PCOS: symptoms, testing and treatment in London

What is PCOS?

Polycystic ovary syndrome (PCOS) is a hormonal condition that affects how the ovaries work. It is characterised by irregular or absent periods, higher levels of androgens (male hormones such as testosterone), and polycystic ovaries (ovaries containing a large number of small follicles). You need at least two of these three features for a diagnosis.

PCOS affects around 1 in 10 women in the UK. Despite the name, it is not primarily a cyst problem. The "cysts" seen on ultrasound are actually undeveloped follicles (egg sacs), not the same as the ovarian cysts that can grow and cause pain.

Symptoms

PCOS presents differently from woman to woman. Some have mild symptoms; others are significantly affected. The most common symptoms are:

Irregular periods. Cycles longer than 35 days, fewer than 8 periods a year, or absent periods altogether. This is the most common reason women seek investigation for PCOS.

Acne. Persistent acne, particularly along the jawline, chin, and lower face, caused by higher androgen levels. Often continues beyond the teenage years.

Excess hair growth (hirsutism). Hair growth on the face, chest, back, or abdomen in a male-pattern distribution. Affects around 70% of women with PCOS.

Hair thinning. Thinning of hair on the scalp, sometimes in a male-pattern distribution (receding at the temples or thinning on top).

Weight gain. PCOS makes it harder to lose weight, particularly around the waist. Insulin resistance, which is present in up to 70% of women with PCOS, drives fat storage and makes weight management more difficult.

Difficulty conceiving. PCOS is the most common cause of anovulatory infertility (not ovulating regularly). Around 70-80% of women with PCOS who have difficulty conceiving respond well to treatment.

Mood changes. Anxiety and depression are more common in women with PCOS, though whether this is a direct hormonal effect or a consequence of the other symptoms is debated.

How PCOS is diagnosed

Diagnosis is based on the Rotterdam criteria: you need at least two of the following three features.

1. Irregular or absent periods

A history of menstrual irregularity (fewer than 8 cycles per year, cycles longer than 35 days, or absent periods) points toward disordered ovulation.

2. Raised androgens

This can be clinical (visible signs like acne, hirsutism, or hair thinning) or biochemical (elevated testosterone, SHBG, or Free Androgen Index on a blood test). A hormone panel confirms the biochemical picture.

3. Polycystic ovaries on ultrasound

A transvaginal ultrasound showing 12 or more follicles in one or both ovaries, or ovarian volume over 10ml. Having polycystic ovaries on ultrasound alone, without the other features, is not the same as having PCOS. Around 20-30% of women have polycystic-appearing ovaries without the syndrome.

At our clinic, Mr Naoum can perform the consultation, blood tests, and ultrasound in a single visit. The hormone panel we use includes testosterone, SHBG, Free Androgen Index, LH, FSH, prolactin, oestradiol, insulin, glucose, HbA1c, and a lipid profile. This gives the full metabolic and hormonal picture in one panel.

Treatment

PCOS treatment depends on which symptoms are bothering you most and whether you are trying to conceive.

Irregular periods

If you are not trying to conceive, the combined oral contraceptive pill regulates your cycle and reduces androgen levels, which also improves acne and hirsutism. The Mirena coil is an alternative for contraception but does not regulate cycles or reduce androgens.

If you are not on contraception and have fewer than 4 periods a year, treatment to induce a withdrawal bleed every 3-4 months is recommended to protect the endometrium (womb lining) from thickening unopposed.

Acne and hirsutism

The combined pill (particularly those containing cyproterone acetate or drospirenone) reduces androgen levels and improves skin and hair growth over 3-6 months. Topical treatments for acne and prescription hair removal creams (eflornithine) can be used alongside.

Weight management and insulin resistance

Weight loss of even 5-10% of body weight can restore ovulation and improve all PCOS symptoms. If insulin resistance is present (confirmed by fasting insulin and glucose testing), metformin may be prescribed to improve insulin sensitivity. Dietary changes (reducing refined carbohydrates and increasing protein and fibre) are part of the treatment plan discussed at your consultation.

Fertility

If you have PCOS and are trying to conceive, the first-line treatment is ovulation induction with letrozole or clomifene citrate, taken as tablets early in the cycle to stimulate the ovaries to release an egg. This works in around 70-80% of women with PCOS-related anovulation.

If ovulation induction does not work, the next steps include injectable gonadotrophins or IVF. A fertility assessment gives a complete picture of your ovarian reserve and other fertility factors alongside your PCOS management.

PCOS and long-term health

PCOS is not just a reproductive condition. It has metabolic implications that matter beyond your reproductive years.

Insulin resistance and type 2 diabetes. Women with PCOS have a higher risk of developing type 2 diabetes. Regular monitoring of fasting glucose and HbA1c is recommended. The well woman check (Advanced tier and above) includes these markers.

Cardiovascular risk. PCOS is associated with higher cholesterol and an increased risk of cardiovascular disease, though the absolute risk in young women is still low. Lipid profiling is part of the PCOS workup.

Endometrial health. Infrequent periods mean the womb lining is not shed regularly, which can lead to endometrial thickening (hyperplasia). This is why regular withdrawal bleeds are recommended for women with very infrequent periods.

These risks are manageable with monitoring and treatment. The important thing is that they are identified and tracked.

Frequently asked questions