Hormones & Cycle Health

By Dr. Mélanie DesChâtelets, ND · Naturopathic Doctor and Menopause Society Certified Practitioner · Burnaby and virtual care across BC

What if your symptoms look like PMOS (formerly PCOS)… but aren’t? Getting this wrong means every decision after it could be off. Because a real PCOS diagnosis is actually two-sided: you have to meet your age-appropriate inclusion criteria, and you have to rule out PCOS look-alikes first. That second half gets skipped all the time. So let’s talk about the labs that help rule out PCOS mimics before the label gets applied.

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Inclusion vs exclusion: why both matter

Someone once asked me, “Hey, I had polycystic morphology on my ultrasound. Isn’t it obvious?” And that’s just not how the diagnostic process works, for good reason. Inclusion criteria are what must be present, and those change with the age you’re diagnosed. Exclusion criteria are what must be absent to avoid a misdiagnosis, and these don’t change with age. They’re the same for everyone. To actually land a PCOS diagnosis, you need both: your age-appropriate inclusion criteria, and a clean set of exclusion labs.

What are PCOS “mimickers”?

Before we call it PCOS, we have to rule out other things that look like it. I sometimes call these mimickers, because they produce the same symptoms as someone with PCOS. Some are common and routinely tested, like thyroid issues and high prolactin. Others are more rare, and those are the ones I see missed. But the guidelines are clear: there’s a set of mandatory exclusion labs for everyone, because if we skip them, we can miss rare conditions that look like PCOS but aren’t. And those people deserve to be caught and treated for what they actually have, not handed a PCOS label.

Which labs are mandatory to rule out PCOS mimics?

There are four, and they’re recommended for everyone at diagnosis, regardless of age or how clear the symptoms seem:

• TSH (thyroid). Thyroid problems can make cycles irregular. If your cycles are off but it’s the thyroid, then it might not be PCOS.
• Prolactin. High levels can block ovulation, which can also look like altered cycles.
• 17-OH progesterone. This screens for congenital adrenal hyperplasia, one of those rarer look-alikes.
• FSH. This checks the brain-ovary communication.

If those were done and came back normal, great, you met the exclusion criteria. If something came back positive, that’s where more nuance and follow-up belong, with your provider.

What are the conditional, case-by-case checks?

Then there are conditional ones, the case-by-case checks. You don’t need these to get a PCOS diagnosis if you’ve met inclusion and cleared the mandatory exclusion labs. But a thoughtful provider keeps them in mind when extra symptoms point somewhere else. A few examples: Cushing’s, if there are features of cortisol excess. Androgen-secreting tumours, if androgen symptoms come on rapidly or severely. And hypothalamic amenorrhea, where a significant gap between energy in and energy out (think very low body weight, over-exercising, or a stretch of weight loss) leads the body to essentially pause the cycle.

What red flags point away from PCOS?

In PCOS, androgen symptoms are slow and progressive. So sudden or very severe hair growth, or voice changes, are red flags for a different cause of high androgens, and that deserves a closer look. A round “moon” face, a pad of fat at the back of the neck, or purple stretch lines on the abdomen can be red flags for high cortisol and Cushing’s. Very low body weight, an extreme training schedule, or very high stress alongside missing periods can point to hypothalamic amenorrhea. And milk discharge when you’re not breastfeeding, or new headaches and vision changes, can be red flags for a prolactin-related issue. None of these are a diagnosis on their own. They don’t automatically mean something serious is going on… but they can, and that’s exactly why they’re worth flagging quickly, so the right testing gets done and anything that needs attention gets caught.

How do you check your own diagnosis?

Here’s the empowering part. You can pull up your own lab work and see whether the four mandatory labs (TSH, prolactin, 17-OH progesterone, FSH) were actually done during your diagnostic process. This isn’t about interpreting your own results… it’s about walking into your next appointment with a sharper question: “were the exclusion labs done, and what did they show?” That’s the kind of question that gets you a real answer.

▶ Want the full walk-through, including the red-flag clusters? Watch the complete video here.

This article is educational, not medical advice or a diagnosis. If something here resonates, bring it to your healthcare team, who can look at it through the lens of your individual health.

Main references

1. Teede HJ, et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2023. PubMed

By Dr. Mélanie DesChâtelets, ND · Naturopathic Doctor and Menopause Society Certified Practitioner · Burnaby and virtual care across BC

Maybe you were diagnosed with PMOS (formerly PCOS) as a teenager. Or maybe you’re under 19 right now and wondering how PCOS is even diagnosed at your age. Here’s the tricky part: diagnosing PCOS in teens is different. The same rules we use for adults don’t apply, and that trips a lot of people up. So if you’re 19 or under, or you were labeled as a teen and you’re older now, this matters… because you’ll want to make sure you actually would have met the adolescent criteria in the first place.

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Why is PCOS in teens diagnosed differently?

Because a teenage body is still finding its rhythm. In the years right after your first period, the communication between your brain and your ovaries is just getting started, so some things that look like PCOS in teens are actually normal for the stage. That’s also why PCOS can look so different from one person to the next… maybe you were given a diagnosis and you look at a friend with the same label and your symptoms barely overlap. Or you suspect you have it but you’ve never really been told what it should look like. To protect against over-diagnosing during a normal phase, the criteria are stricter before 20.

What are the two adolescent criteria?

In this age group, we don’t have a reliable way to assess ovarian morphology, so ultrasound and AMH are off the table. That means the adult “two out of three” rule becomes a stricter “two out of two.” You need both: irregular cycles (defined very specifically for teens, more on that below) and androgen signs, either symptoms or blood work. If you only have one of the two, it can be considered “PCOS at risk,” as long as other causes for those symptoms have been explored first.

What do high androgens look like in a teen?

First we look for the obvious symptoms: aggressive acne that doesn’t respond well to treatment or is very persistent as you get older, a certain kind of hair thinning where the parting line keeps getting wider, or excess hair on the face, tracking up toward the belly button or down the legs.

Here’s a big clinical pearl, though. In PCOS, high-androgen symptoms tend to come on slow and progressive. If excess facial hair shows up very suddenly and very severely, that can point to other causes, and it deserves a different workup. So if it’s fast, flag it… it’s worth raising clearly with your provider so the right testing gets done.

What counts as an irregular cycle for a teen?

This is the part that’s defined differently than in adults, and it all depends on how many years it’s been since your first period. In the first year, irregular cycles are normal. From one to under three years after your first period, cycles shorter than 21 days or longer than 45 days count as irregular. At three years and beyond, the window tightens to shorter than 21 or longer than 35. And at any point more than a year out from your first period, a single cycle of 90 days or more counts too. The cut-offs loosen early on for a reason… your body is still getting the conversation going.

Why doesn’t an ultrasound count under 19?

You may have had a pelvic ultrasound for other reasons, but for diagnosing PCOS, it isn’t reliable until it’s been about 8 years since your first period (which for many is around age 20). Before that, the ovaries normally show more follicles, so an ultrasound can look “polycystic” when nothing is actually wrong. So if you’ve been hanging your diagnosis on an ultrasound done as a teen, it’s worth reconsidering and checking whether you meet the other two criteria.

What does “PCOS at risk” mean, and when do you reassess?

Some teens have a few PCOS features but not quite enough for a clear diagnosis… maybe some irregular cycles but not much on the androgen side, or the reverse. Once other causes have been ruled out, that’s when we’d call it “PCOS at risk.” It’s not a “no,” and it’s not a “yes.” It’s a “let’s keep an eye on this.” The recommendation is to reassess for the first time once it’s been at least 8 years since your first period (which for many is around age 20), when ovarian morphology testing (ultrasound, or AMH if you’d rather not do an internal ultrasound) finally becomes accurate.

I spend a lot of time on this because clarity is everything. If you don’t get this first part right, it affects every decision after it. So whether the answer is a clear yes, a not-yet, or a “let’s watch,” knowing exactly where you stand is the whole point.

▶ Want the full walk-through, with all the age cut-offs explained? Watch the complete video here.

This article is educational, not medical advice or a diagnosis. If something here resonates, bring it to your healthcare team, who can look at it through the lens of your individual health.

If you were the teen who got that label years ago and never revisited it, I wrote this one for you: Diagnosed With PCOS as a Teen? Why It’s Worth a Second Look.

Main references

1. Teede HJ, et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2023. PubMed

By Dr. Mélanie DesChâtelets, ND · Naturopathic Doctor and Menopause Society Certified Practitioner · Burnaby and virtual care across BC

Do I really have PMOS (formerly PCOS)… or not? It’s one of the most common questions I hear. Sometimes you’re convinced you have it, but no one has ever actually diagnosed you. Other times you’ve been told you have it, and it just doesn’t feel right, or it looks nothing like the PCOS your friend has. And that’s the tricky part. A PCOS diagnosis isn’t as straightforward as it sounds, and if it isn’t done right, every decision after it can be off track. So here’s exactly how PCOS is diagnosed when you’re 20 or older.

▶ Liked this video? Subscribe to my YouTube channel.

How is PCOS diagnosed in women 20 and older?

For adults, a PCOS diagnosis comes down to the Rotterdam criteria… the “two out of three” rule. You meet it when two of these three are present, after other causes have been ruled out: signs of high androgens, irregular cycles, or polycystic ovarian morphology (seen on ultrasound, or as an elevated AMH on blood work). Two of three. Not one. One quick nuance on the age line, though: what actually matters isn’t your birthday, it’s that it’s been about 8 years since your first period (which for most people is around age 20). Before that, the diagnostic rules are different. The ruling-out-other-causes part is its own important step, and a whole separate conversation. But the inclusion side starts here.

What counts as high androgens?

High androgens can show up as symptoms or on labs. The symptoms look like excess hair growth on the face, or tracking down toward the belly button or the thighs. Persistent acne that doesn’t let up after the teen years, or acne that’s more aggressive and treatment-resistant when you’re younger. Or female-pattern hair thinning, usually at the crown, where the parting line slowly widens.

And here’s the important part. If those symptoms are clearly present, that alone can count. You don’t always need blood work to confirm high androgens, because we can see them. When the symptoms are subtle or unclear, that’s when labs help. The main ones are total and free testosterone, and when free testosterone isn’t available, we can calculate it using the free androgen index. Sometimes we also look at DHEA-S, which comes from the adrenal glands but is still very androgenic.

Why can’t you test androgens while you’re on the pill?

Here’s a major quick pearl. If you’re on the combined oral contraceptive pill, it’s really hard to reliably measure your androgens. The pill raises sex hormone binding globulin and lowers your available androgens. So if your androgens were tested while you were on the pill, you can’t rely on those numbers. If testing is truly necessary, the guidelines suggest coming off the pill for at least three months, using another form of contraception during that time, and then testing.

What actually counts as an irregular cycle?

This one is defined pretty specifically… it’s not just being off by a couple of days. Irregular means cycles shorter than 21 days or longer than 35 days, or fewer than eight cycles a year. And if you’re more than a year past your first period and you’ve had a single cycle stretch past 90 days, that counts as irregular too.

Do you need an ultrasound to diagnose PCOS?

Not always. This is where the myths pile up. Myth one: everyone needs a pelvic ultrasound. Not true. If you already meet two of the three criteria, you don’t need one. Myth two: an ultrasound done as a teenager still counts. It doesn’t. A pelvic ultrasound isn’t reliable for diagnosing PCOS until it’s been about 8 years since your first period (which for most is around age 20). Before that, the ovaries normally show more follicles, so the scan can look “polycystic” when nothing is actually wrong. Myth three, the big one: polycystic ovarian morphology means ovarian cysts. It doesn’t. What we’re actually counting is follicles. In plain language, think of it as how many eggs are running the show. That’s a completely different thing from ovarian cysts.

And here’s the 2023 update worth knowing about. There’s now a blood test, AMH, that can stand in for the ultrasound. If AMH is elevated, it correlates with a high follicle count. This matters because not everyone has access to a pelvic ultrasound, and some people don’t feel comfortable with an internal one. So it opens a door to access.

Can one symptom on its own mean PCOS?

No. An irregular period on its own isn’t PCOS. High-androgen symptoms on their own aren’t PCOS. One ultrasound finding on its own isn’t PCOS. You need two of the three criteria, and you need the other causes ruled out. And if you’re 19 or younger, the diagnostic rules shift… that’s its own video.

Because here’s the thing I keep coming back to: with clarity comes power. When you actually understand what your PCOS diagnosis rests on, every decision after it gets a little easier… and a lot less frustrating.

▶ Want the full walk-through, with the examples and the nuance? Watch the complete video here.

This article is educational, not medical advice or a diagnosis. If something here resonates, bring it to your healthcare team, who can look at it through the lens of your individual health.

If you want to check your own diagnosis against the criteria, step by step, that’s over here: PCOS Diagnosis Criteria: How to Check Whether Yours Was Done Right.

Main references

1. Teede HJ, et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2023. PubMed