It’s safe to say that Polycystic Ovary Syndrome (PCOS), which affects 1 in 10 women of childbearing age, is something many women deal with. “It’s one of the most common conditions we treat,” says Hannah Dentry, RD, a health coach at Parsley Health. But it frequently takes women over two years and three doctors to receive a PCOS diagnosis, according to a survey in the Journal of Clinical Endocrinology & Metabolism. Understandably, the process can leave women feeling frustrated and hopeless—and that’s all before they start treatment.
There are several reasons it can be tricky to make a PCOS diagnosis, notes Jaclyn Tolentino, DO, a board-certified family physician at Parsley Health. So read on to better understand your symptoms and for help with a holistic, lifestyle-based PCOS treatment plan.
Reason #1: The signs and symptoms of PCOS vary widely.
Symptoms of PCOS women might notice may include:
- Irregular periods (this is one of the most prevalent PCOS symptoms, Dr. Tolentino says)
- Fertility problems (such as not ovulating regularly or at all)
- Excess body hair (also known as hirsutism)
- Thinning hair and/or hair loss on the scalp
- Weight gain and/or challenges in losing weight
- Mood changes (anxiety and depression can be issues for people coping with PCOS)
But not all women with PCOS experience any or all of these symptoms. This is partially because there are several different types of PCOS, and symptoms may vary across types and individuals.
Some of the signs of PCOS are only possible to detect via diagnostic testing, and these are often the most important indicators that lead to a PCOS diagnosis. These include:
- Ovarian cysts on one or both ovaries, which might be seen on an ultrasound
- High levels of androgens such as testosterone, which can be observed via a blood or urine test
- High levels of insulin and insulin resistance, which is also observed via blood tests
But without the right testing, it’s hard to know if some of these symptoms are present. Which can be a challenge, because…
Reason #2: Doctors sometimes miss (or misdiagnose) a PCOS diagnosis.
Because PCOS symptoms manifest in different ways for different people, it can be tricky for doctors to recognize the signs of PCOS—especially if they don’t frequently deal with PCOS patients. “Some patients have metabolic issues, but not all of them,” Dr. Tolentino says. Some patients have an excess of androgens, but not every patient. Not every patient has ovarian cysts.
The criteria for a PCOS diagnosis are also heavily debated, which can make diagnosis complicated for healthcare providers. The Rotterdam Criteria is what’s most commonly used to diagnose PCOS, and it states that a person can be diagnosed with PCOS if they have two of the three following symptoms:
- Irregular or missed periods
- Clinical/biochemical signs of excess androgens
- Multiple cysts on one or both ovaries (confirmed by an ultrasound)
But the Rotterdam Criteria is not without ongoing dialogue in the medical world, Dr. Tolentino says. “I think it really comes down to a lack of data that we’ve had on PCOS. We only just saw the publication of international evidence-based guidelines for treating PCOS back in 2018, so we’re just getting to the point where we’re actually taking the data we do have and synthesizing it into something actionable and practical for a clinician.”
Reason #3: Women don’t always recognize or open up to a doctor about symptoms.
A big reason for this is that conventional medicine practitioners often recommend hormonal birth control for irregular periods, and women sometimes take these medications from their teenage years until adulthood. “Hormonal birth control can help control several other symptoms of PCOS like acne, hair growth, or hair loss,” Dentry explains. Rather than treating these symptoms, hormonal birth control temporarily masks them, so women only experience symptoms once they stop taking hormonal birth control—often when they want to get pregnant.
There’s also the fact that some of the symptoms of PCOS are seen as undesirable by society, Dentry notes. Unfortunately, women are taught to feel shameful about having upper lip hair, not being able to lose weight, or having “bad” skin, she adds. “Sometimes women don’t realize that these issues are related to an imbalance in their body that can be treated,” Dentry says.
Reason #4: There’s so much we still don’t know about PCOS.
For example, we don’t know what causes it: “We know genetics can play a role, and we know excess androgen production from increasing insulin resistance is a relevant factor, but there’s still so many questions we have regarding the exact mechanisms that trigger the disorder,” Dr. Tolentino says. The general lack of clarity and need for further research into what constitutes and what causes PCOS naturally makes it more difficult to diagnose.
The good news: A holistic approach to PCOS treatment looks different.
At Parsley Health, the process starts with a thorough medical history intake. “We’ll review details ranging from your family medical history all the way to your current lifestyle habits. From there, we might order advanced hormone testing or other leading-edge diagnostics,” Dr. Tolentino explains. Patients with symptoms of PCOS are also screened for other medical conditions that might mimic those symptoms, like a thyroid problem. “I spend a lot of time collecting information and reviewing all of those details during the initial visit,” says Dr. Tolentino, “That’s where we might find something that more strongly points to or away from PCOS.”
But the biggest difference is how Parsley treats PCOS. “I think one of the things that make us different is that we have a whole team to support a lifestyle-based treatment approach.” Patients work with a health coach to ensure proper support as they make changes to their habits after a PCOS diagnosis.
Dentry also notes that while conventional PCOS treatment often involves hormonal birth control and counting carbohydrates to keep blood sugar in check, Parsley clinicians focus on addressing the root causes of symptoms. While we might not know exactly what causes PCOS, we do know how to minimize contributing factors like inflammation, hormonal imbalance, and insulin resistance with the following strategies.
Adopt a nourishing diet
“It takes a really nuanced approach to find a nourishing diet for a woman with PCOS,” Dentry says. Often, that involves a PCOS diet that’s moderate-carbohydrate, and intentionality with carbohydrate choices that are high fiber and high nutrient-density. Dentry also helps PCOS patients focus on foods that are healing for the body like healthy anti-inflammatory fats, lean protein, herbs, and functional foods that can help with hormonal and blood sugar imbalances, like cinnamon, flaxseed, and organic soy.
“It’s really an emphasis on which foods can we include that are going to be healing, versus restricting or limiting,” Dentry adds. “Because we also find that women with PCOS are more likely to have chaotic relationships with food or disordered eating patterns.” That might be due to a higher likelihood of struggling with their weight, or from past attempts to treat PCOS that involved strict diets.
Be intentional with exercise
“Exercise is amazing for increasing insulin sensitivity, but we’ve seen that if we’re going too rigorous with exercise, that can actually exacerbate adrenal health imbalances,” Dentry says. So instead of CrossFit five days a week, patients with PCOS are encouraged to go for a mix of some cardio, some strength, and some restorative or parasympathetic nervous system-driven movement. “That could be yoga, for example, or just increasing natural movement throughout the day.”
Be mindful of stress and mental health
“We know stress can absolutely exacerbate symptoms,” Dr. Tolentino notes. Developing a meditation and mindfulness practice, spending time in nature, and somatic practices like cooking or playing music are common recommendations for Parsley patients in general, including those with a PCOS diagnosis and for PCOS treatment.
Just go to sleep
“Sleep is huge, and we find that women with PCOS are more prone to insomnia,” Dentry says. “If they’re getting less than six hours a night, usually we’ll also see a higher fasting insulin level, which then has an inflammatory cascade and affects the androgen hormones.” So getting a good night’s sleep by practicing good sleep hygiene is key.
There are a variety of PCOS supplements Dr. Tolentino might use to help regulate blood sugar and balance hormones, including berberine, saw palmetto, B vitamins, and inositols. These should be taken under the guidance of a provider so you can find the right dose for your needs.
Don’t be afraid of medication
“Medication is absolutely one tool in my toolbox, but often I’m trying to look for longer-term, sustainable solutions that my patient can implement to support longevity,” Dr. Tolentino says. Still, medication is sometimes used at Parsley, especially in the short-term to get symptoms under control.
Parsley clinicians also believe a PCOS diagnosis doesn’t necessarily have to be something you deal with for life.
“We’ve seen PCOS reversed,” Dr. Tolentino says. And often, patients experience a variety of positive changes over the course of PCOS treatment. “The outcomes that we’ve seen include regulating the menstrual cycle when there hasn’t been one for years, finally ovulating, improving fertility, and better control of blood sugar levels,” Dentry says. As a result of these internal changes, patients also notice external changes, like their skin clearing up, for example. “That’s such a great one because it’s looking right there in the mirror back at you.”