Polycystic Ovary Syndrome (PCOS/PMOS): Naturopathic Support for Hormones, Cycles and Fertility

How is PCOS/ PMOS diagnosed?

Many women tell me they’ve been given mixed messages about whether they “really” have PCOS. One doctor says yes, another says no, and an ultrasound or blood test may not seem to provide a clear answer.

That’s because PCOS can’t be diagnosed using a single test.

Diagnosis is based on a combination of your symptoms, medical history, blood tests and, where appropriate, an ultrasound. Healthcare providers also need to exclude other conditions that can cause similar symptoms, such as thyroid disorders, elevated prolactin, non-classic congenital adrenal hyperplasia and hypothalamic amenorrhoea.

The most commonly used diagnostic criteria are the Rotterdam Criteria, which require two of the following three features:

• irregular or absent ovulation
• clinical or biochemical signs of androgen excess
• polycystic ovarian morphology on ultrasound

This means two women can both be diagnosed with PCOS while having very different symptoms and hormone patterns. Understanding what is driving your particular presentation is often more helpful than the diagnosis alone.

Androgens explained in plain language

One of the biggest reasons two women with PCOS can look completely different is because their androgen patterns are different.

You may have been told your testosterone is “normal” and assumed that ruled out androgen-related symptoms such as acne, unwanted facial hair or hair thinning.

Not necessarily.

Testosterone is only one part of the androgen picture.

Women naturally produce several androgens, including testosterone, androstenedione and DHEA-S, from both the ovaries and adrenal glands. These hormones play important roles in normal female physiology, but in PCOS the way they’re produced, converted, cleared or experienced by tissues can become altered.

Some women have clearly elevated androgen levels. Others have relatively subtle blood-test changes but greater sensitivity of the skin or hair follicles to those hormones.

So the more useful question isn’t simply, “Is testosterone high?”

It’s which androgen pathways are involved and how they’re contributing to your symptoms.

What can drive PCOS patterns (and why identifying drivers matters)

PCOS is often treated as though every woman has essentially the same condition.

She doesn’t.

For one woman, insulin resistance may be central to the picture. For another, adrenal androgen production, disrupted ovulation or a combination of hormonal and metabolic factors may be more important.

This helps explain why generic PCOS advice can work brilliantly for one woman and make very little difference for another.

Not every driver below will apply to everyone. The aim is to understand which patterns are most relevant to you so treatment can be targeted accordingly.

Insulin resistance and metabolic signalling

One of the most common reasons insulin resistance is missed is that blood glucose can still look perfectly normal.

Insulin resistance develops when cells become less responsive to insulin, the hormone that helps move glucose from the bloodstream into cells for energy. The body compensates by producing more insulin, sometimes for years, to keep blood glucose within the normal range.

So a normal fasting glucose doesn’t necessarily tell us how hard the body is working behind the scenes to maintain it.

When insulin resistance is present in PCOS, higher insulin signalling can stimulate ovarian androgen production and interfere with normal ovulation. It may also contribute to weight gain, increased hunger, energy fluctuations and difficulty regulating blood sugar.

But not every woman with PCOS has insulin resistance.

The important question is whether insulin is actually driving your pattern, because that should influence how treatment is approached.

Androgen signalling: it’s about more than testosterone

Another common misconception is that PCOS means having high testosterone.

Sometimes it does. But androgen signalling is much more complex than one number on a pathology report.

Symptoms may reflect higher production of ovarian androgens, increased adrenal androgens such as DHEA-S, altered conversion between hormones, changes in clearance, or greater sensitivity of tissues such as the skin and hair follicles.

This helps explain why some women have significant acne, unwanted hair growth or hair thinning while repeatedly being told their testosterone is “normal”.

Looking at the broader androgen picture can reveal a very different story, and help explain why two women with PCOS can have similar symptoms for completely different hormonal reasons.

Adrenal-driven PCOS patterns

Some women with PCOS assume insulin resistance is always the main driver.

For some women, that’s true. But for a smaller subgroup, the picture looks quite different.

Instead of ovarian androgens or insulin resistance dominating the clinical picture, adrenal androgens are more prominent, often reflected by higher DHEA-S relative to ovarian androgens.

In these women, insulin resistance and inflammation are not always the primary drivers. Instead, adrenal hormone regulation appears to be more upregulated at a signalling level, and menstrual cycles may be less disrupted than in more typical anovulatory PCOS.

Recognising this pattern is important because it changes the focus of treatment. Rather than concentrating primarily on metabolic strategies, support may be directed towards adrenal regulation, nervous system health, sleep and overall resilience.

Ovulation, progesterone signalling, and cycle disruption

One of the most frustrating aspects of PCOS is the unpredictability. Your periods may be irregular, months apart, or you may never be quite sure whether you’ve ovulated.

It’s easy to assume this means you’re simply “low in progesterone”, but that’s usually only part of the story.

Progesterone is produced after ovulation. When ovulation doesn’t occur consistently, progesterone naturally remains lower because the body hasn’t released an egg. In other words, low progesterone is often a consequence of disrupted ovulation rather than the primary problem itself.

The more important question is why ovulation isn’t happening regularly.

Depending on the individual, this may be influenced by insulin signalling, androgen excess, inflammation, stress physiology or other hormonal drivers. Identifying what’s disrupting ovulation helps guide treatment, rather than simply replacing the hormone that’s missing.

Inflammation, stress, and overall load

You may have noticed that your skin flares, your cycles become more irregular, or managing your weight feels even harder during periods of prolonged stress.

That is definitely no coincidence.

Low-grade inflammation is increasingly recognised as part of the PCOS picture, and it interacts closely with hormone signalling, ovulation and metabolism. At the same time, chronic stress influences communication between the brain, ovaries and adrenal glands, affecting many of these same pathways.

Stress doesn’t cause PCOS, but it can amplify the hormonal and inflammatory processes already present, making symptoms more noticeable or more difficult to manage.

When relevant, I also consider sleep quality, nervous system regulation and overall stress load because they can influence how resilient the body is and how strongly PCOS expresses itself.

Environmental influences

Our environment has changed dramatically over the past 70 years, and researchers continue to investigate whether this may be contributing to the growing prevalence of hormone and metabolic conditions such as PCOS.

Particular attention has focused on endocrine-disrupting chemicals (EDCs), which are found in some plastics, pesticides, personal care products and industrial chemicals. These compounds can interact with hormone receptors and may influence insulin signalling, androgen production, ovarian function and metabolism.

Environmental exposures are unlikely to be the sole cause of PCOS, but they may contribute to the overall hormonal and metabolic load in genetically susceptible women.

The goal isn’t to eliminate every exposure. It’s to identify where unnecessary exposures can be reduced as one part of supporting your overall hormonal health.

PCOS and weight gain

One of the biggest frustrations I hear from women with PCOS is, “I’m doing all the right things, so why is my weight still going up?”

Weight gain is common in PCOS, but it isn’t universal, and it isn’t required for diagnosis. Many women with PCOS are a healthy weight, while others find that losing weight feels significantly harder than it used to.

Rather than being explained by calories alone, weight changes in PCOS often reflect what’s happening underneath. Depending on the individual, this may involve insulin resistance, androgen signalling, altered appetite regulation, chronic inflammation or other hormonal changes that influence how the body stores and uses energy.

Understanding what’s driving weight gain is often far more useful than focusing on the number on the scales. It allows treatment to target the underlying physiology rather than relying on increasingly restrictive diets that don’t address the reason weight became difficult to manage in the first place.

PCOS and fertility

One of the first questions many women ask after being diagnosed with PCOS is whether they’ll be able to have children.

The reassuring news is that many women with PCOS conceive naturally.

For others, the main challenge is that ovulation occurs less often or unpredictably, making it more difficult to identify fertile windows and achieve pregnancy. Depending on your individual pattern, factors such as insulin resistance, androgen signalling, inflammation and body weight may also influence fertility.

Understanding why ovulation isn’t occurring consistently is often the key to improving fertility outcomes.

For some women, optimising nutrition, metabolic health and hormone signalling is enough to restore regular ovulation. Others benefit from ovulation induction medications or IVF. The right approach depends on your individual circumstances and should always work alongside your fertility specialist or gynaecologist.

When PCOS isn’t the whole story

Receiving a diagnosis of PCOS can answer many questions, but it doesn’t necessarily explain every symptom you’re experiencing.

For example, while some women with PCOS experience discomfort related to enlarged ovaries or ovulation, significant or persistent pelvic pain isn’t considered a typical feature of PCOS itself.

When symptoms don’t quite fit the diagnosis, it’s important to consider whether another condition may also be contributing.

Endometriosis, adenomyosis, pelvic floor dysfunction, ovarian cyst complications, bladder pain syndrome and gastrointestinal conditions can all occur alongside PCOS and may require a different assessment and treatment approach.

Understanding what each diagnosis does (and doesn’t) explain is often the key to making sense of persistent symptoms and developing a treatment plan that addresses the whole clinical picture.

PCOS vs hypothalamic amenorrhoea (HA): why they’re often confused

Not every woman with irregular or absent periods has PCOS.

Hypothalamic amenorrhoea (HA) can look surprisingly similar, with disrupted ovulation, irregular or missing periods and, in some cases, overlapping hormone patterns. It’s one of the reasons getting the diagnosis right is so important.

The difference lies in what’s happening underneath.

HA is typically driven by low energy availability, under-fuelling, excessive exercise, significant psychological stress, or a combination of these factors. The brain responds by reducing reproductive hormone signalling, making ovulation less likely.

PCOS, on the other hand, reflects a different pattern of hormonal and metabolic dysfunction. While both conditions can affect ovulation, they require very different treatment approaches.

This distinction matters because strategies that help PCOS—particularly those focused on calorie restriction or weight loss—can sometimes make hypothalamic amenorrhoea worse. Likewise, the approach used to restore ovulation in HA won’t necessarily address the underlying drivers of PCOS.

Medications and why they don’t address the whole picture

Many women ask whether taking the oral contraceptive pill, metformin or a GLP-1 medication means they’ve “treated” their PCOS.

The answer depends on what you’re trying to achieve.

These medications can be valuable tools and, for many women, play an important role in managing symptoms such as irregular cycles, insulin resistance or weight. For some women, they can be an appropriate part of long-term care.

At the same time, medication doesn’t necessarily explain why PCOS developed or why your symptoms look the way they do. It may improve one aspect of the condition without addressing other factors such as androgen signalling, ovulation, inflammation or the hormonal and metabolic drivers contributing to your individual pattern.

That’s why I see medical treatment and naturopathic care as complementary rather than competing. The goal isn’t to replace medication when it’s needed, but to better understand the physiology underneath so you’re supporting your long-term health as well as managing symptoms.