Most of you may be familiar with polycystic ovary syndrome (PCOS), but I still find that there is still some confusion around this diagnosis! Let’s talk about it. PCOS is the most common endocrine disease affecting women, and it affects about 1 in 10 women. It has impacts across the lifespan, and simply doesn’t “go away” after menopause. In 2003 the Rotterdam criteria for PCOS diagnosis was published, and that is generally the go-to criteria clinicians will use to diagnosis PCOS. According to the Rotterdam criteria, if you have 2 of 3 of these, you met criteria for PCOS:

1) Irregular cycles or ovulatory dysfunction – defined by cycles that occur less than 21 days or more than 35 days, or if you have less than 8 menstrual cycles per calendar year. Additionally, you can have “regular” cycles but may still have ovulatory dysfunction. Meaning, you do not ovulate. This can only be determined from a clinical evaluation.

2) Laboratory or clinical signs of elevated androgens – this means, you either had a blood test that showed high testosterone or DHEAS OR you have “normal” testosterone/DHEAS on a lab and have clinical signs of androgen excess. Clinical signs means what we can see with our eyes – excessive body hair growth known as hirsutism, female pattern hair loss, or acne.

3) Polycystic ovaries on ultrasound – polycystic ovaries have a very characteristic appearance, and simply having a cyst or 2 does not mean your ovaries are polycystic. Every month, if you ovulate, you will have one cyst on your ovaries. This is physiologically normal. To meet criteria for polycystic ovaries, your ovary should have at least 20 follicles present.

So that’s it! You have 2 of 3 of these, you may meet criteria for PCOS. And guess what, PCOS can be diagnosed WITHOUT any labs or an ultrasound. You have irregular cycles and excessive facial hair? Boom, PCOS should be considered. Now I still would recommend a laboratory workup to be complete and also rule out or in other reasons, but the diagnosis to PCOS does not need to be over-complicated.

In 2023, new guidelines came out with evidence showing you could actually use Anti-Mullerian Hormone (AMH) instead of an ultrasound to make the diagnosis of PCOS. Science is always changing and advancing!

Now that we’ve talked about PCOS, let’s switch gears and talk about something that looks similar to PCOS and that is functional hypothalamic amenorrhea (FHA). FHA looks similar to PCOS in that there is a lack of period, or periods of time with NO period. Different than PCOS, FHA typically has a cause. That cause is either over-exercising, under eating, disordered eating or restrictive eating patterns or psychological stress. Similar to PCOS, people with FHA also have abnormalities in the way the hormones from the brain pulsate to stimulate the ovaries to do their thing. According to the Society of Reproductive medicine, FHA is the cause of someone’s period stopping in 20-35% of cases! This is a lot! We should be educating women and menstruating people about this. People with FHA may have had a normal period for some time, and then after an event (trauma, exercise, nutrition) their periods stop.

Now one other option to include in the differential if periods are infrequent is primary ovarian insufficiency or POI. This is premature menopause that occurs before someone is 40. It is important to identify POI, because these people really do require adequate hormone therapy to reduce risk of all cause mortality or development of cardiovascular disease or osteoporosis and to protect cognition.

There are different short- and long-term health implications, including but not limited to fertility, for PCOS, FHA, and POI. It’s important that if your period is not regular (defined as menstruation occurring every 24-35 days), that you seek evaluation from a trusted healthcare practitioner!

Here’s a summary comparing & contrasting polycystic ovary syndrome, functional hypothalamic amenorrhea, and premature ovarian insufficiency.

Resources
1. Teede HJ, Tay CT, Laven JJE, Dokras A, Moran LJ, Piltonen TT, Costello MF, Boivin J, Redman LM, Boyle JA, Norman RJ, Mousa A, Joham AE. Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2023 Sep 18;108(10):2447-2469. doi: 10.1210/clinem/dgad463. PMID: 37580314; PMCID: PMC10505534.
2. Practice Committee of the American Society for Reproductive Medicine Current evaluation of amenorrhea. Fertil Steril. 2006;86:S148. doi: 10.1016/j.fertnstert.2006.08.013