What Is PCOS? A Houston Endocrinologist on Polycystic Ovary Syndrome

August 5, 2026By Dr. Andres Splenser, MD, FACE

PCOS is a hormonal and metabolic condition, not a weight problem and not simply "irregular periods with a few cysts." Most patients arrive at my clinic having been told for years that polycystic ovary syndrome means their cycles are off and birth control is the answer. That framing isn't wrong, but it misses what's actually happening underneath: in most cases PCOS is driven by insulin resistance and androgen (male-hormone) excess, and the visible symptoms — irregular cycles, unwanted hair growth, weight that won't move — are downstream of that. Here is what PCOS actually is, how it's diagnosed, and what treatment looks like when the root cause is addressed rather than just the symptoms.

What PCOS actually is
What causes PCOS: the insulin-resistance connection
What are the symptoms of PCOS?
How is PCOS diagnosed?
Lean PCOS: the often-missed phenotype
What actually treats PCOS
When to see an endocrinologist for PCOS — and when to see someone else
Getting evaluated for PCOS in Houston
Frequently asked questions

What PCOS actually is

PCOS affects an estimated 6–13% of women of reproductive age, and up to 70% of affected women are undiagnosed (World Health Organization). It is the most common hormonal disorder in women in this age group.

The name is misleading, and it trips up patients. "Polycystic ovary syndrome" sounds like a disease of ovarian cysts, but most women with PCOS don't have true cysts at all. What an ultrasound actually shows is a higher-than-usual number of small, immature follicles — the normal structures that hold developing eggs. The follicles are not the disease; they're one visible sign of a hormonal pattern.

That hormonal pattern has two engines. The first is hyperandrogenism — higher levels of androgens, the hormones often called "male" hormones even though every woman makes them. The second is insulin resistance, where the body's cells respond poorly to insulin, so the pancreas produces more of it to compensate. The two reinforce each other: high insulin pushes the ovaries to make more androgens, and the androgen excess worsens the metabolic picture. Treating PCOS well means addressing both, not just regulating the cycle.

What causes PCOS: the insulin-resistance connection

The strongest driver in most cases of PCOS is insulin resistance, and that is the part standard care most often skips. PCOS is not caused by a single gene or a single behavior; it reflects a combination of genetic predisposition and the way the body handles insulin (NIH / NICHD).

Here's the mechanism in plain terms. Insulin is the hormone that moves sugar out of the blood and into cells. When cells respond poorly to it, the pancreas compensates by releasing more insulin. Those higher insulin levels do two things in PCOS: they signal the ovaries to produce more androgens, and they lower a protein called SHBG (sex hormone-binding globulin) that normally keeps androgens in check. The result is more free androgen circulating, which drives the acne, the hair changes, and the disrupted ovulation.

This is also why PCOS raises long-term metabolic risk. Women with PCOS have a meaningfully higher risk of type 2 diabetes and gestational diabetes (Endocrine Society). The same insulin-resistance mechanism connects PCOS to fatty liver disease — many of the women I evaluate for PCOS also warrant screening for metabolic dysfunction–associated steatotic liver disease (MASLD, formerly NAFLD), because the shared root is the same. (I wrote about that liver condition separately in what is NASH.) Seeing PCOS as a metabolic condition, not only a reproductive one, is what changes the workup and the treatment plan.

What are the symptoms of PCOS?

PCOS symptoms cluster around two themes — disrupted cycles and androgen excess — but no single symptom is required, and not every patient has every one. A typical presentation has several of the following (ACOG):

Irregular, infrequent, or absent menstrual periods
Unwanted hair growth in androgen-pattern areas (face, chest, back) — clinically, hirsutism
Acne that is adult-onset or persistent
Weight gain, or weight that is hard to lose, often around the midsection
Thinning hair on the scalp
Skin changes such as skin tags or darkened, velvety patches (acanthosis nigricans), which can be a visible sign of insulin resistance
Difficulty getting pregnant
Mood symptoms, including anxiety and depression, which are increasingly recognized as part of the syndrome

The diagnostic criteria do not require all of these. In my experience most patients present with three to five of them, in different combinations. That variability is part of why PCOS is so often missed or mislabeled.

How is PCOS diagnosed?

PCOS is diagnosed by meeting at least two of three criteria — not by a single test or an ultrasound alone. The framework most clinicians use is the Rotterdam criteria, and a diagnosis requires two of the following three (2023 International Evidence-Based PCOS Guideline, Teede et al.):

Irregular or absent ovulation (which usually shows up as irregular or missing periods)
Signs of androgen excess — either clinical (hirsutism, acne) or measured on bloodwork
Polycystic-appearing ovaries on ultrasound

An important point patients rarely hear: ultrasound alone is not diagnostic. Many women have polycystic-appearing ovaries without having PCOS, and some women with PCOS have normal-appearing ovaries. The ultrasound is one of three criteria, not the deciding one.

PCOS is also a diagnosis of exclusion, which means part of the workup is ruling out other conditions that mimic it — thyroid disease, high prolactin, and certain adrenal conditions among them. In my clinic the workup typically includes hormone and metabolic labs alongside the menstrual and symptom history, tailored to what each patient's presentation calls for.

Lean PCOS: the often-missed phenotype

Not all PCOS comes with weight gain, and the women who don't fit the stereotype are the ones who go undiagnosed the longest. "Lean PCOS" refers to women who meet the diagnostic criteria but have a body-mass index in the normal range. They still have the underlying insulin resistance and androgen excess; it just isn't accompanied by obesity, so it doesn't match the textbook image most people — and some clinicians — carry.

The lab work tells the same story regardless of body weight. The issue is whether the workup gets ordered in the first place. In my experience, the women who fit this profile have usually seen more than one doctor before the diagnosis gets made — not because the labs are ambiguous, but because the workup was never ordered.

What actually treats PCOS

The most effective PCOS treatment targets the metabolic root first, then the symptoms — which is the reverse of the order many patients have experienced. There is no cure, but the condition is very manageable, and treatment is tailored to what the individual patient needs (cycle regulation, symptom control, fertility, or metabolic risk reduction).

Treatment generally falls into a few categories:

Lifestyle changes that improve insulin sensitivity. For patients who are overweight, even a 5–10% reduction in body weight can meaningfully improve cycles and symptoms (Endocrine Society). The emphasis is on a sustainable eating pattern and regular activity, not crash dieting.
Metformin, an insulin-sensitizing medication that targets the underlying mechanism rather than masking symptoms.
GLP-1 receptor agonists, a newer medication class, in selected patients with a significant weight or pre-diabetes component.
Hormonal contraceptives, which regulate cycles and reduce androgen-driven symptoms (acne, hirsutism) when pregnancy is not an immediate goal.
Anti-androgen medications such as spironolactone for hair and skin symptoms, which are not used when a patient is trying to conceive.

The right combination depends on the patient's priorities. Someone focused on fertility follows a different path than someone focused on cycle control or long-term diabetes prevention. That is the conversation I'd rather have in an unhurried first visit than in a rushed appointment.

When to see an endocrinologist for PCOS — and when to see someone else

An endocrinologist is the right choice when the metabolic side of PCOS is in the foreground — insulin resistance, weight, pre-diabetes or diabetes risk, or overlap with conditions like fatty liver. That's the lane where managing the hormones and the metabolism together changes outcomes.

But an endocrinologist is not always the right first call, and I'd rather say so. If your main concern right now is getting pregnant, a reproductive endocrinologist or a coordinated OB-GYN plus fertility team is often the better fit for active fertility treatment. If your symptoms are primarily menstrual and cycle management is the priority, your OB-GYN may be the right person to manage it. In a lot of cases the best care is coordinated — an endocrinologist working alongside your OB-GYN — rather than any one specialist alone. PCOS sits at the intersection of two specialties, and the honest answer is that the right door depends on what you need most right now.

Getting evaluated for PCOS in Houston

If you've had PCOS symptoms for years without a clear plan, the starting point is a full hormonal and metabolic workup — not another prescription handed over at the door. I see patients at my Houston and Sugar Land offices, in English and Spanish, and you do not need a referral — most of my patients find the practice on their own. You can read more about how I approach PCOS specifically on the PCOS care page, and because the same insulin-resistance mechanism connects PCOS to blood-sugar and liver health, the diabetes evaluation is sometimes part of the same workup.

If your case has felt like it doesn't fit the standard explanation, I'd like to look at it with you. Booking is online or by phone.

Frequently asked questions

Can PCOS be cured?

No, PCOS cannot be cured, but it can be managed well, and symptoms often improve substantially with treatment. With an approach aimed at insulin resistance and the specific symptoms that matter most to you, most patients see meaningful improvement in cycle regularity, skin and hair symptoms, and weight over time.

Does PCOS cause diabetes?

PCOS does not directly cause diabetes, but it raises the risk substantially because of the shared insulin-resistance mechanism. Women with PCOS have a higher risk of both type 2 diabetes and gestational diabetes, which is why screening blood sugar and monitoring it over time is part of good PCOS care.

Can you get pregnant with PCOS?

Yes, most women with PCOS can get pregnant. PCOS is the most common cause of ovulatory infertility, but it is also one of the more treatable causes. Many patients conceive with ovulation-support treatment; more complex cases may benefit from a reproductive endocrinologist.

Is PCOS the same as endometriosis?

No. PCOS is a hormonal and metabolic condition involving androgen excess and insulin resistance. Endometriosis is a condition where tissue similar to the uterine lining grows outside the uterus, typically causing pain. They are different conditions with different causes, and a woman can have both.

Do you need an ultrasound to diagnose PCOS?

Not necessarily. PCOS is diagnosed by meeting two of three Rotterdam criteria, and ultrasound is only one of them. A diagnosis can be made on irregular ovulation plus signs of androgen excess without relying on the ultrasound, and a polycystic-appearing ultrasound on its own does not confirm PCOS.

Does PCOS go away after menopause?

The reproductive symptoms, like irregular cycles, generally settle as hormone levels shift with menopause. The metabolic features — insulin resistance and the associated cardiovascular and diabetes risk — do not go away on their own and warrant lifelong attention.

Sources and further reading

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About the author

Dr. Andres Splenser, MD, FACE, is a board-certified endocrinologist practicing in Houston and Sugar Land. The practice focuses on diabetes, thyroid, PCOS, weight management, hormonal health, and cardiometabolic disorders including fatty liver disease. Bilingual English-Spanish patient services. More about Dr. Splenser →