According to the Rotterdam diagnostic criteria for PCOS, you have to have 2 out of 3 of:
- irregular or anovulatory menstrual cycles
- polycystic ovaries on ultrasound (not the same as an ovarian cyst)
- manifestations of androgen excess or high levels of androgen(s) on bloodwork
And these symptoms should not be arising from another health condition like adrenal hyperplasia or hyperprolactinaemia etc. There was a time (just a few years ago actually) where I would get PCOS patients who had not yet been diagnosed with PCOS. Now, however, I actually get a fair few patients who are misdiagnosed as PCOS.
![white square with a red horizontal streak in the middle. On the streak is the acronym PCOS in white, underneat the word misdiagnosed in black](https://annehussain.com/wp-content/uploads/2021/07/Copy-of-Copy-of-pcos-checklist9-e1625695117591-300x157.jpg)
The main differential diagnosis in this case ends up being hypothalamic amenorrhea (HA). This is when the lack of menstruation is arising from more of a stress response due to psychological or physiological, or both types of stress.
The most common types of physiological stress usually stems from a lack of appropriate fuelling for e.g. eating too little or exercising too much (while not eating enough).
In HA, you may see a lot of similarities to PCOS:
- lack of ovulation and/or irregular cycles
- polycystic ovaries on ultrasound
- symptoms similar to those of hyperandrogenism like hair loss and acne
- mood and energy issues
- vitamin D deficiency
But, we don’t see other metabolic dysfunction commonly seen in PCOS (like insulin resistance) in HA. Without a thorough investigation around your medical history, lifestyle, food, nutrition, and testing, these two conditions can definitely be confused with one another, and consequently there could be a completely ineffective (and also inappropriate) treatment plan in place if we end up barking up the wrong tree. We can’t only rely on ultrasound or menstrual symptoms — we have to marry bloodwork, imaging, menstrual symptoms, and everything else mentioned above to get a full picture of what’s going on so you can be supported appropriately.