Symptoms & causes


The symptoms of PCOS include excess hair (hirsutism), scalp hair loss, acne, weight gain, difficulties with fertility, increased anxiety and depression and irregular or infrequent periods. There is also information on the possible causes of PCOS, and other health problems linked with PCOS.

What is PCOS?

Up to 21% of women in some groups, e.g. Indigenous Australians, have PCOSPolycystic Ovary (Ovarian) Syndrome (PCOS) is a hormonal disorder. It affects 12-18% of women of reproductive age and up to 21% in some high-risk groups, such as Indigenous women[1].

PCOS can be a complex condition to identify because there are several symptoms and you don't have to have all of them to be diagnosed with PCOS. Very few women have the same set of symptoms. The name 'polycystic' suggests you might have multiple 'cysts' on your ovaries, but not all women who have PCOS have multiple 'cysts' and not all women who have multiple 'cysts' have PCOS. The term 'cysts' is a bit misleading. The cysts are actually not cysts but partially formed follicles that each contain an egg.

What are the signs & symptoms of PCOS?

Many of the symptoms of PCOS are caused by high levels of androgens circulating in your body, causing 'hyperandrogenism'. Androgens are also called 'male' hormones, and the main one is testosterone. All women produce small amounts of androgens in body tissues including the ovaries and the adrenal glands. High levels of androgens can prevent ovulation and affect the menstrual cycle.

The hormone insulin is also thought to be an important part of the development of PCOS. Insulin is needed in the body for control of blood sugar, and 'insulin resistance' is thought to be a key part of the development of PCOS. Insulin resistance means that some parts of the body are 'resistant' to insulin, meaning that more insulin than usual is needed to keep blood sugar in the normal range. This means that insulin levels are often high or the body doesn't respond normally to insulin. This in turn can affect the function of the ovaries, including hormone and egg production.

 Symptoms of PCOS may include:

Periods & fertility Hair & skin Mental & emotional health Sleep
  • No periods or periods that are:
    • irregular
    • infrequent
    • heavy
  • Immature ovarian eggs that do not ovulate
  • Multiple cysts on the ovaries
  • Difficulty becoming pregnant
  • Excess facial and/or body hair (hirsutism)

  • Acne on the face and/or body

  • Scalp hair loss (alopecia)

  • Darkened skin patches (acanthosis nigricans)

  • Mood changes

  • Depression

  • Anxiety

  • Sleep apnoea (a sleep disorder in which abnormal pauses of breathing  occur during sleep)

PCOS symptoms present in many different ways. Some women will have only some, or mild symptoms, whereas others will have severe symptoms. 

Periods

Although some women with PCOS have regular periods, high levels of androgens and also the hormone insulin can disrupt the monthly cycle of ovulation (when eggs are released) and menstruation.

If you have PCOS, your periods may be 'irregular' or stop altogether. In some girls PCOS is a cause of periods failing to commence. The average menstrual cycle is 28 days with one ovulation, but anywhere between 21 and 35 days is considered 'normal'. An 'irregular' period cycle is defined as either:

  • Eight or less menstrual cycles per year
  • Menstrual cycles longer than 35 days.

As menstrual cycles lengthen, ovulation may stop entirely or only occur occasionally. Some women with PCOS also experience heavier or lighter bleeding during their cycle.

Excess hair (hirsutism)

Hirsutism is excess hair on the face and body due to high levels of androgens stimulating the hair follicles. This excess hair is thicker and darker. The hair typically grows in areas where it is more usual for men to grow hair such as the sideburn region, chin, upper lip, around the nipples, lower abdomen, chest and thighs.

Up to 60% of women with PCOS have hirsutism[2]. Women with PCOS from ethnic groups prone to darker body hair (eg Sri Lankan, Indian and Mediterranean populations) often find they are more severely affected by hirsutism.

Hair loss (alopecia)

For some women with PCOS, the high level of androgens causes hair loss or thinning of the scalp hair in a 'male-like' pattern: a receding frontal hair line and thinning on top of the scalp.

Acne

If you have PCOS, the higher level of androgens can increase the size of the oil production glands on the skin, which can lead to increased acne. Acne is common in adolescence, but young women with PCOS also tend to have more severe acne.

Reduced fertility

High levels of androgens and high insulin levels can affect the menstrual cycle and prevent ovulation (the release of a mature egg from the ovary). Ovulation can stop completely, or it can occur irregularly. This can make it more difficult for women with PCOS to conceive naturally, and some women can also have a greater risk of miscarriage. However, this does not mean that all women with PCOS are infertile. 

Many women with PCOS have children without the need for medical infertility treatment. Others may require medical assistance. But overall, women with PCOS have the same number of children as women without PCOS (Joham, Human Reprod, 2014). 

As being overweight can increase fertility problems, it is important to exercise regularly to maintain a healthy weight and/or prevent weight gain. For those who are overweight, even weight loss of 5-10% will improve fertility.

Psychological effects

Depression and anxiety are common symptoms [3] of PCOS. About 29% of women with PCOS have depression compared to around 7% of women in the general population and even more women with PCOS will have anxiety – 57% compared to 18% of women in the general population[4-5].

There may be some link to hormones and PCOS but more research is needed in this area before we can understand why and how the hormones impact on mental wellbeing in PCOS.

Coping with hirsutism, severe acne, weight changes and fertility problems may affect your body image, self-esteem, sexuality and femininity. This may add to depression and anxiety levels. Problems with fertility can have an impact on your mood, particularly if fertility has been a concern for a long time.

On top of all of this, a delayed diagnosis of PCOS and problems with weight management can make you feel discouraged and helpless. This creates a negative cycle, making it harder to take charge of your health and live the healthiest lifestyle you can.

What causes PCOS?

While the cause of PCOS is unknown, there do appear to be connections with family history, insulin resistance and lifestyle or environment.

Family history

Immediate female relatives (ie daughters or sisters) of women with PCOS have up to a 50% chance of having PCOS. Type 2 diabetes is also common in families of those with PCOS. So far, no single gene has been found to cause PCOS, so the link is likely to be complex and involve multiple genes.

Insulin resistance & lifestyle

One of the roles of insulin is to keep the levels of glucose in the blood from rising after eating.  If you are insulin resistant, your body doesn't use the available insulin effectively to help keep your glucose levels stable.

Because the insulin is not working effectively, the body produces more insulin.  These high levels can increase the production of androgens such as testosterone, in the ovaries. This contributes to excessive hair growth and acne, and can contribute to symptoms such as irregular periods, trouble ovulating, excess hair growth and acne.

Insulin resistance is present in up to 80% of women with PCOS. It can contribute to an increased risk of developing type 2 diabetes and cardiovascular disease.

Insulin resistance is caused in part by lifestyle factors – including being overweight – because of a diet or physical inactivity. While women without PCOS who are overweight can have this form of insulin resistance, women with PCOS are more likely to have a particular form of insulin resistance caused by genetic factors separate from the insulin resistance associated with being overweight. That means that slim women with PCOS can also have insulin resistance.

This means women with PCOS can have:

  • Insulin resistance as a result of genetic factors
  • Insulin resistance as a result of being overweight (related to diet and inactivity)
  • A combination of both of these factors

Weight

Being above a healthy weight worsens insulin resistance and the symptoms of PCOS. Some women with PCOS report that when they are a healthy weight, they don't have symptoms such as menstrual irregularity or excessive hair growth. These symptoms only appear once they gain weight. A healthy lifestyle of nutritious food and physical activity can help to treat PCOS and prevent it.

Health problems linked to PCOS

Women with PCOS appear to be at increased risk of developing the following health problems during their lives:

  • Insulin resistance (if they don't already have it)
  • Type 2 diabetes
  • Cholesterol and blood fat abnormalities
  • Cardiovascular disease (heart disease, heart attacks and stroke)
  • Endometrial carcinoma (cancer)

For more information on these problems see our webpage on PCOS complications.

Sleep apnoea

Women with PCOS, particularly when they are overweight or insulin resistant, can be at an increased risk of developing sleep disordered breathing or sleep apnoea. Sleep apnoea occurs when the upper airway is obstructed during sleep.  Excessive fatty tissue in the neck can partially block the airway leading to sleep loss, fatigue, tiredness and reduced quality of life.

If you suspect you may have PCOS it is important you see a doctor. You may be referred to a specialist such as an endocrinologist (hormone specialist) or gynaecologist for more detailed assessments. An early diagnosis can help manage the symptoms of PCOS and reduce the potential long term health risks posed by PCOS. 

References

  1. March WA, Moore VM et al. The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Hum Reprod 2010; 2:544–551.

  2. Fauser B, Tarlatzis B et al. Consensus on women's health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertility Sterility. 2012;97(1):28-38.

  3. Deeks A, Gibson-Helm, Paul E, Teede H. (2011). Is having polycystic ovary syndrome (PCOS) a predictor of poor psychological function including anxiety and depression? Human Reproduction June;26(6):1399-407

  4. Deeks A, Gibson-Helm ME et al. Anxiety and depression in polycystic ovary syndrome: a comprehensive investigation. Fertility Sterility. 2010;93:2421-3.

  5. 4102.0 Australian Social Trends 2009; http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features30March%202009

Last updated 24 April 2018 — Last reviewed 20 April 2017

** Currently under review **

This web page is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. The information above is based on current medical knowledge, evidence and practice as at April 2017.

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