PCOS / PMOS
Polycystic ovary syndrome (PCOS / PMOS)
The most common hormonal disorder in women
Polycystic ovary syndrome is the most common hormonal disorder in women of reproductive age. It affects 7-20% of women of reproductive age, depending on the diagnostic criteria used and the geographic region. Most of them do not know that they have it, or they are diagnosed only after many years and after seeing many doctors.
Despite its name, the syndrome is not a disease of the ovaries and is not caused by “cysts”. The small follicles seen on ultrasound are egg follicles that have stopped maturing. They are not cysts. PCOS is a complex hormonal and metabolic condition. It affects the cycle, the skin, fertility, metabolism, the heart and mental health. That is why, in May 2026, the name of the syndrome was changed to PMOS (Polyendocrine Metabolic Ovarian Syndrome). The aim of the new name is greater awareness of how complex the syndrome is. It also aims to stop the syndrome being presented only as a gynecological and reproductive disease.
Why does it develop?
The syndrome has a strong hereditary basis and often appears in several members of the same family. The daughters of women with the syndrome have a higher chance of developing it. Two mechanisms play a central role, and each one makes the other stronger. The first is a higher production of androgens. These are the “male” hormones, which every woman produces in small amounts. The second is insulin resistance, which means that the body responds less well to insulin. Insulin resistance also occurs in women with a normal weight, but weight gain makes it worse. The environment, lifestyle and stress also play an important role. Today the syndrome is seen as the result of internal and external factors. In a woman with a genetic tendency to an androgen disorder, these factors start to act before birth, in the womb.
What are the signs?
The picture varies a lot from woman to woman. This explains why the diagnosis is often delayed.
In the cycle, periods are irregular, rare or absent, because ovulation does not happen regularly. There is, however, also a form of the syndrome with regular periods (the third phenotype), with raised androgens and polycystic ovaries. Irregular or absent periods are therefore not a requirement for the diagnosis. The androgens cause extra hair growth on the face, chest or belly (hirsutism), acne that continues beyond puberty, and thinning of the hair on the top of the head. In fertility, irregular ovulation can delay pregnancy. With good family planning, and unless something unexpected happens, all women with the syndrome have the family they wish for in the end. In metabolism, there is often weight gain, mainly around the belly, difficulty losing weight, and changes in blood sugar and blood lipids. Mental health is often affected. Anxiety, depression, eating disorders and a negative body image are much more common in women with the syndrome, already from puberty.
How is the syndrome diagnosed?
The diagnosis is based on the Rotterdam criteria, which were established in 2003 and published in 2004. In adult women, two of the following three are needed: an irregular cycle or no ovulation, clinical or laboratory signs of raised androgens, and polycystic ovaries on ultrasound or a raised level of the hormone AMH. The option to use AMH instead of ultrasound is one of the most important changes in the 2023 guideline.
When a woman already has an irregular cycle and raised androgens, the diagnosis is made without ultrasound or AMH. For the androgens, the guideline recommends measuring total and free testosterone first, and then, if needed, androstenedione and DHEA-S. Before the diagnosis, the doctor must rule out other conditions that cause the same symptoms, such as thyroid disorders, raised prolactin and non-classic congenital adrenal hyperplasia. Polycystic ovary syndrome is a diagnosis of exclusion.
Depending on which criteria are present, there are four phenotypes of the syndrome. The phenotype helps to understand the individual hormonal and metabolic profile of each woman, because the risks, the course and the treatment priorities are not the same for everyone.
The four phenotypes of the syndrome
Why is puberty different?
During puberty the diagnosis is especially difficult, because an irregular cycle, acne and the look of the ovaries on ultrasound can be normal at this age. That is why girls in puberty need both an irregular cycle and raised androgens. Ultrasound and AMH are not used for the diagnosis in the first eight years after the first period. When there are signs but the criteria are not met, the girl is considered “at risk”. She has regular check-ups and a new assessment later. Recognizing this early allows prevention and support from an early stage, without rushed diagnoses.
Does the syndrome stay for life?
The syndrome does not “go away” after puberty or after a pregnancy. It changes over the years. During puberty, irregular periods and skin signs of raised androgens are the main concerns. In the reproductive years fertility comes first, and later metabolism and the heart. The guideline stresses that women with the syndrome have a higher risk of type 2 diabetes, diabetes in pregnancy, high blood pressure, high blood lipids and heart disease, whatever their weight. When periods are very rare for a long time, the risk of thickening of the womb lining and of cancer of the womb lining is also higher. The risk of sleep apnea is higher too.
After the menopause the signs of the syndrome usually fade, and their medical importance changes, especially when there has been careful and regular follow-up before. An early diagnosis, ideally already in puberty, is therefore very important.
That is why good care does not stop at regulating the period. It includes regular check-ups: measuring blood pressure, checking blood sugar (preferably with a glucose tolerance test) and blood lipids, following the weight, and asking about mood, anxiety, sleep and the relationship with food. How often these checks are needed depends on the individual risk of each woman.
The syndrome across a woman’s life
Puberty
Cycle, acne, hair growth, body image.
Diagnosis only with an irregular cycle and raised androgens.
Reproductive years
Fertility, weight, skin and hair, mental health.
Regular checks of blood sugar, blood lipids and blood pressure.
Pregnancy
Gestational diabetes, high blood pressure, pre-eclampsia.
Glucose tolerance test before and during pregnancy.
After the menopause
The hormonal symptoms fade.
The metabolic and cardiovascular risk remains.
Is there a treatment for the syndrome?
It is often said that PCOS cannot be cured. This is true in the sense that no treatment makes the syndrome disappear for good. But there are effective treatments for each individual problem, such as cycle disorders, extra hair growth, hair loss, acne, weight gain, or the burden on mental health and quality of life.
Care is needed here. The treatment of symptoms should not aim only at a quick result. It must also take into account the future course of the syndrome. A stable cycle or less hair growth are important goals. But the doctor must always weigh them against the safety of the treatment and its long-term effects. Without a correct assessment of the form of the syndrome, a treatment may not be enough or, in some cases, may make the course worse.
Why is lifestyle the basis?
The guideline sees a healthy lifestyle as the basis of treatment for all women with the syndrome, whatever their weight. There is no special “PCOS diet” that is better than the others. What matters is a balanced diet that a woman can keep up in the long run. Regular exercise improves insulin sensitivity, metabolism and mood, even without weight loss, and it includes both aerobic exercise and strength training. In women with a higher weight, even a moderate weight loss can improve the cycle, ovulation and metabolic values.
The 2023 guideline also puts special emphasis on weight stigma. Women with the syndrome often feel blamed for their weight, as if it were only due to diet and too little exercise. In the syndrome, however, insulin resistance is present in about 75% of slim women and in almost all women with a higher weight. High insulin levels promote fat storage and increase androgen production. The androgens in turn promote fat build-up around the belly, and belly fat makes insulin resistance even stronger. A long-term study from Australia showed that women with the syndrome gain more weight over the years than women without it. The doctor discusses weight with respect and only with the woman’s consent.
What are the treatment options?
The treatment is chosen according to the main problem, the phenotype and the goals of each woman, in a shared decision with the doctor. There is no single treatment for all women with the syndrome.
The contraceptive pill. For an irregular cycle and symptoms caused by androgens, when a woman does not wish to become pregnant, the guideline recommends the combined contraceptive pill. It regulates the cycle, protects the womb lining, improves acne and hair growth, and provides contraception. However, each pill has a different combination of estrogen and progestin, with a different effect on the risk of thrombosis, on blood sugar, on blood lipids and on blood pressure. The guideline asks for the lowest effective dose of estrogen. It also asks doctors to consider pills with natural estrogens and to weigh each woman's metabolic and cardiovascular risk. It does not recommend higher-risk pills, such as those with cyproterone acetate, as a first choice. The different pills work about equally well on hair growth, but their effect on the mechanisms of the syndrome is not the same. That is why the pill must be chosen with care, so that it does not favor heart or metabolic problems later. And that is also why the pill cannot be a standard treatment for every woman with the syndrome.
Metformin. For many years metformin was presented as a cure-all for the syndrome. Today it is clear that its benefit applies mainly to women with a metabolic profile, meaning insulin resistance, changes in blood sugar or a higher weight. In these women it may improve metabolic values, but there is no clear effect on lowering the risk of heart disease. Even in these women, the doctor should prescribe it only after carefully weighing the benefit against the side effects, and only when its benefit is greater than what diet and lifestyle can offer. It can be given on its own or together with the pill. Giving it to every woman with the syndrome is not justified.
Anti-androgens. Anti-androgens have a place when hirsutism or acne do not improve enough after six months of treatment with the pill, when the pill is not allowed for medical reasons, or when the woman prefers a non-hormonal treatment. Because there is a risk of birth defects in the first trimester of pregnancy, they are given only with reliable contraception. How anti-androgen treatments are used depends on the symptom. The following sections describe this in detail.
Extra hair growth
Extra hair growth in a male pattern (hirsutism) affects the majority of women with raised androgens. The hair grows on the upper lip, chin, neck, chest, belly, back or thighs. The doctor assesses it with a simple scale that rates nine areas of the body. Ethnic background is important here, because normal body hair differs greatly between population groups. Many women remove the hair regularly, and so their own assessment is just as important as the findings of the examination.
The guideline and the Endocrine Society guideline on hirsutism recommend the pill together with cosmetic hair removal as the first step. The pill lowers the free androgens in the blood. Its effect on hair growth, however, appears only after at least six months, because every hair has a long growth cycle. Only after this time can it be judged whether the treatment is enough.
If the effect is not enough, the doctor adds an anti-androgen, for example spironolactone. Anti-androgens can disturb the development of a male baby. Reliable contraception is therefore needed during treatment. Laser and light treatment is especially effective on the face, and works best on dark hair on light skin. It hardly works on blond, gray or white hair. Combining it with hormonal treatment improves the result.
For the face, there is also a cream with eflornithine, which slows down hair growth. It works as long as the woman uses it, and it can be combined with laser treatment.
Hair loss
Female-pattern hair loss shows as thinning on the top of the head, while the hairline at the front usually stays. For many women it is one of the most distressing symptoms of the syndrome. Data on treatment are limited. Hormonal treatments and anti-androgens can slow it down, and minoxidil applied to the scalp is an option. Before treatment, the doctor rules out other causes, such as iron deficiency or a thyroid disorder. Here, too, the effect of any treatment appears only after many months.
Newer data show that minoxidil in a very low dose taken by mouth works about as well as the solution applied to the scalp. However, it can increase hair growth in other parts of the body, which is already a problem in the syndrome. For this reason, the doctor chooses the form of treatment carefully, together with the woman.
Acne
Acne that continues beyond puberty or starts only in adulthood is a common sign of raised androgens. It often appears on the chin, the jawline and the neck. The pill improves the skin in many women, and anti-androgens can help further. With severe acne, working together with a dermatologist makes sense. Some skin treatments, such as isotretinoin, harm an unborn baby and also need reliable contraception.
Newer data give strong support to spironolactone. A large randomized trial in 410 adult women with acne (SAFA, BMJ 2023) showed a clear improvement of the skin compared with placebo and a better quality of life at 24 weeks. The women also needed fewer antibiotics. Spironolactone is therefore an evidence-based alternative to long-term antibiotics.
The symptoms and the treatment options
Medication for weight loss. An important new addition to the 2023 guideline is medication for weight loss, mainly GLP-1 receptor agonists such as liraglutide and semaglutide. These medicines reduce appetite, slow down stomach emptying and improve the response to insulin. In a meta-analysis of 13 randomized trials with about 800 women with the syndrome (Scientific Reports, 2025), GLP-1 receptor agonists reduced weight by about 3.6 kg and, compared with placebo, by about 5.4 kg. They also lowered the body mass index by about 1.6 points and reduced insulin resistance. A 2026 meta-analysis (European Journal of Endocrinology) shows that the cycle becomes more regular. The effect on androgens, however, is small: total testosterone fell compared with placebo, but not compared with metformin. The most common side effects are nausea, vomiting and dizziness. Most trials were small and short, and the certainty of the evidence is still low.
After stopping, weight often goes up again. In a large study of people with obesity, one year after stopping semaglutide, participants had regained about 67% of the weight they had lost. During treatment, a woman needs reliable contraception. A woman should stop semaglutide at least two months before a planned pregnancy, and tirzepatide can reduce the effect of the contraceptive pill. For this reason, the doctor plans these medicines as part of an overall plan, together with lifestyle, and makes an individual decision. More in the article “PCOS and weight”.
Inositol. The guideline still considers inositol and other supplements an experimental treatment. The evidence is not enough for a general recommendation. The doctor discusses their use with the woman, with realistic expectations. They should not replace an evidence-based treatment.
Why does the cycle matter for the lining of the womb?
An irregular cycle is not just a nuisance. Without ovulation, the progesterone that regularly sheds the lining of the womb is missing. The lining is then under the influence of estrogen alone for a long time and can thicken. Before the menopause, women with PCOS have a two to six times higher risk of cancer of the womb lining. The absolute risk, however, remains low. For this reason, treatment is often needed here too, even when a woman has no other troublesome symptoms.
The guideline recommends protecting the lining when cycles last longer than 90 days, for example with the pill or with a progestin. Routine measurement of the lining's thickness is not needed. With a lining that stays thick, bleeding outside the cycle or other risk factors, a prompt examination is needed.
What about treatments beyond the guidelines?
Guidelines reflect the knowledge of a specific moment and are written for all women with the syndrome. There are many treatments that have not yet found their way into the guidelines. For some of them, the evidence is not yet final, although it may be very impressive for certain forms of the syndrome. For others, the benefit does not justify the cost for the whole population, although for one particular woman they may be the right choice.
Any treatment, hormonal or non-hormonal, classical or complementary, can be considered when two conditions are met. It must be safe, effective and fit into the woman's daily life, and it must support a good course in the long term. The aim is to prevent complications such as fertility problems, diabetes, metabolic syndrome and heart disease.
A doctor who specializes in the syndrome can present all these options, with their advantages and their limits. The final decision is individual. It is based on evidence-based medicine, but also on clinical experience, the form of the syndrome and the needs of each woman.
The practice's approach
The practice treats PCOS/PMOS individually, according to the needs, the priorities and the stage of life of each woman.
The specialization in gynecological endocrinology allows the doctor to assess the hormonal, metabolic, reproductive and mental health effects of the syndrome together.
When a woman understands how complex and long-lasting the syndrome is, she can also cope better with the difficult phases.
Many years of experience with all clinical forms of the syndrome and the certification of the International Society of Gynecological Endocrinology (ISGE) for polycystic ovary syndrome allow highly specialized and individual care.
At every appointment, the woman fills in a short quality-of-life questionnaire that the practice developed for this purpose. In this way, the doctor sees how the woman’s daily life changes with the treatment, and not only the lab values.
Sources: International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (Monash University, ESHRE, ASRM, 2023). The Lancet (May 2026) – international consensus on renaming PCOS as PMOS. The Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group, Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome, Human Reproduction 2004. Stepto NK et al., Women with polycystic ovary syndrome have intrinsic insulin resistance on euglycaemic–hyperinsulaemic clamp, Human Reproduction 2013. Teede HJ et al., Longitudinal weight gain in women identified with polycystic ovary syndrome, Obesity 2013. Martin KA et al., Evaluation and treatment of hirsutism in premenopausal women: an Endocrine Society clinical practice guideline, Journal of Clinical Endocrinology and Metabolism 2018. Santer M et al., Effectiveness of spironolactone for women with acne vulgaris (SAFA): randomized controlled trial, BMJ 2023. Ramos PM et al., Minoxidil 1 mg oral versus minoxidil 5% topical solution for the treatment of female-pattern hair loss: a randomized clinical trial, Journal of the European Academy of Dermatology and Venereology 2020. Barry JA et al., Risk of endometrial, ovarian and breast cancer in women with polycystic ovary syndrome, Human Reproduction Update 2014. Lin S et al., Efficacy and safety of GLP-1 receptor agonists on weight management and metabolic parameters in PCOS women: a meta-analysis of randomized controlled trials, Scientific Reports 2025. GLP-1 receptor agonist treatment in women with polycystic ovary syndrome – a systematic review and meta-analysis, European Journal of Endocrinology 2026. Wilding JPH et al., Weight regain and cardiometabolic effects after withdrawal of semaglutide: the STEP 1 trial extension, Diabetes, Obesity and Metabolism 2022. EMA – Wegovy (semaglutide) and Mounjaro (tirzepatide), product information.