Can you have PCOS without cysts?

 Key takeaways

• PCOS is a health condition that occurs as a result of hormonal imbalance.
• Although the name “polycystic ovary syndrome” portrays the presence of cysts in the ovary, it is possible to have PCOS without ovarian cysts.
• PCOS cysts aren't cancerous. They're benign (non-cancerous) fluid-filled sacs in the ovary that can rupture or be removed by surgery.

Polycystic ovarian syndrome (PCOS) is a reproductive health condition that is caused by an imbalance of hormones, usually due to high levels of male hormones called androgens. PCOS is one of the most common causes of female infertility, affecting about 6–12% of women in the US and about 8–13% of women globally. 

Usually, the ovary contains many follicles containing immature eggs (ova), but one mature egg (ovum) is released from the ovary every month; this is called ovulation. In PCOS, no egg is released. This might be caused by the excess secretion of androgens by the ovary. The absence of ovulation might lead to the growth of small fluid-filled sacs at the outer edge of the ovary called cysts.

The exact cause of PCOS is unknown, but research has shown that genetics may play a role in its development. Also, obese women are at increased risk of developing this condition. And PCOS increases the risk of developing type II diabetes, hypertension, or some other cardiovascular diseases.

PCOS, as the name implies—polycystic ovarian syndrome—consists of a set of primary symptoms, including:

• Irregular periods or absence of periods 
• Presence of cysts in the ovary on imaging investigation (e.g. ultrasound)
• High levels of androgen in the blood
• Absence or reduced ovulation (anovulation)

At least two of the symptoms listed above must be present for a diagnosis to be made.

 Can you have PCOS without ovarian cysts?

Although having ovarian cysts is one of the criteria for diagnosing PCOS, it is not a mandatory criterion. You can have PCOS without having ovarian cysts. For PCOS to be diagnosed, two or more of the above-mentioned criteria should be present after every other differential diagnosis is ruled out.

 Are the cysts in PCOS large?

Ovarian cysts can be of various sizes, which may depend on the content or severity of the condition. Nonetheless, the cysts in PCOS are usually small in size, about 0.5 cm–0.8 cm. These cysts tend to develop at the outer part (cortex) of the ovary and are mostly filled with fluid and immature eggs that do not get released.

 Can PCOS cysts go away? Do they rupture?

"PCOS cysts do not, on most occasions, go away on their own," said Dr. Oluwatobi Oni, a gynecologist at the Federal Teaching Hospital in Lokoja, Kogi State, Nigeria. But with surgery, medical doctors can remove or reduce the number of cysts in people with PCOS, increasing their chances of ovulating.

"In the past, we used wedge resection surgery for this purpose, but with technological advancement in medicine, a procedure known as laparoscopic ovarian drilling is commonly used," Dr Oluwatobi explained. 

PCOS is a lifelong condition that currently has no cure. However, with proper management—medications and lifestyle adjustments—the symptoms may subside to the point where they do not interfere with your day's work.

Additionally, regardless of the type of ovarian cyst, it can rupture or burst. However, in PCOS, this is very rare because the size of the cysts is usually very small.

Some symptoms of a ruptured ovarian cyst are sudden, sharp pain in the lower back and/or belly, vaginal spotting, abdominal bloating, nausea, and vomiting. If you begin to experience unusual symptoms suggestive of a ruptured cyst, make sure to see your doctor.

 Symptoms of PCOS cysts

"PCOS cysts rarely cause any symptoms," said Dr. Oluwatobi. "Nonetheless, if an ovarian cyst gets infected, regardless of the type, it can cause pain to the patient, and depending on the severity, it may also result in some other symptoms such as nausea, vomiting, bloating, and fatigue."

Generally, PCOS symptoms differ from person to person. Possible symptoms may include:

• Heavy, long, Irregular, or absent periods
• Excess acnes 
• Abnormal hair growth on the face, chest, back, or other unusual places (hirsutism)
• High androgen levels in the blood (hyperandrogenism)
• Polycystic ovary on ultrasound scan
• Hair thinning or male-pattern baldness
• Unusual weight gain
• Infertility
• Dark velvety patches on the neck, groins, and back (acanthosis nigricans)
• Presence of skin tags

 Can you have PCOS without symptoms?

It’s not possible to have PCOS without having its symptoms. PCOS involves a set of symptoms, such as irregular menstruation, abnormal excess hair growth, and high androgen levels, which must be present before it is called PCOS. If you are experiencing any such unusual symptoms, it is best to visit the hospital for a proper medical check-up.

 Can you experience PCOS symptoms without having PCOS?

Yes, it's possible to experience some of the symptoms of PCOS without having PCOS. Some other health conditions can mimic the symptoms of PCOS, e.g., thyroid disease, high prolactin levels, Cushing's syndrome, and congenital adrenal hyperplasia.

A case study carried out on a 20-year-old lady who was initially thought to have PCOS found that her actual diagnosis was functional hypothalamic amenorrhea after a clinical and biochemical profile investigation [⁴].

Therefore, if you're experiencing symptoms suggestive of PCOS, it's best to visit a gynecologist for a proper examination. Your symptoms might be signs of another condition that is not PCOS.

 Are PCOS cysts cancerous? Can they be removed?

PCOS cysts are not cancerous. They are benign growths of fluid-filled sacs. However, research has shown some links between PCOS and endometrial cancers. Endometrial cancer may be linked to the absence of ovulation in people with PCOS, causing their endometrium to thicken, leading to endometrial hyperplasia, which poses a risk of cancer. 

Research also suggests that PCOS can increase the risk of a woman developing certain cancers, e.g., ovarian and breast cancers. However, this is still a debate and is inconclusive.

PCOS cysts can be removed through a surgical procedure known as laparoscopic ovarian drilling. This is considered a minor surgery. It involves the insertion of an instrument, known as a laparoscope, into the lower abdomen via a small incision on the abdominal wall. This allows the surgeon to view the ovary while removing the cysts.

 Wrap up

Polycystic ovary syndrome (PCOS) is more common than we think. About 70% of cases are undiagnosed. This is because the symptoms of PCOS may be mild that they don't interfere with the individual's life. Most women find out they have the condition only when they go for infertility treatment.

Having ovarian cysts does not imply you have PCOS. There are criteria for its diagnosis. Also, you can have PCOS symptoms without having PCOS. All in all, it is important to visit a doctor when you start experiencing any unusual symptoms.