111. PCOS Awareness Month Special: The Right Way to Diagnose & Treat

During this month, of Polycystic Ovary Syndrome (PCOS) Awareness, we discuss one of the most common yet misunderstood conditions women face. Too often, the diagnosis is handed out—or dismissed—based on a single untimed lab or quick ultrasound. In this episode of Cycle Wisdom, Dr. Monica Minjeur dives into the real signs of PCOS, why proper timing and context matter, and how a restorative approach leads to more accurate diagnoses and effective treatments. You’ll also hear Maya’s story of finding clarity and healing after years of confusion and misdiagnosis.

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Transcript

Monica: 0:02

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles, to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I'm so glad you're listening today. What if your diagnosis of PCOS or polycystic ovarian syndrome was based on a single ultrasound or maybe a random hormone draw? Or a symptom checklist without anyone actually asking when in your cycle the labs were done and looking to verify diagnostic criteria. Today we're going to cut through the confusion. We will discuss the real signs of PCOS, why timing and context matter, and how to get a diagnosis that actually leads to effective treatment from the lens of restorative reproductive medicine. September is PCOS Awareness Month, and I want to help provide an understanding of how to evaluate PCOS more effectively in a way that helps to improve your long-term health outcomes. We're also going to cut through any confusion in regards to the diagnostic and treatment process, as well as answer questions in regard to fertility. So let's get started, as always, with a patient story about a patient of mine who will call Maya. Now, Maya came to me at 27 years of age, and she was having significant problems with flareups of acne, thinning of her hair at the temples, some facial hair growth and cycles that were ranging between 35 to 60 days. Now an app that she was used for tracking, flagged that she might have possible PCOS, so she went to see her OB doctor to try and get a diagnosis. She had a single untimed hormone panel that was told that she was normal as well as an ultrasound. She was prescribed birth control in order to try and help regulate her cycles, but unfortunately, this made her mood and libido worse. She wanted answers and not just suppression, so she went to see a few different doctors in the meantime. Unfortunately, over the course of the last three years, she had seen three different doctors and had different conclusions. Two of them said you definitely have PCOS. One said you definitely don't have PCOS, but all of them had prescribed birth control and told her that this was the only option she had. After three years, she still didn't have a clear answer as to whether or not PCOS was causing her symptoms, and most importantly, she didn't have any improvement of her initial symptoms that she had concerns about in the first place. So a friend sent Maya to see me and as always, we started off with charting her cervical mucus and ovulation signs. We quickly confirmed she had long inconsistent follicular phases and typically was not ovulating on a regular basis. Her cycle timed labs showed a normal hemoglobin A1C, but elevated fasting insulin levels. And this is pretty common that we find this in PCOS. Labs also showed that she had mildly elevated testosterone levels, but normal prolactin, normal thyroid levels, and borderline low iron stores and Vitamin D. She did not have a progesterone level that spiked during our phases of evaluation, but we also were able to identify this was likely because she wasn't ovulating consistently. Over the course of the next few months, we worked together with Maya specifically in regards to nutrition status to help with balancing and regulating her insulin levels. We also incorporated supplements, prescription strength medications, and focused exercise strength training to help with restoring natural cycle. Over the next few months, Maya's cycles started to be closer to 30 to 35 days apart, and she also noticed significant improvement in her skin and her hair. And she said to me at her follow-up appointment, for the first time in my life, I not only understand what's happening, but I know what I need to do next. So let's talk a little bit about what PCOS. Is and what it isn't. Now, PCOS as defined by the definition of the name itself, is a syndrome. This is not just one test. And in our office, we utilize established medical criteria, which means you must have at least two out of the three of the following diagnostic criteria. So the first criteria we look for is signs that you are either not ovulating or that you're ovulating inconsistently. And typically we say this means six to eight times or less over the course of a year. The second sign we look for is either clinical signs or lab markers of elevated testosterone levels. So this could be excessive acne, especially along your jawline or your chest. This could be significant facial hair growth or hair growth on your chest or around your belly button, or this could be an actual lab test that shows elevated testosterone levels. And then the third criteria we look for is polycystic ovaries on ultrasound. Now, this can show up either as enlarged ovaries, so again, we're looking for ovaries that are larger than 10 milliliters in volume or. Ovaries that show multiple cysts or undeveloped follicles. And typically we say those follicles need to be less than a centimeter in size. And generally it's if we are seeing more than 12 of those on either side. And interestingly enough, we can see that you can have a polycystic ovary on just one side, but not the other. Now, it's also really important to make sure that we rule out other things that can mimic PCOS, so things like thyroid dysfunction or elevated prolactin, or a congenital disease called congenital adrenal hyperplasia. Or even things like being on birth control or recently coming off of them. Now we're gonna talk in next week's episode number one 12 about other things that can mimic PCOS. But for today's focus, we're focusing just on those things that do include PCOS. Now I want to include one other diagnostic criteria that has been proposed. It's not officially in the literature yet, but we are looking at the possibility that an elevated A MH or anti MALIAN hormone may also be able to be utilized as diagnostic criteria for PCOS. So as of September, 2025, that is on the horizon, but it is not specifically diagnostic criteria at this time across the board. So, as I mentioned, not everyone with irregular Cycles has PCOS, and not everybody with facial hair growth has PCOS. So these are common things that we see along with it, but it does not mean that it is diagnostic criteria. Similarly, just because you have polycystic appearing ovaries does not give you the automatic diagnosis of PCOS. I can't tell you the number of times that I've seen a woman come into my clinic and she was told that she has PCOS because they found multiple cysts on her ovaries on an ultrasound scan. Many of these women had scans that were done on an ultrasound. While they were on birth control, and this is not reflective of PCOS, and in fact it is known that being on oral birth control pills can cause these multiple follicles to be present. So this is not able to be utilized as diagnostic criteria for PCOS. Another important piece here is that timing makes all the difference because as we discussed in last week's episode number one, 10 hormone timing changes across your cycle. So getting labs that are not timed to your cycle can really mislead and delay a real diagnosis. Now, one other piece that you'll notice here that I mentioned is that PCOS does not have as a diagnostic criteria weight or your BMI. It also does not include diagnostic criteria for insulin resistance or blood sugar intolerance. Now many women with PCOS do struggle with their weight. With metabolism and insulin resistance, but this is not a diagnostic criteria for PCOS, and we'll talk a little bit later that there are different phenotypes or different kind of subcategories of PCOS, and not all of them include your weight. Or insulin resistance problems. And so this is why it's so important, especially if you are someone who struggles with your weight and has irregular cycles, that you don't let someone just tell you you have PCOS without getting the full diagnosis and evaluation completed. So how do we get the diagnosis right when it comes to a restorative reproductive medicine approach? So the first thing we notice as always, is we're looking at your history. We're looking at cycle charting, and we're trying to confirm or identify ovulation that's happening. Now, this can happen by looking at progesterone levels about a week after ovulation. It can happen just by looking at your charting to see if we identify mucus that's happening in response to a fertility window. Or it may show up through LH testing. We also wanna look back and see what's happened over time, because again, it may be that you're ovulating some cycles and not in other cycles, but it's important to make sure we're ruling out other factors that may be playing a role with that irregular ovulation. So things like stress or thyroid dysfunction, or adrenal insufficiency. All of those things can also throw off your cycles, but may not be specifically diagnostic of PCOS. Again, as I mentioned previously in last week's episode, it's important that we do a full diagnostic evaluation when it comes to your lab work. Again, not only trying to rule out other diagnoses, but also trying to rule in what is actually going on. So again, some of the highlights that we're looking for in order to confirm that diagnosis of PCOS are going to be. Elevated androgen levels, so things like elevated DHEA, elevated andro, Stine, Dion, or testosterone levels. All of those things are oftentimes seen with PCOS. Now, although it's not diagnostic criteria in women who we suspect of having PCOS, we also want to make sure that we're doing that full two hour oral glucose tolerance and insulin test, because even just a fasting blood sugar and insulin test can miss the diagnosis. We wanna make sure that we're doing that full diagnostic evaluation to determine if insulin resistance or sensitivity is playing a role, because this has a huge. Huge role when it comes to not only metabolism, but also to ovulation function. So for more information all about insulin resistance and how that plays a role with your hormones, go back and listen to episode number 1 0 7. The other piece for diagnostic criteria that we always are going to evaluate is ultrasound. So again, looking for ideally that transvaginal ultrasound, looking at the ovarian volume, as well as looking at how many follicles or cysts that we may be seeing. Now, we want to always interpret this based on a woman's age, as well as making sure that ideally she is not currently on birth control pills or hasn't recently come off because again, that can give us an inaccurate reading. The other pieces, as I mentioned that we want to pay attention to are what is the particular type, or as I like to say, flavor of PCOS that you have. So there are four main categories of PCOS that you have, and again, it's based on which of the three criteria that you have. So one of the types of PCOS is if you have all three diagnostic criteria signs present. So having irregular ovulation, having signs or symptoms or lab work that confirm elevated androgen levels. And then also having the ultrasound criteria. So that's the most common and typically the most severe type of PCOS is if you have all three diagnostic criteria, and then the other three diagnostic criteria. Typically are a mix of one type has high androgen levels and ultrasound findings, but not irregular cycles. Another type has irregular cycles, plus ultrasound findings, but not high androgen levels. And then the final type has irregular cycles and high androgen levels, but no ultrasound finding. So depending upon the flavor of PCOS that you have, this helps to guide us on what we need to do for treatment, and then add on top of that. Any of those different subtypes of PCOS may or may not have insulin resistance as a part of it may or may not have metabolism as a part of it. Based on your symptoms, and so we really focus on how do we individualize treatment based on your unique type of PCOS, as well as the symptoms and concerns that you have. So ways that you can advocate for yourself and what things you wanna be looking for. Again, always advocating for making sure that we are drawing labs appropriately timed to your cycle when possible. Now, in some cases, it is okay to get Untimed Labs with PCOS, but only if you have long irregular cycles. Or no signs of ovulation. In some of these cases, we have to just do the best that we can with getting baseline labs and then recheck those labs over time. As we are working through treatment, after you've started on nutrition, exercise training, medications or supplements, we always want to make sure that we're retesting labs to verify that there's improvement. I also want people to be aware to just not base it on labels alone or on diagnosis that you may have been given in the past, especially if you didn't have all three diagnostic criteria looked at. We don't want an app to just be telling you that it. Thinks you have PCOS and you going and running with that. We want to make sure that you are working with a knowledgeable healthcare professional who can give you an appropriate diagnosis, as well as work through treatment strategies to help optimize your overall health. Again, with PCOS, it is not just about getting your cycles back on track and regulating them or masking your symptoms with birth control. We need to make sure that we're identifying the underlying risk factors that go along with it so that we are helping with your long-term health. Women with untreated PCOS that are on birth control long-term go on oftentimes to develop significant problems with pre-diabetes and diabetes, heart disease, depression and anxiety. And if we instead we focus on treating the underlying hormonal and metabolic dysfunction that comes along with PCOS, we oftentimes are improving your long-term care, delaying or preventing the development of PCOS. Related diabetes and helping to regulate and better manage your weight, your metabolism, and your overall mental health. The other piece that we didn't talk a lot about today is how significant it is to help improve your overall health and regulate your cycles with PCOS, especially if you are trying to conceive. Now we always wanna make sure we're taking mail factor into account with this, but PCOS when trying to conceive can be especially tricky. Ideally focusing on getting your cycles back on track, helping to improve that ovulation function again by focusing on insulin resistance. Treating that in order to help improve overall ovulation function can make all the difference in the world as far as your ability to try and conceive naturally. Imagine if you worked with a healthcare team who focused on evaluating PCOS subtype based on your specific body's needs. Not just a template, not just a wastebasket diagnosis, and not just a bandaid that tried to cover up your symptoms with giving you birth control. Imagine if you got your labs drawn on the right days, had a full assessment of your unique insulin levels metabolic system, and also a plan that helped to evolve and change with your cycle data Over time, this way forward is possible. We can help to remove a confusing label and give you a clear path forward to help your overall symptoms, your energy levels, your cycles. And your fertility get back on track to help you feel like you again. If you're ready to work with our elite team of healthcare professionals, go to our website, radiant clinic.com to schedule a free discovery call and learn more about our package based pricing for comprehensive care. We are currently able to see people for in-person appointments in our Cedar Rapids, Iowa Clinic, or can arrange for a telehealth visit if you live in many different states across the us. Check out our website for current states that we can serve medical clients and let us know if your state is not listed to see if we can still cover you there as we are constantly expanding our reach. Please note that our fertility educators are able to take care of clients no matter where they live. Thank you so much for listening to this episode. Please share this podcast with someone in your life who would benefit from our services. Remember to subscribe to this podcast for more empowering content that I look forward to sharing with you on our next episode of Cycle Wisdom.