PCOD, or polycystic ovarian disease, is a hormonal condition where the ovaries produce higher-than-normal levels of androgens (often called “male hormones,” though all women produce them in small amounts). This hormonal imbalance disrupts the normal release of eggs, causing small, immature follicles to accumulate in the ovaries. It affects an estimated 10 to 13% of women of reproductive age worldwide, and up to 70% of those affected don’t know they have it.
What Happens Inside the Ovaries
In a typical menstrual cycle, the brain signals the ovaries to mature and release an egg each month. Two hormones drive this process: luteinizing hormone (LH), which triggers egg release, and follicle-stimulating hormone (FSH), which helps eggs develop.
In PCOD, LH levels run too high, pushing the ovaries to produce excess androgens. At the same time, FSH levels are relatively low, so follicles (the tiny fluid-filled sacs that hold developing eggs) start growing but stall before they fully mature. These stalled follicles accumulate along the edges of the ovary, creating the “polycystic” appearance seen on ultrasound. The result is that ovulation either happens irregularly or doesn’t happen at all.
This isn’t a one-time glitch. The excess androgens make the brain less sensitive to the hormones that would normally correct the imbalance, creating a self-reinforcing cycle where high androgen levels keep driving more androgen production.
The Two Main Drivers: Androgens and Insulin
The condition has two core hormonal problems that feed off each other. The first is excess androgens, which is considered the fundamental cause of most PCOD symptoms. The second is insulin resistance, where the body’s cells don’t respond well to insulin, so the pancreas pumps out more to compensate.
That extra insulin doesn’t just affect blood sugar. It directly stimulates the ovaries and adrenal glands to produce even more androgens. It also suppresses production of a protein called sex hormone-binding globulin (SHBG) in the liver. SHBG normally binds to testosterone and keeps it inactive, so when SHBG drops, more testosterone circulates freely in the body. Meanwhile, high androgens themselves worsen insulin resistance, completing the vicious cycle. This is why PCOD tends to get progressively harder to manage without intervention.
Common Symptoms
PCOD symptoms vary widely from person to person, which is one reason it so often goes undiagnosed. Many women don’t connect their symptoms because they seem unrelated. The most common signs include:
- Irregular or absent periods: skipped cycles, very long gaps between periods, or periods that come with heavy bleeding
- Excess hair growth (hirsutism): thicker, darker hair on the face, chest, belly, or upper thighs
- Persistent acne: severe breakouts that start late or don’t respond to typical treatments
- Weight gain: especially around the waist, with difficulty losing weight
- Oily skin
- Dark, velvety skin patches: typically on the neck, groin, or under the breasts, a sign of insulin resistance called acanthosis nigricans
- Difficulty getting pregnant
Some women have only one or two of these symptoms. Others experience several at once. The severity often depends on the degree of androgen excess and insulin resistance.
How PCOD Is Diagnosed
There’s no single test for PCOD. Doctors typically look for a combination of clinical signs, blood work, and ultrasound findings. The most widely used framework requires at least two of three criteria: irregular or absent ovulation, elevated androgen levels (confirmed through blood tests or visible signs like hirsutism and acne), and polycystic ovarian morphology on ultrasound.
On ultrasound, the current guideline defines polycystic morphology as 20 or more small follicles (each 2 to 9 mm in diameter) in at least one ovary, or an ovarian volume greater than 10 cubic centimeters. This threshold has evolved over time. Earlier criteria set the cutoff at 12 follicles, and a 2014 recommendation suggested 25 for newer, higher-resolution ultrasound probes. The current number of 20 represents a middle ground. Blood tests typically check testosterone levels, insulin, and other hormones to confirm the hormonal pattern.
Long-Term Health Risks
PCOD isn’t just a reproductive issue. The underlying insulin resistance carries serious metabolic consequences over time. More than half of women with PCOD develop type 2 diabetes by age 40. The risk of heart disease is also elevated and increases with age. These risks make early management important even for women who aren’t trying to conceive.
How PCOD Affects Fertility
PCOD is the leading cause of anovulatory infertility, accounting for about 80% of cases where women aren’t ovulating. Women with the condition have lower natural conception rates, take longer to become pregnant, and are more likely to need fertility treatment.
The good news is that PCOD-related infertility is one of the most treatable forms. Losing just 5 to 10% of body weight has been shown to restore ovulation and improve conception rates in many women. Exercise helps even when weight doesn’t change, specifically by improving insulin resistance. Exercising five times a week for 30 minutes, with at least three of those sessions being aerobic, has been shown to improve ovulation. Combining dietary changes with exercise produces better results than diet alone.
Lifestyle Changes That Help
Lifestyle management is the first-line approach for PCOD, regardless of whether medication is also needed. Two strategies have the strongest evidence behind them: a low glycemic index diet and regular physical activity.
A low glycemic index diet focuses on foods that raise blood sugar slowly, like whole grains, legumes, most vegetables, and nuts, while limiting refined carbs and sugary foods. Following this type of diet for at least eight weeks has been shown to reduce waist circumference, improve insulin sensitivity, and improve levels of reproductive hormones, all of which contribute to more regular menstrual cycles.
For exercise, the guidelines recommend at least 150 minutes per week of moderate activity (like brisk walking) or 75 minutes of vigorous activity (like running or cycling) to maintain weight and prevent worsening symptoms. For active weight loss, the target is higher: 250 minutes per week of moderate activity or 150 minutes of vigorous activity. Strength training on two non-consecutive days per week is also recommended, along with reducing the amount of time spent sitting.
Medical Treatment Options
When lifestyle changes aren’t enough on their own, two main types of medication target the condition’s core hormonal problems from different angles.
Hormonal contraceptives (combination pills containing estrogen and progestin) are generally the most effective option for managing excess hair growth, acne, and irregular periods. They work by directly regulating the menstrual cycle and lowering free androgen levels in the blood. They’re typically the first choice for women who aren’t trying to get pregnant and whose primary concerns are cycle regularity and androgen-related symptoms.
Insulin-sensitizing medication works differently, targeting the metabolic side of the condition. It reduces insulin resistance and lowers insulin levels, which in turn decreases androgen production. It can also improve ovulation and help prevent weight gain. This approach is generally preferred when insulin resistance and metabolic risk are the bigger concerns.
For women with both significant metabolic risk and androgen-related symptoms, combining both medications appears to be more effective than either alone. The combination targets both sides of the vicious cycle simultaneously: lowering insulin to reduce androgen production, while also directly suppressing androgen effects. This dual approach tends to produce the best improvements in both hormonal and metabolic markers, particularly in women at higher metabolic risk.