PCOS Diagnosis and Testing: What a Complete Workup Should Include
Written and medically reviewed by Dr. Karolina Skrzypek, MD
PCOS & Hormones
Read Time: 7 min
Irregular or missing periods. Acne along the jawline. Unwanted facial hair. Hair thinning on the scalp. Weight gain or difficulty losing weight. These symptoms can all happen with polycystic ovary syndrome, or PCOS. But PCOS can look very different from one woman to another, which is why diagnosis and treatment are not always straightforward. Some women are diagnosed after an ultrasound. Others are told they have PCOS because of irregular periods or acne. And some have had the diagnosis for years without ever having a full evaluation to confirm what is actually driving their symptoms.
A complete PCOS workup looks at more than ovarian cysts.
It should help answer three important questions:
Do you actually meet the criteria for PCOS?
Could another condition be causing similar symptoms?
Which part of PCOS is affecting you most: ovulation, androgen levels, insulin resistance, fertility, or long-term metabolic health?
Those answers are what allow treatment to become more individualized.
In short
PCOS is diagnosed using a combination of symptoms, laboratory findings, and sometimes imaging.
In adults, diagnosis generally requires at least two of the following:
Irregular or absent ovulation
Clinical or laboratory evidence of elevated androgens
Polycystic ovarian morphology on ultrasound or, in some situations, supporting AMH findings
Other conditions that can mimic PCOS should also be considered, including thyroid dysfunction, elevated prolactin, and non-classic congenital adrenal hyperplasia.
Insulin resistance is common in PCOS, but not every woman with PCOS has it.
Treatment should therefore be based on your individual presentation and goals rather than assuming that every person with PCOS needs the same plan.
Why PCOS can look so different from one woman to another
PCOS is not one single pattern.
Two women can both meet the diagnostic criteria and have completely different symptoms.
One may struggle primarily with irregular ovulation and infertility.
Another may have regular-looking cycles but elevated testosterone, acne, and unwanted facial hair.
A third may have significant insulin resistance and weight gain but relatively mild androgen symptoms.
And some women with PCOS are lean and have no significant weight concerns at all.
This is important because the treatment that helps one woman may not be the right treatment for another.
For example, if insulin resistance is a major part of the picture, nutrition, exercise, medications, or supplements that improve insulin sensitivity may be helpful.
If insulin levels are normal but androgen symptoms are the main concern, treatment may look different.
And if pregnancy is the goal, preserving or inducing ovulation becomes a much higher priority.
That is why we try to identify which features of PCOS are actually present before deciding what treatment should look like.
What are the different PCOS presentations?
PCOS can present in several different combinations.
Irregular ovulation, elevated androgens, and polycystic ovaries
This is what many people think of as the “classic” presentation of PCOS.
Periods may be irregular or absent, androgen levels may be elevated, and the ovaries may show a polycystic appearance on ultrasound.
Irregular ovulation and elevated androgens without polycystic ovaries
You can still have PCOS even if your ultrasound looks normal.
If ovulation is irregular and there is evidence of androgen excess, the absence of polycystic ovarian morphology does not necessarily rule out PCOS.
Irregular ovulation and polycystic ovarian morphology without obvious androgen excess
Some women have irregular cycles and polycystic-appearing ovaries but do not have significant acne, excess facial hair, or elevated androgen levels.
This presentation can sometimes be overlooked because the more visible androgen symptoms are absent.
Elevated androgens and polycystic ovarian morphology with relatively regular cycles
Some women appear to have regular menstrual cycles but still have androgen excess and ovarian findings consistent with PCOS.
This is one reason symptoms such as persistent jawline acne or unwanted hair growth deserve a broader evaluation rather than being treated only as cosmetic concerns.
Who should consider PCOS testing?
A PCOS evaluation may be appropriate if you experience:
Irregular menstrual cycles
Periods that are frequently more than 35 days apart
Missing periods
Difficulty determining whether you are ovulating
Jawline or hormonal acne
Increased facial or body hair
Hair thinning on the scalp
Difficulty becoming pregnant
Unexplained weight gain or difficulty losing weight
Signs of insulin resistance
Or if you were previously diagnosed with PCOS based only on an ultrasound and never had a more complete evaluation.
If your menstrual cycles are regular and your primary concern is weight, a broader metabolic or hormone evaluation may be more appropriate than assuming PCOS is the cause.
You can read more about that on our hormone imbalance symptoms in women page.
How is PCOS diagnosed?
PCOS is generally diagnosed using the Rotterdam criteria.
In adults, at least two of the following three findings are typically required after other potential causes have been considered.
Irregular or absent ovulation
This may show up as long menstrual cycles, skipped periods, or difficulty confirming that ovulation is occurring consistently.
Androgen excess
This may be clinical, meaning symptoms such as acne or unwanted facial hair, or biochemical, meaning elevated androgen levels on laboratory testing.
Polycystic ovarian morphology
An ultrasound may show an increased number of small follicles or other findings consistent with polycystic ovarian morphology.
Despite the name PCOS, you do not have to have ovarian “cysts” to have the condition.
The follicles seen on ultrasound are also not the same thing as ovarian cysts in the way most people use the word.
In some adult patients, AMH may provide additional information about ovarian follicle activity, although it is not used by itself to diagnose PCOS.
What should PCOS testing include?
A thorough PCOS evaluation should do more than simply confirm the diagnosis.
It should also look for conditions that can mimic PCOS and identify which metabolic and hormonal factors may be contributing to your symptoms.
Thyroid testing
Thyroid dysfunction can contribute to irregular menstrual cycles, weight changes, fertility concerns, hair changes, and fatigue.
Depending on your history, testing may include:
TSH
Free T4
Additional thyroid testing when clinically appropriate
Prolactin
Elevated prolactin can affect ovulation and menstrual cycles and may sometimes resemble PCOS.
This is one reason prolactin is often included when evaluating irregular or absent periods.
17-hydroxyprogesterone
This test may be used to help screen for non-classic congenital adrenal hyperplasia, or CAH.
Non-classic CAH can cause irregular periods, acne, and elevated androgen symptoms that resemble PCOS.
Androgen testing
Depending on your symptoms, androgen testing may include:
Total testosterone
Free testosterone
Sex hormone-binding globulin, or SHBG
DHEA-S
The combination of these markers gives us more information than testosterone alone.
Metabolic testing
PCOS is strongly associated with insulin resistance in many, but not all, women.
Depending on your history and risk factors, metabolic testing may include:
Fasting glucose
Fasting insulin
Hemoglobin A1c
A lipid panel
Sometimes a glucose tolerance test
The goal is not simply to determine whether someone has diabetes.
We are also looking for earlier signs that insulin regulation may be contributing to symptoms such as weight gain, cravings, elevated androgens, or irregular ovulation.
Ovulation assessment
Having a menstrual period does not always guarantee that ovulation occurred.
If confirming ovulation is important, progesterone testing during the luteal phase may provide useful information.
The timing of testing should be based on your individual cycle rather than automatically using the same calendar day for everyone.
Pelvic ultrasound
Pelvic ultrasound may be useful when ovarian morphology needs to be evaluated or when other gynecologic causes of irregular bleeding or pelvic symptoms need to be considered.
However, an ultrasound alone does not diagnose PCOS.
Endometrial health
Very infrequent menstrual cycles deserve attention even if pregnancy is not a current goal.
When ovulation occurs only occasionally, the uterine lining may go long periods without the progesterone exposure that normally follows ovulation.
Your clinician may therefore discuss ways to protect the endometrium when periods are very infrequent.
When androgen symptoms should be evaluated more urgently
Most androgen-related symptoms in PCOS develop gradually.
Acne may become more noticeable over time, hair growth may slowly increase, or scalp hair may gradually thin.
If androgen symptoms appear very suddenly or progress rapidly over a matter of months, that deserves a different level of evaluation.
Your clinician may want to check testosterone and DHEA-S promptly to rule out less common causes of significant androgen excess.
These conditions are uncommon, but rapidly developing symptoms should not automatically be assumed to be routine PCOS.
What type of doctor should I see for PCOS?
Many women with PCOS benefit from more than one type of clinician.
Gynecologist or OB/GYN
A gynecologist can help evaluate irregular bleeding, menstrual cycles, ovarian findings, contraception, and endometrial health.
They are also important when pelvic imaging or a gynecologic condition needs to be ruled out.
Reproductive endocrinologist
A reproductive endocrinologist is especially helpful when fertility is the primary concern.
They specialize in ovulation induction and other fertility treatments when pregnancy is the goal.
Endocrinologist
An endocrinologist may be helpful when another endocrine condition needs to be ruled out or when diabetes, significant thyroid disease, pituitary disorders, or other endocrine conditions require specialty management.
Functional medicine physician
A functional medicine approach may be helpful when the goal is to understand the broader hormonal and metabolic picture.
At NaturaMed, we look at PCOS by asking questions such as:
Are you ovulating consistently?
Are androgens elevated?
Is insulin resistance present?
Is thyroid function contributing?
Are there nutritional, metabolic, sleep, or lifestyle factors affecting the picture?
Do we need additional gynecologic or fertility evaluation?
At NaturaMed, care is physician-led by Dr. Karolina Skrzypek, MD, who is double board-certified in internal medicine and integrative medicine.
Patients are seen in the Maitland and Orlando area as well as through telemedicine in states where Dr. Skrzypek is licensed.
When fertility treatment, surgery, or specialized gynecologic management is needed, we coordinate with the appropriate specialist.
You can learn more about how we work.
Registered dietitian or nutrition professional
Nutrition support can be extremely helpful, particularly when insulin resistance or metabolic concerns are part of the picture.
The goal should be to build a sustainable eating pattern rather than creating unnecessary restriction.
Nutrition care often works best alongside medical evaluation and appropriate laboratory testing.
Where PCOS evaluations commonly fall short
There are a few patterns we frequently see when someone has been diagnosed with PCOS but still doesn’t have a clear understanding of what is happening.
PCOS was diagnosed based on an ultrasound alone. Polycystic ovarian morphology can be part of PCOS, but it is not the entire diagnosis.
The ultrasound needs to be considered together with menstrual patterns, androgen symptoms or laboratory findings, and the broader clinical picture.
Other causes of irregular periods were not considered. Thyroid disorders, elevated prolactin, and other endocrine conditions can mimic aspects of PCOS.
When appropriate, these should be considered before assuming PCOS explains everything.
Metabolic health was never evaluated. Glucose and A1c are useful tests, but they may not tell us everything about insulin regulation.
For some patients, fasting insulin or additional metabolic testing may provide useful information.
Birth control was prescribed but the underlying picture was never explained. Hormonal contraception can be very helpful for managing irregular bleeding, acne, unwanted hair growth, and endometrial protection.
But patients still deserve to understand why they are having symptoms and whether metabolic risk or other factors also need attention.
Weight loss became the entire treatment plan. Weight loss may improve symptoms for women who have excess weight and insulin resistance.
But not every woman with PCOS is overweight.
And even when weight is part of the picture, simply telling someone to lose weight without addressing insulin resistance, nutrition, sleep, stress, or other contributors is rarely a complete plan.
How PCOS treatment depends on what we find
There is no single best PCOS treatment.
Treatment should depend on your symptoms, test results, and goals.
Finding or goal | Treatment may include |
|---|---|
Insulin resistance | Nutrition changes, resistance training, sleep optimization, and when appropriate medications such as metformin or supplements such as inositol |
Elevated androgens, acne, or unwanted hair growth | Addressing metabolic contributors when present, hormonal treatment, and sometimes anti-androgen therapy |
Very infrequent menstrual cycles | A plan for menstrual regulation and endometrial protection |
Trying to conceive | Ovulation assessment and, when needed, referral for fertility-focused treatment |
Weight or metabolic concerns | Individualized nutrition, exercise, insulin assessment, and cardiometabolic risk reduction |
The key is that treatment should match the problem we are actually trying to solve.
How we approach PCOS at NaturaMed
At NaturaMed, we don’t start with the assumption that every woman with PCOS needs the same treatment.
We begin by reviewing your menstrual cycles, symptoms, previous testing, medications, fertility goals, weight history, metabolic health, and any previous PCOS diagnosis.
Then we determine what still needs to be evaluated.
For some women, that means confirming whether the diagnostic criteria are actually met.
For others, the diagnosis is already clear, but the missing piece is determining whether insulin resistance, elevated androgens, thyroid dysfunction, or inconsistent ovulation is contributing to persistent symptoms.
Our Feel Better Faster program begins with an in-depth physician evaluation with Dr. Skrzypek.
Testing is selected based on your individual history rather than using the same predetermined laboratory panel for everyone.
The program includes physician follow-up along with nutrition and health coaching over six months so we can evaluate your response and adjust the plan as needed.
When repeat testing is appropriate, laboratory results are considered together with changes in your cycles, symptoms, metabolic health, and overall progress.
Advanced testing is priced separately, and recommended testing is reviewed with you before it is ordered.
You can learn more about how the program works or explore our approach to hormone health.
Frequently Asked Questions
Can I have PCOS without cysts on my ovaries?
Yes. You do not need polycystic ovaries on an ultrasound to have PCOS. In adults, diagnosis generally requires two of the three Rotterdam criteria, so someone may have irregular ovulation and androgen excess while having a normal-appearing ultrasound. The “cysts” associated with PCOS are also not true ovarian cysts in the way many people imagine. They are small follicles.
Can I have PCOS if I am not overweight?
Yes. Women can have PCOS at any body size. Weight is not part of the diagnostic criteria. This is important because a treatment plan focused entirely on weight loss may not be appropriate for someone whose weight and insulin levels are normal.
I was diagnosed with PCOS based only on an ultrasound. Is that enough?
Usually, no. Ultrasound findings are only one part of the diagnostic criteria. A complete evaluation should also review your menstrual and ovulation patterns, signs or laboratory evidence of androgen excess, and other conditions that can cause similar symptoms. If your PCOS diagnosis was made only from an ultrasound, it is reasonable to ask whether the rest of the workup was completed.
I was diagnosed with PCOS as a teenager. Should I be reevaluated?
It may be worth reviewing the diagnosis as an adult. Irregular menstrual cycles are common during the first years after menstruation begins, and ovarian appearance can also differ during adolescence. Because of this, PCOS diagnosis in teenagers is approached more cautiously. If you were diagnosed years ago and have never had the diagnosis reassessed, discussing it with your physician may be useful.
Does birth control treat PCOS?
Hormonal birth control can be an important part of PCOS treatment. It can help regulate bleeding, protect the uterine lining, and often improve acne and unwanted hair growth. But birth control does not necessarily address every aspect of PCOS. For example, if insulin resistance or other metabolic concerns are present, those may need to be treated separately. It also suppresses ovulation while you are taking it, so treatment is different when pregnancy is the goal.
Does PCOS mean I won’t be able to get pregnant?
No. Having PCOS does not mean that you cannot become pregnant. PCOS can make pregnancy more difficult for some women because ovulation may happen less consistently. But many women with PCOS conceive naturally, while others may need treatment to help regulate or induce ovulation. If pregnancy is your goal, the first step is understanding whether you are ovulating consistently and whether other factors, such as insulin resistance, thyroid function, your partner’s fertility, or other reproductive factors, also need to be evaluated. When fertility treatment is needed, medications used to support ovulation can be very effective for many women with PCOS. The important thing is not to assume infertility simply because you have the diagnosis.
Does everyone with PCOS have insulin resistance?
No. Insulin resistance is very common in PCOS, but it is not universal. This is why we prefer to evaluate metabolic health rather than automatically treating every patient as though insulin resistance is present. If insulin resistance is identified, it can become an important treatment target. If it is not present, the treatment plan may need to focus more heavily on other aspects of the condition.
