Is a PCOS diagnosis always a black and white, clear-cut diagnosis, or are there shades of grey?
These are questions we medical providers ask ourselves on a regular basis! The current Rotterdam diagnostic criteria for PCOS say that you need to have 2 out of 3 of these markers:
- Irregular or complete absence of periods – no period, infrequent periods, super long cycles, unexpected periods.
- Symptoms or labs that show elevated levels of androgens (“male hormones”) such as DHEA and/or testosterone – unwanted hair growth, scalp hair loss, boils, acne, high lab levels.
- Polycystic ovaries on ultrasound (12 or more enlarged follicles in an ovary or both ovaries) – can cause a swollen feeling, or severe pain if a cyst ruptures, but often no obvious symptoms.
However, many of us practitioners have patients that don’t exactly fit this diagnostic criteria. Yet they have enough symptoms to warrant a workup for PCOS or other hormone imbalances.
One major concern with using only the Rotterdam criteria is that insulin resistance is a VERY common issue with PCOS and hormone imbalance, yet is not even considered in part of the criteria . . . .
What? The diagnostic criteria does not include insulin resistance?
Nope. You may have heard us mention the statistic that at least 70% of women with PCOS have insulin resistance. Based on our clinical experience, and from teaching women in our online PCOS SOLUTION Program, we suspect that more than 70% of women with PCOS have issues with blood sugar and insulin.
You may not have full-blown insulin resistance, pre-diabetes or diabetes, but you could have early signs of impaired glucose tolerance. Perhaps your fasting glucose is higher than it should be. Perhaps you have sugar cravings. Or maybe when you eat sugar or refined carbohydrates you get an energy spike and then crash.
In this post we detail the tests for blood sugar dysregulation and insulin resistance. Many women with PCOS show signs of early sugar and insulin problems on these test results. You may be thin or of normal body weight yet still have lab markers that are off-target.
Adding sugar and insulin dysregulation into diagnosis
Practitioners who see lots of women with PCOS automatically test for these metabolic abnormalities, including fasting glucose, triglycerides, insulin, and the other labs we mention here. When these markers are off, combined with 1 of the 3 Rotterdam criteria (period problems, high androgens or cysts), it’s a clear signal that hormone imbalance is in play.
We use the glucose and insulin labs as a fourth PCOS diagnostic marker! Why wait until insulin resistance, PCOS, or hormone imbalance is full-blown to deal with it? We count insulin resistance and blood sugar dysregulation as a fourth criterion for PCOS diagnosis – as many PCOS practitioners do. However, insulin resistance by itself, with no other signs of hormone imbalance, is not enough for a PCOS diagnosis.
Beware, as this can easily lead to reproductive hormone imbalances in the future. Sometimes they pop up during times of hormone upheaval, such as postpartum or peri-menopause.
We recommend that women with insulin resistance alone as a single symptom/diagnosis, take our PCOS SOLUTION Program right away, as it addresses all aspects of insulin resistance, including underlying causes and drivers.”
Functional Medicine Diagnostic Criteria for PCOS
As Functional Medicine practitioners, when we assess PCOS (as with all female hormone imbalance), we check for adrenal stress hormone imbalance, intestinal microbiota disruption (dysbiosis), and endocrine disrupting toxins as underlying co-factors or drivers. So, our diagnostic criteria for PCOS is broader than the current Rotterdam criteria used in conventional medicine.
Our functional diagnostic criteria includes:
- Period problems – no period, periods come infrequently, super long cycles, never know when your period is expected, really heavy periods, painful or heavy periods.
- Symptoms or labs that show elevated levels of androgens – unwanted hair growth, scalp hair loss, boils, acne, high lab levels, super high or insatiable libido.
- Polycystic ovaries on ultrasound – several (does not need to be 12) enlarged follicles or cysts in/around 1 or both ovaries – can cause a swollen feeling, or severe pain if a cyst ruptures, but often no obvious symptoms.
- No ovulation – when you use the LH predictors sticks at home, and you don’t get positive signs for ovulation.
- Metabolic Syndrome markers – high fasting glucose, insulin, hemoglobin A1C, triglycerides, among other lab markers.
- Adrenal stress hormone dysregulation – when you take a 24-hour salivary or urine test that shows your cortisol is too high, too low, or is off in its rhythm. We also use our adrenal stress hormone survey/quiz.
- Signs of endocrine disrupting toxic burden – lab signs of poor estrogen metabolism, high estrogen levels, low progesterone levels, impaired liver detoxification, fatty liver, elevated liver enzymes, among others. Symptoms can be those of estrogen dominance – like PMS, breast tenderness, fibrous breasts, uterine fibroids, endometriosis, or heavy clotty periods.
- Signs of gastrointestinal OR vaginal dysbiosis – pelvic pain, period pain, stool or urine tests that show unwanted bacteria or candida overgrowth, stool tests that show inflammation or high levels of betaglucuronidase (an enzyme that beneficial bacteria produce that help break down bad estrogen), vaginal infections, or digestive symptoms such as bloating, constipation, diarrhea or gas.
So as you can see, we investigate at least 8 markers, not just 3. Depending on the results, we can decide if you fall on the “PCOS Spectrum,” or have other hormone imbalances.
How to view PCOS as a spectrum
A spectrum can range from mild to severe. A severe case of PCOS may meet all 3 of the Rotterdam criteria and several more of the 8 Functional Medicine criteria. A classic example of a “severe” case is that you may have a lot of stress, poor sleep, excess abdominal weight, bloating, incomplete elimination via stool, crave sweets, have difficulty losing weight, irregular periods, and signs of androgen access such as acne and male pattern hair growth.
A mild case may meet only a single criterion. Functional Medicine practitioners have hormone imbalance and PCOS on our radar even if you only have 1 of these signs. The more you have, the stronger the case for female hormone imbalance – which may meet the Rotterdam criteria for classic PCOS, may categorize you as “on the spectrum” with a mild version, or may mean you have hormone imbalance that is not manifesting as PCOS . . . at least not now.
Besides the 8 functional markers, we get a broad picture of your history and current symptoms in order to diagnose. It’s not difficult to do this detective work. However, PCOS has a reputation of being “hard to diagnose,” probably because the Rotterdam criteria is not inclusive enough. If your conventional doctor is only using the Rotterdam criteria, then it’s true, your mild PCOS may not be caught.
Don’t treat mild pcos and hormone imbalances lightly
A mild version of PCOS or female hormone imbalance is not something to take lightly! The drivers that got you there are not going to steer you to health unless you do something about them! The most effective means to healthily regulate your hormones is through lifestyle interventions. This includes stress, sleep, food, exercise, toxic exposure, detoxification, the right supplements, and optimal digestion and gastrointestinal microbiota. You do the bulk of this yourself!
Often simply applying these interventions steers your hormones back on track, and then symptoms go away and lab markers normalize. By the way, this is true with mild hormone imbalance all the way to full-blown classic PCOS.
Our 6-week online Functional Medicine program for PCOS and hormone imbalance addresses all of the lifestyle interventions you need to learn about, and helps you easily put them into practice. Many graduates of our program who have no formal diagnosis of PCOS (they may have mild PCOS or other female hormone imbalances) get great results with their symptoms and their lab markers in the program and beyond.
We recommend the PCOS SOLUTION for women with:
- Diagnosed PCOS (from your provider, or use the Rotterdam criteria).
- Mild PCOS (you have symptoms, or use our Functional Medicine 8-criteria assessment).
- Cycle and period problems (no periods, no ovulation, irregular periods, infrequent periods, long periods of time between periods, periods are totally unpredictable, cycles over 35 days, painful periods, PMS).
- Before pregnancy to get healthy, and during postpartum.
- Peri-menopause for sure!
- Female hormone problems like fibroids and endometriosis.
- Insulin resistance, obesity, abdominal fat (apple-shaped body), or any blood sugar dysregulation.
In addition, you will benefit from our program if you have 1 of the above PLUS:
- Digestive problems like IBS, sluggish bowels, diarrhea, bloating, SIBO, or candida.
- Adrenal stress dysregulation – not sure? Take our Adrenal Stress Quiz!