Can you have PCOS with regular periods? Your top questions, answered by the Women’s Wellness Centre

We recently asked the Instagram TTC community what they wanted to hear more about and the resounding response was PCOS (Polycystic Ovary Syndrome). For those who may not be aware, Polycystic Ovary Syndrome (PCOS) is a health problem which affects approximately 1 in 10 women. That’s huge!

With so many of you wanting to know more about how it can be treated and how it can affect fertility, we’ve spoken to the brilliant Fertility Specialist, Dr Despina Mavridou at The Women’s Wellness Centre in London, to find out all about it and the latest development in the treatment of Polycystic Ovarian Syndrome (PCOS). She also talks about when to seek fertility advice and help.

The Women’s Wellness Centre in London have the most resourceful and supportive free Facebook group, which we would strongly recommend you join.

Over to Fertility Specialist, Dr Despina Mavridou.

Your one-stop PCOS Q&A

Here’s the key thing to understand about PCOS: it’s a syndrome. That means it’s not just one issue, but a cluster of symptoms that tend to show up together. PCOS doesn’t affect a single body part or stem from one specific malfunction – it shows up across multiple systems in the body, making it a complex condition to manage.

PCOS is typically diagnosed when someone has either irregular or infrequent periods, signs of high androgen levels (like acne or excess hair growth), and/or ovaries that appear polycystic (meaning multiple cysts are visible) on an ultrasound scan – remember, you may not have all of these symptoms.

There are also several health conditions that more commonly show up alongside PCOS, including:

• endometrial hyperplasia
• insulin resistance and diabetes
• endometrial cancer
• cardiovascular disease

Wondering if you can have both PCOS and endometriosis? You’re not alone. These two conditions can co-occur – and it’s worth understanding how they overlap.

What are the symptoms of PCOS?

Because PCOS affects multiple systems in the body and involves a complex web of hormonal pathways, it can be tough to sum up neatly – especially in a short consultation. The symptoms women experience are often wide-ranging, making the condition feel even more confusing.

If you’re noticing any signs that feel off, or if you’re TTC (trying to conceive) or thinking about it soon, it may be worth seeking help from a fertility specialist to explore what’s going on.

How is PCOS diagnosed?

There are agreed diagnostic criteria for PCOS. In order to receive a diagnosis, two out of three symptoms need to be present – keep reading for what these are.

That said, many women don’t tick every box – and as a result, they may remain undiagnosed or misdiagnosed for years. If any of the symptoms above feel familiar, don’t hesitate to ask your doctor to evaluate you for PCOS.

Getting diagnosed early – ideally during your reproductive years, not just when you’re trying for a baby – is important. That’s because PCOS doesn’t just affect fertility. It can also increase your risk of long-term health issues like type 2 diabetes, cardiovascular disease, and even certain cancers. Later in this guide, we’ll get into how PCOS may require fertility treatment if you’re TTC.

Can you have PCOS with regular periods?

Short answer: yes. PCOS is diagnosed when two out of three key symptoms are present:

• Irregular periods (or no periods at all)
• Elevated levels of androgens (think acne or hirsutism)
• Polycystic-looking ovaries on an ultrasound scan

So, can you have PCOS with regular periods? Absolutely – because a diagnosis doesn’t require all three signs to be present. You might have a completely regular cycle, but still meet the other criteria.

What is androgen excess?

Androgens are hormones typically found at higher levels in males. In women with PCOS, these hormone levels are usually lower than in men but still higher than in women without the condition.

This hormonal imbalance is what causes many of the visible symptoms of PCOS. The most common signs of androgen excess? Hirsutism and acne. Hirsutism refers to excessive hair growth in areas where women don’t typically grow much hair – like the face, upper lip, abdomen, or back.

How common is PCOS?

PCOS is the most common endocrine disorder affecting women of reproductive age. It’s estimated that around 5-10% of women have PCOS, making it the leading cause of infertility in those experiencing ovulatory issues.

Broadly speaking, there are four main causes of subfertility:

• Male factor
• Unexplained infertility
• Anatomical and tubal factors
• Ovulatory problems (which includes PCOS)

Read more: Male factor infertility and improving sperm health after a poor semen analysis

Is PCOS hereditary?

While PCOS has multiple contributing factors, there is a clear genetic component to its aetiology (underlying causes).

It is strongly linked with type 2 diabetes, which itself has hereditary patterns. In fact, populations with a higher prevalence of type 2 diabetes also tend to have a higher prevalence of PCOS.

PCOS is also more commonly observed in South East Asian populations.

What causes PCOS?

Unfortunately, it’s complicated. There’s no definitive answer yet on what causes PCOS. The good news? Ongoing research is steadily uncovering more. While there are several theories, no single cause has been confirmed.

Let’s unpack a couple of the most common, to give you a starting point.

Theory 1:

Intraovarian increased androgen concentrations are often seen in women with PCOS. This means there are more follicles in the ovaries compared to women without PCOS, at the same age. Usually, this happens because ovulation isn’t occurring regularly. So follicles, in a way, don’t want to ‘come out’.

Theory 2:

The two-cell theory looks at how oestrogen and androgen are produced in the ovary. In PCOS, luteinizing hormone (LH) levels are much higher, which leads to more androgen production in the ovaries. PCOS is also associated with insulin resistance, which can further impact androgen levels.

Ultrasound findings of PCOS

Normally, at a scan there is a follicle seen in the ovaries which is the dominant one or the ‘chosen one’ and this will continue to grow and release the egg. We then have the corpus luteum left behind after ovulation.

The number of follicles seen on the scan is a representation of ovarian reserve and this is assessed by a fertility specialist.  There is a group of women who have ovaries that look like they have many follicles or PCOS without actually having the syndrome. This is usually found in women in their 20s who have a high ovarian reserve but not necessarily PCOS.

The level of Anti-Mullerian Hormone produced by the follicles is a reflection of ovarian reserve. This is also best interpreted by a fertility specialist.

Some women have high AMH, indicating a high ovarian reserve or possibly PCOS.  Thus AMH has been suggested as an additional criterion for diagnosing PCOS but is not yet officially used.

Also, other endocrine disorders need to be excluded, such as thyroid disease and hyperprolactinaemia (a raised level of prolactin in the blood).

Is PCOS related to oestrogen insufficiency or early menopause?

PCOS and early menopause are two distinct conditions that share some similar symptoms.

As women with PCOS have a higher than average ovarian reserve, they reach menopause at an older age than women with no PCOS.

On ultrasound scans, in terms of number of follicles, women with PCOS aged nearly 40 have ovaries that look like the ovaries of 30-year olds . Again, this needs to be carefully assessed before final diagnosis.

How does PCOS impact fertility?

PCOS inhibits regular ovulation – if no egg is released,  there is no fertilisation or implantation.

In a 20-year-old with PCOS where she ovulates 3-4 times per year, with regular sexual intercourse it might be enough to fall pregnant because the fecundity per ovulation ratio is high.

This might not be the case in women in their late thirties. It is worth having this assessed by a fertility specialist over a period of time.

Women can influence the frequency of ovulation through lifestyle changes. For example,  a woman with PCOS and a BMI of 40 who makes nutritional and exercise changes to her lifestyle, may be able to regain regular periods and ovulation, reversing the diagnosis of PCOS. This is not absolute and it depends on the severity of PCOS.

Is it essential to know if you have PCOS early on?

For many reasons, women have more choices if PCOS is detected early on in their reproductive years: in discussion with their doctor, they can plan not only their fertility and building their family, but also the long-term management of PCOS.

General health promotion and screening by a clinician is especially important for PCOS women, who have an increased risk of metabolic syndrome, diabetes and cardiovascular disease.

It is essential these are managed in a multidisciplinary approach with the correct nutrition, exercise and general health.

Our aim as clinicians is not only to help women fall pregnant, but also to ensure they have a healthy pregnancy and, by reducing the risk of diabetes and cardiovascular disease, to enable them to grow old and enjoy life with their children

Treatment of PCOS for fertility

The main medical approach to induce ovulation is with clomid (clomiphene) which is an oral medication. It induces ovulation in women who do not ovulate and induces more than one follicle in women who already ovulate.

Another medication is letrozole, which is an aromatase inhibitor which assists in the conversion of androgen to oestrogen (used in breast cancer patients to reduce oestrogen levels in oestrogen sensitive tumours). The question is whether letrozole is better or worse than clomiphene, which is the traditional treatment used for a number of years.

Studies  showed that letrozole was  better than clomid in terms of live births and also has fewer side effects than clomid and fewer twin births.

A  possible link between Letrozole and birth defect risk has caused controversy but studies have found the concern to be unwarranted.

If letrozole does not work, then injectable gonadotropins would be the next step of treatment. Your fertility specialist will advise you on alternative options, usually IVF.

How effective are GnRH analogue injectables?

FSH analogues are very effective but there is the risk of producing multiple follicles. Injectable GnRH analogues are used as part of timed intercourse or IUI set up.

This form of treatment can result in higher risk of multiples and these patients need to be monitored closely as there is a narrow window in which the treatment works and also because in PCOS patients there can be a sudden increase in follicle formation once the threshold is reached.  This close monitoring is done by ultrasound.

Sometimes, it is not possible to induce the follicle safely and, in this case, the treatment plan is converted into IVF where the follicles can be collected all at once.

PCOS and gynecological cancer

Do women with PCOS have a higher risk of certain cancer?

 In women with PCOS, there is a drawn-out follicular phase, with a prolonged build-up of oestrogen and prolonged thickened endometrium.

There is no progesterone secretion as the follicle does not release the egg, nor is there the corpus luteum (mass of cells that forms in an ovary), which normally produces progesterone.

Without progesterone, the oestrogen secretion from the follicles is unopposed,  which causes a thickened endometrium and this can lead to endometrial cancer.

What are the tests to check for endometrial cancer or endometrial hyperplasia?

If there is a high suspicion of endometrial hyperplasia or cancer, an endometrial biopsy can be done at the clinic.

This is a decision that a clinician needs to make based on ultrasound findings and an individual’s medical history.

Endometrial hyperplasia is the preliminary stage of cancer and, if found, is easily treated with high doses of progesterone. There are ways of protecting the endometrium.

Weight and PCOS

Is weight the cause or a symptom?

Obesity is not the cause of PCOS, but is an exacerbating factor which can sometimes be removed by lifestyle changes. Ask your doctor for the right advice. Not every overweight woman will have PCOS.

Is it harder for women with PCOS to lose weight?

Losing weight is hard for anyone who is obese. This is a national problem that governments find challenging to tackle.

In PCOS women, the hormonal and metabolic situation makes it even harder. We always encourage women to try and lose weight by tracking their meals and implementing nutritional advice on types of carbohydrates and reducing processed foods, as well as foods with a high sugar content.

Is there medical treatment for weight loss in PCOS?

The main medication which has been discussed over the years is metformin.  PCOS  is the most commonly misdiagnosed condition and metformin is the most mis-prescribed medication.

In the early 2000’s, metformin emerged as one of the treatment options for Type 2 Diabetes, as it was found to reduce sugar levels. It was also found it could help with ovulation in PCOS, as there is a known overlap of PCOS and Type 2 DM (Diabetes Mellitus).

There was a lot of excitement and enthusiasm at the time but, after extensive research,  it has been suggested that diet and lifestyle changes have better results than metformin.

Regarding ovulation induction treatment, it was also found that clomid was superior to metformin.

Read up on the ideal BMI for fertility, for more on this.

PCOS in pregnancy

Does PCOS affect the foetus in utero?

A study published in 2018 investigated the role of high AMH levels in pregnant PCOS mice on the development of the foetus, and whether this contributed to the pathogenesis of developing PCOS in adulthood.

They found that mice offspring had developed PCOS-like reproductive and endocrine phenotype in adulthood. They then treated GnRH antagonists to block these effects, which restored the adult offspring to a normal state.

This could also be a potential new therapeutic avenue.

That’s it! Our great big PCOS Q&A, with expert perspective from Dr Mavridou. Click here to book a consult today. Also, don’t miss the opportunity to find out more from The Women’s Wellness Centre by joining their free Facebook group here.