Interview with Dr. Thaïs Aliabadi, OB-GYN Explaining the 4 Systems PCOS Can Disrupt

PCOS is not just about irregular periods, infertility, or “cysts” on the ovaries. It is a whole-body condition that can disrupt metabolism, hormones, inflammation, and mental health at the same time. That is why so many women spend years feeling exhausted, bloated, anxious, dismissed, and confused about why their bodies do not seem to respond the way other people’s bodies do. Dr. Thais Aliabadi and Mary Alice Haney sit down to discuss this important issue.

We need to say this clearly: stubborn weight gain, acne, facial hair, hair thinning, food cravings, brain fog, anxiety, and cycle changes are not personal failures. They can be clues. And when those clues point to PCOS, addressing the root issue can change everything.

Table of Contents

• Understanding PCOS as a Whole-Body Condition
• How PCOS Is Diagnosed
• The First Domino: Insulin Resistance and Weight Gain
• The Hormonal Domino Effect
• Inflammation, Brain Fog, and Mental Health
• Recognizing PCOS in Teenagers
• Addressing the Root Cause of PCOS
• Acne, Birth Control, and Symptom Relief
• PCOS, Fertility, and Egg Quality
• The Biggest PCOS Myths We Need to Leave Behind
• Be Your Own Health Advocate

Understanding PCOS as a Whole-Body Condition

What is PCOS, and why is it so often misunderstood?

PCOS stands for polycystic ovary syndrome, although that name does not fully explain what the condition actually is. PCOS affects roughly 15% of women of reproductive age, yet many cases go unrecognized. In our experience, the number of women who are undiagnosed may be even higher because symptoms are routinely minimized or treated as separate problems.

Someone may see a dermatologist for acne, an endocrinologist for weight changes, a psychiatrist for anxiety or binge eating, a fertility doctor for trouble conceiving, and a gynecologist for irregular periods. But these symptoms may all be connected by the same underlying condition.

PCOS is increasingly being called polycystic metabolic ovarian syndrome, or PMOS, because metabolism is central to the disorder. It affects far more than the ovaries. It can influence:

• Metabolic health: insulin resistance, visceral fat accumulation, weight changes, and diabetes risk.
• Hormonal health: elevated androgen effects, disrupted ovulation, irregular estrogen patterns, and low progesterone.
• Inflammation: fatigue, bloating, and a persistent feeling that the body is not functioning well.
• Brain and mental health: anxiety, depression, food cravings, brain fog, concentration problems, PMS, and PMDD.

That is why we cannot reduce PCOS to a period issue or an infertility issue. It is a systems issue. For a broader overview of symptoms, testing, long-term risks, and care options, review this PCOS information resource.

How PCOS Is Diagnosed

What are the diagnostic criteria for PCOS?

PCOS is diagnosed when a patient meets two out of three criteria. The reason diagnosis can be complicated is that patients can meet different combinations of those criteria. There is no single PCOS look, body type, blood test, or ultrasound finding.

The three diagnostic criteria are:

1. Hyperandrogenism: symptoms or evidence of elevated androgens, including testosterone.
2. Ovulatory dysfunction: irregular or absent ovulation.
3. Polycystic ovarian morphology: a particular appearance of the ovaries on ultrasound, or in adults, a high anti-Müllerian hormone, or AMH, level may sometimes contribute to this assessment.

What does hyperandrogenism look like?

Hyperandrogenism does not mean someone must have a visibly high testosterone result in their bloodwork. Clinical symptoms matter. A patient may have acne, especially persistent cystic acne around the jawline, scalp hair thinning, facial hair, or excess body hair. Many women spend years having repeated laser hair removal because the hair keeps returning, without anyone connecting it to PCOS.

A normal testosterone blood level does not automatically rule PCOS out. Symptoms can still show that androgens are affecting the body.

What counts as ovulatory dysfunction?

Irregular periods are a major clue. This can mean cycles occurring more than 35 days apart or fewer than eight periods per year. These patterns may reflect infrequent ovulation or no ovulation.

But here is an important point: having a monthly bleed does not guarantee ovulation. Some women with PCOS have apparently regular cycles but are not consistently releasing an egg. Their bleeding may be related to irregular estrogen changes rather than the normal progesterone withdrawal that follows ovulation.

Do you need cysts on your ovaries to have PCOS?

No. And this is one of the most harmful myths around PCOS. The name itself creates confusion. What clinicians may see on ultrasound is not simply a large ovarian cyst. It is often a pattern of numerous small follicles that have not matured and released an egg. This can look like a “string of pearls” around the ovary.

Some patients with PCOS do not have this ovarian appearance at all. They can still meet the other diagnostic criteria and absolutely still have PCOS. Conversely, ovarian morphology is not used as a diagnostic criterion for teenagers because it is normal for adolescents to have many follicles.

Why do different people with PCOS have such different symptoms?

There are several PCOS phenotypes. One patient may have irregular periods, androgen symptoms, and polycystic ovarian morphology. Another may have acne and excess hair but a normal ultrasound. Someone else may have irregular periods and polycystic ovarian morphology without obvious androgen symptoms.

This variation is exactly why patients can fall through the cracks. We cannot wait for every possible symptom to show up before taking someone seriously.

The First Domino: Insulin Resistance and Weight Gain

Why is insulin resistance so central to PCOS?

We think of insulin resistance as the first domino. It begins a cascade of metabolic, hormonal, inflammatory, and psychological effects. Many PCOS patients have insulin resistance, including patients in smaller bodies who are often described as having lean PCOS.

When we eat carbohydrates, the body breaks them down into glucose. Insulin helps move that glucose from the bloodstream into muscle and liver cells to be used for energy. In insulin resistance, the cells do not respond effectively to insulin’s signal. The glucose does not move into cells as efficiently, so the body produces more insulin to compensate.

That elevated insulin can trigger several problems at once:

• The liver may convert more circulating glucose into fat.
• Fat may accumulate viscerally, around internal organs, rather than only beneath the skin.
• Visceral fat releases inflammatory markers called cytokines.
• Inflammation worsens insulin resistance, creating a vicious cycle.
• High insulin reduces sex hormone-binding globulin, or SHBG, allowing more free testosterone to circulate.
• PCOS ovaries may be especially sensitive to insulin, which can stimulate more androgen production.

This is why someone can feel as if she eats and exercises similarly to a sibling or friend, yet gains weight much more easily and struggles to lose it. It is not that she is lazy. It is not that she has failed. The metabolic system may not be responding normally.

It is also why a normal hemoglobin A1C does not necessarily settle the question in a younger patient. Tissue-level insulin resistance can exist before standard blood markers become abnormal. More specific assessments, such as HOMA-IR, may be considered by a clinician, but medical evaluation must always be individualized.

The Hormonal Domino Effect

How does insulin resistance disrupt ovulation and hormones?

When insulin levels rise and the ovaries produce more androgens, including testosterone, the ovarian environment becomes difficult for follicles to mature normally. In a typical cycle, one follicle matures, releases an egg, and leaves behind a structure that produces progesterone.

In PCOS, higher androgen activity can interfere with that process. Follicles may remain underdeveloped instead of progressing to ovulation. This contributes to irregular ovulation, irregular periods, fertility challenges, and the follicle pattern sometimes seen on ultrasound.

The hormone feedback loop also becomes disrupted. Instead of a predictable sequence of estrogen rise, ovulation, and progesterone production, PCOS can involve erratic estrogen levels, low progesterone, and persistent androgen stimulation. The brain signals that regulate ovulation, including GnRH and luteinizing hormone, can become dysregulated, leading to even more ovarian testosterone production.

That is the second loop: metabolic dysfunction fuels hormonal dysfunction, and hormonal dysfunction makes the cycle harder to break.

Why do irregular cycles matter beyond fertility?

When ovulation is infrequent, progesterone may remain low and the uterine lining may not shed regularly. For patients who do not get periods consistently, especially those with additional metabolic risks, this can increase the risk of endometrial hyperplasia, which can be a precursor to uterine cancer.

That is why cycle management matters even when pregnancy is not a goal. A care plan may include lifestyle measures, metabolic treatment, or hormonal medication to protect the uterine lining and manage symptoms. It is never one-size-fits-all.

Inflammation, Brain Fog, and Mental Health

Can PCOS really affect anxiety, depression, cravings, and focus?

Absolutely. This is one of the most important things to understand. PCOS can affect the brain and mental health through the combined effect of irregular estrogen, low progesterone, elevated androgens, insulin resistance, inflammation, cortisol, poor sleep, and the lived burden of symptoms.

We often describe the limbic system as the emotional headquarters of the brain. It includes structures involved in emotional processing, fear, mood, and memory. For this system to function calmly, it benefits from balanced hormones, lower inflammation, and restorative sleep.

In PCOS, those conditions may not be present. The result can be anxiety, sadness, irritability, food cravings, binge eating, brain fog, memory difficulty, and trouble concentrating. At the same time, the prefrontal cortex, which acts like the brain’s brake system, can struggle under the effects of inflammation, high stress, poor sleep, and hormone disruption.

That does not mean mental health symptoms are “all hormonal,” or that therapy and psychiatric care do not matter. They do matter. It means we should not isolate the psychological symptoms from the rest of the body. Treating only the emotional distress without asking why it is happening can leave the root problem untouched.

For a deeper discussion of the relationship between PCOS, depression, anxiety, treatment, and emotional support, explore PCOS and mental health resources.

Why is it so damaging to tell someone with PCOS to simply eat less and exercise more?

Because it ignores the physiology and can deepen shame. Cravings, appetite changes, difficulty losing weight, and binge eating can be connected to insulin resistance, inflammation, sleep disruption, emotional distress, and hormonal imbalance.

We cannot punish people for symptoms that may be signs of an untreated metabolic condition. A compassionate plan addresses eating patterns, movement, mental health, sleep, and medical options without reducing anyone to a number on a scale.

Recognizing PCOS in Teenagers

How should parents and clinicians think about PCOS in teenagers?

Diagnosing PCOS in adolescence requires care because irregular cycles and acne can be common in the years after a first period. We should not use ovarian morphology as a diagnostic criterion in teenagers, because many healthy adolescents have numerous ovarian follicles.

But caution should never become dismissal. When a teenager has a bigger pattern of symptoms, PCOS should be considered. Red flags may include:

• Persistent irregular periods
• Significant or rapid weight gain despite regular activity and balanced eating
• Cystic acne that does not respond to usual treatment
• Facial hair or excess body hair
• Hair thinning
• Darkened skin under the arms, sometimes associated with insulin resistance
• Anxiety, depression, intense cravings, binge eating, or disordered eating
• A family history of PCOS, diabetes, gestational diabetes, or metabolic concerns

We do not need to wait until a young person is in crisis before evaluating metabolic health. Even when clinicians are not ready to apply a definitive diagnostic label, they can still take symptoms seriously and support the teenager’s confidence, nutrition, movement, sleep, mental health, and medical needs.

The goal is not to make a teenager feel like her body is broken. The goal is to recognize what her body may be asking for, before years of shame and symptoms pile up.

Addressing the Root Cause of PCOS

What is the most important treatment priority in PCOS?

If we could lift one tile first, it would be insulin resistance. Addressing metabolic health can lower insulin levels, improve insulin sensitivity, reduce ovarian androgen signaling, and create better conditions for ovulation and symptom improvement.

That does not mean every patient needs the same treatment, medication, or supplement. It means we start by recognizing PCOS as a metabolic condition, not merely a period problem.

What foundational lifestyle steps can support insulin sensitivity?

We want realistic, sustainable strategies, not punishment. The basic principles include reducing highly processed foods and excess sugar, recognizing that carbohydrate tolerance can differ from person to person, and building consistent movement into daily life.

One simple tool is a 10 to 15 minute walk after meals. Muscle activity can help glucose move into muscle cells and may reduce the insulin response after eating. This is not about perfection. It is a practical way to support the body repeatedly throughout the day.

Nutrition and exercise can be meaningful parts of PCOS management, particularly when they are approached without restriction, guilt, or extremes. Read more about sustainable approaches to PCOS diet and exercise.

What medical and supplement options may be part of an individualized plan?

Depending on symptoms, goals, medical history, and laboratory findings, clinicians may discuss different options. Inositol has commonly been used to support insulin sensitivity. Checking and correcting deficiencies or low levels of nutrients such as vitamin D, B12, iron, ferritin, and omega-3s may also be relevant for some patients.

Dr. Aliabadi also discusses Ovii, a nonprescription supplement developed to address metabolic support with multiple ingredients rather than relying on a single supplement. Any supplement should be reviewed in the context of a patient’s full health history, medications, pregnancy plans, and clinician guidance.

For patients with more substantial metabolic challenges or weight-related health risks, prescription medications can be considered. Metformin may improve insulin sensitivity, though some patients experience nausea or diarrhea. GLP-1 medications may also be used in appropriate patients under medical supervision. These medications are not simply about appetite suppression. In this approach, they are used because of their effects on insulin regulation and insulin sensitivity.

Treatment should be personal. Some patients tolerate metformin easily. Others do not. Some may use GLP-1 medication for a period of time, then taper with clinician guidance once health goals are reached. There is no single protocol that belongs to every person with PCOS.

Acne, Birth Control, and Symptom Relief

Does birth control treat PCOS?

Birth control pills can have an important role in PCOS care, but they are not the whole answer. They can help regulate bleeding, protect the uterine lining, provide contraception, influence LH signaling, and increase SHBG. More SHBG can bind free testosterone and may improve acne, facial hair, and excess body hair.

For patients with very irregular periods, a hormonal method can be especially important for ensuring the uterine lining sheds regularly. Certain options may be better suited to specific symptoms. For example, Dr. Aliabadi notes that some pills may be helpful for PMS or PMDD, while a progesterone-only, anti-androgenic option may be considered for others.

But we cannot stop at birth control. If someone’s periods become regular but she still feels bloated, gains weight, struggles with cravings, has brain fog, and feels emotionally unwell, we have not addressed the entire condition. We need to address metabolic health, hormonal symptoms, inflammation, and mental health together.

What about acne and excess hair?

Acne is often treated in isolation, sometimes with very aggressive dermatologic therapies. But in PCOS, acne can be part of androgen excess driven by metabolic dysfunction. Improving insulin sensitivity may help lower androgen activity over time.

Spironolactone, an anti-androgen medication, may also be considered for acne and unwanted hair in appropriate patients. This must be prescribed and monitored by a clinician, particularly because pregnancy prevention is important while taking it.

The point is not that every case of acne is PCOS. The point is that stubborn acne alongside irregular periods, facial hair, hair thinning, or unexplained weight changes deserves a more complete conversation.

PCOS, Fertility, and Egg Quality

Does PCOS mean infertility?

No. PCOS is not a fertility sentence. Many patients with PCOS get pregnant naturally or with support. But PCOS can affect fertility in several ways, and understanding those factors early gives people more options.

The first issue is ovulation. Many PCOS patients do not ovulate consistently, and some who have regular bleeding may still not release an egg every month. When insulin resistance and androgen levels improve, ovulation may become more likely.

The second issue is egg quality. PCOS patients often have a high follicle count and may have elevated AMH because many immature follicles are present. A high egg count does not automatically mean optimal egg quality. These follicles may have developed in a hormonally and inflammatory hostile ovarian environment.

For patients with PCOS who are not ready to have children and have the resources to consider egg freezing, Dr. Aliabadi advises discussing fertility preservation earlier rather than assuming a high follicle count guarantees future fertility. Her approach is more aggressive for PCOS patients because of concerns about egg quality with age.

The third issue is the uterine and pelvic environment. Inflammation, abnormal hormone patterns, and other coexisting conditions may affect implantation or miscarriage risk. Dr. Aliabadi also emphasizes looking for endometriosis in PCOS patients when symptoms or history suggest it, because endometriosis can also affect fertility, egg quality, pelvic inflammation, and the fallopian tubes.

Why have some patients become pregnant after metabolic treatment?

When insulin resistance is addressed, insulin levels may improve. That can reduce ovarian androgen stimulation. As androgen levels come down, follicles may have a better chance to mature and ovulate. This is why improving metabolic health can matter profoundly for fertility, even though it is not a guarantee and should always be coordinated with pregnancy planning.

Anyone using GLP-1 medications, metformin, hormonal medications, or supplements while trying to conceive should speak with a qualified clinician about safety, timing, and a pregnancy-specific plan.

The Biggest PCOS Myths We Need to Leave Behind

What are the most harmful myths about PCOS?

Myth 1: You need high testosterone on bloodwork to have PCOS.

No. Clinical signs of androgen excess, such as cystic acne, facial hair, excess body hair, and hair thinning, can count as hyperandrogenism even if a single blood test is not elevated.

Myth 2: You need ovarian cysts to have PCOS.

No. Many PCOS patients do not have the characteristic ovarian morphology on ultrasound. And the small structures seen in polycystic ovarian morphology are follicles, not simply “cysts.”

Myth 3: PCOS is only about fertility.

No. Fertility is one part of the picture. PCOS can affect cardiometabolic health, weight, blood pressure, diabetes risk, inflammation, mood, eating behaviors, skin, hair, sleep, and uterine health.

Myth 4: Birth control fixes PCOS.

Birth control can manage important symptoms and protect the uterine lining. But it does not, by itself, resolve the underlying insulin resistance that may be driving the condition.

Myth 5: Thin people cannot have insulin resistance or PCOS.

Not true. Lean PCOS exists, and insulin resistance can occur in people of many body sizes. Genetics, hormones, and tissue-level insulin sensitivity matter.

Be Your Own Health Advocate

What should we do if our symptoms have been dismissed?

Do not dismiss yourself. Track your cycles, symptoms, weight changes, acne patterns, hair changes, mood, sleep, cravings, and family history. Bring that information to an OB-GYN, endocrinologist, or clinician familiar with PCOS.

Ask direct questions:

• Could my symptoms meet two of the three criteria for PCOS?
• Could I have ovulatory dysfunction even if I bleed monthly?
• Are my acne, hair changes, and cycle symptoms signs of hyperandrogenism?
• Should we discuss insulin resistance beyond a hemoglobin A1C?
• What can we do to protect my uterine lining if my periods are infrequent?
• What metabolic, hormonal, dermatologic, mental health, and fertility supports make sense for me?

For parents, this advocacy can be life-changing. When a teenager is exercising frequently, struggling with body changes, dealing with acne or excess hair, and feeling anxious, depressed, or ashamed, she deserves curiosity and care. She does not need another lecture about discipline.

The message we want every woman and every young girl to hear is simple: it is not you, it is your body asking for support. Diagnosis is the first step. Once we understand the pattern, we can build a plan that addresses the actual problem rather than blaming the person living with it.

PCOS Frequently Asked Questions

Can we have PCOS with normal testosterone bloodwork?

Yes. Symptoms of androgen excess, including cystic acne, facial hair, excess body hair, or hair thinning, can be clinically meaningful even when testosterone bloodwork is normal.

Can we have PCOS without cysts on an ultrasound?

Yes. PCOS is diagnosed using two of three criteria, and polycystic ovarian morphology is only one of them. Many patients meet the criteria without the classic ovarian ultrasound appearance.

Can we have a monthly period but not ovulate?

Yes. Some patients with PCOS have regular bleeding without consistent ovulation. A clinician can help assess ovulation if this is a concern, especially when trying to conceive.

Why does PCOS cause weight gain and cravings?

Insulin resistance can make it harder for cells to use glucose effectively, leading to higher insulin levels, fat storage, inflammation, and increased androgen production. These processes can also contribute to cravings and eating difficulties.

Is PCOS only a fertility problem?

No. PCOS can affect metabolism, hormones, inflammation, mental health, skin, hair, sleep, cardiovascular risk, uterine health, and fertility. Many people with PCOS do become pregnant.

What is the first step if we think we may have PCOS?

Document symptoms and seek evaluation from a clinician familiar with PCOS. Correct diagnosis is essential because treatment should address the full picture, including metabolic health, hormonal symptoms, inflammation, and emotional well-being.