Polycystic ovary syndrome (PCOS) affects roughly 1 in 10 women and people with ovaries, making it the most common hormonal disorder in reproductive-age women, and many are never diagnosed. Despite the name, it’s not really an ovary disease: it is a hormonal and metabolic condition involving higher androgens, irregular ovulation and often insulin resistance.
There is no single cure, but each problem has effective treatments: the birth control pill for cycles, acne and hair growth; metformin and lifestyle changes for insulin resistance; letrozole as first-line fertility treatment; and increasingly GLP-1 drugs for weight. Research into the brain hormones kisspeptin and neurokinin B, which drive the high LH typical of PCOS, is opening new approaches. Here’s the full guide, based on the 2023 international PCOS guideline.
What PCOS actually is
PCOS involves a cycle of hormonal imbalances that reinforce each other:
- The brain’s hormone pulse generator runs fast. GnRH pulses from the hypothalamus are more frequent, which favours LH over FSH from the pituitary.
- High LH pushes the ovaries to make more androgens (male-type hormones like testosterone).
- Insulin resistance, present in many with PCOS regardless of weight, raises insulin, which further boosts ovarian androgen production and lowers SHBG, increasing free testosterone.
- High androgens disrupt follicle development, so eggs don’t mature and release regularly. Many small follicles accumulate, the “cysts” on ultrasound, which are not true cysts.
- No ovulation means irregular periods and unopposed estrogen on the uterine lining.
Genetics plays a large role: PCOS clusters in families. Weight gain worsens it, and weight loss often improves it, but people of every body size can have PCOS.
How it’s diagnosed (2023 criteria)
The 2023 International Evidence-based Guideline for PCOS uses the Rotterdam criteria: two of three of the following, after other causes are excluded (Teede et al., 2023):
| Criterion | How it’s assessed |
|---|---|
| Irregular or absent ovulation | Cycles shorter than 21 or longer than 35 days, or fewer than 8 periods a year |
| High androgens | Clinical signs (excess hair, acne, scalp hair thinning) or high blood testosterone |
| Polycystic ovaries | Ultrasound, or in adults, a high anti-Müllerian hormone (AMH) blood test |
Two important updates in the 2023 guideline: AMH can now replace ultrasound in adults, and in adolescents neither ultrasound nor AMH is used, because many healthy teens have multi-follicular ovaries; diagnosis there requires both irregular cycles and androgen excess.
Conditions to rule out
- Thyroid disease (TSH)
- High prolactin
- Non-classic congenital adrenal hyperplasia (17-hydroxyprogesterone)
- Pregnancy
- Hypothalamic amenorrhea from low energy intake or intense exercise, which can look similar on ultrasound but has low hormone levels
- Rarely, androgen-secreting tumours (very high testosterone, rapid virilization) or Cushing’s syndrome
Long-term health risks
| Risk | Why | Screening |
|---|---|---|
| Type 2 diabetes | Insulin resistance | Glucose testing regularly; an oral glucose tolerance test is preferred |
| Gestational diabetes | Insulin resistance | Early glucose testing in pregnancy |
| Endometrial hyperplasia and cancer | Lining exposed to estrogen without regular periods | Aim for a withdrawal bleed at least every 3 months |
| Cardiovascular risk factors | Lipids, blood pressure, weight | Regular checks |
| Fatty liver | Insulin resistance | See fatty liver treatment |
| Sleep apnea | Weight, androgens | Ask about snoring, daytime sleepiness |
| Depression and anxiety | Biological and psychosocial factors | Routine screening |
Treatment by goal
PCOS treatment depends on what you want to fix right now:
| Goal | First-line | Next options |
|---|---|---|
| Regular periods / protect the uterus | Combined birth control pill | Cyclic progestin, hormonal IUD, metformin |
| Excess hair and acne | Birth control pill + cosmetic hair removal | Add spironolactone (with contraception) |
| Weight and insulin resistance | Lifestyle changes + metformin | GLP-1 drugs, bariatric surgery |
| Pregnancy | Letrozole | Gonadotropins, ovarian drilling, IVF |
| Mood | Screening, therapy | Medication as indicated |
Lifestyle: what actually helps
For people with PCOS and excess weight, losing even 5% to 10% of body weight can restore ovulation, improve cycles, lower androgens and reduce diabetes risk. The guideline emphasizes that no specific diet is superior for PCOS: a sustainable, healthy pattern that achieves an energy deficit works.
- Exercise: at least 150 minutes per week of moderate activity, plus strength training, improves insulin sensitivity independent of weight loss.
- Sleep: poor sleep worsens insulin resistance and appetite.
- Avoid extreme diets, which are hard to sustain and can trigger disordered eating, a higher risk in PCOS.
- Weight stigma: the guideline explicitly calls out weight bias in care. Lifestyle advice should be respectful and practical.
The birth control pill
Combined oral contraceptives (estrogen plus progestin) are first-line for people with PCOS who don’t want to get pregnant. They:
- Regulate bleeding and protect the uterine lining
- Reduce ovarian androgen production and raise SHBG, lowering free testosterone
- Improve acne and, over 6 to 12 months, excess hair
- Provide contraception
The guideline recommends lower-dose formulations; no specific brand is clearly better. Not suitable for everyone, for example those with migraine with aura or a history of blood clots. Alternatives for uterine protection include a hormonal IUD or cyclic progestin.
Metformin
Metformin improves insulin sensitivity. In PCOS it can modestly help weight, metabolic markers and cycle regularity, and is recommended alongside lifestyle changes, particularly for people with higher BMI or insulin resistance. It is inexpensive and widely covered. Gastrointestinal side effects are common at first; starting low and using the extended-release form helps. Long-term use can lower vitamin B12.
GLP-1 drugs and PCOS
GLP-1 drugs such as semaglutide and tirzepatide aren’t approved specifically for PCOS, but many people with PCOS qualify for them for weight management. Smaller studies in PCOS show weight loss, improved insulin sensitivity, lower androgens and more regular cycles, consistent with what weight loss itself does. The 2023 guideline recognizes anti-obesity medications as an option alongside lifestyle changes.
GLP-1 drugs are not recommended in pregnancy and should be stopped before trying to conceive, usually at least two months ahead for semaglutide. Because weight loss can restore ovulation unexpectedly, reliable contraception matters while using them. Some GLP-1s may also reduce the effectiveness of oral contraceptives when doses change, so ask your prescriber.
For options and prices in Canada, see weight loss injections in Canada, and for muscle protection, muscle loss on GLP-1 drugs.
Excess hair, acne and hair loss
Excess hair (hirsutism)
- Laser or electrolysis hair removal: the most effective for visible improvement; laser works best on dark hair and lighter skin, with newer devices for darker skin.
- Birth control pill to reduce new growth (takes 6+ months).
- Spironolactone, an anti-androgen, added if needed; must be used with reliable contraception because it can affect a male fetus.
Acne
Standard acne treatments (topical retinoids, benzoyl peroxide) plus hormonal therapy usually work well. See our acne and acne scar guide.
Scalp hair thinning
Androgen-related thinning at the crown is treated with topical minoxidil, often with spironolactone. See hair loss treatment in Canada.
Fertility: letrozole first
PCOS is the most common cause of ovulation-related infertility, but most people with PCOS can conceive with treatment.
- Letrozole is now first-line for ovulation induction. In a major trial, it produced more live births than clomiphene (27.5% vs 19.1%) in women with PCOS (Legro et al., 2014).
- Clomiphene, with or without metformin, is an alternative.
- Gonadotropin injections or laparoscopic ovarian drilling are second-line.
- IVF is third-line, or used for other factors.
People with PCOS are at higher risk of ovarian hyperstimulation syndrome (OHSS) during fertility treatment because they have many follicles; careful monitoring and specific protocols reduce that risk.
IVF and funding in Canada
Fertility funding varies widely by province. Ontario funds one IVF cycle per eligible patient through the Ontario Fertility Program, Quebec funds some treatment with eligibility limits, and several other provinces offer partial funding or tax credits. Waitlists for funded cycles can be long. Medications are often covered partly by private plans. Ask your fertility clinic which programs apply where you live.
Inositol and other supplements
| Supplement | Evidence | Guideline view |
|---|---|---|
| Myo-inositol / D-chiro-inositol | Some metabolic benefits in small trials; limited clinical outcomes | Considered experimental; can be tried with realistic expectations |
| Vitamin D | Correct deficiency | Helpful if low |
| Omega-3 | Small effects on lipids | Not specific to PCOS |
| Spearmint tea | Tiny studies on androgens | Weak |
| Berberine | Some insulin effects | Limited evidence; drug interactions |
Inositol is popular because it’s low-risk, and some people report improved cycles. The guideline concluded the evidence for meaningful outcomes is limited and that people should be informed of that when choosing it.
Mental health and PCOS
Depression, anxiety, body image distress and eating disorders are more common in PCOS. Visible symptoms like hair growth, acne and weight, plus fertility worries, take a toll. The 2023 guideline recommends routine screening for mood and eating disorders. Treating physical symptoms often helps, and therapy is effective. See our anxiety treatment guide.
Kisspeptin and neurokinin B research
The fast GnRH pulses at the heart of PCOS are controlled by KNDy neurons in the hypothalamus, which use kisspeptin, neurokinin B and dynorphin as signals. That has made them a research target:
- Neurokinin B blockade: in a small trial, an experimental NK3 receptor antagonist lowered LH and testosterone in women with PCOS (George et al., 2016). It’s the same receptor targeted by the menopause drug fezolinetant (see menopause treatment).
- Kisspeptin as an IVF trigger: because kisspeptin triggers a more natural, shorter hormone surge than standard triggers, researchers tested it to mature eggs in women at high risk of OHSS, including many with PCOS. In a key study, it achieved egg maturation with very low rates of OHSS (Abbara et al., 2015).
- Diagnostics: kisspeptin responses are being studied to understand reproductive disorders.
These are research directions, not current PCOS treatments.
| Research compound | Relevance | From |
|---|---|---|
| Kisspeptin | Reproductive axis, IVF trigger research | $34 |
| hCG | LH-like reference compound in reproductive research | $24 |
| Tirzepatide | Metabolic and weight research | $73 |
| Retatrutide | Metabolic and weight research | $90 |
For laboratory research only, with reports in our COA library. More background in kisspeptin vs hCG vs PT-141.
PCOS in teens
Irregular cycles are normal for the first few years after a first period, so diagnosing PCOS in adolescents is done carefully. The guideline requires both irregular cycles (judged by years since first period) and androgen excess, and doesn’t use ultrasound. Teens who don’t fully meet criteria may be labelled “at risk” and re-assessed later. Treatment focuses on symptoms (acne, hair, cycles), healthy habits without weight stigma, and mental health.
PCOS and pregnancy
Most people with PCOS who want children can have them, but pregnancy carries some additional risks worth planning for:
| Risk | What helps |
|---|---|
| Gestational diabetes | Early glucose testing in pregnancy; healthy weight gain; physical activity |
| High blood pressure and preeclampsia | Blood pressure monitoring; discuss low-dose aspirin with your care provider if risk factors apply |
| Preterm birth | Standard prenatal care with awareness of risk |
| Twins (with fertility treatment) | Careful monitoring of ovulation induction |
Before trying to conceive: start folic acid, review medications (stop spironolactone and GLP-1 drugs in advance as advised), check blood sugar and blood pressure, and optimize weight where relevant. Pre-conception planning with your doctor makes a real difference.
PCOS after 40 and through menopause
PCOS doesn’t simply disappear with age. As women with PCOS approach menopause:
- Cycles often become more regular in the late 30s and 40s as ovarian reserve declines.
- Androgen levels tend to fall gradually but may stay higher than in women without PCOS.
- Metabolic risks persist: type 2 diabetes, high cholesterol and cardiovascular risk need continued monitoring.
- Menopause may arrive slightly later on average in women with PCOS.
Menopause management in women with PCOS follows the same principles as for anyone else; see menopause treatment in Canada.
PCOS diet myths
- “You have to go keto.” No specific diet has been shown to be superior; the guideline supports any healthy pattern that creates a sustainable energy deficit when weight loss is a goal.
- “Dairy causes PCOS.” There’s no good evidence that cutting dairy treats PCOS, although some people with acne notice links.
- “Gluten-free helps PCOS.” Not unless you have celiac disease.
- “PCOS means you can’t lose weight.” It can be harder because of insulin resistance, but weight loss is achievable and effective, especially with medical support.
- “Seed cycling balances hormones.” No evidence.
- “Spearmint tea cures hirsutism.” Small studies only; effects are modest at best.
Questions to ask your doctor
- Do I meet the 2023 criteria for PCOS, and have other causes been ruled out?
- Which symptom should we treat first, and with what?
- Should I be screened for diabetes, cholesterol, sleep apnea and fatty liver?
- Is metformin or a GLP-1 drug appropriate for me?
- What should I do before trying to get pregnant?
- Can I see an endocrinologist, gynaecologist or dietitian?
- Is there a fertility program in my province I’m eligible for?
Excess hair: a deeper look
Hirsutism, coarse dark hair in a male-type pattern (upper lip, chin, chest, abdomen, back), affects a large share of people with PCOS and is often the most distressing symptom. Clinicians sometimes use the modified Ferriman-Gallwey score to rate severity across body areas.
| Approach | How it works | Time to results |
|---|---|---|
| Shaving, waxing, threading | Removes hair temporarily | Immediate |
| Laser hair removal | Damages follicles; reduces regrowth | Several sessions; maintenance needed |
| Electrolysis | Destroys individual follicles; works on all hair colours | Many sessions |
| Combined birth control pill | Lowers androgen production and free testosterone | 6+ months |
| Anti-androgens (spironolactone) | Blocks androgen effects at the follicle | 6+ months; requires contraception |
| Topical eflornithine cream | Slows facial hair growth | Weeks to months |
Combining medical treatment (to reduce new growth) with laser or electrolysis (to remove existing hair) usually works best. Shaving does not make hair grow back thicker.
Sleep apnea and fatigue in PCOS
People with PCOS have a higher risk of obstructive sleep apnea, linked to weight, androgens and insulin resistance. Untreated sleep apnea worsens insulin resistance, fatigue, mood and blood pressure. Warning signs include loud snoring, observed pauses in breathing, morning headaches and daytime sleepiness. A sleep study, increasingly available as a home test in Canada, can diagnose it, and treatment improves both energy and metabolic health. For broader sleep help see insomnia treatment in Canada.
Supporting someone with PCOS
- Avoid comments about weight, food choices or appearance; they rarely help and often harm.
- Understand that symptoms like hair growth and acne are hormonal, not about hygiene or effort.
- Be patient with fertility stress, which can be intense and prolonged.
- Offer practical support: joining walks, cooking together, coming to appointments.
- Take mood changes seriously and encourage professional support if needed.
PCOS glossary
| Term | Meaning |
|---|---|
| Androgens | Male-type hormones such as testosterone |
| Anovulation | Cycles where no egg is released |
| AMH | Anti-Müllerian hormone; often high in PCOS |
| LH / FSH | Pituitary hormones that control the ovaries |
| SHBG | A protein that binds testosterone; low SHBG means more free testosterone |
| Hirsutism | Excess coarse hair in a male-type pattern |
| Insulin resistance | Cells respond less to insulin, so the body makes more |
| OHSS | Ovarian hyperstimulation syndrome, a fertility treatment complication |
| Rotterdam criteria | The 2-of-3 diagnostic criteria for PCOS |
FAQ
Tap a question to reveal the answer.
What is the best treatment for PCOS?
It depends on your goal. The birth control pill treats irregular periods, acne and excess hair; lifestyle changes and metformin target insulin resistance; letrozole is first-line for fertility.
Can PCOS be cured?
There’s no cure, but symptoms can be well controlled, and weight loss in people with excess weight can restore regular ovulation.
Does Ozempic help PCOS?
Semaglutide isn’t approved specifically for PCOS, but in people with PCOS who qualify for weight management, it produces weight loss that improves insulin resistance, androgens and cycles. It must be stopped before trying to conceive.
Is letrozole better than clomiphene for PCOS?
Yes. In a large trial, letrozole led to more live births than clomiphene (27.5% vs 19.1%) and is now first-line.
Does inositol work for PCOS?
Small studies suggest some metabolic benefits, but the 2023 international guideline considers the evidence limited and inositol experimental.
Can you have PCOS without cysts?
Yes. Diagnosis needs two of three criteria; you can have PCOS with irregular cycles and high androgens and normal-looking ovaries.
Does PCOS cause weight gain?
Insulin resistance in PCOS makes weight gain easier and weight loss harder, though people of any weight can have PCOS.
What is the link between kisspeptin and PCOS?
Kisspeptin and neurokinin B neurons in the brain drive the fast hormone pulses typical of PCOS. Blocking neurokinin B lowered LH and testosterone in a small trial, and kisspeptin has been studied as a safer IVF trigger.
Does PCOS go away after menopause?
Cycles become irrelevant after menopause and androgens may decline, but metabolic risks like diabetes and heart disease persist and need monitoring.
What is the best diet for PCOS?
No single diet is best. The 2023 guideline supports any healthy eating pattern that you can sustain, with an energy deficit if weight loss is a goal.
What is the best way to remove PCOS facial hair?
Combining medical treatment, such as the birth control pill or spironolactone to reduce new growth, with laser hair removal or electrolysis to remove existing hair usually works best.
Related reading
- Fatty liver treatment in Canada
- Hair loss treatment in Canada
- Acne and acne scar treatment
- Menopause treatment in Canada
References
- Teede HJ, Tay CT, Laven JJE, et al. Recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome. J Clin Endocrinol Metab. 2023. PubMed
- Legro RS, Brzyski RG, Diamond MP, et al. Letrozole versus clomiphene for infertility in the polycystic ovary syndrome. N Engl J Med. 2014;371:119–129. PubMed
- George JT, Kakkar R, Marshall J, et al. Neurokinin B receptor antagonism in women with polycystic ovary syndrome: a randomized, placebo-controlled trial. J Clin Endocrinol Metab. 2016. PubMed
- Abbara A, Jayasena CN, Christopoulos G, et al. Efficacy of kisspeptin-54 to trigger oocyte maturation in women at high risk of ovarian hyperstimulation syndrome. J Clin Endocrinol Metab. 2015. PubMed
This article is general information, not medical advice. See a doctor, nurse practitioner or gynaecologist for PCOS diagnosis and treatment. TrueLabs research compounds are sold for in vitro and laboratory research use only and are not intended for human or veterinary use.