Polycystic ovary syndrome (PCOS) is the most common endocrine condition affecting women of reproductive age, with global prevalence estimated at 6 to 13 percent. Yet up to 70 percent of those affected remain undiagnosed. Its name is also misleading: PCOS is not primarily about cysts and you do not need to have "polycystic" ovaries to have the condition.
What Is PCOS?
PCOS is a complex hormonal condition characterised by a disruption in how the ovaries function, often accompanied by insulin resistance and elevated androgens (hormones such as testosterone, which all bodies produce but typically in smaller amounts in women). It is not a single disease but a syndrome, meaning it presents differently from one person to the next.
Diagnosis is made using the Rotterdam criteria, which require at least two of the following three features: irregular or absent ovulation, clinical or biochemical signs of elevated androgens and polycystic-appearing ovaries on ultrasound. Other causes of these symptoms must also be ruled out.
Recognising the Signs
PCOS symptoms vary widely, which is part of why diagnosis is so often delayed. Common presentations include:
• Irregular, infrequent, or absent periods
• Difficulty conceiving, particularly due to absent or erratic ovulation
• Acne, particularly along the jawline, or adult-onset acne
• Hirsutism, meaning excess hair growth on the face, chest, or abdomen
• Hair thinning on the scalp in a male-pattern distribution
• Weight gain, particularly around the midsection, or difficulty losing weight
• Skin changes such as darkened patches (acanthosis nigricans), often linked to insulin resistance
• Mood changes, including higher rates of anxiety and depression
It is worth naming that PCOS presents across all body sizes. The stereotype of PCOS as a condition affecting only higher-weight individuals is inaccurate and has contributed to delayed diagnosis in many lean women.
The Insulin Connection
Insulin resistance is present in a majority of people with PCOS, including those of a lower body weight. When cells become less responsive to insulin, the pancreas produces more to compensate. High insulin levels, in turn, stimulate the ovaries to produce more androgens, which drives many of the hallmark symptoms.
This is why blood sugar management sits at the heart of evidence-based PCOS care, regardless of weight.
Evidence-Based Management
There is no cure for PCOS but symptoms can be significantly improved with a combination of approaches:
Nutrition and movement: A diet rich in fibre, protein and healthy fats, with minimised refined carbohydrates, supports insulin sensitivity. Regular movement, particularly resistance training, is strongly evidence-backed.
Medications: Metformin improves insulin sensitivity. Combined oral contraceptives regulate cycles and reduce androgen-driven symptoms. Inositol, particularly myo-inositol with D-chiro-inositol in a 40:1 ratio, has growing evidence for both ovulation and insulin response.
Fertility support: Letrozole is now the first-line treatment for inducing ovulation in those trying to conceive.
Mental health: PCOS increases risk of anxiety and depression; psychological support is not an optional add-on.
The Long View
PCOS is lifelong but it is manageable. Early diagnosis matters not only for symptom relief and fertility, but because PCOS raises long-term risk of type 2 diabetes, heart disease, and endometrial cancer. If your cycle, skin or hair changes are not adding up, name PCOS specifically in your next appointment. The question deserves to be asked.