PCOS (Polycystic Ovary Syndrome)

While OB/GYNs diagnose PCOS, an endocrinologist manages insulin resistance, long-term metabolic risks, and comprehensive hormonal treatment. If fertility is a priority, a reproductive endocrinologist (REI) is ideal.

Request fasting glucose, insulin level, HOMA-IR, lipid panel, and HbA1c. If you have insulin resistance, metformin is evidence-based and costs $4/month. Even lean PCOS patients often have insulin resistance.

A low-glycemic diet reduces insulin levels and improves PCOS hormonal markers. Exercise — especially strength training and aerobic exercise — improves insulin sensitivity. Even modest weight loss (5–10%) dramatically improves symptoms for women with PCOS and overweight.

Metformin: $4–15/month. Spironolactone: $10–30/month. Generic oral contraceptives: often free through insurance. Letrozole for ovulation: ~$20/cycle. The exception is GLP-1 agonists (semaglutide/Ozempic), which are expensive but have co-pay programs.

PCOS increases lifetime risk of type 2 diabetes, high cholesterol, high blood pressure, and endometrial cancer. Annual screening: fasting glucose or HbA1c, blood pressure, lipid panel. Use a progestin-containing IUD or oral contraceptive to protect the uterine lining if periods are irregular.

PCOS is diagnosed using the Rotterdam criteria — you need 2 of 3: (1) irregular or absent periods; (2) clinical or biochemical signs of excess androgens (hirsutism, acne, elevated testosterone); and (3) polycystic ovaries on ultrasound. Blood tests rule out other causes: TSH (thyroid), prolactin, 17-OH progesterone. There is no single definitive test.

PCOS is undertreated and underfunded relative to its prevalence. Metformin, oral contraceptives, and spironolactone are all old, cheap, off-patent drugs — there's no financial incentive for pharma to conduct expensive trials for official PCOS approval. Several trials for newer treatments (GLP-1 agonists, inositol) are ongoing.

PCOS is the most common cause of ovulatory infertility. Most women with PCOS can conceive with treatment. First-line: letrozole (now preferred over clomiphene per ACOG) on days 3–7 of cycle. Metformin is used adjunctively. If oral agents fail, injectable gonadotropins or IVF are options. Weight loss of 5–10% in women with PCOS and obesity significantly improves ovulation rates.

Insulin resistance is the metabolic core of PCOS. 70–80% of women with PCOS have insulin resistance regardless of weight. Women with PCOS have 3–7× higher risk of type 2 diabetes. By age 40, up to 10% of PCOS patients have type 2 diabetes. Annual glucose/HbA1c screening is recommended for all PCOS patients.

Yes — significantly. Low-glycemic index diets minimize blood sugar spikes and improve hormonal markers and menstrual regularity. Anti-inflammatory diets (Mediterranean pattern) reduce testosterone and inflammation. Limiting refined carbohydrates is the highest-yield change. Weight loss of 5–10% substantially improves ovulation and androgen levels for women with PCOS and overweight.