Polycystic Ovaries vs. PCOS: What's the Difference?

Polycystic ovaries are a condition commonly confused with Polycystic Ovarian Syndrome (PCOS). However, the two are not the same.

While both conditions can affect females of reproductive age, polycystic ovaries appear to be a normal variation with no known health consequences. On the other hand, PCOS is a complex hormonal imbalance with varying phenotypes (or types) and root causes.

This article discusses polycystic ovaries vs. PCOS, the diagnostic criteria for PCOS, and the four types of PCOS, including the common symptoms of each type.

What is PCOS?

PCOS is one of the most common conditions affecting reproductive-aged females.

In fact, it affects up to one in five young women and often leads to reproductive, metabolic, and psychological complications such as infertility, type 2 diabetes, and depression.

Common symptoms of PCOS include:

Insulin resistance
Increased risk of diabetes
Weight gain
Elevated cholesterol
Fatty liver
Acne
Hirsutism (or excess hair growth on the face, stomach, and back)
Alopecia (or loss of hair on the top of the scalp)
Mood disorders such as anxiety and depression
Anovulation (or the absence of ovulation)
Difficulty conceiving
Increased risk of pregnancy complications

Requirements for a PCOS Diagnosis

There are two schools of thought when it comes to diagnosing PCOS:

According to the 2003 Rotterdam criteria, a female must present with at least two of the following symptoms:

Hyperandrogenism (i.e., too much testosterone)
Irregular menstruation
Polycystic ovaries

According to the 2009 Androgen Excess & PCOS Society criteria, a female must have hyperandrogenism as well as either irregular menstruation or polycystic ovaries.

Per the Rotterdam criteria, hyperandrogenism is an optional criterion, whereas it is a requirement according to the Androgen Excess & PCOS Society criteria.

Hyperandrogenism is defined as the presence of excess male hormones, such as testosterone, DHEA-S, and androstenedione.

Polycystic Ovaries vs. PCOS

Understanding the difference between polycystic ovaries and PCOS is important, as having one condition does not necessarily mean you have the other.

Ovaries contain follicles, or small fluid-filled sacs, where eggs develop. Polycystic ovaries are an indication that there are more follicles on your ovaries than usual.

Normally, only two to five follicles develop at a time. However, in polycystic ovaries, up to 20 follicles can develop at the same time.

Polycystic ovaries can be detected on ultrasound as multiple immature follicles covering the ovaries. Polycystic ovaries also tend to be larger in size and have a slightly different appearance compared to normal ovaries.

Polycystic Ovaries vs. PCOS: Common Causes

Polycystic ovaries as a standalone symptom are not enough to warrant a diagnosis of PCOS.

Interestingly, one study on normal women who ovulate regularly found that 32% of them had polycystic ovaries on ultrasound, yet they had no signs of decreased fertility or symptoms of PCOS. The authors of this study concluded that polycystic ovaries in isolation do not require further evaluation.

In addition to PCOS, other possible causes of polycystic ovaries include:

Going through puberty
Coming off hormonal birth control
Hypothyroidism

Polycystic Ovaries vs. PCOS: Key Differences

Polycystic ovaries are a common phenomenon affecting up to 22% of childbearing women and tend to be discovered incidentally during a health evaluation.

Polycystic ovaries may be a normal variation and do not share the same metabolic and reproductive risks as PCOS.

Women with polycystic ovaries tend to have normal and consistent menstrual cycles and often do not struggle with infertility as compared to PCOS women.

In summary, polycystic ovaries can present as an isolated phenomenon without the classic features of PCOS or as part of the greater PCOS picture. On the other hand, you can have normal ovaries and still get a PCOS diagnosis.

Four Types of PCOS

Once you receive a diagnosis of PCOS, it’s important to discover your PCOS type so you can better manage your symptoms and reverse the condition naturally.

In my professional opinion, there are four types of PCOS.

1. Insulin-Resistant PCOS

Insulin-resistant PCOS is the most common type, affecting up to 70% of women with this syndrome.

Insulin resistance occurs when the cells in the body resist or ignore the signal from insulin, a hormone that controls your body’s glucose or blood sugar level.

As a result, the body continues to produce insulin in an effort to escort glucose into the cell (glucose comes primarily from your diet in the form of carbohydrates), which in turn leads to excess insulin AND glucose in the bloodstream due to the cells being resistant to insulin.

High insulin levels cause the ovaries to overproduce testosterone, leading to an excess of male hormones and PCOS related complications.

In addition, excess glucose in the bloodstream can lead to significant issues as well, such as weight gain, diabetes, and non-alcoholic fatty liver disease.

Symptoms specific to insulin-resistant PCOS include:

Weight loss resistance
Sugar and carbohydrate cravings
Mood swings and irritability
Fatigue
Brain fog
Fatty liver
Skin tags and dark patches in the folds of skin

In insulin-resistant PCOS, you will see one or more of the following markers elevated on lab work:

Fasting glucose
Fasting insulin
Hemoglobin A1c

2. Inflammatory PCOS

Inflammatory PCOS is a condition in which chronic inflammation causes the ovaries to overproduce testosterone. Inflammation plays a role in each type of PCOS, but it is the primary driver in inflammatory PCOS.

Symptoms specific to inflammatory PCOS include:

Headaches
Muscle and joint pain
Unexplained fatigue
Skin issues such as eczema and cystic acne
Digestive issues like IBS
Frequent allergies or asthma
Brain fog
Anxiety and depression
Painful periods
Concurrent autoimmune conditions like Hashimoto’s disease

In inflammatory PCOS, you will see very high inflammatory markers on lab work, such as elevated c-reactive protein (CRP).

The best intervention for inflammatory PCOS is to identify and remove the underlying source of inflammation. The two most common sources of inflammation are food sensitivities and autoimmune diseases.

Conducting an elimination diet or running a food sensitivity panel can help uncover your specific food sensitivities. In many cases, eliminating common food sensitivities such as gluten and dairy is especially useful for calming down inflammation and improving PCOS related symptoms.

Additionally, it’s important to determine if your inflammation is stemming from an autoimmune condition. I see this in my practice often, where an autoimmune disorder such as Hashimoto’s disease or ulcerative colitis is driving significant inflammation and, in turn, worsening PCOS symptoms.

If you already have a diagnosed autoimmune condition, working with an experienced functional medicine nutritionist can help you quell the inflammation and reduce both the autoimmune and PCOS specific symptoms through dietary and lifestyle changes.

3. Adrenal PCOS

In the case of adrenal PCOS, the adrenal gland will produce higher levels of androgen hormones, often due to an abnormal stress response.

While the ovaries are typically to blame for elevated androgens, an estimated 20 to 30 percent of women with PCOS have adrenal PCOS.

In this condition, the ovaries will release a normal amount of androgens while the adrenal glands will produce an excess amount of androgens, specifically androstenedione and dehydroepiandrosterone-sulfate (DHEA-S). An elevated DHEA-S on lab work is the most common indication of adrenal PCOS.

Ultimately, a woman with adrenal PCOS can have normally functioning ovaries with no cysts and no insulin resistance yet still fit the symptomatic profile of PCOS.

Researchers believe genetics play a strong role in adrenal PCOS, but more research is needed to confirm the exact cause of adrenal malfunction in these women.

For this population, managing stress levels, getting enough sleep, and avoiding caffeine are critical practices to begin healing the adrenal glands and, in turn, their PCOS symptoms.

4. Thyroid PCOS

A phenomenon that I am seeing more and more of in my practice is the coincidence of both PCOS and hypothyroidism. The research is also confirming this phenomenon, indicating that 25% of women with PCOS also have a concurrent thyroid disorder.

While the exact link between these two disorders has yet to be fully established, PCOS and thyroid disorders have many overlapping symptoms and share a bidirectional relationship.

Furthermore, when comparing thyroid PCOS to euthyroid PCOS (normal thyroid levels), the severity of hyperandrogenism, insulin resistance, and cholesterol abnormalities were found to be more pronounced in the thyroid PCOS group. In other words, a poorly functioning thyroid gland can exacerbate PCOS symptoms.

While PCOS and hypothyroidism have distinct symptoms, there is also a long list of overlapping symptoms that can make diagnosis and intervention difficult. In fact, a shared feature between PCOS and hypothyroidism is the presence of polycystic ovaries.

In women with PCOS, high androgen levels can prevent the follicles from growing and maturing properly, resulting in polycystic ovaries. Similarly, decreased amounts of thyroid hormones in hypothyroidism can also lead to the formation of polycystic ovaries.

Other shared characteristics include:

Weight gain
Hair loss
Fatigue
Depressed mood
Irregular or absent periods
Infertility

To find out if you have a thyroid disorder (with or without PCOS), the best approach is to run a comprehensive thyroid panel:

TSH
Total T4 & T3
Free T4 & T3
Reverse T3
Thyroid Peroxidase Antibody
Thyroglobulin Antibody

Post-Birth Control Pill PCOS

Another type of PCOS is called post-birth control pill PCOS (or post-pill PCOS). I don’t group this type of PCOS with the other four types because this type is often short-lived.

In this condition, there is a temporary surge (usually lasting 6-12 months) in androgens after coming off the pill. This type of PCOS occurs due to certain synthetic progestins found in many birth control pills.

Women with post-pill PCOS tend to recover naturally. However, they may experience suppressed ovulation for a short period of time.

For post-pill PCOS, helping the body re-establish communication between the brain and ovaries is the best approach to expediting the healing process and finding symptom relief. Some tips include eating a well-balanced diet, getting optimal sleep, exercising regularly, and managing stress.

Lastly, if you received a PCOS diagnosis within a few months of coming off the pill, I would recommend getting another evaluation to determine if it is in fact a true diagnosis or a temporary state such as post-pill PCOS.

Polycystic Ovaries vs. PCOS: The Bottom Line

There is a difference between having polycystic ovaries and PCOS. Although similar in name, the risks and interventions for these conditions are vastly different.

Polycystic ovaries as an isolated symptom are considered normal and often do not require further assessment or intervention, whereas a PCOS diagnosis comes with significant reproductive, metabolic, and psychological consequences.

Further, polycystic ovaries as a standalone symptom are not enough to warrant a diagnosis of PCOS. Depending on the diagnostic criteria used, a PCOS diagnosis requires additional symptoms, such as hyperandrogenism and irregular periods, to be present.

In addition, PCOS can be further divided into the following subtypes:

Insulin-resistant
Inflammatory
Adrenal
Thyroid

Discovering your PCOS type is critical to understanding the root cause that is contributing to your symptoms and also helps determine the best course of action for putting your PCOS into remission.

Getting the right diagnosis is key to understanding your unique situation.

Functional Medicine Approach to PCOS

PCOS is a complex hormonal disorder with a variety of underlying root causes. In many cases, prescription medication is not enough to put the condition into remission.

My one-on-one consultation program helps you manage and reverse the symptoms of PCOS using a functional medicine approach.

This six-month program helps you discover your PCOS type and gets to the root of your hormonal health concerns through a detailed health history review and comprehensive functional lab testing.

Rest assured, you will receive an action plan that outlines personalized diet, supplement, and lifestyle recommendations to help you achieve PCOS remission.

Polycystic Ovaries vs. PCOS: What’s the Difference?