What is PCOS? Symptoms, Warning Signs, And How To Tell If You Have It

Polycystic ovary syndrome is a hormonal condition that affects how your ovaries function. But did you know that it affects more than your reproductive system? And that PCOS affects around 8 to 13% of women of reproductive age in Australia? Also, up to 70% of those women remain undiagnosed. That difference in how common it is and how often it is reported says a great deal about how misunderstood and mismanaged this condition is, and how often it is dismissed as "just irregular periods."

If you have been looking for answers about potential PCOS symptoms (things like weight gain, cycles that never seem to arrive on time, acne that came back in your twenties, or hair growing where you do not want it), you'll find plenty of information below to help you understand what PCOS actually is, how it shows up in your body, what to do next, and when to get help. If you think you might already have PCOS and want personalised support, Floralia Wellness offers naturopathic consultations to work alongside your existing medical care.

How PCOS affects your body (not just your ovaries)

The name "polycystic ovary syndrome" isn't actually very accurate. While something is going on with your ovaries, it's not where the problem begins. PCOS is not just an ovarian problem; it's a hormonal and metabolic disorder that affects the entire body. Your ovaries are responding to messages from other parts of your body, such as your pancreas, your adrenal glands, your gut, and your fat cells. If those messages are off, you can begin to present with PCOS symptoms.

Understanding these mechanisms is important because it will determine which treatments will actually work for you.

The role of insulin resistance

Insulin resistance is the most common cause of PCOS, affecting 70 to 80 per cent of PCOS patients. It does not matter if you are overweight or not. If your body is no longer able to respond to insulin in a normal way, your body will produce more insulin. These high insulin levels will cause your ovaries to produce more hormones that are commonly referred to as "androgens. These hormones are male hormones, and they will also lower your sex hormone-binding globulin (SHBG) level. This hormone is responsible for controlling and regulating your androgen levels. According to the 2023 International Evidence-Based Guideline for PCOS, insulin resistance is one of the defining factors of PCOS, and that's why individuals with PCOS should be screened for metabolic problems.

This explains why women with PCOS have issues with weight gain, especially in the midsection of the body, and why losing that weight is so difficult. The insulin resistance itself creates a metabolic environment that favours fat storage. This is also why, in the face of insulin resistance, the blood glucose levels can be normal on a standard test, while the insulin levels are already rising in the background. A fasting glucose level will not pick this up. Fasting insulin levels, as well as glucose tolerance tests with insulin levels, need to be done.

Why androgens increase and what this triggers

Androgens such as testosterone are present in every woman. They just become a problem if they increase beyond your normal level or if your body becomes sensitive to their effects. With PCOS, one of your first problems is that your insulin is too high. However, it is not the only problem. Your adrenal glands also produce androgens. In some women, adrenal output is the bigger issue.

As androgens increase, this sets off a series of effects. First, hair follicles respond by thickening hair growth on your face and chest, often down to your abdomen. Your hair on your scalp becomes thinner. Your skin will respond with acne on your jawline and more oil production. Your ovaries will respond by stopping egg production in your follicles instead of releasing an egg.

This is why your ultrasound will show "polycystic" ovaries. Problems with ovulation, due to more hormones such as testosterone, will cause problems with fertility, which is why many women seek support from a professional in the first place. If you are concerned about your androgen levels, testosterone tests can help determine if elevated androgens are part of your picture.

Chronic low-grade inflammation and gut health

Chronic low-grade inflammation is another aspect of PCOS that, surprisingly, doesn't receive enough attention. It has been proven that white blood cells produce inflammatory markers at a higher rate in women suffering from PCOS. This, in turn, increases insulin resistance and the production of androgens. It is a vicious circle, as inflammation leads to metabolic disorders, and metabolic disorders lead to inflammation.

Your gut is directly involved in the process. The balance of your gut bacteria affects how your body metabolises oestrogen as well as how it manages inflammation. It also affects how your cells respond to insulin. If your gut bacteria are out of balance, it can fuel all other causes of PCOS. Research into the effects of gut dysbiosis in PCOS has revealed that an imbalance in gut bacteria leads to hyperinsulinemia and oxidative stress, which, in turn, increases hormonal imbalance. This is an area where naturopathic treatment can have a practical application, as improving gut health is one area that can effectively improve the inflammation cycle.

Common symptoms of PCOS

Symptoms of PCOS vary greatly from one woman to another. This is the reason why it may take an average of two years and seeing many medical practitioners before arriving at a diagnosis. Some women may have symptoms that are quite visible, while others may have symptoms that can only be seen when analysing blood test results.

Visible changes

The most obvious changes that are associated with PCOS are those that have an effect on your appearance. Excessive hair growth, known as hirsutism, affects about 70% of women who have PCOS. It is usually seen as thick, dark hair on the face, chest, lower abdomen, and back. The hair on your face is the most difficult change for most women, and it is the change that usually prompts women to speak with their GP.

Another obvious symptom is acne, particularly on the jawline and on the chin. This is indicative of a hormonal cause, as opposed to a bacterial one. Oily skin is often a feature, too. If you experience persistent problems with your skin, our holistic skin naturopaths take a whole picture view on determining if hormones are playing a role. Scalp hair loss is another feature. This is more of a thinning than any actual bald spot, unlike conditions such as alopecia areata. Skin tags, small fleshy growths in areas such as skin folds, and areas of darkened skin (acanthosis nigricans) on the neck or under the arms are indicative of insulin resistance.

Weight gain is common, but not in all cases. If present, it is often in the abdominal region.

Changes you might not notice

Some of the biggest changes of PCOS are the ones that might go undetected. Irregular periods, or periods that stop altogether, are the most common symptom of PCOS. Perhaps you experience periods that last longer than 35 days, or maybe you experience fewer than eight periods a year, or no periods at all. All of this occurs because your ovaries are not functioning normally, and without ovulation, the cycle that leads up to your periods will not be complete.

But in the background, your metabolic profile is changing. Your insulin levels may be rising, and your inflammation markers are on the up. And yet, your risk for cardiovascular disease is changing without any obvious warning signs. An overview published in Nature Reviews Disease Primers confirms that PCOS is associated with a significantly increased risk of type 2 diabetes and cardiovascular disease throughout a woman's life. Women with PCOS have a two to three times greater risk of developing type 2 diabetes or pre-diabetes. And if PCOS is not managed, this risk will continue to increase. Women with PCOS also frequently experience anxiety and depression at significantly higher rates than those without PCOS. This is due to the impact of hormone imbalances and physical symptoms on their lives, as well as their feelings of being unheard by the medical system.

Why symptoms present differently in every woman

One of the biggest mysteries of PCOS is that two women can have the same diagnosis, but look completely different. For example, one woman may have regular periods but also have a lot of hirsutism and a high level of testosterone. Another woman may have infrequent or no periods and insulin resistance, but not have a single hair growth problem. A third woman may be thin, have irregular ovulation, and have problems with acne and anxiety.

This is because PCOS is not one disorder with a specific form of presentation. It has different phenotypes, which are actually different forms of the combination of the three diagnostic criteria of androgen levels, ovulatory dysfunction, and the presence of polycystic ovaries on ultrasound examination. The Rotterdam criteria, which are the diagnostic framework used in Australia, have four phenotypes based on the combination of two of the three diagnostic features that are present.

In Phenotype A, all three characteristics are present: high levels of androgens and ovulatory dysfunction or absence of ovulation, and polycystic ovaries. This is considered the "classic" type and is said to have the highest risk for metabolic issues. In Phenotype B, androgens are high and ovulatory dysfunction is present, but polycystic ovaries are not evident. Then there is Phenotype C, in which androgens are high and polycystic ovaries are present, but ovulatory dysfunction is not evident. Finally, there is Phenotype D, in which ovulatory dysfunction and polycystic ovaries are present, but androgens are not high. This is considered to be the one that is most likely to be missed, due to the fact that it presents with such subtle symptoms. A review of PCOS phenotypes and their clinical implications explains in greater detail how these different phenotypes differ in terms of risk and symptoms.

What this means for you is that your experience of PCOS is determined by your phenotype, your genetic makeup, your metabolic status, your stress levels, your gut function, and your stage of life. Working with a practitioner who understands the concept of phenotyping means your treatment plan can be tailored to your actual metabolism and endocrine status. A treatment plan built around your actual pattern, such as those available through PCOS specialist naturopathic care, will always be more effective than generic advice offered for PCOS.

How PCOS is diagnosed in Australia

PCOS is defined by the presence of at least two out of three specific criteria, including hype hyperandrogenism (evidenced by high male hormone production or symptoms of it) and ovulatory dysfunction (irregular or absent periods), together with polycystic ovarian morphology. However, other conditions that could cause symptoms must first be excluded, including thyroid dysfunction and congenital adrenal hyperplasia. In addition, prolactin disorders must also be excluded. A review of differential diagnosis in PCOS outlines the conditions that should be excluded before a diagnosis is confirmed.

What your GP will check

Your doctor will first take a detailed medical history from you. They will ask about your menstrual cycle, any changes in your skin or hair, your weight changes, and your family history. Your doctor will also conduct a physical examination. They will look for any obvious symptoms such as hirsutism, acne, and acanthosis nigricans. If your age permits, your doctor will ask for a pelvic ultrasound to check your ovarian morphology. However, this is not always required if your doctor is able to clearly identify the other two symptoms.

Blood tests and hormone markers to expect

Blood tests for PCOS may include the level of testosterone (free and total), sex hormone-binding globulin, dehydroepiandrosterone sulphate (DHEA-S), follicle-stimulating hormone, luteinising hormone, and anti müllerian hormone.

Your GP will also want to check your fasting insulin levels, along with your fasting blood glucose levels, lipid levels, thyroid function, and possibly an HbA1c to check your blood glucose levels over a period of time. They may also want to check your thyroid levels to rule that out as a cause. To get a good idea of your hormonal balance, hormone levels can also be tested through a naturopathic practitioner to look for levels that may not show up in your regular blood test results.

If your results come back showing high levels of androgens and insulin resistance, then that will play a role in your treatment. If your results come back showing relatively normal levels, that doesn't necessarily mean that you don't have PCOS, especially if you have Phenotype D.

What happens if PCOS is not diagnosed?

If insulin resistance is not treated, type 2 diabetes will ensue. Cardiovascular risk factors such as high blood pressure and high cholesterol will continue to build up silently, accompanied by inflammation. Irregular periods mean that your uterine walls will not shed their lining as they normally would. This makes you more susceptible to cancer in this region if PCOS is not treated.

There are also psychological effects. If PCOS is not treated, years of unexplained symptoms, inability to lose weight, changes in your hair and skin that affect your self-esteem, and difficulties conceiving will take their toll on your psyche. Women have reported feeling relieved just to know they finally have a diagnosis, simply because they know they are not going crazy. A recent clinical update on PCOS diagnosis and management confirms this.

The sooner PCOS is diagnosed, the sooner it is possible to manage the condition. This is true for any woman, no matter her age.

The gut-hormone connection in PCOS is often overlooked

Your gut microbes control oestrogen metabolism, as well as inflammation. In addition, they control how sensitive your cells are to insulin. When the balance of microbes in your gut changes, all of those processes can be made worse.

The microbes in your gut, which control oestrogen, are called the estrobolome. When you have gut dysbiosis, which is to say that the balance of good to bad microbes in your gut has been altered, oestrogen metabolism can be affected. This, in turn, affects the hormone imbalance that is behind PCOS.

However, the link extends beyond oestrogen. Women suffering from PCOS have lower microbial diversity than women who do not have PCOS. Lower microbial diversity leads to increased intestinal permeability, which in turn allows bacterial endotoxins, such as lipopolysaccharides, to leak into the blood. The endotoxins activate the immune system, leading to an increase in inflammation and insulin resistance. The end result is an increase in androgens and an increase in the severity of the symptoms.

Probiotics have been seen to have a beneficial effect on the metabolic status of women suffering from PCOS, including insulin sensitivity and inflammation status. However, it is very difficult to treat dysbiosis using a handful of probiotic capsules. The practical approach to addressing gut health for PCOS management includes understanding what has gone wrong in the first place (antibiotics, diet, stress, and oral contraceptives), supporting the gut lining, restoring microbial diversity, and removing offending food items that cause inflammation. Gut microbiome testing can provide a detailed picture of your microbial balance and guide targeted treatment.

Floralia Wellness treats gut health as a foundational part of PCOS management. When the gut is functioning well, hormonal and metabolic pathways respond, and inflammatory markers tend to improve alongside them.

What you can start doing now to manage your symptoms

Lifestyle changes are the first-line treatment for PCOS in all clinical guidelines, and that's because they work. The problem is that "eat well and exercise" is not a clear instruction, and unclear advice doesn't work. Here's what actually works:

Dietary changes that support insulin sensitivity

The most important dietary modification for most PCOS patients is to lower the glycaemic index of their meals. This does not mean cutting carbohydrates. It means choosing low-glycaemic index carbohydrates and pairing them with protein and fat to slow down their absorption, as well as cutting back on sugars and starches.

A healthy PCOS diet consists of sufficient protein at each meal to balance your blood sugars, plenty of fibre from vegetables to feed your gut bacteria and support your oestrogen clearance, anti-inflammatory fats from oily fish, olive oil, and nuts and seeds, and a variety to support the diversity of your gut microbes.

Working with a clinical nutritionist can help you create a diet that is tailored to your individual needs, not simply based on guidelines. If you are significantly overweight, even a weight loss of 5 to 10 per cent will significantly improve your insulin sensitivity and menstrual cycle regularity, as well as your hormone balance. However, the aim is to improve your metabolism, not your weight.

Exercise that actually helps (and how much you need)

Exercise has been proven to increase insulin sensitivity and lower androgens regardless of weight loss. This is good news, as it means exercise is beneficial regardless of whether the pounds are coming off or not. This is important, as losing weight in PCOS can be a slow process.

A combination of strength training and cardio exercise at a moderate level is recommended. Strength training is particularly good, as it builds muscle mass, which helps your body process sugar more effectively. Two to four strength workouts each week, along with regular walking or other low-intensity exercise most days, is a good foundation. High-intensity workouts can be good for some women, but bad for others, especially if stress levels are high. It is very important to pay attention to your body and not just follow some arbitrary fitness routine.

When to think about working with a practitioner alongside lifestyle changes

Lifestyle changes are extremely powerful, and they have their limits. If you have been eating well and exercising consistently for three months and your cycles have not changed, your skin is still flaring, your energy is still stagnant, or your blood work has not changed, that is a clue that something else is going on. Without blood work, without understanding your unique phenotype, and without knowing if your primary imbalances are insulin, androgens, inflammation, or gut health, you are essentially guessing.

This is where a practitioner can help you make a significant difference. A naturopathic doctor can use functional medicine to interpret your blood work in the context of your entire health picture, not just whether your numbers are in the reference range or not. They can then create a personalised protocol to address your unique imbalances. Herbal medicine and supplements can help balance your insulin, your androgens, your inflammation, and your gut in ways that diet and exercise may not.

At Floralia Wellness, PCOS management often involves working alongside your GP or fertility specialist. It will not replace your medical treatment. For example, if you’re already on metformin, your dietary and supplement program will consider that. If you’re getting ready to do IVF, your focus will be to improve the quality of your eggs within your treatment cycle. A fertility naturopath can coordinate this kind of support alongside your medical team.

When to seek advice from a practitioner about your symptoms

If you experience changes in menstrual cycles, unexplained weight changes, acne, hair growth, hair loss, or difficulty conceiving, it is best to seek advice. There is no need to experience all of the symptoms. Two or three changes will do.

It is best to consult with your GP to get initial blood tests done and ultrasound scans, if necessary. If you need additional support beyond what conventional medicine can offer, or you have been diagnosed with the problem but feel that your treatment plan does not take into account all aspects of the problem, then it is best to consult with a naturopath. Floralia Wellness sees women at every stage of PCOS, from first suspicion through to fertility treatment, through its women's health clinic.