Ultrasounds are a common topic when it comes to discussing a potential PCOS diagnosis - but why? If you suspect you have PCOS, will your healthcare provider definitely conduct one of these exams? And what can you expect, if you do request one from your practitioner? Ultrasounds, for those who have not received one, can seem intimidating and represent a source of uncertainty, but fortunately they are almost always painless - if a little uncomfortable. But that’s not all there is to them. In most cases, they are a useful tool used by healthcare providers to understand if you qualify for a PCOS diagnosis, or if something else could be at play. In this article, we’ll be discussing how effective ultrasounds are in diagnosing PCOS, what they can show us about the internal workings of our ovaries, and why - even if you do have PCOS - you might never need to receive one for this purpose at all. Let’s discuss.
What is an ultrasound?
Most of us know from either television or personal exposure that an ultrasound is commonly used to confirm pregnancy and monitor the health of a fetus throughout its development, but they also are used for the following:
- Diagnosing gallbladder disease
- Evaluating blood flow
- Helping guide needles for biopsy and/or tumor treatment
- Examining a lump in the breast
- Checking your thyroid gland
- Assessing joint inflammation
- Diagnosing PCOS
According to the United States’ National Institute of Biomedical Imaging and Bioengineering, ultrasounds can fall into two categories: diagnostic or therapeutic. If you suspect you have PCOS and your practitioner orders an ultrasound, it will be diagnostic. This is the type that produces images, and provides “information maps” that help doctors identify abnormalities, monitor developments, or confirm a diagnosis. Most diagnostic ultrasound probes are placed on top of the skin, although sometimes they can also be placed inside the body via the gastrointestinal tract, vagina, or blood vessels.
So how do ultrasounds work? Well, they leverage the use of a small transducer which emits sound waves into the body; this transducer then records the waves that echo back. Ultrasounds are so effective because these same sound waves travel until they hit an area such as fluid, soft tissue, bone, and so on - the different refractions that bounce off these internal walls generate electrical signals that are sent to the ultrasound scanner. These signals are how the scanner can calculate the distance from the transducer to the tissue boundary; the different distances recorded are in turn used to generate two-dimensional images which we, and our practitioners, can see and use to make a diagnosis or gather information.
Ultrasound’s role in diagnosing PCOS
Ultrasounds are sometimes used to help confirm two of the three Rotterdam criteria often used for a PCOS diagnosis (if your practitioner uses this criteria). Not all practitioners will use the same criteria for diagnosing PCOS, which is why it is recommended - if you disagree with your doctor’s conclusion or feel unheard - that you seek a second opinion. Essentially, though, the Rotterdam consensus specifies that a woman needs to display two of the following three criteria:
- Polycystic ovaries
- This is defined as 12 of more follicles measuring 2mm to 9mm in diameter and/or increased ovarian volume >10 cm3
- Lack of ovulation
- This means that you have not ovulated (and thus not had a period) for several months, when there is no other identifiable reason - such as birth control or pregnancy - that could explain the irregularity of your period
- To be considered to have an absent or irregular cycle, you typically need to have less than 8 periods in one calendar year.
- This is characterized by androgenic alopecia, excess hair growth on the face, backs of the legs, arms, chest, and/or breasts, and hormonal acne, and/or lab-tests that indicate an imbalance of androgens (male sex hormones) in the body
The above three criteria are also why some women who are given a positive PCOS diagnosis never experience an ultrasound: if your doctor conducts blood tests detecting a hormonal imbalance, and you report symptoms of PCOS, then they may positively diagnose you without checking for polycystic ovaries. On the other hand, if you do not meet the other two criteria, but you do have cysts on your ovaries, then you won’t be diagnosed with PCOS. Instead, other underlying causes will be evaluated for any irregularities found on your ultrasound. In this sense, an ultrasound can be viewed as an effective supplementary tool to helping diagnose PCOS: it is not prescriptive, and should definitely not be used in isolation, in order to reach a conclusion.
What an ultrasound can show us about our ovaries
Before we dive into addressing this question, let’s back up a bit and discuss what you can expect on the day if you have a transvaginal ultrasound for PCOS.
Most often, this type of ultrasound is performed in your healthcare provider’s office. Your doctor may request beforehand that you drink up to 42 ounces of fluid, in order to fill your bladder, which will make it easier to see your ovaries in the 2D imaging. For this procedure, the lubricated ultrasound probe will be placed inside the vagina, and an ultrasound technician will then take measurements and pictures to share the results with your healthcare provider. The sonographer will also likely not just examine your ovaries, but also examine your uterus and cervix as well. The number of follicles detected on your ovaries will be counted as part of an AFC (antral follicle count).
Now let’s touch on what this AFC is used for in the context of PCOS.
Antral follicles are considered “resting follicles”, and they are typically found in the ovary at the beginning of each menstrual cycle. But hang on - polycystic ovarian syndrome indicates in its name that your practitioner should be looking for cysts. So what do follicles have to do with it? Well, both cysts and follicles are common in women with PCOS, but follicles are especially worth paying attention to because - in women without PCOS - these follicles contain egg cells, and they ultimately mature and get released from the ovaries during ovulation, to potentially be fertilized. Unfortunately, in women with PCOS, these follicles are still produced, but as a result of the aforementioned hormonal imbalance (of which insulin resistance may play a powerful role), these follicles often do not mature or get released thanks to anovulation. This can lead to problems with fertility, as we discussed in our post on the relationship between PCOS and infertility.
Should you ask for an ultrasound if you suspect you have PCOS?
If you suspect you have PCOS, then there is no harm in asking your physician if they will consider running an ultrasound to look for internal signs of PCOS (such as cysts or excess follicles). A good physician will explain why or why not they think this is a good idea; they will address any concerns you may have about the ultrasound, and they will detail what other information they need from you to determine a PCOS diagnosis.
Unfortunately, medical gaslighting is extremely real, especially if you are a BIPOC, identify as LGBT, or come from a low income background - because of this sad reality, it is important that as much as possible you advocate for your own care. That can mean asking follow up questions, switching primary care physicians, or doing your own research when it comes to the signs and symptoms of PCOS. Ultrasounds can be an excellent tool your physician and yourself use to come to an accurate diagnosis - but keep in mind they aren’t everything. Physical symptoms are also incredibly important and not to be ignored. For that reason, we suggest reading our article, Do I Have PCOS?. It can be an excellent resource in your journey to figure out if you have PCOS, and what your journey may look like after a positive diagnosis.
Allara Health provides personalized treatment that takes the guesswork out of managing PCOS, and offers a customized, holistic plan of attack that merges nutrition, medication. supplementation, and ongoing, expert support to begin healing your body.