PCOS Testing and Diagnosis: In this episode, we talk about the testing and labs for a diagnosis for PCOS. These testing and labs are also a good way to monitor PCOS.
Ultrasound: Checking for multiple cysts on or in the ovaries. It is still very common to have PCOS but have not cysts ( string of pearls ).
LH: FSH ratio:
DHEA-S:
Testosterone:
Estrogen
Vast reference typical reference ranges for most labs:
Progesterone:
The Triad risk for Diabetes:
Hemoglobin A1C:
Cortisol:
Thyroid function is lowered:
If you have questions, leave a comment or send an email to [email protected]. Also, download our free hormone video series on PCOS, Perimenopause, Menopause, and Hypothyroid.
Thank you for being part of our Progress Your Health community
PYHP 062 Full Transcript:
Dr. Maki: Hello, everyone. Thank you for joining us for another episode of the Progress Your Health podcast. I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: So on this episode, we’re gonna continue our series, our PCOS series. Today, we’re gonna talk about lab testing and diagnosis. So, Dr. Davidson, why don’t we kind of just dive right in and get started?
Dr. Davidson: Yeah, absolutely. So, last time we talked about what PCOS is and described it. This one, we’re going to talk about testing and diagnosis. And of course, when you’re thinking about Polycystic Ovarian Syndrome, you’re thinking about cysts on the ovaries. So one of the first tests or testing that a doc would do with D and transvaginal ultrasound to actually look at your ovaries to see if you’ve got cysts.
Dr. Maki: Yeah, right. So maybe someone’s experiencing some pain. Maybe literally they could have a ruptured cyst. We’ve had lots of stories over the years where patients are having a lot of discomfort. They go to the gynecologist and they do an ultrasound. And sure enough, they find cysts or like we talked about in the last episode, they go in to do the ultrasound and there is no cysts which can easily happen as well too.
Dr. Davidson: Yes. So one definitive diagnosis when you’re looking for PCOS is, if you go and do a transvaginal ultrasound and you see a string of pearls, a bunch of cysts that looks literally like a string of pearls on the ovaries, then you can pretty much say 100 percent that person has PCOS. Now, like we said on the other podcast, women with PCOS don’t normally have cysts. It’s actually not as common as you think. In fact, actually having a follicular cyst or a simple cyst is quite normal for us females. But in PCOS with women, you might not even see those cysts. But definitely, first thing off is you wanna get a transvaginal ultrasound.
Dr. Maki: Right, yeah. And that’s obviously a very conventional approach to do the ultrasound. That’s usually the first step in this process. And then there might be some follow-up bloodwork that comes in on the backside. We kind of do it in the opposite direction. We always do the bloodwork first. And depending on that bloodwork, we may or may not do the ultrasound. We may not have to do the ultrasound. They might have had that in the past. But we’re always kind of on the lookout, so to speak, for PCOS diagnosis anyways.
Dr. Davidson: That’s why we wanted to do this podcast on the diagnosis is because a lot of times women aren’t getting what we think would be the proper testing to check for PCOS, ’cause one of my most favorite tests to check for PCOS is to do a blood test on the Follicle Stimulating Hormone, which is abbreviated FSH (Follicle Stimulating Hormone) along with the Luteinizing Hormone, abbreviated LH.
You do what’s called a ratio. So an FSH to an LH ratio in women with PCOS will have that LH (The Luteinizing Hormone) usually double or more to that FSH, which definitely points you in the direction of PCOS. So like for example, you run an LH in a woman’s LH is 14 and her FSH is seven. That’s a 2 to 1 ratio. So that definitely makes you say, Hey, we need to go look at the PCOS and do some more testing too, and also get their subjective information as well .
Dr. Maki: Yeah, right. And I think FSH and LH levels are done routinely by a gynecologist or a primary care doctors, but I don’t think they necessarily know a lot of times what those numbers even really mean.
Dr. Davidson: Exactly, or they might only do an FSH and not the LH. And the FSH is a great test. It tells you, like if I were in perimenopause or going into menopause, it’s a great way to tell you where you’re at in terms of that transition. But for PCOS, you’ve gotta have that LH in there. And then do, you know, the math is easy and sometimes it might be that the LH might be 20 and the FSH is five. So anything two to one or more for that LH to FSH ratio is really what you’re looking at with that. And one of the main reasons behind that is because with PCOS, like we talked about, is one hallmark is those high levels of androgens.
Dr. Maki: Right. Yeah. So the first androgen that you would expect almost in most PCOS cases, but sometimes it is elevated, sometimes as normal is DHEA or we like to test for DHEA sulfate.
Dr. Davidson: DHEA sulfate is probably a little bit more accurate or specific when you’re looking at levels of DHEA for a female. Doing a total DHEA doesn’t give you a whole lot ’cause pretty much everybody kind of falls into the same level. Now, I got to say, on the flip side, these reference ranges which we’re going to go through with you are huge and vast and it’s hard to differentiate. So, for example, DHEA sulfate has a very big reference range. So, of course, DHEA comes from our adrenal glands, its highest when we’re young, you know, like 20, 25 and then it comes down with time.
So when you’re 90, your DHEA is gonna be considerably lower than when you were 25. But for example, let’s say a female is 35 years old and we want to check her DHEA sulfate because we’re considering that her DHEA might be a little elevated pointing to PCOS. The reference range for a DHEA sulfate for a 35-year-old female is 23 to 266 micrograms per deciliter. 23 to 266 is a huge reference range.
Dr. Maki: Yeah. Right. Yeah. So we do DHEA sulfate pretty much on every menstruating woman and even non-menstruating women because as we said on the last ones, sometimes you don’t know whether that number is going to be high or low. If that number is let’s say in the low 20s or the low 30s or anything even below 100. But then you go all the way up to the high 200s, that woman is going to feel in some ways completely different on one end of that spectrum to the other.
Dr. Davidson: So for the sake of looking at the lab reference values, you can pretty much say, let’s say a 35 year old female considering PCOS, if that DHEA sulfate is 200 or more, then you definitely want to delve into looking more into that PCOS diagnosis ’cause typically if you might see it at 150, 177, over 200, you start saying, you know what, if you’re not taking DHEA as a supplement and you’re DHEA is over 200, even if you’re in your 30 to 45, you’re checking them. Even 30 to 45, if it’s over 200, then that’s gonna strike a little flag saying, Hey, you know what, that’s looking like it’s kind of a little bit on that high end . Then, of course, you’d want to jump into the testosterone.
Dr. Maki: Yeah, right. And there might be, especially if some of those physical characteristics start to show up. There is some acne, there’s some hair growth in unwanted places. And then you look at a number like the DHEA sulfate that’s high normal, certainly that is going to be a red flag. Testosterone Reference Range for testosterone for a woman, it doesn’t really change much but 2 to 45, 8 to 48, depending on which lab you’re using. Again it’s a huge range but when that number- where would you say, when you start to suspect- when the number is in the, maybe the mid-30s.
Dr. Davidson: Exactly. So like you were saying, Quest has a reference range of 2 to 45 nanograms per deciliter. That’s huge. 2 to 45 in LabCorp is at 8 to 48 and I think some other labs might have it up to 55 depending on the age.
But whenever you see that testosterone over 35, that’s gonna spark a little interest in you and say, Hey, you know what, this has a little higher to high normal values of testosterone, which is an androgen like the DHEA, that’s gonna make you want to look and into that PCOS diagnosis. So one thing I didn’t mention earlier is one beautiful thing about DHEA, because it’s really a great hormone, is DHEA can convert to testosterone for us ladies. So it’s a way for us to be able to get our testosterone levels. So if you do see that higher normal or high level of DHEA, you can pretty much assume that it’s converting into testosterone. Then you check the testosterone and if it’s over 35, you know that you definitely wanna look at that PCOS diagnosis.
Now, there are plenty of women with actual, you can see it right off the bat that PCOS and their DHEA is well over 200 and their testosterone is like 90. It’s double the reference range. But those of you that might get missed with the PCOS is definitely looked at that high to normal Testosterone as well.
Dr. Maki: Yeah, right. Yeah. So hypothetically, you go in, you get an ultrasound. There’s no cysts. You get a DHEA that’s high. Normally get a testosterone is high normal. But they’re all you have a negative ultrasound, high normal. Well, at that point, what can you diagnose? You can’t diagnose anything at that point because everything’s in the reference range. That’s why when something is approaching there, especially if there’s clinical presentation, then you can assume that that is an actual diagnosis.
Dr. Davidson: Exactly. You wanna put that clinical presentation together along with what their health goals are or how they’re feeling. You know, Hey, I’m gaining weight and my hair’s falling out or I’m considering, you know, possibly pregnancy, but I haven’t been able to get pregnant . Why? It could be part of this kind of this diagnosis of PCOS. Now, later in the series of PCOS, we’re gonna go into the different types that we see and why some people get missed and why some people don’t get missed.
Dr. Maki: Right. So, of course, we’re talking a female hormone issue. So, of course, estrogen has to be part of that conversation. Some doctors don’t even test estrogen levels that they might do a total estrogen. We prefer almost invariably to do an estro dial level.
Dr. Davidson: And again, if you look at the typical reference ranges, they are huge. They’re looking at stuff they called the follicular phase, which would be day one to day 11, 19 to 144 picograms per milliliter. And then mid cycle, which would be your typical ovulation, would be 64 to 357. That is a huge reference range. Not to mention the Ludio phase, which is supposed to be post-ovulation is vast as well. But what we do find in PCOS is that the estrogen levels don’t necessarily drop. They have the higher levels of the androgens, but they still have levels of estrogen as well.
Dr. Maki: Yeah, right, and one thing that you would see often in a PCOS patient, if they’re not having a regular period, then you know something is not really quite right with their estrogen. If they’re having a regular period, then you can make some assumptions about estrogen levels if they’re cycling every single month. Again, it’s part of the complication of PCOS. Those androgen start to get to be a little bit too high and now the normal female rhythm starts to get thrown off.
Dr. Davidson: Exactly, which leads you to the other most important female reproductive hormone which is progesterone. Now classically in PCOS and pretty much all the types which we’ll go over the next couple of podcasts or the next podcast is progesterone is low. That’s pretty much another hallmark that usually gets missed. Like everyone thinks PCOS, high androgens, high testosterone. But really another hallmark is the low progesterone.
Dr. Maki: Yeah. Right, and that could create a having a low progesterone and we use progesterone the time with patients as a way to help them feel better, but also to kind of change a little bit of the hormonal signalling that’s happening as well. So why don’t we run through kind of where their progesterone levels would be?
Dr. Davidson: Now, if there are plenty of women that have PCOS that have a period every single month. And if they do, that’s great. It’s really easy to test their progesterone levels. You want to check it between day 16 and day 35, 28 to 35, depending on how long their cycles are, ’cause sometimes in PCOS, women can have a little bit longer cycles. But anywhere from day 16 to their next period is a great time to check for progesterone. But again, on that flip side, there’s a lot of women with PCOS that don’t have regular periods. They might miss six months. They might miss three months. They might miss every other month. And then they’re also women with PCOS that have had their uterus taken out. They have had an ablation because they had such heavy periods. So they had a uterine ablation to diminish that. That makes it a little bit more tricky in determining what their progesterone levels are.
Dr. Maki: Yeah, because you don’t have the landmark of the periods. So how do you decide what day they’re on? So usually we recommend in the beginning, when you don’t have a day to start with, right? You don’t have a way to keep track of it month by month, then you just pick a random day, go any time. It doesn’t matter. And then we can test it shortly thereafter and then see the difference between those numbers and maybe get some kind of a conclusion from that. Or maybe the number is pretty much the same thing, which would be common in a patient with PCOS anyways.
Dr. Davidson: So for example, let’s say, Hey, I’m missing periods or I had an ablation, so I don’t know when my period would be coming , is I’d say go get your blood work done right now. And if the progesterone shows up at less than 1 or less than 0.5 nanograms per milliliter, you think, okay, that level is low. Then we wait about two weeks, maybe three, and we retest it because then you’ll see, Hey, look, that progesterone rose up because that’s what’s supposed to happen in a typical cycle . And a woman that has had a hysterectomy or they they’ve had an ablation, they’re still gonna be cycling. You just can’t follow it in terms of the period. So, we do that first one of that progesterone, then maybe two, three weeks later, we check the progesterone level again. If it’s still less than 1 or less than 0.5 nanograms per milliliter, then you’re then you can definitively say, “Hey, you’ve got low levels of progesterone.”
Dr. Maki: Yeah, right. And for a woman that is cycling or doesn’t have a uterus, you can’t really give them estrogen, right? They’re not really a candidate. But for women of all the different age ranges, giving them progesterone can be very beneficial in how they feel. Not to mention that the clinical benefit of adding a hormone in like that ’cause, like you said, especially in a case like this, they have usually more progesterone deficiency than estrogen dominance, so to speak.
Dr. Davidson: Exactly like you said, adding in some progesterone. There’s also lots of supplements and herbs that can help modify and balance that and work with your progesterone as well. So that’s looking at kind of what when people think of PCOS, they’re thinking the hormones, the progesterone, the androgens. But there are other hormones that are just as affected in PCOS than these female hormones or the testosterone of the DHEA in particular, which Dr. Mackey loves to talk about, which we all do, is the insulin levels. In PCOS, you’ll see the higher levels of insulin.
Dr. Maki: Now we get a little frustrated or at least I get a little frustrated because a lot of doctors don’t even test insulin levels or a fasting insulin. We test them just like the DHEA and testosterone. Specifically, for this reason, we want to see a fasting insulin, because if that number is greater than 10 on a fasting insulin, we can make some assumptions, especially if we know if we couple that with these other numbers. Now, it paints a very specific story, even though that story might not be completely a classic representation. Things are starting to lean in a particular direction. So ideally, a fasting insulin should be less than five. Less than seven would be appropriate once it gets into those double digits. And the higher it is now, you can feel pretty confident that is really kind of the underlying mechanism that is driving all those female hormone issues and the high androgens.
Dr. Davidson: And we kind of call it the triad. So what you’ll see is you’ll see higher levels of insulin, and granted the insulin reference range is huge. It’s like 2 to 19 or 2 to 20 IUs per milliliter and reference in labs. Ignore that. Like Dr. Maki said, ideally anything under 5, 5 to 7. Anything over 9 to 10, then you know they have higher levels of insulin. But the triad we talk about is higher levels of insulin, high triglycerides, which is part of a cholesterol panel and then possibly high glucose.
Dr. Maki: Yeah. Right. So a normal glucose level, again, fasting glucose levels can be a little bit misleading. Just because that number is under 100 doesn’t make it ideal. I think a good like a really ideal range for a human is probably right around 85, 83 to 87, something like that when you start to get into the mid-90s and above. Now you can assume that there some other issues going on there. And I would say the 85 range is normal, not very common. An American with a blood sugar of 95 and above I think is very common but not normal. And that is something that that I think happens an awful lot. We just take these numbers in the high 90s as being in the normal reference range. But I think it’s telling a story that it’s leading to a problem or that problem already exists.
Dr. Davidson: Exactly. So if you have high normal glucose, higher levels of insulin, especially over 9 or 10, and then the triglycerides, like I said, which is on it, cholesterol panel, ideally you want your triglycerides 150 or below. If you see those triglycerides right around 150 or higher, then you’re looking at that triad which the consequence is insulin resistance and diabetes type 2. That’s the risk factor there. There’s another kind of interesting equation that I want to let Dr. Mackey kind of explain, which gives you an idea what your actual insulin resistance status is.
Dr. Maki: Yeah, it’s basically just an insulin-resistant calculation. And this, again, as we talked about last time, this is kind of like the underpinning or the underlying reason as to where the PCOS comes from, and it’s called the HOMA-IRs or H-O-M-A, and it’s literally just a calculation. So you take insulin, multiply it by glucose and then you divide that by 4 or 5. So a typical insulin that we would see would be, let’s say, somewhere between 7 to 12. You know, the higher the number, the worse it is. A fasting glucose would be somewhere in the let’s say the 90 somewhere. You multiply the insulin times the glucose, you divide that by 4 or 5 and that gives you a score that gives you a number usually in the lower digits, 1 or less is optimal, right? That means that that person is insulin sensitive, meaning their body is responding to insulin very well. Once that number gets to be like 1.9 and above, maybe 2.0 and above, they have kind of mild early-stage or kind of mild to moderate insulin resistance. Once that number is above 3, then you can determine that they probably have significant level of insulin resistance. And more than likely, like you just said, Dr. Davidson, that their triglycerides are gonna be elevated. They’re gonna have probably baby cysts on their ovaries, their testosterone DHEA is going to at least be high normal, it’s really going to paint that picture and that HOMA-IRs or something that you can track over time as well, because if you there are improving and they’re becoming more insulin sensitive now that HOMA-IRs score is going to actually start coming down?
Dr. Davidson: Yes. So you’d be able to see that as you’re going along with the treatment or with your health goals. So, I know that’s a little complicated. I’ll definitely put that HOMA-IR into the show notes so that you can read it and see the calculation and see the equation. And I’ll put an example on there too so that perhaps if you have your levels or you’re going to have your levels tested, you can have this equation to be able to check your IR score. So and then, of course, that the next one, which I’m sure a lot of people already know about, is your hemoglobin A1 C.
Dr. Maki: Yeah, and that one has gotten to be very popular over the last several years. If you’re a non-diabetic, that number can be a little bit confusing. But it should be, I remember when you and I first started the practice a long time ago, anything under 6 was considered to be normal. And now the reference range is already down. Some labs it goes down to like 5.6. So they’ve really kind of tightened up that reference range. They are using that number to be kind of a diagnostic number. So if that number is elevated, now, though, your doctor might tell you that you’re pre-diabetic. Pre-diabetic and insulin resistance in some ways is kind of the same thing. At least that’s the way we view it. But I think it’s a little bit unfair if your number is 5.6, 5.7, 5.8 and your doctor says you’re pre-diabetic. You can’t base it solely on that one test. You gotta have a little bit more information on the things we’re talking about, a higher normal glucose, a high fasting insulin, elevated triglycerides to really see if someone is either insulin resistant and or pre-diabetic, which in our mind is kind of the same thing.
Dr. Davidson: I absolutely agree but I still love the hemoglobin A1 C tests. So anything over 5.7 percent, you’re gonna have to put this picture together, put all the data together to say, hey, this is really pointing in that – definitely that insulin resistance, which is part of that PCOS picture. And then, of course, cortisol. Everybody loves talking about cortisol. Cortisol is a hugely important hormone in our body. But at the same time, too much of a good thing isn’t a good thing.
Dr. Maki: Yeah, right. And testing cortisol for a normal, relatively healthy person, testing it through blood is really not the best way to do it. Honestly, that’s why we do. The other reason why we do DHEA sulfate a lot because you can infer a little bit about cortisol through DHEA and doing blood work, the DHEA is easier to do or more accurate than doing the cortisol. So the best way if you want to assess cortisol, the best way to do that would either be a saliva test, which usually to provide for samples morning, noon afternoon and night. That can be all but time-consuming. Usually that is an out of pocket expense because most insurance companies do not cover salivary testing. The newer tests that a lot of people are aware of nowadays is also doing a Dutch test, which is a dried urine test, kind of a newer technology.
Dr. Davidson: But like Dr. Maki is mentioning is cortisol is secreted in a diurnal curve. So it’s supposed to be highest in the mornings or bright-eyed, bushy-tailed, and then it comes down at night. And truly, the saliva or the urine test is the best way to accurately see what your diurnal curve is of cortisol. Now, usually with PCOS, what you’ll see is that cortisol is low in the morning, which is why it’s tired and hard to get going. And then you’ll see that cortisol come up at night, which is why the food cravings come in and it’s very hard to go to sleep at night. So it’s a really good test, not just for PCOS but also just in general with checking the adrenal glands.
Dr. Maki: Yeah, I think that that gets missed an awful lot. In conventional medicine when it comes to cortisol, the only things they really consider to look at whether you have Cushing’s disease, which is an excess of cortisol or if you have Addison’s disease, which is an insufficiency of cortisol. But those two are on the extreme ends of the spectrum. I definitely think there is a subclinical Cushing’s, there’s a subclinical Addison’s that no one really ever talks about. It’s almost like they just kind of blow it off. And I think that is a huge, especially in PCOS. This plays a very big role in in the development, the progression of PCOS over time.
Dr. Davidson: And then another test that kind of gets missed with PCOS because everyone’s focusing on the reproductive hormones and the androgens is the thyroid function. Pretty much I’d say 95 percent of all PCOS women that we deal with have some type of lowered thyroid function. Now, do they have thyroid disease? No. But they’re still have some that hypothyroid or Hashimoto’s in conjunction. But you do see that thyroid function tends to drop with PCOS.
Dr. Maki: Yeah. Right, and we could maybe even make the, as we’re talking about the insulin and the insulin resistance, there’s definitely a connection between insulin sensitivity and thyroid issues. So as they become more insulin sensitive, their thyroid numbers are going to improve over time. But we see all the time. We see these high normal TSH numbers. We see low, normal 3T3 numbers. And if pregnancy is part of what they’re trying to accomplish, approaching and improving thyroid function is necessary in their success.
Dr. Davidson: Exactly and it doesn’t mean you have to go out and throw them on a bunch of thyroid medication, which some people that does qualify for. But there’s lots of things you can do with PCOS to help raise up that thyroid function, because having a lower thyroid function almost like compounds that PCOS symptoms, because lower thyroid is going to reduce your metabolism, is going to make your hair fall out more. It’s gonna make you tired. And then you’ve got this, and then like Dr. Mackey was saying, with fertility and, with, gosh, with pregnancy and even when thyroid is low, especially that low T3 or even a low normal T3 can really set people up also for miscarriages, it increases the risk of miscarriage.
Dr. Maki: Yeah. Right. So thyroid, even though it’s not a female hormone, it is one of those major metabolic hormones just like insulin and cortisol that can have a huge impact on their on their eventual success. So before we forget, if you would like more information about PCOS and a few other very common female hormones, you can visit our website progressyourhealth.com. Right on the home page, you can enter your email to get access to our short free hormone video series. We go through PCOS, we go through a hypothyroid, you go through menopause, peri-menopause. We have some profiles there about what those things look like. Very good. You just enter your email, you get direct access to it right away.
Dr. Davidson: Absolutely. And then I’m on the video. So you get to see me up close and personal.[chuckles] But with the show notes, I’ll definitely write these up and also put down the typical reference ranges. And then what we’re looking at, too because, like Dr. Maki was saying with the thyroid, the TSH, I’ll have the reference ranges on there and the T4 the T3 so you can look at where, if you’re looking at your own T3 and you see it at 2.2, you know, you’ve got lower T3 function. So I’ll put that all together for you.
Dr. Maki: Yeah. So I think we cover what we wanted to cover for this one. The next couple of episodes, we’re going to actually talk about the different types of PCOS. There’s not just one or we at least we don’t think there is. It’s not a matter whether you have it or not. It’s kind of where you fit in the continuum or the spectrum of PCOS. So do you have anything else to add for this one, Dr. Davidson?
Dr. Davidson: No. This was great.
Dr. Maki: Okay. Alright. Until next time. I’m Dr. Maki.
Dr. Davidson: I’m Dr. Davidson. Take care. Bye-bye.
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