated male hormones.
This classification is more than theory. The phenotypes differ in their metabolic risk, for instance in the risk of insulin resistance, of type 2 diabetes, or of unfavourable blood lipids. That is why experts recommend naming the phenotype clearly when making the diagnosis. A review by Lizneva and colleagues in 2016 describes exactly this distribution and significance of the phenotypes within the extended Rotterdam criteria (according to PubMed, doi:10.1016/j.fertnstert.2016.05.003, PMID: 27233760). And now you know why the question of the phenotype is not a quibble but helps shape your care.
"The ultrasound showed many cysts, so I have PCOS." It is not that simple. The ultrasound appearance is only one of three building blocks, and it can also occur in healthy women, especially when young. Conversely, there are PCOS phenotypes without this picture. So an ultrasound finding alone does not prove PCOS, and its absence does not rule it out. What matters is the overall picture and the exclusion of other causes.
Insulin resistance: the driver in the background
If one thread runs through the whole of PCOS, it is often this: insulin resistance. Insulin is the hormone that moves blood sugar into the cells. With insulin resistance the cells respond less well to this signal. The body answers by releasing more insulin. And this excess of insulin does not stay with the blood sugar but reaches deep into the hormone balance.
The mechanism is well described. Elevated insulin can directly stimulate the ovaries to produce more androgens. At the same time it lowers the sex hormone binding globulin, SHBG for short, in the liver. This protein normally binds part of the androgens and renders them inactive. When SHBG falls, more free, active androgens circulate. In this way hyperandrogenism and insulin resistance reinforce each other.
Insulin resistance across the tissues in PCOS
Review According to PubMed, Han Zhao and colleagues summarised in 2023 in the Journal of Ovarian Research how insulin resistance in PCOS arises across different tissues and what consequences it may have. They describe insulin resistance and the compensatory rise in insulin release as one of the essential causes of PCOS, and show that the extent of insulin resistance differs between the phenotypes. Genetic and epigenetic changes, elevated androgens and excess weight can intensify insulin resistance. Insulin-sensitising approaches are discussed as a treatment route.
Zhao H, Zhang J, Cheng X, et al. J Ovarian Res. 2023;16(1):9. doi:10.1186/s13048-022-01091-0 · PMID: 36631836
This connection is supported by a further review. Yalan Xu and Jie Qiao described in 2022 in the Journal of Healthcare Engineering how the over-exposure to androgens is directly linked with insulin resistance and the raised insulin release, and class both as essential contributors to PCOS (according to PubMed, doi:10.1155/2022/9240569, PMID: 35356614). One note for context: not every woman with PCOS has marked insulin resistance, and not every one is overweight. But in very many, the metabolism plays a leading role.
The craving in PCOS is often not a lack of willpower. It can be an expression of insulin resistance, in which the body responds to blood sugar with a rollercoaster. Once you understand that, the focus shifts. It is less about restriction and discipline and more about keeping blood sugar calm. That is a kinder and often more effective approach than pure self-control.
The four PNI lenses on PCOS
In clinical psychoneuroimmunology, PNI for short, we do not look only at the ovaries. We look at four interwoven levels that together explain why PCOS arises and persists. Each lens explains one part at the cellular level. Together they form the picture.
Metabolism and insulin
For many, this is the core. Insulin resistance leads to elevated insulin, which stimulates the ovaries to make androgens and lowers SHBG in the liver. As a result, more free androgens circulate. A calm blood sugar across the day eases this loop and is therefore a central point of entry in PCOS, not just a side topic of weight.
Immune system and inflammation
PCOS shares a state of silent inflammation with other chronic conditions. Inflammatory messengers can disturb insulin action at the cellular level and so stoke insulin resistance. Excess weight and visceral fat also contribute through inflammatory signals. This explains why PCOS and metabolism are so closely intertwined.
Hormone system and ovaries
The control by the hypothalamus and pituitary is often altered in PCOS, for instance in the ratio of the hormones LH and FSH. This disturbs the maturation of the egg follicles, so ovulation is absent and many small follicles stall. Without ovulation, the progesterone of the second cycle half is also missing, which can strain the lining of the uterus.
Genes and environment
PCOS is strongly heritable and multifactorial. Several genes act together, and epigenetic changes as well as environmental factors can shape the picture. This means: the predisposition cannot be changed, but the interplay with lifestyle and surroundings very much can be influenced. This is exactly where the room to act lies.
These four lenses are not a theoretical model. They are the reason why, in PCOS, diet, movement, sleep and stress regulation often achieve more than expected. And now you know why good PCOS care looks at more than just the cycle or the weight.
How PCOS is diagnosed
PCOS is a diagnosis of exclusion. That is an important sentence. It means that other causes which can produce a similar picture must be ruled out first, for example a thyroid disorder, a raised prolactin, or rarer hormonal conditions. Only then is PCOS established on the basis of the three building blocks.
The work-up involves several steps. A detailed history captures cycle patterns, complaints and family history. The physical examination notes signs of male hormones such as increased hair. In the lab, androgens and other hormones are measured to document hyperandrogenism and disturbed ovulation. An ultrasound of the ovaries is often added. Because insulin resistance is so important, examining the metabolism is sensible, for instance fasting insulin, blood sugar and blood lipids.
PCOS as a diagnosis of exclusion
Review According to PubMed, an international team led by Ricardo Azziz described PCOS in 2016 in Nature Reviews Disease Primers as a diagnosis of exclusion, resting mainly on hyperandrogenism, disturbed ovulation and the polycystic ovarian appearance. In the great majority of those affected, a metabolic disturbance with insulin resistance and compensatory raised insulin is found. The authors stress that treatment should be guided by the complaints and goals of the patient, from metabolism through androgens to fertility.
Azziz R, Carmina E, Chen Z, et al. Nat Rev Dis Primers. 2016;2:16057. doi:10.1038/nrdp.2016.57 · PMID: 27510637
A comprehensive review by Hosna Mohammad Sadeghi and colleagues in 2022 in the International Journal of Molecular Sciences places the many contributing factors in context, from genetics and environmental substances through insulin resistance and hyperandrogenism to inflammation and oxidative stress, and names lifestyle adjustments as the preferred first step in many cases (according to PubMed, doi:10.3390/ijms23020583, PMID: 35054768). And now you know why a single value is not enough and why diagnosis belongs in experienced hands.
What may help in PCOS: three levers and the matter of inositol
Before reaching for single symptoms, it is worth looking at the foundations. They are not spectacular, but they address the root, often insulin resistance. These three levers are a beginning, not a treatment plan. You will find your individual path with medical guidance.
Keep your blood sugar calm across the day
Regular, protein- and fibre-rich meals could keep blood sugar steadier and so ease the load on insulin. Because elevated insulin helps fuel the androgen drive, this is exactly where it may make a difference for acne, hair and cycle. It is not about a perfect scheme but about less rollercoaster. Even that could ease the whole system.
Move regularly, even in small doses
Movement can improve insulin sensitivity, regardless of whether the weight changes. Even regular walking, strength training or endurance could favourably influence metabolic values. What matters is regularity, not peak performance. Here movement is not a means of weight loss alone but a direct lever on insulin action.
Have the whole system evaluated and supported
In PCOS it is worth having diagnostics that look at hormones, metabolism, thyroid and life phase, not just a single value. This clarifies phenotype, risks and goals, be it a calmer cycle, fewer androgen symptoms, or a wish to conceive. Good care takes your complaints seriously and thinks long-term.
Among the supplementary substances, inositol has comparatively good evidence in PCOS. Inositol is a sugar-like natural substance involved in insulin action.
Inositol in PCOS: a more regular cycle, more favourable values
Meta-analysis, n=1691 According to PubMed, Dorina Greff and colleagues evaluated in 2023 in Reproductive Biology and Endocrinology 26 randomised controlled trials with 1691 women. Under inositol, the chance of a regular menstrual cycle was about 1.8 times higher than under placebo. The body mass index, free and total testosterone, and blood sugar also improved compared with placebo, and SHBG rose. On most points inositol showed itself not inferior to the standard medication metformin and appeared well tolerated. The authors class inositol as an effective and safe option in PCOS.
Greff D, Juhász AE, Váncsa S, et al. Reprod Biol Endocrinol. 2023;21(1):10. doi:10.1186/s12958-023-01055-z · PMID: 36703143
A smaller randomised study by Mario Nordio and colleagues in 2019 in the European Review for Medical and Pharmacological Sciences compared different mixing ratios of the two inositol forms myo-inositol and D-chiro-inositol and found that a ratio of 40 to 1 could best support ovulation (according to PubMed, doi:10.26355/eurrev_201906_18223, PMID: 31298405). One honest note for context: inositol may be a sensible building block, but it is no panacea and does not replace evaluation. Before taking it, it should be discussed with a doctor, especially when trying to conceive, in pregnancy, or alongside other medications.
It is also worth a sober look at diet. A review by Di Lorenzo and colleagues in 2023 in Current Nutrition Reports describes that a healthy nutritional approach could improve insulin resistance as well as metabolic and reproductive function, and discusses among others the Mediterranean orientation (according to PubMed, doi:10.1007/s13668-023-00479-8, PMID: 37213054). For movement, a meta-analysis by Chris Kite and colleagues in 2019 in Systematic Reviews shows favourable effects on fasting insulin, insulin resistance and blood lipids, but urges caution because of limited study quality (according to PubMed, doi:10.1186/s13643-019-0962-3, PMID: 30755271).
PCOS is a system, not a verdict
Your PCOS is not a switch that is flipped, and not a flaw you have to carry. It is an interplay of genes, hormones and metabolism with many points of entry. When you calm the blood sugar, move, and seek good support, you give your body the chance to settle. You are not the problem. You are learning to read a many-layered system.
Frequently asked questions about PCOS
What is PCOS (polycystic ovary syndrome)?
Polycystic ovary syndrome, PCOS for short, is the most common hormonal and metabolic disorder in women of reproductive age. Estimates range from around five to twenty percent. It is not a single defect but an interplay of three building blocks: elevated male hormones (hyperandrogenism), a disturbed or absent ovulation, and a typical ultrasound appearance of the ovaries with many small follicles. Importantly, the small follicles seen on ultrasound are not true cysts, and not every woman with PCOS has them. In many women an insulin resistance sits in the background as well. PCOS is a diagnosis that should be made by a doctor and distinguished from similar disorders.
Which symptoms point to PCOS?
Typical signs are irregular, very long or absent cycles, signs of elevated male hormones such as increased body hair in a male pattern, acne especially on the chin and jaw, and hair thinning on the scalp. Many women with PCOS also have difficulty becoming pregnant, as well as signs of insulin resistance such as food cravings, weight gain around the middle, or dark skin patches in skin folds. Low mood can also occur. These complaints are non-specific and can have many causes. That is why a suspicion of PCOS belongs in medical hands rather than being self-diagnosed.
What role does insulin resistance play in PCOS?
In many women with PCOS, insulin resistance is considered a central driver. Insulin is itself a hormone. When cells respond less well to insulin, the body releases more of it. This elevated insulin can stimulate the ovaries to produce more androgens and at the same time lower the sex hormone binding globulin in the liver. As a result, more free, active androgens circulate. This may explain why acne, increased hair and cycle disorders often appear together. That is precisely why, in an integrative view of PCOS, blood sugar is at the centre too, not just the single sex hormone.
What PCOS phenotypes exist?
According to the internationally used Rotterdam criteria, four PCOS phenotypes are distinguished, depending on which of the three features are present. Phenotype A combines elevated male hormones, disturbed ovulation and the typical ultrasound appearance. Phenotype B has elevated male hormones and disturbed ovulation but no abnormal ultrasound. Phenotype C has elevated male hormones and the ultrasound appearance but regular ovulation. Phenotype D has disturbed ovulation and the ultrasound appearance but no elevated male hormones. The phenotypes differ in their metabolic risk. That is why the phenotype should be clearly named when the diagnosis is made.
How is PCOS diagnosed?
PCOS is a diagnosis of exclusion. That means similar causes must be ruled out first. The work-up includes a detailed history, the assessment of signs of male hormones such as increased hair, hormonal lab values to confirm elevated androgens and a disturbed ovulation, and often an ultrasound of the ovaries. It is also sensible to examine the metabolism with fasting insulin, blood sugar and blood lipids, because many of those affected have insulin resistance. A single lab value is not enough. What matters is the overall picture of symptoms, findings, and the exclusion of other conditions.
What can you do about diet with PCOS?
With PCOS, diet may achieve more than often expected, because it acts directly on insulin resistance. A healthy nutritional approach can improve insulin action as well as metabolic and reproductive function. In research, a Mediterranean orientation and, in some studies, lower-carbohydrate approaches are discussed. In practice it is less about a rigid scheme and more about stable blood sugar: regular, protein- and fibre-rich meals instead of a blood sugar rollercoaster. That is a direction, not a recipe. You will find your individual path best with medical and nutritional guidance.
Does inositol help with PCOS?
For inositol, a sugar-like natural substance, there is comparatively good evidence in PCOS. A systematic review and meta-analysis of 26 randomised trials with almost 1700 women found that inositol increased the chance of a regular cycle and that metabolic and androgen values changed favourably. On most points inositol was not inferior to the standard medication metformin and appeared well tolerated. Inositol may therefore be a sensible building block, but it does not replace medical evaluation or individual advice. Before taking it, the use should be discussed with a doctor, especially when trying to conceive, in pregnancy, or alongside other medications.
Can you get pregnant with PCOS?
Yes, many women with PCOS do become pregnant, even if the path sometimes takes patience and support. PCOS is one of the most common causes of an irregular or absent ovulation, which can make conception harder. Measures that favourably influence insulin resistance and the cycle, such as lifestyle adjustments, may improve the chance of a regular ovulation. When trying to conceive there are also established medical options, which are guided by a doctor. Importantly, PCOS can be associated with increased risks in pregnancy. That is why the wish to conceive with PCOS belongs in good medical care.
Is PCOS curable or does it last a lifetime?
PCOS is regarded as a chronic, strongly heritable disorder that can change across the phases of life. The goal of care is therefore not a one-time removal but good steering: easing symptoms, lowering the metabolic risk, and, depending on the life phase, supporting fertility or protecting the lining of the uterus. Many complaints can improve markedly through lifestyle and targeted therapy. With menopause the hormone balance shifts, and some symptoms ease. The metabolic risk, however, remains relevant. PCOS therefore calls for long-term, individual care rather than a single treatment.
When should I see a doctor with suspected PCOS?
You should have the following evaluated medically: persistently irregular or absent cycles, an absent period over several months without pregnancy, pronounced signs of male hormones such as strong increased hair, hair loss or a deeper voice, an unfulfilled wish to conceive, and signs of a metabolic disorder. An honest note matters here: behind such complaints there can be, alongside PCOS, other treatable causes, for example thyroid disorders or rarer hormonal conditions. Good diagnostics look at the whole system and take your complaints seriously. If you have severe low mood or thoughts of not wanting to live anymore, please get help immediately.
All topics in the cluster "Hormone Guide"
This article is a spoke in the larger cluster. Each topic illuminates one part of the connected system of female hormones.
- Hormonal Imbalance in Women (Overview/Pillar)
- Estrogen Dominance: recognising symptoms and addressing them naturally
- Xenoestrogens: hormone disruptors in everyday life
- Coming off the pill: what happens in the body
- Progesterone deficiency: symptoms and testing
- PMS: symptoms and what can help
- PMDD: when PMS hits the psyche
- Perimenopause: symptoms and when it begins
- Menopause: symptoms and what can help
- PCOS: Causes and Symptoms
- Hormonal acne from within
- Endometriosis: an integrative view
- Hormone-free contraception compared
- Loss of libido in women
- Testing hormones: which test, when
- Lowering estrogen naturally (the liver)
- Cycle-based nutrition
- The thyroid and female hormones
- Insulin resistance and hormones
- Cortisol, stress and female hormones
- Chasteberry and herbal hormone helpers
Connections to other topics
How the ratio of estrogen and progesterone arises and why a disturbed ovulation in PCOS also affects progesterone.
The other side of androgens. In PCOS they are often elevated, yet the honest look at male hormones in women is worth it in both directions.
Thyroid disorders can produce a PCOS-like picture and belong in every work-up. Why normal values are not always enough.
Through the immune system and silent inflammation, the gut helps shape how pronounced an insulin resistance, and thus PCOS, becomes.
Exhaustion in PCOS does not always have to do with hormones. An iron deficiency can intensify similar complaints.
Fasting is often discussed with insulin resistance. Why women respond differently and what to watch for in PCOS.
Sources and further reading
- Azziz R. Polycystic Ovary Syndrome. Obstet Gynecol. 2018;132(2):321-336. doi:10.1097/AOG.0000000000002698 · PMID: 29995717 [Review]
- Azziz R, Carmina E, Chen Z, et al. Polycystic ovary syndrome. Nat Rev Dis Primers. 2016;2:16057. doi:10.1038/nrdp.2016.57 · PMID: 27510637 [Review]
- Lizneva D, Suturina L, Walker W, et al. Criteria, prevalence, and phenotypes of polycystic ovary syndrome. Fertil Steril. 2016;106(1):6-15. doi:10.1016/j.fertnstert.2016.05.003 · PMID: 27233760 [Review]
- Zhao H, Zhang J, Cheng X, et al. Insulin resistance in polycystic ovary syndrome across various tissues: an updated review of pathogenesis, evaluation, and treatment. J Ovarian Res. 2023;16(1):9. doi:10.1186/s13048-022-01091-0 · PMID: 36631836 [Review]
- Xu Y, Qiao J. Association of Insulin Resistance and Elevated Androgen Levels with Polycystic Ovarian Syndrome (PCOS): A Review of Literature. J Healthc Eng. 2022;2022:9240569. doi:10.1155/2022/9240569 · PMID: 35356614 [Review]
- Sadeghi HM, Adeli I, Calina D, et al. Polycystic Ovary Syndrome: A Comprehensive Review of Pathogenesis, Management, and Drug Repurposing. Int J Mol Sci. 2022;23(2):583. doi:10.3390/ijms23020583 · PMID: 35054768 [Review]
- Di Lorenzo M, Cacciapuoti N, Lonardo MS, et al. Pathophysiology and Nutritional Approaches in Polycystic Ovary Syndrome (PCOS): A Comprehensive Review. Curr Nutr Rep. 2023;12(3):527-544. doi:10.1007/s13668-023-00479-8 · PMID: 37213054 [Review]
- Kite C, Lahart IM, Afzal I, et al. Exercise, or exercise and diet for the management of polycystic ovary syndrome: a systematic review and meta-analysis. Syst Rev. 2019;8(1):51. doi:10.1186/s13643-019-0962-3 · PMID: 30755271 [Meta-analysis]
- Greff D, Juhász AE, Váncsa S, et al. Inositol is an effective and safe treatment in polycystic ovary syndrome: a systematic review and meta-analysis of randomized controlled trials. Reprod Biol Endocrinol. 2023;21(1):10. doi:10.1186/s12958-023-01055-z · PMID: 36703143 [Meta-analysis]
- Nordio M, Basciani S, Camajani E. The 40:1 myo-inositol/D-chiro-inositol plasma ratio is able to restore ovulation in PCOS patients: comparison with other ratios. Eur Rev Med Pharmacol Sci. 2019;23(12):5512-5521. doi:10.26355/eurrev_201906_18223 · PMID: 31298405 [RCT]