Hormone Imbalance and PCOS: Symptoms and Care

Hormone imbalance and PCOS are closely linked, with polycystic ovary syndrome disrupting the normal regulation of reproductive and metabolic hormones in roughly 1 in 10 people with ovaries in the UK. PCOS affects androgens, insulin, and the hormones that control ovulation, producing a wide range of symptoms from irregular periods and excess hair growth to difficulties with weight and mood. Understanding which hormones are involved, what symptoms to look out for, and how lifestyle and medical management can help is essential for anyone living with or suspected of having this condition.

What is PCOS and how does it affect your hormones?

PCOS disrupts the balance of reproductive and metabolic hormones by altering LH to FSH ratios, impairing ovulation and driving insulin resistance, which in turn stimulates excess ovarian androgen production.

Polycystic ovary syndrome (PCOS) is a common hormonal condition affecting roughly 1 in 10 people with ovaries in the UK, a figure cited by the NHS, and it disrupts the normal balance of reproductive and metabolic hormones.^[1] The name can be misleading: not everyone with PCOS has cysts on their ovaries, and the condition is better understood as a disorder of hormone regulation rather than a purely structural problem.

PCOS is typically diagnosed when at least two of three criteria are present: irregular or absent periods, elevated androgens (male-type hormones) either on a blood test or through symptoms such as excess hair growth, and polycystic-appearing ovaries on ultrasound.^[2][4] Importantly, a diagnosis of PCOS should only be made after other conditions that can cause similar features have been excluded. These include thyroid disease, raised prolactin levels, non-classic congenital adrenal hyperplasia, Cushing's syndrome and androgen-secreting tumours. Your GP will usually arrange blood tests to rule these out before confirming PCOS.

In younger people who have only recently started their periods, diagnosis requires particular care. Irregular cycles are common in the first one to two years after the first period, and ultrasound findings of polycystic-appearing ovaries are less reliable in this age group, so clinicians generally rely more on symptoms and blood tests rather than imaging in adolescents.^[2][4]

The hormonal disruption in PCOS begins in a cycle that involves the ovaries, the pituitary gland and the pancreas. The pituitary releases luteinising hormone (LH) and follicle-stimulating hormone (FSH) to coordinate ovulation, but in PCOS the ratio of LH to FSH is often elevated, which interferes with normal follicle development and prevents regular ovulation.^[2][13] Without ovulation, progesterone levels remain low and oestrogen goes relatively unopposed, contributing to irregular periods.

Insulin resistance is also central to PCOS in many cases. When cells respond poorly to insulin, the pancreas compensates by producing more of it. High circulating insulin then stimulates the ovaries to produce excess androgens, reinforcing the hormonal imbalance. This interconnected pattern means that PCOS is not simply a gynaecological condition but a systemic one with metabolic consequences that extend well beyond the reproductive system.

Which hormones are out of balance in PCOS?

Androgens, insulin, LH and FSH are the most dysregulated hormones in PCOS; elevated androgens and raised insulin suppress SHBG, increasing free testosterone and worsening symptoms.

Several hormones are typically dysregulated in PCOS, with androgens, insulin, LH and FSH being the most clinically significant. Androgens, including testosterone and androstenedione, are produced in excess by the ovaries and, to a lesser extent, the adrenal glands. Elevated androgens drive many of the most visible symptoms of PCOS, including hirsutism (excess facial or body hair), acne and, in some people, scalp hair thinning.

In UK primary care, the standard initial blood tests for androgen excess are total testosterone and sex hormone-binding globulin (SHBG), which together allow calculation of the free androgen index. Dehydroepiandrosterone sulphate (DHEAS) is measured when an adrenal source of androgen excess is suspected, rather than routinely. This approach is consistent with NICE Clinical Knowledge Summary (CKS) guidance on PCOS.

Insulin is another key player. Raised insulin levels not only stimulate androgen production but also suppress SHBG, a protein that normally binds testosterone and keeps it inactive. Lower SHBG means more free, biologically active testosterone circulates in the blood, amplifying androgenic effects. NICE CKS on PCOS acknowledges the role of insulin resistance and recommends that clinicians assess metabolic risk accordingly.

The LH to FSH ratio is often elevated in PCOS, though the degree varies between individuals and this measurement is not used as a diagnostic criterion on its own. Elevated LH further stimulates ovarian androgen production and disrupts follicle maturation. Oestrogen levels in PCOS are not always low; rather, they may be persistently moderate without the cyclical rise and fall that accompanies normal ovulation. Progesterone, which rises after ovulation, is often low because ovulation does not occur regularly. This relative progesterone deficiency means the uterine lining is not shed in a predictable pattern, leading to irregular or prolonged periods.

What symptoms should I look out for?

Common PCOS symptoms include irregular or absent periods, hirsutism, acne, scalp hair thinning and difficulty managing weight; rapid virilisation or heavy bleeding warrants prompt medical review.

The most common symptoms of PCOS include irregular periods, excess hair growth, acne and difficulty managing weight, though the condition presents very differently from person to person. Periods may be infrequent, absent altogether (amenorrhoea) or unpredictably heavy when they do occur. Because ovulation is disrupted, fertility can be affected, and PCOS is one of the most common causes of ovulatory infertility in the UK.^[8][2] It is worth noting that ovulation can still occur intermittently even with irregular cycles, so pregnancy remains possible; if you are not trying to conceive, discuss contraception with your GP or practice nurse.

Androgen-related symptoms are often the most distressing for those affected:

• Hirsutism: coarse, dark hair on the face, chest, abdomen or back

• Acne: particularly along the jawline, chin and back, which may persist beyond the teenage years

• Scalp hair thinning: a pattern similar to male-pattern hair loss, affecting the crown or temples

• Oily skin: driven by androgen stimulation of sebaceous glands

Weight gain or difficulty losing weight is reported by many people with PCOS, particularly around the abdomen, and is closely linked to insulin resistance. However, PCOS also affects people of a healthy weight, and symptoms can be equally significant regardless of body mass index.

Mood-related symptoms, including low mood, anxiety and reduced quality of life, are increasingly recognised as part of the PCOS picture, though the mechanisms are not fully understood.

Some symptoms warrant prompt or urgent medical attention rather than a routine appointment. Seek prompt review if you experience very rapid onset or worsening of androgenic symptoms such as significant voice deepening or marked virilisation, as these may suggest a cause other than PCOS. You should also seek timely assessment for heavy or prolonged bleeding that is difficult to manage, severe pelvic pain, or symptoms of high blood glucose such as increased thirst, frequent urination and unexplained fatigue. If you have irregular periods and think you might be pregnant, seek advice promptly.

If you are experiencing irregular periods alongside any of the above symptoms, speaking to your GP is the right first step. They can arrange appropriate blood tests and, if indicated, a pelvic ultrasound. Early assessment allows timely management and reduces the risk of longer-term complications.

Can lifestyle changes help rebalance hormones with PCOS?

Yes; a balanced diet limiting refined carbohydrates and at least 150 minutes of weekly exercise can improve insulin sensitivity, lower androgen levels and restore more regular ovulation.

Lifestyle changes are a first-line recommendation for managing PCOS in people who are overweight, according to NICE CKS guidance on PCOS, and evidence suggests they can meaningfully improve hormonal balance, menstrual regularity and metabolic health.^[2][3] The 2023 International Evidence-Based Guideline for the Assessment and Management of PCOS supports the finding that even a modest reduction in body weight of around 5 to 10 per cent is associated with improvements in androgen levels, ovulation frequency and insulin sensitivity in people with PCOS who carry excess weight.^[4] These changes work partly by reducing circulating insulin, which in turn lowers ovarian androgen production and raises SHBG.

A balanced diet that limits refined carbohydrates and added sugars is generally recommended, as these foods cause rapid rises in blood glucose and insulin. There is no single diet proven superior for PCOS, but approaches consistent with the NHS Eatwell Guide that prioritise whole grains, vegetables, lean protein and healthy fats support insulin sensitivity. Some people find a lower glycaemic index (GI) approach helpful, though individual responses vary.

Regular physical activity improves insulin sensitivity independently of weight loss. Both aerobic exercise (such as brisk walking, cycling or swimming) and resistance training have shown benefit in studies. The UK Chief Medical Officers' Physical Activity Guidelines recommend at least 150 minutes of moderate-intensity activity per week for adults, and this target is broadly applicable to people with PCOS.^[6][7]

Stress management and adequate sleep also matter: chronic stress raises cortisol, and there is some evidence that elevated cortisol can contribute to insulin resistance and may influence androgen levels, though the relationship is complex and not fully characterised. Holistic lifestyle support is therefore an important part of PCOS care.

For those considering structured weight management support, Bolt Pharmacy is a GPhC-registered UK online pharmacy offering online weight-management consultations, with prescriber review and pharmacist support, where a range of options may be considered depending on individual clinical circumstances.

What are the long-term health risks of untreated PCOS?

Untreated PCOS significantly raises the risk of type 2 diabetes, cardiovascular disease and endometrial cancer, requiring regular screening for glucose, lipids, blood pressure and menstrual regularity.

Untreated PCOS is associated with several significant long-term health risks, the most important of which include type 2 diabetes, cardiovascular disease and endometrial cancer. Insulin resistance is common in PCOS and substantially raises the risk of developing type 2 diabetes over time, though published estimates of its prevalence vary depending on the population studied and the method used to define it. NICE CKS on PCOS recommends that people with PCOS are offered screening for impaired glucose regulation, and the 2023 International PCOS Guideline recommends considering an oral glucose tolerance test (OGTT) in those at higher metabolic risk, as this may detect abnormalities that fasting glucose or HbA1c alone can miss.^[2] Screening should be repeated periodically, with the interval guided by individual risk factors.

Cardiovascular risk is elevated in PCOS, primarily because of associated metabolic risk factors including dyslipidaemia (abnormal blood fats), hypertension and central adiposity. The evidence on whether PCOS independently increases the rate of hard cardiovascular events such as heart attack or stroke is mixed, and absolute risk depends heavily on individual factors such as weight, smoking status and family history. What is clear is that the clustering of metabolic risk factors in PCOS warrants regular monitoring of blood pressure, lipids and glucose as part of ongoing care.

Endometrial cancer risk is increased in PCOS because infrequent or absent ovulation leads to prolonged exposure of the uterine lining to oestrogen without the protective effect of progesterone. NICE CKS guidance recommends that people with PCOS who have fewer than three to four periods per year are offered treatment to induce a withdrawal bleed, typically with cyclical progestogen or a combined hormonal contraceptive, to reduce this risk.^[2]

Mental health is also a long-term concern: rates of depression, anxiety and eating disorders are higher in people with PCOS than in the general population, and these should be actively screened for and addressed as part of holistic care.^[10][11] Regular review with a GP or specialist ensures that both hormonal and metabolic aspects of PCOS are monitored over time.

Scientific References

1. Polycystic ovary syndrome (PCOS) – NHS.
2. Polycystic ovary syndrome – NICE Clinical Knowledge Summary (CKS).
3. Polycystic ovary syndrome | Treatment summaries – BNF – NICE.
4. 2023 International Evidence-Based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (Monash University / NICE adaptation documentation).
5. Diagnostic accuracy of oral glucose tolerance tests, fasting glucose and HbA1c in detecting dysglycaemia in women with polycystic ovary syndrome.
6. Physical activity guidelines: UK Chief Medical Officers' report – GOV.UK.
7. Physical activity guidelines for adults aged 19 to 64 – NHS.
8. Causes of infertility – NHS.
9. Polycystic Ovary Syndrome-Associated Acne: The Interplay of Hyperandrogenism, Insulin Resistance, and Therapeutic Strategies. Cureus..
10. Polycystic ovary syndrome and mental disorders: a systematic review and exploratory meta-analysis. Neuropsychiatric Disease and Treatment..
11. Direct economic burden of mental health disorders associated with polycystic ovary syndrome: Systematic review and meta-analysis. eLife..
12. Sexual function in women with polycystic ovary syndrome: a systematic review and meta-analysis. Human Reproduction Update..
13. Polycystic ovary syndrome: An insight into pathophysiology, current management, and emerging therapeutic approaches. Current Opinion in Pharmacology..
14. The value of anti-Mullerian hormone for diagnosing polycystic ovary syndrome in adolescents: a case-control study based on an epidemiological survey. Frontiers in Reproductive Health..

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