You don't have to have Ovarian Cysts to have PCOS


Polycystic Ovarian Syndrome (otherwise known as PCOS) is a common condition found in women. So common. that it is actually found in about 1 in every 10 women of child bearing years. Unfortunately, it often takes years of struggling with symptoms to finally be diagnosed. The typical patient with PCOS will experience irregular cycles, acne, facial hair, as well as multiple cysts on the ovaries as seen with a trans-vaginal ultrasound.

The women who fit this “common” symptom picture will likely be diagnosed quicker and treatments can be implemented sooner. But did you know there are actually different types of PCOS and not all of them involve the typical cysts on the ovaries?

PCOS is actually a collection of a variety of symptoms, ranging from facial hair and fatigue to hair loss and weight gain. For a woman to be diagnosed with PCOS, she must present with two of the three required criteria said forth by the Rotterdam consensus. The Rotterdam consensus is a diagnostic criteria used to diagnose PCOS. For a woman to be diagnosed with PCOS, she must present with anovulation (lack of ovulation) , hyperandrogenism (elevated hormone levels) and, or polycystic ovaries.


Although anovulation translates as a lack of ovulation within a cycle, it can also mean that your ovulation is delayed. Remember that the typical length of a woman’s cycle is 28 days. Day one of the cycle is marked as the first day of her period and around day 14, ovulation typically occurs. The problem in PCOS is a woman may not ovulate at all or ovulate outside the “normal day 14” window. This can delay cycles making them irregular. This is why we now classify anovulation as a woman with fewer than 10 menstrual cycles per year OR cycles that are 35 days or longer. This is important to know because as you can see, you can still have a “regular” menstrual cycles, but your cycles can be longer than 35 days, and still be classified as experiencing anovulation. If you have not been formally diagnosed with PCOS, but have cycles that are 35 days or longer, make sure to talk to your doctor, as cycles longer than 35 days are often a major factor in PCOS. But remember, anovulation is only one of the three criterias for PCOS, so if you have a normal" cycle of less than 35 days, you may still in fact be experiencing a form of PCOS.


When we typically think about PCOS, we think about elevated testosterone levels because many women with PCOS suffer from unwanted facial hair. However, did you know that hyperandrogenism means you may experience elevated testosterone, DHEA OR androstenedione. In other words, make sure your physician is evaluating ALL of your hormones, because your testosterone levels may look “normal”. This is where working with a provider who understands the different forms of PCOS can be so vital in optimizing your health. Elevated testosterone, DHEA and, or androstenedione can present as facial hair, specifically on the chin, upper lip, around the nipples as well as on the chest/stomach. It can also present as acne, most often found along the lower jawline and/or back. Elevation in these hormones can also lead to hair loss, specifically on the head.

Ovarian Cysts

Ovarian cysts are also a major feature of PCOS, however, you don’t have to have cysts on the ovaries to be diagnosed with PCOS. Remember the Rotterdam concensus only requires two of the three main criteria to be met to be diagnosed with PCOS. The ovarian cysts commonly found on a trans-vaginal ultrasound have been known as a “string of pearls.” What is also important to know is that the technology involved in these scans has greatly advanced allowing us to capture more cysts than ever before. Previously only 12 cysts needed to be identified to meet the criteria of PCOS, however, due to the advancement in ultrasound technology, a total of 26 cysts (ranging from 2 to 9 millimeter long) are a better marker of PCOS.

Forms of PCOS:

As previously mentioned, a woman only needs two of the three Rotterdam criteria to be diagnosed with PCOS. It is important to know which form of PCOS you are experiencing and is why I highly recommend completing a transvaginal ultrasound as well as comprehensive hormonal testing. Understanding exactly which form you are experiencing allows us to better target your treatment.

Type A PCOS patients experience anovulation, hyperandrogenism, as well as polycystic ovaries on ultrasound.

Type B PCOS patients experience anovulation, hyperandrogenism, but DO NOT have polycystic ovaries on ultrasound. (this is why ALL patients with suspected PCOS need a transvaginal ultrasound).

Type C PCOS patients experience hyperandrogenism, polycystic ovaries on ultrasound but ovulate normally.

Type D PCOS patients experience anovulation, polycystic ovaries but do not experience hyperandrogenism.

Although you need to experience two of the three criteria for a formal diagnosis of PCOS, there a a variety of other symptoms commonly experienced by women with PCOS. Some of these symptoms include:

  • Weigh Gain

  • Insulin Resistance (lack of response of insulin, in the presence of sugar in the blood)

  • Hair Loss

  • Infertility

  • Severe Menstrual Cramps

  • PMS

  • Chronic Fatigue

  • Depression and Mood Swings

Treatment for PCOS

Although the Rotterdam concensus allows us to better identify PCOS, the underlying cause of PCOS is still very much a mystery. There are however, a few major factors that can effect the severity of your PCOS. These factors include chronic inflammation, obesity, stress, diet, and environment. Addressing all of these core factors is essential in reducing the severity of your symptoms and improving your overall hormone health.


Chronic inflammation was previously thought to be a side effect of PCOS, but now, it is thought that inflammation can actually be a trigger for PCOS. Not only can chronic inflammation disrupt our hormones but it can also lead to premature aging and damage to our egg quality, which can ead to infertility. If you are planning on having a child today or someday, addressing your inflammation is going to be essential. Ask your doctor to run a high sensitivity c-reactive protein (hs- CRP) as well as an Erythrocyte sedimentation rate (ESR) blood test to accurately evaluate your level of inflammation.


Obesity is another major trigger for PCOS. Unfortunately women with PCOS have an uphill battle to lose weight as they have abnormalities in the way their fat cells are stored and how fatty acids are metabolized. That being said, diet is one of the most important aspects in treating PCOS and has been shown to work more effectively than some of the common PCOS pharmaceuticals including Metformin.


The quick release of cortisol from the adrenal glands, in acutely stressful situations, like when you are being chased by a bear, allows us to quickly escape before we even have the time to think about it. This is obviously very important and has allowed humans to survive for centuries. Chronic stress, however, like that experienced with a stressful job or a strained relationship can cause our cortisol levels to stay elevated for extended periods of time. Our body is not meant to sustained these elevated levels of cortisol and will eventually lead to a dysregulation in your cortisol production. At first, your body will start to spit out way too much cortisol, even during the tiniest of stressors until finally your poor little adrenal glands can no longer keep up with your chronic stress and will start to fatigue and eventually will give out. Implementing stress management techniques daily is a must for everyone, especially those suffering from PCOS.


In my private practice, I am constantly talking to my patients with PCOS about diet. “Feeding ourselves is something we do multiple times a day and is a way we can either nurture or torture our body.” When it comes to diet, it is important to provide your body with whole -foods that include organic fruits and vegetables, grass-fed meats while limiting processed sugars and simple carbohydrates. If eating all organic is not financially possible, start with avoiding the Dirty Dozen. The Dirty Dozen list is an up to date annual list produced by the Environmental Worker’s Group (EWG) and provides you with a list of fruits and vegetables that contain the highest amount of pesticides and should always be bought as organic products. There is also a supplemental list known as the Clean Fifteen which contains fruits and vegetables with the least amount of pesticides, which can be bought as non-organic. Make sure you check the list often, as it is updated annually.


Understanding how our environment affects our hormones is vital in treating PCOS. We are constantly exposed to chemicals from the beauty products we use, the house cleaning products we use to the food storage containers we use. These chemicals have been known to disrupt our bodies natural hormone production and can even mimic our hormones. Cleaning up our environment and limiting our exposure to harsh chemicals can be one of the easiest and most effective ways to balance our hormones.

me best.jpg

Having trouble with your health? At NMD Wellness of Scottsdale, we offer personalized integrative solutions for all your hormone and fertility needs.

Dr. Zen is a licensed naturopathic physician specializing in Women's Hormones and Fertility. Her local private practice is located in Scottsdale, Arizona, however, she works with patients around the world. Her goal is to educate, inspire and empower women to take control of their health naturally. She believes in providing integrative healthcare options that get to the root cause of your unique symptoms. She has been featured as an expert in a variety of publications including Shape, Elite Daily and Forbes.

Feel Free to Follow us on Instagram @drzennmd

Click here to book a FREE 15 minute consultation to find out how she can uniquely help you and your health