PCOS Frequently Asked Questions
What kind of doctor can diagnose and treat PCOS?
Any type of doctor familiar with PCOS might make the diagnosis, but the disorder is
complicated and may be best treated by a specialist. Those having difficulty getting
pregnant should see a reproductive endocrinologist, while long-term management by an
endocrinologist should be considered. A general practitioner or an OBGYN may treat
some women with the syndrome, but someone who specializes in endocrine disorders may
be more familiar with treatment options and recent studies on PCOS. A list of fertility
specialists is available on INCIID and PCOSupport.org has a list of doctors familiar
with PCOS.
How should one prepare for initial medical appointment to discuss PCOS?
Write down any questions before the appointment. It is usually faster and more orderly
to have a list, no matter how long it may get. Many questions will be answered in the
general course of conversation.
Gather up any appropriate or requested medical records follow through and make sure
the doctor gets them before the appointment, or bring them. (Sending in advance is
generally preferred.) If the visit is for fertility reasons and one has already done a
hysterosalpingogram (HSG, x-ray test of the uterus and tubes), a copy of the actual
film is preferred to the printed interpretation or report.
Be ready to supply family history, especially about insulin resistance, diabetes, lipid
abnormalities such as high cholesterol, obesity, high blood pressure, heart disease,
and infertility. Include information from both parents and their families. PCOS
characteristics may be passed down from either side of the family.
Familiarize oneself with the symptoms of PCOS and discuss any concerns with the doctor.
If looking for help in getting pregnant, consider bringing in basal body temperature
(BBT) charts to initial evaluation.
See if it would be helpful to arrive for the doctor's appointment in a fasting state,
and clarify any other requirements.
What are some questions to ask the doctor?
The purpose of the following list of questions, and this entire FAQ, is to help women
have better communication with their doctors, not to substitute for diagnosis,
treatment, and frank discussion with one's own physician.
What specific tests are used to confirm PCOS?
What tests are done to confirm insulin resistance and/or diabetes?
Are insulin-sensitizing medications prescribed for insulin resistance, or only for
diabetes?
What recommendations or medications, if any, are typically given for the symptoms of
PCOS, such as weight gain/obesity, acne, hirsutism, balding, lack of menses, high
cholesterol, high blood pressure, and insulin resistance?
After initial diagnosis of PCOS, what kind of future monitoring is recommended?
Is treatment of PCOS similar among different doctors in this practice?
Will diet and exercise information and support be provided?
What kind of birth control is recommended for women with PCOS?
What kind of treatment is offered to women with PCOS who are trying to conceive?
Is weight loss in obese patients a requirement before any stage of fertility treatment?
For example, would one be allowed to try Clomid, but not allowed to pursue in vitro
fertilization?
Can insulin-sensitizing medications be used while trying to conceive?
Can insulin-sensitizing medications be continued in pregnancy?
Which medications used to reduce PCOS symptoms, such as those for acne and hirsutism,
can be continued while trying to conceive or when pregnant?
Is there one definitive test to diagnosis PCOS?
At this time, there is no single definitive test for PCOS. This is because no exact
cause of PCOS has been established yet. This is why there is a wide-range of opinion on
how to diagnose and treat PCOS.
How should PCOS be diagnosed?
PCOS should be diagnosed based on physical exam, ultrasound of the ovaries, and the
results of various blood tests. Diagnosis is made based on having several of the
symptoms listed above. There is some disagreement in the medical community about the
diagnostic criteria to be used. Some doctors suggest that at least three of the symptoms
must be present to diagnose PCOS, others may make the diagnosis on the basis of fewer
criteria (often emphasizing lack of ovulation), while others believe that PCOS is a
diagnosis of exclusion meaning if there are hormonal abnormalities for which no other
explanation can be found, PCOS is presumed. Since there is no consensus as to how PCOS
is defined or diagnosed, there should be little surprise when a variety of opinions
emerge on how this problem should be treated!
How are polycystic ovaries diagnosed by ultrasound?
An ultrasound of the ovaries is usually done transvaginally where a probe is placed
into the vagina to gain view of the ovaries. In some cases, an abdominal ultrasound may
be needed as well, but this tends not to give as clear a view.
A classic PCOS ovary is enlarged and has a "string of pearls" appearance, where the
pearls are the cysts. Usually ultrasound diagnosis of polycystic ovaries is made if
there are at least 8-10 cysts that are less than 10mm in size on each ovary. It is not
known how long each individual cyst will last, or what caused the arrested development
of the follicle leading to the formation of the cyst in the first place. The polycystic
ovary tends to be enlarged to 1.5-3 times the size of a normal ovary and often has an
increase in the stromal tissue in the center of the ovary and around the follicles. Both
the cysts and the stroma produce hormones, so the more cysts and the more stroma, the
more likely one is to have other signs and symptoms of PCOS.
Is it possible to have polycystic ovaries without having the syndrome?
About 20-30 percent of women will have the appearance of polycystic ovaries, while only
an estimated 5-10 percent of women would be diagnosed as having Polycystic Ovary
Syndrome as based on signs and symptoms. It may be best to consider the finding of
polycystic ovaries as a possible sign of PCOS, but not to rely on this as the sole
criterion in making a diagnosis.
A large percentage of women with polycystic ovaries have at least some subtle hormone
alterations, even if they do not clearly exhibit other signs of the syndrome.
Is it possible to have PCOS without having cysts?
This is another area of some disagreement among medical professionals. Most women with
PCOS will in fact have the polycystic ovaries for which the syndrome is named, but it
is possible to be diagnosed with the syndrome without this particular symptom. Some
doctors diagnose PCOS based on the appearance of other physical symptoms or hormone
abnormalities, regardless of ultrasound findings.
It is difficult to make a firm diagnosis of PCOS without the presence of either an
increased number of small cysts or ovarian enlargement. Polycystic ovaries may not have
been recorded as an official finding on an ultrasound even though they were seen. Often
ultrasounds have been performed to exclude pathology and may not have diagnosed minor
increases in cystic structures or ovarian enlargement. Some ultrasonographers may
consider the milder forms of PCOS as variations of normal. Ovarian enlargement is not
always associated with ovarian cyst development, but still can be a variant PCOS. In
other words, if one has the signs and symptoms of PCOS it is likely that there is some
alteration in the appearance of the ovary, even if it has not been recognized.
What blood tests should be done to diagnose PCOS?
Much of the bloodwork that should be done in diagnosing or ruling out PCOS is the same
as a basic fertility workup; however, there are a couple of additional tests for insulin
resistance that should be added, as well as some cholesterol screening to evaluate
general health status because of the future risks associated with PCOS. A good basic
screening would include:
Fasting comprehensive biochemical and lipid panel;
2-hour GTT with insulin levels (also called IGTT);
LH:FSH ratio;
Total testosterone;
DHEAS;
SHBG;
Androstenedione;
Prolactin and
TSH
What are normal values for the blood tests?
Note: Values are laboratory dependant, so while this list is provided as general
information, one needs to ask her own doctor to explain the results based on individual
lab standards. This is provided for discussion purposes only, not for self-diagnosis.
Please note the units of measure as these also vary from lab to lab.
Hormone Levels
Hormone to test Time
to Test Normal
Values What value means
Follicle Stimulating Hormone (FSH) Day 3 3-20 mIU/ml FSH is often used as a gauge of
ovarian reserve. In general, under 6 is excellent, 6-9 is good, 9-10 fair, 10-13
diminished reserve, 13+ very hard to stimulate. In PCOS testing, the LH:FSH ratio may be
used in the diagnosis. The ratio is usually close to 1:1, but if the LH is higher, it
is one possible indication of PCOS.
Estradiol (E2) Day 3 25-75 pg/ml Levels on the lower end tend to be better for
stimulating. Abnormally high levels on day 3 may indicate existence of a functional
cyst or diminished ovarian reserve.
Estradiol (E2) Surge/hCG
day 200 + pg/ml The levels should be 200-600 per mature (18 mm) follicle. These levels
are sometimes lower in overweight women.
Luteinizing Hormone (LH) Day 3 < 7 mIU/ml A normal LH level is similar to FSH. An LH
that is higher than FSH is one indication of PCOS.
Luteinizing Hormone (LH) Surge Day > 20 mIU/ml .
Prolactin Day 3 < 24 ng/ml Increased prolactin levels can interfere with ovulation.
They may also indicate further testing (MRI) should be done to check for a pituitary
tumor. Some women with PCOS also have hyperprolactinemia.
Progesterone (P4) Day 3 < 1.5 ng/ml .
Progesterone (P4) 7 dpo > 15 ng/ml A progesterone test is done to confirm ovulation.
When a follicle releases its egg, it becomes what is called a corpus luteum and produces
progesterone. A level over 5 probably indicates some form of ovulation, but most
doctors want to see a level over 10 on a natural cycle, and a level over 15 on a
medicated cycle. Some say the test may be more accurate if done first thing in the
morning after fasting.
Thyroid Stimulating Hormone (TSH) Day 3 .4-4 uIU/ml Mid-range normal in most labs is
about 1.7. A high level of TSH combined with a low or normal T4 level generally
indicates hypothyroidism, which can have an effect on fertility.
Free Triiodothyronine (T3) Day 3 1.4-4.4 pg/ml Sometimes the diseased thyroid gland
will start producing very high levels of T3 but still produce normal levels of T4.
Therefore measurement of both hormones provides an even more accurate evaluation of
thyroid function.
Free Thyroxine (T4) Day 3 .8-2 ng/dl A low level may indicate a diseased thyroid gland
or may indicate a non-functioning pituitary gland which is not stimulating the thyroid
to produce T4. If the T4 is low and the TSH is normal, that is more likely to indicate
a problem with the pituitary.
Total Testosterone Day 3 6-86 ng/dl Testosterone is secreted from the adrenal gland and
the ovaries. Most would consider a level above 50 to be somewhat elevated.
Free Testosterone Day 3 .7-3.6 pg/ml
Dehydroepiandrosterone Sulfate (DHEAS) Day 3 35-430 ug/dl
Androstenedione Day 3 .7-3.1 ng/ml
Sex Hormone Binding Globulin (SHBG) Day 3 18 114 nmol/l Increased androgen production
often leads to lower SHBG
Fasting Insulin 8-16 hours fasting < 30 mIU/ml The normal range here doesn't give all
the information. A fasting insulin of 10-13 generally indicates some insulin
resistance, and levels above 13 indicate greater insulin resistance.
Blood Glucose Levels
Type of test Time to
Test Normal
Values What value means
Fasting Glucose 8-16 hours fasting 70-110 mg/dl A healthy fasting glucose level is
between 70-90, but up to 110 is within normal limits. A level of 111-125 indicates
impaired glucose tolerance/insulin resistance. A fasting level of 126+ indicates type
II diabetes.
Glycohemoglobin / Glycosylated Hemoglobin (HbA1c) anytime < 6 % An HbA1c measures
glucose levels over the past 3 months. It should be under 6% to show good diabetic
control (postprandial glucose levels rarely going above 120). Good control reduces the
risk of miscarriage and birth defects.
Cholesterol, Triglycerides and C-Peptide
What to test Time to Test Normal
Values What value means
Triglycerides (TG) 8-16 hours fasting < 200 mg/dl Borderline high is 200-400, high is
400-1000, and very high is >1000. Elevated levels are a risk factor for coronary artery
disease.
Cholesterol Total 8-16 hours fasting < 200 mg/dl A level of 200-239 is borderline high,
and a level 240+ is high. Increased levels are associated with increased risk of heart
disease.
low-density lipoprotein cholesterol (LDL) 8-16 hours fasting < 160 mg/dl This is the
"bad" cholesterol. In someone with one risk factor for heart disease, <160 is
recommended, with 2 risk factors <130, and those with documented coronary heart disease
the target is <100
high-density lipoprotein cholesterol (HDL) 8-16 hours fasting > 34 mg/dl This is the
"good" cholesterol which may be increased through a healthy diet and exercise. The HDL
level is usually estimated by taking total cholesterol and subtracting LDL, rather than
by direct measure.
C-peptide 8-16 hours fasting 0.5 to 4.0 ng/ml Levels increase with insulin production.
Creatinine <1.4 mg/dl Levels 1.4 mg/dl and higher may indicate renal (kidney) disease
or renal dysfunction.
Some doctors will suggest an oral glucose tolerance test in addition to the tests above
for insulin resistance.
What does an abnormal test value mean?
Nearly all patients with PCOS will have at least some subtle laboratory abnormalities,
though the levels may not be outside normal limits. Lab values that are at the upper
or lower end of the normal range may show a tendency toward a problem rather than a
discrete abnormality. It may be a pattern within the group of tests that points to PCOS,
rather than one or more values outside the normal limits.
Usually a hormone level that is marginally elevated is associated with a dysfunction,
while a severe elevation or suppression may be more likely to be pathologic (a physical
cause, such as an adrenal tumor).
It is important to note that many lab reference ranges were probably set irrespective
of PCOS, and often are set based on screening for a certain abnormality. For example,
the range of normal on a fasting insulin test may be set to screen for an insulinoma
(an insulin-producing tumor in the pancreas), rather than to check for insulin
resistance.
Does it matter when hormone tests are performed?
Most endocrine tests should be performed within a few days after a spontaneous or
induced menstrual period. These tests may be misleading if oral contraceptives are
being used. Glucose, insulin and lipid evaluation should be done in the morning after
fasting for at least 8 hours, but less than 16 hours. Accurate glucose and insulin
testing requires the patient to be in good health. Progesterone levels to confirm
ovulation should be done seven days after suspected ovulation.
How often should tests be repeated?
Most of the blood work, unless monitoring a fertility treatment cycle, does not have to
be repeated unless there is abnormal result. Most infertility clinics will repeat basic
labs annually.
How important is the LH:FSH ratio?
The emphasis doctors place on the ratio of luteinizing hormone (LH) to follicle
stimulating hormone (FSH) varies. Most pre-menopausal women have a ratio close to1:1.
In PCOS, the LH level may rise above the FSH, sometimes significantly. Any case where
the LH is higher may be suggestive of PCOS and further investigation may be warranted.
Some doctors say that an LH:FSH greater than 2:1 or 3:1 indicates PCOS.
Are PCOS and hypothyroid related?
No. It may be that PCOS and thyroid disease are both common, so will sometimes be seen
in the same patient.
A good number of PCOS patients have under-active thyroid glands. Since many of the
symptoms are the same, evaluation of the thyroid gland with a blood test for thyroid
stimulating hormone (TSH) should be a part of the evaluation for PCOS. The TSH is almost
always the only test needed to evaluate thyroid function.
Likewise, PCOS should be evaluated in the patient with under-active thyroid gland.
