PCOS Part 2: How We Diagnose It + Why Weight Won’t Budge

This is a re‑air of Part 2 in my 3‑part PCOS series.

In this episode, I walk you through how we actually confirm a PCOS diagnosis — and why so many women with PCOS struggle with stubborn, belly‑centered weight gain.

I briefly recap common symptoms like irregular or missing periods, acne, unwanted facial or body hair, scalp hair thinning, weight gain, and difficulty getting pregnant. I explain how irregular bleeding happens because you’re not ovulating, and how higher testosterone levels drive many of the skin and hair changes.

Then I break down how we diagnose PCOS, including:

• Hormone blood work
• Transvaginal ultrasound showing multiple small follicle cysts
• Key labs to rule out other causes (thyroid, adrenal issues, prolactin levels, and pituitary hormones like FSH and LH)

A big focus of this episode is insulin resistance and hyperinsulinemia — the vicious cycle that increases hunger, promotes fat storage, and raises long‑term risks like diabetes, heart disease, and high cholesterol. I explain why weight loss can feel so frustrating with PCOS and what’s actually happening in your body.

In the next episode, I’ll cover treatment options and fertility support.

You can write to us at Questions@GynoInfo.net

And follow us on Instagram @gynoinfo

Transcript

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Welcome to Gyno Info, Frank Talk with Dr. Berkey, the podcast dedicated to teaching everyday women what they need to know about their body and how it works, to successfully deal with the healthcare system and communicate with their doctors. Each week, I'll provide you with new information and practical tips about gynecology and women's health care. I want to prepare you for your doctor's appointments by teaching you what to expect, what information your doctor will need to know from you, and what questions you will need and should ask her so you can be confident and make the most out of every visit. Gynefo will give you the knowledge you need to take charge of your health and do this in a clear and frank way that you can understand without having a medical degree, one episode at a time. So now let's begin. Hello. Welcome back to Gyno Info, the podcast about women's health in normal, everyday language that normal, everyday people can understand. No special medical words and certainly no doctor speak. A special welcome to those who just discovered us and are listening for the first time. Please take a moment now and subscribe to GynoInfo. It will make it easier getting back to this episode in case you have to interrupt in the middle and would like to finish the podcast later on. The same episode might not show up in your feed anytime soon. Josh and I decided to slow down our GynoInfo podcast a little bit over the summer and run a new episode only every other week. Then my only sister died at the beginning of July, and as you can imagine, that sapped my strength a whole lot. Grieving is hard work and leaves you exhausted. And I'm not quite ready yet to research a lot of new topics for you right now. So this week we're going to rerun three episodes on PCOS polycystic ovary syndrome that we had produced last February. Each of these three episodes deals with a different problem caused by PCOS, from too much facial hair and acne to insulin resistance and not being able to lose weight to being unable to have children. The good news is that all these issues can nowadays be dealt with quite effectively, and women with PCOS can get better skin, lose weight, and have babies. I strongly suggest that you watch all three episodes and that you do it on YouTube so you can see all the interesting slides, including the one on how polycystic ovaries actually look like on an ultrasound. So here's the second run of the second of my three PCOS episodes. Enjoy it, learn from it, and please share it around to all women you know who might be suffering from PCOS. Hello, welcome back to GynoInfo. A special welcome to those who just discovered us and are listening for the first time. Today I'm going to continue talking about PCOS, polycystic ovary syndrome, how to diagnose it, and why women with PCOS have such a hard time with their weight. PCOS is a mix-up, a disturbance in the normal functioning of the ovaries, whose main function is to produce eggs, and a mix-up with the various hormones that go along with that egg production. Just as a recap, the typical symptoms that make up polycystic ovary syndrome are irregular periods, often quite heavy. Instead of regular periods every month, a woman with PCOS bleeds only a few, no more than eight times a year. This is called oligomenorrhea in Dr. Speak. Or she may even have no periods on. Or she may even have no periods at all, which is called amenorrhea in Dr. Speak. A second classic symptom is acne, often quite severe, leaving deep scars, both in the skin but also emotionally in the fragile young women who suffer from it. Then there is growth of thick dark hair in the face and on the body where you don't want it, but losing hair from the head where you would like to have a lot of hair. Typical for the syndrome is also that most of the time, but not always, women with PCOS are very much overweight. And generally, women with PCOS have a really hard time getting pregnant. In my last episode on PCOS, which was episode number 130, if you want to look it up, we talked about how PCOS gets its name and how polycystic ovaries look like. We also talked about in more detail about the first four main symptoms that I just listed and which are part of the polycystic ovary syndrome and what causes them. The irregular periods happen because women with PCOS do not regularly make an egg every month, so their monthly cycle is not regular and their bleeding is irregular because of that. The other three PCO symptoms I discussed last time acne, unwanted growing of thick face and body hair, and the unwanted loss of scalp hair are all three caused for the most part by too much testosterone, hormone being produced by the ovaries that are not working right. I'm gonna say that one again. The other three PCOS symptoms I discussed last time, acne, unwanted growth of thick face and body hair, and the unwanted loss of scalp hair are all three caused for the most part by too much testosterone, too much male hormone being produced by the ovaries that are not working right. If you want to know the details, you need to stop now and go back and listen to episode 130. I suggest that you actually do take the time to do that because it will help you understand today's episode a lot better. Gynoinfo is, when I'm not answering specific questions from listeners, really an ongoing course for women about their bodies and how it works. It is often helpful to have listened already to a previous episode to better understand what I'm saying. When this is the case, I try to remember to point out which episodes might be helpful for understanding today's episode. Having listened to the first PCOS episode, which is episode number 130, definitely helps. There will also be a third episode on PCOS treatment, and especially about infertility and PCOS. It might also help to actually watch these episodes on YouTube instead of just listening to it because I added some slides. Now let's continue and assume that you know and understand everything I said in my first PCOS segment, episode 130. Today I want to first discuss how to confirm the diagnosis once you and your doctor suspect that you have polycystic ovarian syndrome. After that, I will talk about insulin resistance and how this relates to one of the most typical signs of PCOS: massive weight gain, especially around the belly. There are basically two main tests that prove that you have PCOS. The first are blood tests that measure the levels of certain hormones in your blood. These are also helpful in making sure that you do not have other reasons than PCOS to have irregular periods or no periods or too much face and body hair and for the loss of scalp hair. The other exam is to look at your ovaries with an ultrasound machine. One can see the ovaries much better with a transvaginal ultrasound exam than with an abdominal exam through the belly wall, that often is quite thick in women who have polycystic ovaries. With the transvaginal exam, the ultrasound wand is put inside the vagina, which gets it much closer to the ovaries that you want to look at. Because the ovaries are sitting deep inside the belly at the upper end of the vagina. Because of that, the ovaries are hard to show with an ultrasound probe through the often very thick belly wall. How exactly an ultrasound machine manages to catch pictures of the things inside your body goes well beyond this podcast. All I can tell you is that it works and is very good at getting pictures of internal organs that a regular X-ray machine, which is good at seeing bones and air inside your body, could not do. It also goes without radiation, whereas X-rays have radiation. A transvaginal ultrasound, an exam through the vagina, lets you see and take pictures of the typical PCOS type ovaries full of little follicle cysts that are all lined up like beads, the same size on a necklace. I talked about that in my last episode. These follicles look all black because they're filled with clear fluid, which looks black on ultrasound. Together with the typical signs and symptoms of PCOS that I just described, PCOS-like ovaries on an ultrasound exam are enough to make the diagnosis of polycystic ovary syndrome. Which blood tests the doctor will order depends a bit on which ones are available to her, depending in which country she practices, and how much money is available to do them. They're not cheap. Some tests may also depend on whether an ultrasound is being done at the same time. Now let's assume for now that all useful blood tests can be done. A progesterone test about three weeks after the last periods might be helpful to actually document whether a woman is ovulating, is making an egg or not. If she has an ovulation, then and only then would she be producing progesterone. If a woman has no periods at all, or if the ultrasound shows classical PCOS ovaries, there is no real need to do a progesterone test. A progesterone test is actually more useful after you start treating PCOS to see if this treatment is working and the ovaries are beginning to work normally and making eggs. If they make eggs, they will be making progesterone as well. You would also like to see if and how much too much testosterone is being made, and if other male hormones are also higher than normal. Testosterone is made both by the ovaries and by a second gland called the adrenal gland. Some male hormones in women are mostly produced by the adrenal gland. If those other male hormones are massively higher than normal, then it may be a hint that the problem is actually a problem of too male hormones being made by the adrenal glands and not by the ovaries, which would then say you don't really have classical polycystic ovary syndrome. There's some adrenal gland illnesses and adrenal tumors that can do this, that can make too much male hormones. Then you would like to make sure that it's not a problem with the thyroid gland, which can also cause irregular periods, weight gain, and loss of hair, which are all part of the polycystic ovary syndrome. So you should check the main thyroid hormones as well. Irregular or no periods at all can be the result of certain brain tumors. One of those brain tumors produces a hormone called prolactin. So prolactin is also something that needs to be measured to make sure that prolactin made by a brain tumor is not the problem. And then there are the two hormones called FSH for follicle stimulating hormone and LH for luteinizing hormone. Those are produced by the pituitary gland, a gland that is attached to the bottom of the brain between the eyes. In women with PCOS, both FSH and especially LH are much higher than normal, which in itself is one of the telltale signs that helps make the diagnosis. FSH and LH both tell the ovaries what to do. They have to be sat out in the right amount and in the right order during a woman's cycle for everything to work as it should. If they are absent or they're sent by the to the ovaries in the wrong order or in the wrong amount, the ovary will not work correctly, it will not make eggs and not make the correct hormones in the correct amounts. These two hormones, FSH and LH, are produced in turn on the orders of hormones coming from another part of the brain, the so-called gonadotropin-releasing hormones, the GNRH hormones. When for some reason, such as extreme stress or sometimes the brain tumor, the brain does not send out these hormones, nothing works at all. The brain does not tell the pituitary gland to work, the pituitary gland does not tell the ovaries to work, the ovaries shut down and make neither eggs nor hormones, so no uterine lining will grow, and there will be no periods and no pregnancies. As you can see, all this is very complicated, but also quite fascinating. It's one of the reasons I keep finding it so interesting being a gynecologist and continue to figure out how women's bodies work. New discoveries are constantly being made, and there is new stuff to learn all the time. It's absolutely wonderful. You can also easily see how this complex system can get messed up, as it does with polycystic ovary syndrome. And so far, nobody really knows why the ovaries stop working correctly in PCOS. As usual, genetics and family seem to play a role. If other women in your family have PCOS, you're much more likely to have it as well. In recent years, a new key player in the PCOS story has been found: insulin and insulin resistance. It has long been known that being overweight, especially around the belly, is a key symptom of PCOS. More than half of the women with PCOS suffer from that. Now we know why that is, and also why it's so incredibly difficult for women with PCOS to lose weight once they've put it on. Insulin is a hormone that is made by the pancreas, yet another hormone-producing gland in the human body. The pancreas sits inside the belly, attached to the back wall, behind the stomach. If you want to know where it is. When you eat carbohydrates that starches such food as bread and pasta, and then sweets, it's also broken down into sugar. Insulin is like a key that opens a door and helps sugar move from the blood into the cells, where it is either used as energy right away or stored as a quick energy cloud glycogen. Glycogen is kind like snack food for when the cells need energy really quickly. Any of the sugar that is not broken down by insulin that way is turned into fat at the long-term energy stores. In PCOS, for some reason, so far still unexplained, the cells become resistant to insulin and less sugar enters the cells. It's like the lock opening the door for the sugar to enter the cells is rusty and the door is hard to open. This causes the sugar in the blood to become too high, which can damage many organs. The body, of course, notices the high blood sugar, and the pancreas begins to make more insulin to help break down the extra sugar. There is now too much insulin in the blood, something called hyperinsulinemia. Hyperinsulinemia. Hyper for too much anemia for in the blood, so hyperinsulinemia, too much insulin in the blood. When the insulin is too high, blood sugar drops. You feel hungry and weak, and you eat. And then more insulin is being made. And because the cells are resistant to insulin, the door to the cells doesn't open. The sugar in the fruit that you just ate cannot be processed and turned into energy, and again it's turned into fat. Then more insulin is being made, the blood sugar drops again, you feel hungry, you eat, and the blood is not processed right and turns into fat, and on and on and on. In English, this is called a vicious circle. In my language, it is called a devil's circle. It's certainly a terrible situation to be stuck in and devilishly hard to get out of. And it is exactly the situation many women with polycystic ovaries are in. The more weight they gain, the more serious the insulin resistance gets, and the more fat they deposit, which in turn makes them even more resistant to insulin. And this eventually leads to sugar diabetes, heart disease, high cholesterol, all common diseases for people who are seriously overweight. Breaking this vicious, devilish circle is extremely hard, but not impossible. Most people, though, do not manage it without the help of prescription medications. But I'm running out of time for today. There will be a third episode soon about the treatment of PCOS and especially about infertility and PCOS. Fertility treatments in PCOS are generally quite successful because there are actually many, many follicles present in the ovaries. All one has to do is find a way to make them produce eggs that can be fertilized and turned into a pregnancy, and nine months later comes out that baby. So if you're interested in the latest treatments for PCOS and all its symptoms, including weight gain or problems getting pregnant, please stay tuned for segment three on PCOS. I hope you found today's information about PCOS useful. And if you or any of your friends or relatives or coworkers' life is touched by polycystic ovary syndrome, let them know about this podcast. Please also take the time to subscribe to it, as the algorithm seems to like that and it makes it easier for more women to find us. And remember, you can send in any questions you might have or suggestions for future episode topics to questions at gynoinfo.net. Again, that's questions at gynoinfo.net. Goodbye and have a really safe week. Until next time, thank you for listening. And remember that you and your health are super important and deserve your full attention. Don't ever put off contacting your doctor because you're scared or embarrassed when something feels wrong about your body. Doctors are here to help you, not to judge you. And also, regular well-woman visits are always a good idea that you should make time for. You deserve it and you owe it to yourself, and you owe it to your body and your health. This podcast is part of Pride House Media, hosted by me, Dr. Berkey, produced and edited by Josh Rosenzweig. Original music composed by Nell Balaban. If you enjoyed this episode, please subscribe wherever you listen to podcasts. And while you're there, leave us a rating and a review. It really helps others discover the show. Stay connected and join the conversation by following me on Instagram and Facebook at gynoinfo and on LinkedIn at gyneoinfopodcast. Remember, any questions that I answer or information that I give you on this podcast are to be understood as information only, not treatment of your medical problems. While I'm a very knowledgeable gynecologist, I'm not your gynecologist who has talked to you and examined you personally and is therefore actually able to treat you. So please consult your own healthcare professional with any medical questions or concerns.