What are the Main PCOS Symptoms and How Do They Present?

PCOS is a complex metabolic and endocrine condition characterized by an imbalance of reproductive hormones. According to the Rotterdam Criteria, a diagnosis is typically made when at least two of the following are present: excess androgens (male hormones), irregular or absent periods, and/or polycystic ovaries visible on ultrasound.

While every woman’s experience is unique, recognizing these signs early is the first step toward effective management.

The most common PCOS symptoms include:

PCOS can manifest in many different ways,  some visible, others more subtle. The most common include:

• Irregular or Absent Periods (Oligo- or Amenorrhea): This is the hallmark symptom. Cycles may be longer than 35 days, or you may have fewer than eight periods a year. This indicates an imbalance in ovulation caused by hormonal disruption.
• Acne and Oily Skin: Hormonal imbalances can cause persistent breakouts, clogged pores, blackheads, and cystic acne — especially around the jawline, chin, upper neck, and back.
• Facial or Body Hair Growth (Hirsutism):  Due to high levels of androgens (like testosterone), women may experience thicker, darker hair growth on the face, chest, back, or abdomen.
• Weight Gain or Difficulty Losing Weight: PCOS often disrupts insulin sensitivity, leading to sugar cravings, mood changes, and post-meal energy crashes. These blood sugar fluctuations are a hallmark sign of metabolic imbalance in PCOS and contribute to weight gain, especially around the midsection. Some women may also have Lipedema, a condition that makes fat tissue resistant to weight loss despite healthy habits.  Difficulty losing weight, especially around the midsection. This abdominal weight gain is often linked directly to underlying insulin resistance, a key driver of PCOS.
• Hair Thinning or Hair Loss: Paradoxically, high androgens can also cause male-pattern hair loss or thinning on the scalp. In some women with PCOS, a low-functioning thyroid may also play a role, further contributing to shedding or slower regrowth.
• Fertility Issues: Irregular or absent ovulation (anovulation) can make conceiving more difficult. Many women with PCOS experience longer cycles or no ovulation at all, which affects natural fertility and timing for conception. .
• Dark Skin Patches (Acanthosis Nigricans): PCOS-related insulin resistance can cause dark, velvety patches of skin — often appearing around the neck, underarms, inner thighs, or groin. These PCOS skin changes are a visible sign of hormonal and metabolic imbalance, and they often improve as insulin levels stabilize.
• Skin Tags: Small, soft growths of skin that appear in areas of friction such as the neck, underarms, or beneath the breasts. They’re another common skin symptom of PCOS, linked to elevated insulin levels and inflammation.
• Facial Puffiness or “Moon Face”: Hormonal fluctuations, inflammation, and cortisol imbalances can lead to facial bloating or roundness — often referred to as “PCOS moon face.” This symptom may become more noticeable during times of high stress or elevated inflammation levels.
• Pelvic Pain: Some women with PCOS experience cramping or pelvic pressure around ovulation or menstruation. This discomfort may stem from enlarged ovaries, cysts, or hormonal inflammation.
• Digestive Issues: Hormonal fluctuations and chronic inflammation can affect the gut, leading to bloating, constipation, or IBS-like symptoms. Many women notice PCOS-related digestive issues that improve with balanced blood sugar and stress support.
• Chronic Inflammation: Low-grade inflammation is common in PCOS and can contribute to fatigue, joint pain, and muscle tenderness. Managing inflammation through nutrition, sleep, and stress balance supports overall PCOS symptom relief.

Are there emotional or less obvious PCOS symptoms?

Yes, PCOS is not purely physical. The hormonal fluctuations, especially high androgens, and the visible physical symptoms often lead to significant emotional distress. Less obvious symptoms include:

• Fatigue and Low Energy: Constant tiredness is one of the most common symptoms of PCOS. Hormonal imbalance and insulin resistance can cause blood sugar fluctuations that drain energy, leaving you feeling sluggish even after a full night’s sleep. 
• Brain Fog or Forgetfulness: Many women with PCOS report mental fatigue, trouble focusing, or feeling “foggy.” These cognitive symptoms are linked to unstable blood sugar, inflammation, and stress hormone imbalance.
• Mood Swings, Anxiety, and Depression: Hormonal imbalances can deeply affect mood and emotional well-being. Fluctuating levels of estrogen, progesterone, and androgens can disrupt serotonin and dopamine, leading to mood swings, anxiety, or low motivation. PCOS can also affect self-esteem, making it an emotionally challenging condition to navigate. 
• Sleep Problems or Insomnia: Hormonal changes, elevated cortisol, and blood sugar instability can interfere with quality sleep, making it harder to fall or stay asleep. Many women with PCOS and insomnia also experience restless nights before their cycle.
• Fluctuating Body Temperature or Night Sweats: Many women notice sudden shifts in temperature, feeling unusually hot or cold. Hot flashes at night can be a sign of estrogen dominance or thyroid imbalance.
• Sleep Apnea: In some cases, higher androgen levels and weight gain can contribute to sleep-disordered breathing. Addressing inflammation, weight balance, and hormone regulation can help reduce apnea symptoms. 
• Low Sex Drive: Hormonal imbalance and stress can affect libido and sexual response. Restoring balanced testosterone and insulin levels often helps improve sexual well-being.
• Frequent Headaches or Dizziness: Insulin resistance, fluctuating estrogen, and blood sugar crashes can cause headaches, lightheadedness, or dizziness — especially between meals.

How is a Clear PCOS Diagnosis Reached?

What is the process for a formal PCOS diagnosis?

The path to effective PCOS management starts with a formal and accurate PCOS diagnosis. Understanding how to get diagnosed with PCOS is the first step toward clarity and treatment. Most doctors use  the internationally recognized Rotterdam Criteria to confirm a PCOS diagnosis — which requires showing at least two of the following three signs:

• High androgen levels (excess “male” hormones)
• Irregular or absent ovulation (ovarian dysfunction)
• Polycystic ovaries visible on ultrasound

What is the significance of the "polycystic ovaries" found during diagnosis?

It is important to know that these "cysts" are not true cysts, but rather antral follicles—small sacs that contain eggs but have stalled in development and failed to mature or be released due to the hormonal imbalance. A diagnosis of polycystic ovaries simply means an ovary has 12 or more of these small, immature follicles.

How to Test for PCOS & What specialized tests should I expect during a PCOS diagnosis?

If you’re wondering how to test for PCOS, the process involves both medical history and specific lab or imaging tests. These help doctors confirm hormonal imbalance and rule out other causes: Medical History: Your doctor will review your menstrual cycle history (first period, cycle length, bleeding patterns), weight fluctuations, and hair growth (using the Ferriman-Gallwey score).

• Hormone Blood Tests: Checks for high androgen levels (Free and Total Testosterone) and the ratio of Luteinizing Hormone (LH) to Follicle-Stimulating Hormone (FSH), which is often elevated in PCOS.
• Metabolic Blood Tests: Tests like fasting glucose, fasting insulin, or an oral glucose tolerance test (OGTT) help identify insulin resistance, a core feature of PCOS. 
• Pelvic Ultrasound: Used to visualize the ovaries and measure the size and number of follicles, which are actually immature eggs (sometimes called “cysts”). Doctors look for the characteristic “string of pearls” appearance around the ovary.  This feature is what gave Polycystic Ovary Syndrome (PCOS) its name, but it’s important to remember that you don’t need visible cysts on your ovaries to be diagnosed with PCOS. 

What Do Polycystic Ovaries Mean?

Despite the name, the “cysts” in polycystic ovaries aren’t true cysts. They’re antral follicles — small sacs containing eggs that haven’t matured or been released due to hormonal imbalance. When an ovary has 12 or more of these small follicles, it meets the ultrasound criteria for PCOS. 

This finding helps confirm the diagnosis, but it’s only one piece of the overall picture. Your symptoms, hormone levels, and menstrual cycle history are just as important in understanding and confirming the condition.

What other conditions must be ruled out before confirming PCOS?

To ensure an accurate PCOS diagnosis, doctors must rule out conditions that mimic PCOS symptoms or identify those that may coexist with PCOS. These may include: 

• Thyroid disorders (hypothyroidism or hyperthyroidism)
• High prolactin levels (hyperprolactinemia)
• Diabetes or insulin resistance
• Uterine fibroids
• Adenomyosis
• Autoimmune diseases (such as Hashimoto’s thyroiditis or lupus)
• Non-classic congenital adrenal hyperplasia (NCCAH)
• Ruling out these conditions helps ensure PCOS is correctly identified and managed with a tailored treatment plan.

PCOS and Mental Health

How does PCOS impact mental health and emotional well-being?

The emotional toll of PCOS is often overlooked but significant. The chronic symptoms, the struggle with weight, and the visible signs like acne and hirsutism can lead to:

• Depression and Anxiety: Hormonal fluctuations (especially androgens) directly affect mood-regulating neurotransmitters. The diagnosis itself can also be a source of stress.
• Body Image Issues: Visible symptoms can severely impact self-esteem and body image, leading to avoidance behaviors and social withdrawal.
• Emotional Eating: Dealing with insulin resistance can lead to intense cravings and blood sugar crashes, contributing to emotional eating cycles.

What supportive strategies should be used for mental health management?

Integrating mental health care into your PCOS management plan is essential. This includes stress reduction (meditation, adequate sleep), seeking support from a therapist who specializes in chronic conditions, and connecting with PCOS support communities. Addressing the root cause (insulin resistance) often naturally improves energy and mood.

Long-Term Management and Fertility

What are the long-term health risks associated with PCOS?

Effective PCOS management significantly lowers long-term health risks. Without intervention, high insulin levels and chronic inflammation increase the risk of:

• Type 2 Diabetes: Due to persistent insulin resistance.
• Cardiovascular Disease: Elevated blood pressure and cholesterol are common.
• Endometrial Hyperplasia/Cancer: Due to unopposed estrogen if periods are infrequent or absent for long periods.

What are the fertility options for women with PCOS?

Difficulty conceiving is one of the most stressful PCOS symptoms. The good news is that PCOS is highly treatable.

• Ovulation Induction: Often the first line of treatment. Medications like Clomiphene or Letrozole are used to stimulate the ovaries to release an egg. Lifestyle changes often make these drugs more effective.
• In Vitro Fertilization (IVF): Used when ovulation induction is unsuccessful. PCOS patients often respond well to IVF, but protocols must be managed carefully due to the risk of Ovarian Hyperstimulation Syndrome (OHSS).
• Laparoscopic Ovarian Drilling (LOD): A surgical option used to reduce androgen production by the ovaries in select cases.

What should I do after receiving a PCOS diagnosis?

Receiving a PCOS diagnosis is a call to action, not a final sentence. While the journey involves consistency in your PCOS diet and movement, navigating the hormonal and metabolic complexity often requires targeted, research-backed support. Milamend is here to be that partner in your health journey. We provide the essential, high-quality supplements and resources you need to address the root causes of PCOS symptoms, from insulin resistance to hormone balance. Ready to move from managing symptoms to achieving profound, lasting balance? Explore the Milamend difference today and take control of your PCOS management.