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Abnormal or missed periods can feel stressful, since there can be many possible causes. One of these causes is polycystic ovary syndrome (PCOS). Even though PCOS is common, it can be difficult to diagnose because no single test confirms it.
PCOS is usually diagnosed by an endocrinologist (a doctor who specializes in gland and hormone diseases) or a gynecologist (a doctor who specializes in the female reproductive system). To diagnose PCOS, your healthcare provider will review your medical and family history, do a physical examination, and may order blood work and imaging tests. Together, these evaluations can help your provider diagnose your PCOS and create a treatment plan for your symptoms.
Here’s a closer look at how you may be diagnosed with PCOS (also known as polycystic ovarian syndrome).
To diagnose PCOS, your doctor must first rule out other possible causes of your symptoms. Then, they will look to see if you meet certain criteria for diagnosing PCOS, known as the Rotterdam criteria. According to these guidelines, you must meet at least two of these three main criteria:
According to updated international guidelines, polycystic ovaries are defined as enlarged ovaries or ovaries that contain 20 or more follicles (as seen in a pelvic ultrasound).
An ovarian follicle is a small, fluid-filled sac that contains an egg. In a typical menstrual cycle, a mature follicle releases its egg during ovulation. But in some cases, follicles don’t mature. These immature follicles can build up in the ovary and become cysts.
It’s important to know that ovarian cysts can also be linked to other conditions, such as ovarian tumors. And you can have PCOS even if you don’t have ovarian cysts.
Hyperandrogenism means having higher-than-normal levels of androgens (also called male hormones or male sex hormones).
In PCOS, the ovaries produce too much of a hormone called androgen. High levels of androgen can throw off the body’s hormonal balance and cause symptoms of PCOS like absent or abnormal periods.
Doctors may check androgen levels with blood tests or by looking for signs of high androgen, such as excess hair growth on the body or face (hirsutism), male-pattern baldness, or severe acne. One study found that over 80 percent of women with hyperandrogenism were ultimately diagnosed with PCOS.
Scant periods, or oligomenorrhea, are menstrual cycles that happen nine times a year or fewer, or cycles that last longer than 35 days.
Cycles of these lengths are often due to a lack of ovulation. In some cases, there may be no period at all (known as amenorrhea). A lack of menstrual period by age 15 is called primary amenorrhea. Secondary amenorrhea refers to the absence of periods for more than three months in women who previously had regular menstrual cycles, or for more than six months in women who have always had irregular cycles.
PCOS often begins during adolescence, though symptoms may not appear until adulthood. Many women don’t realize they have PCOS until they have trouble getting pregnant in their 20s or 30s.
In adolescents, the absence of excess androgen rules out a diagnosis of PCOS. This is true even if both irregular periods and polycystic ovaries are present. Adolescent girls who meet these criteria but don’t have signs of androgen imbalance are usually monitored by a doctor over time to check for changes in androgen levels.
In women with both irregular menstrual cycles and high androgen levels, PCOS can be diagnosed without imaging tests. Some doctors diagnose specific types of PCOS, while others don’t.
There isn’t one single test that can diagnose PCOS on its own. Instead, doctors use a combination of a physical exam, blood tests, and imaging tests. These help rule out other causes of symptoms before diagnosing PCOS. Ultrasound scans can show whether ovarian cysts (polycystic ovaries) are present. Meanwhile, blood tests can check for hormonal imbalances.
Your endocrinologist or other healthcare provider will use these results, along with your symptoms, to diagnose PCOS.
As part of the evaluation for PCOS, your doctor will take a detailed medical history. They’ll likely ask about your symptoms, your menstrual cycle, and whether you’ve had problems with infertility or other health conditions. You may be asked how often your periods come, how long they last, and how old you were when you had your first period.
Having a family history of PCOS is a risk factor for developing the condition. Your doctor may ask whether your mother or sisters have it. They may also ask about female relatives with type 2 diabetes and high blood pressure, since those are common complications of PCOS.
In order to diagnose PCOS, your endocrinology or gynecology provider will perform a physical exam. This includes a general physical exam and a pelvic exam.
A general physical exam looks for signs of androgen excess, such as facial hair or acne. Meanwhile, a pelvic exam is used to examine your reproductive organs. Your doctor will look and feel for growths, swollen areas, or other irregularities.
Ultrasound imaging is an important tool for diagnosing PCOS. Ultrasounds use high-frequency sound waves to create images of your uterus and ovaries on a computer. This type of imaging can measure the thickness of the uterine lining and detect ovarian cysts. Ultrasounds are painless and don’t expose you to harmful radiation.
There are two types of ultrasounds: transvaginal and abdominal.
For those who are or have been sexually active, a transvaginal ultrasound is usually performed. During this test, a probe (wand) called a transducer is covered with a protective covering and ultrasound gel, then gently inserted into the vagina. The probe sends out sound waves that are transmitted through the gel. The sound waves then bounce back, allowing the computer to create images of the ovaries. Your doctor can review the computer-made images to check for cysts or enlarged ovaries.
Abdominal ultrasounds are less accurate, but they’re preferred for people who haven’t been sexually active or don’t feel comfortable with transvaginal ultrasounds. In an abdominal ultrasound, the doctor or technician will spread ultrasound gel on your belly and move a probe across your skin. Because the sound waves have to travel through the abdominal wall, the images of the ovaries are less clear than with a transvaginal ultrasound.
According to international guidelines, an ovary is considered polycystic if ultrasound imaging shows that it has more than 20 follicles or a volume of 10 milliliters or more.
Your doctor may also order blood tests to check your hormone levels. This is because hormonal imbalances can provide key evidence to support a diagnosis of PCOS and help rule out other conditions.
If you’re on hormonal birth control and need to have your androgen levels tested, you’ll need to stop birth control for about three months before your levels can be accurately measured. However, if you already meet the other PCOS criteria — irregular periods and polycystic ovaries on ultrasound — blood tests for androgen levels may not be necessary.
Blood tests can be used to measure hormones such as:
You may also be tested for anti-Müllerian hormone (AMH), which reflects the number of eggs remaining in your ovaries. In adult women, a high AMH level — over 34 picomoles per liter — combined with irregular periods may be enough to diagnose PCOS without an ultrasound. However, AMH levels naturally rise during adolescence, so an AMH test isn’t reliable for girls who’ve had periods for less than eight years.
To receive a PCOS diagnosis, your provider must first rule out other possible causes of your symptoms. Several conditions can look like PCOS and need to be excluded before a PCOS diagnosis is made. The results of your blood tests may point to causes other than PCOS, including:
Because insulin resistance often plays a role in PCOS, your doctor may also order a blood test to check your glucose levels. Your provider may also want to check your cholesterol, since PCOS can raise cholesterol levels.
If blood tests reveal that another medical condition is causing your symptoms, your doctor will focus on treating that first. Once other causes are treated, if you still have symptoms, your provider may re-evaluate you for PCOS.
On myPCOSteam, people share their experiences with PCOS, get advice, and find support from others who understand.
What was your journey to PCOS diagnosis like? Let others know in the comments below.
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