Not every young woman with irregular periods and multiple ovarian follicles has PCOS.
In recent years, more young women have been told they have Polycystic Ovarian Syndrome (PCOS)—often after a single ultrasound or a brief evaluation. For many, the diagnosis comes with fear. A quick online search brings up infertility, insulin resistance, weight gain, and increased risk of diabetes.
According to Steven R. Goldstein, a leading Gynecologist in NYC, this fear is frequently unnecessary. In his clinical experience, a growing number of young women diagnosed with PCOS do not actually meet the full criteria for the condition. Instead, they are experiencing a normal stage of reproductive maturation. Let’s unpack what’s happening—and why careful evaluation matters.
Why So Many Young Women Are Being Told They Have PCOS
Dr. Goldstein has seen numerous teenage girls and women in their early twenties come into his office distressed after being told they have PCOS. The typical scenario goes something like this:
A young woman has slightly irregular periods.
- An ultrasound is performed.
- The ultrasound shows multiple small follicles in the ovaries.
- She is told she has “polycystic ovaries.”
- The diagnosis quickly becomes Polycystic Ovarian Syndrome.
But here’s the critical point: polycystic ovaries on ultrasound do not automatically equal PCOS.
Many adolescents and young adults naturally have multiple small follicles in their ovaries. This can be a completely normal finding during the years when the menstrual cycle is still maturing.
Understanding the Hypothalamic-Pituitary-Ovarian (HPO) Axis
To understand why irregular periods are common in teens and young women, we need to briefly review how the reproductive system matures.
The menstrual cycle is regulated by a hormonal communication system called the hypothalamic-pituitary-ovarian (HPO) axis. This axis involves:
The hypothalamus (in the brain)
- The pituitary gland
- The ovaries
In adolescence, this system is still developing. It takes time for the hormonal signaling patterns to become consistent and cyclical. During this maturation process, irregular periods are extremely common—and often completely normal.
Slight cycle irregularity in a 17-, 18-, or even 21-year-old is not automatically pathological. In many cases, it is simply biology at work.
The Rotterdam Criteria: Where Confusion Can Begin
Much of the over-diagnosis issue stems from how PCOS is defined.
According to the internationally recognized Rotterdam Criteria, a woman may be diagnosed with PCOS if she has two out of three of the following:
1. Irregular menstrual cycles
2. Elevated androgens (either clinically or on blood tests)
3. More than 12 follicles in one ovary on ultrasound
On the surface, this seems straightforward. However, modern clinical realities complicate the picture.
Issue #1: Irregular Cycles in Adolescence
As mentioned, irregular cycles are common in younger women because the HPO axis has not fully matured.
Issue #2: Ultrasound Technology Has Improved
Today’s high-resolution transvaginal ultrasounds are far more sensitive than those available when the Rotterdam Criteria were first established. As a result:
- Many completely healthy women have more than 12 follicles.
- Studies suggest that up to 50% of normal women may meet the follicle threshold using modern imaging.
This means a young woman with slight cycle irregularity and multiple follicles on a sensitive ultrasound may technically meet “two out of three” criteria—even if she has no hormonal abnormalities. And that is where mislabeling can occur.
What True PCOS Typically Looks Like
Dr. Goldstein, a top NYC Gyn, emphasizes that classical PCOS usually presents with additional, more specific findings. Traditionally, women with PCOS often have:
- Obesity or significant weight challenges
- Male-pattern hair growth (especially on the chin or face)
- Elevated androgen levels (such as testosterone or DHEA-S) on bloodwork
- Persistent ovulatory dysfunction
PCOS is fundamentally a hormonal disorder characterized by androgen excess and ovulatory dysfunction—not simply the presence of multiple follicles.
In contrast, many of the young women seen by Dr. Goldstein:
- Are not obese
- Have no clinical signs of androgen excess
- Have normal androgen levels on laboratory testing
- Are otherwise extremely healthy
These women do not fit the classic PCOS profile.
“Multicystic Ovaries” vs. Polycystic Ovarian Syndrome
Dr. Goldstein uses a helpful distinction: many of these patients have what he refers to as multicystic ovaries, not Polycystic Ovarian Syndrome.
This distinction is important.
Multicystic Ovaries:
- Common in adolescents and young women
- Often reflect normal ovarian activity
- Not associated with hormonal abnormalities
- Typically resolve as cycles mature
- Do not inherently increase future health risks
PCOS:
- Endocrine disorder
- Associated with androgen excess
- Linked to metabolic risks
- Can affect long-term fertility
- Often requires ongoing medical management
By labeling multicystic ovaries as PCOS, we risk medicalizing a normal developmental phase.
The Emotional Toll of a Premature Diagnosis
The psychological impact of a PCOS diagnosis in a young woman can be profound.
Patients often leave their initial appointment believing:
- They may struggle with infertility.
- They are at high risk for diabetes.
- They will gain weight uncontrollably.
- Their health outlook is compromised.
Dr. Goldstein, a top Gynecologist in Manhattan reports that many of these women arrive at his office distraught. They have spent hours researching worst-case scenarios online. In reality, many of them are completely healthy young women whose bodies are simply still calibrating hormonally.
A premature diagnosis can create anxiety that lingers for years—especially when it concerns fertility and long-term health.
What Happens Over Time?
In Dr. Goldstein’s experience, the overwhelming majority of these young women:
- Develop regular menstrual cycles in their mid- to late twenties
- Have normal fertility
- Do not develop insulin resistance
- Do not show increased risk for diabetes
As the HPO axis matures, cycles stabilize. The ovaries continue functioning normally. The body does what it was biologically designed to do.
Time, in many cases, is the most important “treatment.”
Why Proper Evaluation Matters
A thoughtful evaluation for PCOS should include:
- Detailed menstrual history
- Assessment of weight and metabolic health
- Clinical evaluation for androgen excess
- Appropriate laboratory testing
- Careful interpretation of ultrasound findings
Ultrasound alone should never determine the diagnosis.
In adolescents especially, major medical organizations caution against diagnosing PCOS too early unless clear androgen excess is present and symptoms persist over time. A diagnosis with lifelong implications deserves careful consideration.
The Metabolic Component: A Key Differentiator
True PCOS is often associated with insulin resistance. Over time, this can increase the risk for:
- Type 2 diabetes
- Cardiovascular disease
- Metabolic syndrome
But these risks are typically seen in women who have clear metabolic dysfunction—not in healthy young women with isolated ultrasound findings.
If a patient is lean, metabolically healthy, hormonally normal, and simply has slightly irregular cycles at age 19, the long-term outlook is usually excellent. Context matters.
When Should PCOS Be Considered Seriously?
PCOS should be strongly considered when a woman has:
- Persistent cycle irregularity well beyond adolescence
- Clear signs of androgen excess
- Elevated androgens on lab testing
- Obesity or insulin resistance
- Difficulty ovulating over time
In such cases, early intervention can be beneficial. But labeling every young woman with multiple follicles as having PCOS dilutes the meaning of the diagnosis.
The Importance of a Second Opinion
If you have been told you have PCOS—especially at a young age—and your only findings were irregular cycles and an ultrasound showing multiple follicles, it may be worth seeking further evaluation.
A second opinion can clarify:
- Whether androgen levels are truly elevated
- Whether metabolic risk is present
- Whether the menstrual irregularity is simply part of normal maturation
An accurate diagnosis provides reassurance when appropriate—and targeted care when necessary.
A Reassuring Perspective for Young Women
The key takeaway from Dr. Goldstein’s clinical experience is this:
Many young women diagnosed with PCOS do not, in fact, have the syndrome.
They have:
- A developing reproductive system
- Normal hormonal fluctuations
- Multicystic ovaries that are common and benign
And most importantly, they have excellent long-term reproductive and metabolic health. Medicine must balance vigilance with restraint. Not every variation from textbook “regularity” represents disease.
Final Thoughts
Polycystic Ovarian Syndrome is a real and important condition that deserves proper diagnosis and management. However, over-diagnosis—particularly in adolescents and young adults—can cause unnecessary stress and medicalization.
According to Steven R. Goldstein, a top Obgyn in Manhattan, many young women who have been labeled with PCOS are simply experiencing a normal phase of reproductive development.
If you have concerns about a PCOS diagnosis or would like a careful, individualized evaluation, consider consulting an experienced specialist like Dr Steven R. Goldstein. An informed, nuanced approach can provide clarity, reassurance, and peace of mind—without attaching a lifelong label that may not apply.
