Interview has been edited for clarity.
Thanks to Polycystic Ovary Awareness Month and other programs, PCOS is drawing more attention than ever, and there’s a reason why. “Surveys of women have suggested that PCOS is underdiagnosed,” says Dr. Tahir Mahmood. “A lot of women experience anxiety because they have a limited understanding of PCOS. Quite often, people are labeled with PCOS too early in their lives when their physiological systems are still maturing.”
He also says that a lot of practitioners don’t have experience dealing with young adolescents who are very self-conscious about their irregular periods, may have some acne, and are concerned about their appearance. These doctors often say the teens have PCOS and write a prescription for contraceptive pills.
“But actually, a diagnosis hasn’t been made. No tests have been done. And this becomes like a stigma in their life that they may have PCOS, but they may not even have it,” explains Dr. Mahmood. “New international guidelines on PCOS recommend that the diagnosis of PCOS should not be made until eight years after the onset of periods.”
He also says that it’s still not clear why some people develop PCOS and others don’t or why some racial groups are more prone to it. “We call it a multifactorial syndrome — there is a racial and genetic predisposition, and, above all, environmental factors play an important part. Average BMI — body mass index — is increasing globally, and it is more marked in some populations than others.”
According to Dr. Mahmood, increased awareness is important in understanding what real PCOS is. But the main issue, he says, is that people consider it a disease. “It is not a disease but a syndrome with diverse symptoms, biochemical abnormalities, and varying clinical manifestations. And, above all, we still lack a gold standard for how to make a confirmed diagnosis.”
In addition to previously mentioned PCOS risk factors like genetics and environment, the condition also has trigger factors. But the most important one, according to Dr. Mahmood, is a high body mass index (BMI).
“Up to 15 percent of women with a normal BMI could be diagnosed with PCOS at ultrasonography. Not everyone with a high BMI may have all the hallmarks of PCOS and could have regular cycles. The high BMI manifestations in PCOS vary in different populations when comparisons are made between women in Northern Europe, Southeast Asia, and even Southern Europe.”
An important question that is quite often debated is whether PCOS leads to obesity or obesity leads to PCOS.
In addition to genetics and environment, PCOS also has trigger risk factors. But the most important one is a high body mass index (BMI).
“It is important to remember that insulin insensitivity is a key factor in the manifestation of PCOS symptoms,” explains Dr. Mahmood. “We are trying to figure out why periods become increasingly irregular, why people start having symptoms like facial hair growth once BMI starts creeping up, and why it has variable manifestations in different races.”
Furthermore, environmental factors also play a major role, he says. The increased use of chemicals in industry and agriculture pollutes water, which has a direct impact on the development of sperm, eggs, and offspring.
Insulin insensitivity is a key factor in the manifestation of PCOS symptoms.
“So, there are multiple factors we are learning more and more about. Almost every day, new research comes out trying to explain why some women develop these symptoms, and some don’t.”
Along with all of these other factors, people now get their first periods at a younger age than they used to — it’s not uncommon for someone to start menstruating when they’re 10 or 11. As Dr. Mahmood explains, one of the triggers is fat in the human body. So people who have more fat tissue in their adolescent years start menstruation earlier. “And then there is a group of people who will have the delayed onset of menstruation (after age 16), and medicine doesn't know why.”
The most common symptoms of PCOS are irregular periods and excessive hair growth, which can manifest as facial hair (usually on the upper lip, the chin, and sometimes as sideburns). It can also cause hair growth around the nipples and below the belly button.
“Some people with PCOS will have facial acne. It may be mild or very intense (pimples with dark heads), and the intensity varies in different genetic groups. That sort of condition is more often seen among young women from Southeast Asia and maybe even Southern Europe,” explains Dr. Mahmood.
“Excessive facial hair and acne can affect some people’s confidence levels,” says Dr. Mahmood. “Some may encounter infertility, which can lead to depression for people who are trying to conceive. This usually requires further investigations and treatment by an infertility expert. And when pregnancy does occur, some people with PCOS may have adverse outcomes during pregnancy, such as developing high blood pressure and gestational diabetes. Most of these women would like something to be done about it, of course.”
Dr. Mahmood says that this is an area that’s full of controversy. Most doctors make a diagnosis based on clinical features, such as irregular periods, excessive body hair growth, and acne, and then they do some blood tests.
“In an ideal world, one should take account of the individual and the age of the patient, look at the clinical manifestations (as mentioned above), look at their weight — whether the BMI is above 30 — because that is more relevant, and then do hormonal tests.”
He says that it’s important not to do random blood sampling for hormonal assessment at any random stage of a cycle since some hormone levels vary depending on the phase of the menstrual cycle. It’s preferable to do them in the early follicular phase during a period. It’s better to measure the level of free testosterone, but it may not be raised in everyone. Most studies report that about 60 percent of women will have increased levels of testosterone.
Another useful test is calculating the free androgen index, which is a ratio that measures abnormal androgen (male hormone) levels.
Dr. Mahmood says that sometimes pelvic ultrasound scans show the characteristic appearance of PCOS, but the ovaries appear normal.
“So, for making a diagnosis, the clinician should not only rely on blood tests and ultrasound scans but also note the clinical manifestations. It is also important to look at the person’s age before labeling them with the diagnosis of PCOS, as young people may have cycle irregularity due to physiological changes. In summary, there is no single golden standard for diagnosing PCOS.”
Dr. Tahir Mahmood believes that a wider awareness about the condition and its effect on self-confidence is very important, and education is the key. “Young people should be treated more sensitively, and their concerns need to be taken seriously. In that respect, the education of the specialist is also important.”
The training of specialists and family doctors is not the same worldwide, says Dr. Mahmood. “In some countries, they are specifically taught more about endocrine problems and have a better understanding of them. In other countries, the training of these specialists is not very specific, and some may not have been trained in all aspects of women’s health.”
He also says that most doctors specialize only in endocrine problems. They may specialize in dealing with pregnancy issues, cancer treatment, bladder problems, fertility treatment, but they may not be specifically trained to deal with women who have endocrine problems, and that is when PCOS comes in.
“PCOS does affect about 8–13 percent of the population, so it is a big group. But expertise in finding the best treatment for PCOS isn’t the same among all women’s health practitioners.”
Dr. Mahmood suggests several tips to spot and prevent early symptoms of PCOS.
- Keep a period diary
The first thing is to keep a diary if you have irregular periods. The diary should clearly note the days when menstruation starts and when they are over. This diary should be kept for 6–12 months. This record will be useful when you see a specialist. “The diary may show that although periods are not happening every four weeks, they may be coming every 5–6 weeks, which may be normal in that age group, especially for girls under 18,” explains Dr. Mahmood.
- Know when to do a pelvic ultrasound scan
People often wonder if a young adult should be referred for a pelvic ultrasound scan to diagnose PCOS. Dr. Mahmood says that most recently, international guidelines on PCOS recommend that “the diagnosis of PCOS should not be made by ultrasound scan, at least before eight years have elapsed from the onset of periods.”
So, he suggests that if someone starts getting periods at the age of 11, an ultrasound scan to diagnose PCOS shouldn’t be done until the age of 19. “That is very important because there is an overlap between pubertal development, hormonal changes, and the maturing process of the hypothalamus-pituitary-ovarian axis in early adolescent years, which may be confused with PCOS. It is the duty of the clinician to explain to the patient and their parents that their hormonal systems are still maturing,” explains Dr. Mahmood.
- Monitor your food intake
Dr. Mahmood suggests eating low-glycemic foods, especially fruits and vegetables. Doing so can reduce the risk of excess fat deposits around the waist. “It has been reported that the average waist size is getting bigger, and we see it every day. Regular exercise can help control waist expansion. It has been noted that individuals who have a waist-hip ratio (WRH) of greater than one potentially have a higher risk of developing other diseases in the long run, such as diabetes and hypertension.”
Generally speaking, the range for a healthy BMI is 18.5–25. And once it’s above 30, explains Dr. Mahmood, the menstrual cycle may become irregular, which is considered to be a sign of PCOS.
Tahir Mahmood says that diet is key because weight management is a lifestyle intervention. And every management has to be individualized — there is no fast formula.
“Antioxidant-rich foods and low-glycemic diets are good,” says Dr. Mahmood. “Recently, data have been published on a dietary regimen called DASH (Dietary Approaches to Stop Hypertension), which is essentially eating low-sodium and very balanced foods. DASH has been shown to lower the levels of free glucose, which is a trigger for insulin release.”
- Food supplements
Supplements can also help, according to Dr. Mahmood: “There is one food supplement called inositol, and it is claimed to have positive effects on the hormonal profile of PCOS. More research on its effectiveness in young adults is needed.”
According to Dr. Mahmood, it’s recommended to exercise regularly for up to 150 minutes per week, which should include 90 minutes of moderate and high-intensity exercise.
- Prescriptions and drugs
Dr. Mahmood says that prescriptions should be written according to symptoms. He says that if the main sign is irregular cycles, then birth control pills are a safe choice for a young person who doesn’t smoke and has a BMI under 30.
Taking birth control pills with a BMI greater than 30 has an increased risk of deep venous thrombosis, and that risk increases as the BMI grows above 35. So it’s important to choose a medication that takes this into account and can reduce the risk.
“There is a drug called Metformin,” says Dr. Mahmood, “which is widely used for Type 2 diabetes. But this drug has a positive effect on insulin insensitivity, which is commonly seen both in people who have PCOS and people who are obese. That drug is widely used, but it’s important to discuss it with your endocrinologist before using it.”
However, says Dr. Mahmood, if PCOS is causing excessive hair growth (hirsutism), especially on the face, there isn’t a quick fix for it. Most hormonal treatments for this last 12–18 months. The objective of hormonal drugs is to lower the levels of free testosterone because it encourages hair growth. “Sometimes, physicians prescribe non-hormonal drugs that are diuretics that can lower the levels of free testosterone. If they’re prescribed, the physician needs to keep an eye on liver function and monitor electrolytes.”
“People may also consider non-medical options such as waxing and laser treatment if they choose,” suggests Dr. Mahmood. “Their potential effects can be enhanced if a person considers weight management regimens as well. None of these treatments have a permanent effect, although the intensity of hair growth may become less intense. The treatment of facial hair growth can also be managed with certain anti-androgen creams.”
It’s important to discuss individualized treatment options with your health care provider because each medication has potential side effects.
Bariatric surgery’s role in PCOS treatment is very limited, says Dr. Mahmood. “Bariatric surgery reduces weight, but it also limits the absorption of healthy nutrients. Although it will lower the levels of free testosterone, it will not have an immediate effect on hirsutism. Overall, it can create a healthy trend of biochemical changes in the individual, and if they have lost enough weight, their menstrual cycle’s regularity may improve significantly. However, it is not a cure for hirsutism nor PCOS.”
“We have no experience in using homeopathy,” says Dr. Mahmood. “And there are no large-size studies to show the benefit of it compared to traditional medicines used in regular practice. There's no magic PCOS cure, no matter what the supporters of homeopathy say.”
Dr. Mahmood says that yoga helps improve mood and manage anxiety. It can help people cope with their emotions and symptoms more positively, but yoga is not a natural cure for PCOS.
“Not really,” says Dr. Mahmood. “Once PCOS has manifested, it can’t be cured entirely. The symptoms of PCOS can only be reduced in intensity.”
As Dr. Mahmood explains, if a polycystic change has developed within the ovary, it will remain a polycystic ovary. But the manifestation becomes less evident if you manage it proactively.
Once PCOS has manifested, it can’t be cured entirely. The symptoms of PCOS can only be reduced in intensity.
“For example, if somebody has a BMI of 35 and they manage to lose weight proactively and their BMI becomes 25, then there’s a greater than 80 percent chance their periods would become regular. There is a higher chance that their acne will improve, and they may not require any antibiotics or hormonal manipulation. Their hirsutism will also get better. But the change that has taken place within the ovary will remain there. So, it would still be diagnosed as a polycystic ovary when an ultrasound scan is carried out.”
There are no studies on the natural progression of PCOS in any racial groups or weight groups, says Dr. Mahmood.
“We have to look at the BMI and age of the individual. If someone has a BMI below 25 and irregular cycles but is diagnosed to have PCOS on the scan, that will not change much. It will remain the same,” he says. “However, if someone with a BMI of 35 has PCOS on an ultrasound scan, has irregular cycles, and doesn’t manage their weight appropriately, they have an increased risk of metabolic syndrome. Metabolic syndrome increases the risk that they’ll develop Type 2 diabetes and the associated cardiovascular risks during their lifetime.”
Dr. Mahmood also explains that if someone with PCOS and higher BMI becomes pregnant, they’re at a higher risk of developing gestational diabetes, which has an adverse outcome for them and their baby. About 40 percent of women who have gestational diabetes during pregnancy will develop Type 2 diabetes within seven years of their pregnancy unless they lose a significant amount of weight after delivery.
Another risk is cardiovascular disease, according to Dr. Mahmood.
“PCOS is a risk factor, but the development of heart diseases is, again, multifactorial. It depends on the individual — are they smokers? Do they have another medical condition, such as high blood pressure or cholesterol metabolic disorder? Do they have an underactive thyroid?” A lot of people with PCOS may have other medical problems. All these factors play an important role in increasing the individual’s risk of developing heart disease in people with PCOS.
Dr. Mahmood says that the treatment of hirsutism depends on the extent of it.
- Firstly, it needs to be determined whether the hirsutism is only due to PCOS. “In addition to the ovaries, there are other endocrine glands that can also increase hirsutism. So, the initial investigation should also include the thyroid and adrenal glands, and blood tests should be done from the very beginning to make sure the diagnosis of PCOS is correct.”
- Secondly, any treatment of PCOS that lowers the levels of free testosterone and free androgens will have a measurable effect on hair growth. “The lifecycle of hair that manifests as hirsutism is long. Any hair that appears on the skin spends 6–9 months developing before it shows up. So, any treatment given has to have a long duration, ideally 12–18 months, and, in fact, may be lifelong, as hair follicles keep on developing.”
Dr. Mahmood adds that for people who would prefer to avoid hormonal treatment, laser ablation of hair follicles is an option. This focused laser treatment destroys the base of the hair follicles and has a greater effect on hair regrowth than medication alone. However, not all lasers are equally effective, and some people have adverse skin reactions to them.
He says that laser treatment doesn’t deliver permanent results because people respond differently to different laser preparations. “Some laser preparations are very specific for certain areas, and some laser modalities don’t work in certain racial groups at all. If they have thick hair growth, only one specific laser could work, not all of them. So, the physician or the beautician needs to know which is the best laser for this person.”
- Thirdly, Dr. Mahmood wants to stress weight management. “It’s important to work toward a BMI under 25 because it will reduce the levels of free testosterone in circulation.”
Dr. Mahmood says that any endocrine conditions with higher levels of circulating androgens can cause generalized thinning of scalp hair, which may lead to significant loss of hair from the scalp in extreme situations.
Dr. Mahmood mentions several possible conditions and causes for hair loss:
- Conditions such as PCOS and conditions affecting the adrenal gland (congenital adrenal hyperplasia, Cushing syndrome)
- Underactive thyroid and long-term conditions (diabetes, lupus, inflammatory bowel disease, liver disease, iron deficiency, and syphilis, rarely)
- Use of drugs (antidepressants, anticoagulants, anabolic steroids, carbimazole, oral contraceptives, and chemotherapy)
- Poor nutrition, low protein intake, and excessive dieting
- Hair follicle sensitivity to a hormone called DHT (dihydrotestosterone)
- Age (sometimes occurs in postmenopausal years)
“There are so many potential causes that it’s important to be seen by a specialist who has vast experience in endocrinology, not just an interest in PCOS,” explains Dr. Mahmood.
Some people with PCOS might like the masculinizing effects PCOS can have. For instance, they might enjoy growing a mustache.
Dr. Mahmood suggests that people can choose how they want to live. “Medicine has to address what their needs are and how it can support them.”
It comes down to the individual choice, he believes. “But it is also important to understand that excessive male-type hormones do have adverse effects on the lipid profile. The lipid profile is cholesterol and fat metabolites, which increase the risk of cardiovascular disease, so that is an important consideration in their treatment.”
Dr. Mahmood says that science is moving toward understanding the best way to diagnose PCOS and treat its various manifestations.
Secondly, he says, science is moving toward a very focused approach on how to treat people with various manifestations because some of them will have very few symptoms, and they may have PCOS with cycle problems, which requires different treatment.
“Then, there is a group of people who have severe manifestations of the condition,” explains Dr. Mahmood. “We are trying to understand how to manipulate the hormonal treatment by working with natural and low-glycemic dietary supplements. The new focus is on a lifecycle approach and encouraging a healthy lifestyle. There is a huge group of experts who believe in educating people about PCOS rather than giving them a ton of hormones.”
We must invest more to understand what women want and think about their condition and its impact on them.
He also says that the role of laser treatment for hair growth is increasing rapidly, and we need to learn which type of laser is best for specific types of hirsutism as well as the long-term impact of these treatments on hair regrowth.
PCOS can cause excessive loss of hair, leading to generalized thinning of hair and baldness. More research is needed on drugs that bind to free circulating androgens, local treatments, and the role of hair growth stimulants and anti-inflammatory agents in hair loss.
And of course, bariatric surgery is coming into focus, which can help people to control their weight and give them a healthy lifestyle.
“Finally, we must invest more to understand what women want and think about their condition and its impact on them,” says Dr. Mahmood. “And we know now that PCOS has a big impact on mental well-being and energy levels. So more and more input is coming from psychiatrists who are trying to understand how to support people with PCOS rather than find a magic cure.”
“It is important to encourage people to not be afraid of asking their physicians difficult questions during their examinations and visits and to have grounded expectations and a realistic discussion,” says Dr. Mahmood. A realistic discussion is talking about what your symptoms are, what tests you need, and what your precise diagnosis is.
“And the expectation should be that sometimes the doctor may not know the answers to all the questions. Each person needs to find an appropriate specialist who can look after them and have patience because there isn’t a magic cure for PCOS. It is a lifelong condition,” says Tahir Mahmood.
“It is not cancer. It is not a disease. It is a syndrome that manifests in different ways with different symptoms. And every condition has to be managed, so they should work very closely with their physician.”
“Lastly, going back to my favorite lifestyle intervention, my advice is to drink lots of non-fizzy fluids and eat healthy foods with a low-glycemic index that are rich in antioxidants so that your sugar level is low. Eat three meals a day and avoid the habit of walking into a fast-food shop to buy something to eat when you get hunger pangs.”