The Mental and Physical Toll of PCOS

Remember the infamous bearded lady showcased as a circus attraction in Barnum & Bailey’s freak shows? You may have seen depictions of her in The Greatest Showman or Ripley’s Believe It or Not! museums. It turns out that she wasn’t that freaky after all. Annie Jones, the “Bearded Woman,” likely experienced extreme hirsutism, or “male-like” facial hair growth, as a result of having a high amount of male hormones.^[18] However, many females with high amounts of male hormones will have coarser or more visible facial hair growth, but not a full beard. Other famous “bearded women” from history and myth include Josephine Clofullia, Jane Barnell, and the witches from Shakespeare’s Macbeth.^[7]

Polycystic ovary syndrome (PCOS), (update: as of May 12, 2026, PCOS is now called Polyendocrine Metabolic Ovarian Syndrome (PMOS)), is a hormonal disorder that is diagnosed when at least two of the following are present: menstrual abnormalities, excess of male “androgen” hormones, and/or ovaries with polycystic structure (morphology).^[10,18]

Symptoms present in women with PCOS may include:^{[2,3 4,18,19]}

• mood instability
• male-like facial hair growth (hirsutism)
• weight gain or a hard time with weight loss
• oily skin and acne
• difficulty becoming pregnant
• menstrual misses or irregularities

Other health complications linked to PCOS are:^{[1,4,11,12,17]}

• type 2 diabetes
• obesity
• infertility
• metabolic syndrome
• inflammatory gastrointestinal tract issues
• mental health issues
• insulin resistance
• increased risk for cardiovascular disease, breast cancer, and endometrial cancer

PCOS is complicated because many different factors can contribute to it, including genetics, environment, lifestyle, and stress. It is also a heterogeneous condition, meaning not everyone will present with the same symptoms, and symptoms may sometimes overlap with those of other conditions.^{[1,4,5,10,19]} This makes diagnosis challenging.

Physical health plays a major role in PCOS symptoms. Hormones such as insulin, estrogen, testosterone, and others that regulate ovulation can become dysregulated.^[2] Insulin resistance is very common in people with PCOS. It occurs when the body does not respond properly to insulin, the hormone that regulates sugar in the blood after eating. This may lead to higher blood sugar levels, weight gain, difficulty losing weight, and increased androgen production.^{[2,9,15, 8]} It is typical for PCOS symptoms to worsen over time through a “bidirectional feedback loop” or “positive feedback loop.”^[2,18] For example, weight gain can worsen insulin resistance, which can lead to increased weight gain. Other cycles may include the relationship between insulin resistance and high testosterone or between low estrogen and metabolic syndrome (MetS). These cycles can make the condition harder to manage.

Epigenetics, when the environment changes genetic expression, may also influence PCOS. A person may inherit genes that increase their risk for developing the condition, but environmental factors such as diet, stress, illness, or trauma can affect whether those genetic risks result in PCOS.^[8,14,18] A common analogy to imagine is a light switch; when trauma occurs, the gene’s switch is flipped “on” or “off.” In this way, genetics, life experiences, and even certain lifestyle choices may contribute to the condition.^[16] This is important to understand because PCOS is highly heritable.^[8,13,18] In fact, there is a fivefold increased risk for the daughter of a woman with PCOS to be diagnosed with it as well.^[14] 

Mental health is another important part of PCOS, especially when stress or trauma collides with epigenetics. Symptoms like weight gain or excess hair growth can impact self-esteem and emotional wellbeing. Many individuals with PCOS reportedly experience higher levels of stress, anxiety, or depression.^[6] Stress can worsen physical symptoms, emphasizing how closely mental and physical health are connected.

PCOS treatments target individual symptoms and do not necessarily help the “problem” as a whole.^[13] Some medications like birth control can be used to increase female hormone presence in the body, but must be administered carefully, as too much or little of the supplemental hormone may bring about other health complications. These medications are meant to facilitate the metabolic processes of what the body should already be doing on its own.^[2,3,13] Other medications commonly used include spironolactone or metformin to treat high amounts of male hormones and other symptoms like weight gain, acne, and insulin resistance. Lifestyle changes like diet and exercise, and mental health support such as counseling and support groups have the potential to mitigate symptoms associated with stress.

PCOS is a complex condition that impacts both the body and the mind. Understanding how hormones, genetics, the environment, and mental health interact may help improve diagnosis, treatment, and long-term care for people living with the condition. PCOS should be treated as a multifaceted issue in order to target symptoms from all angles.

Returning to Annie Jones, it is very possible that the high amounts of androgens that caused her facial hair were a symptom of what we now recognize as polycystic ovary syndrome. With today’s medical understanding, it’s clear she was not a “freak,” but a woman living with an untreated hormonal condition.

Maya Yanchuck

References:

[1] Azziz, R. (2004). PCOS: A diagnostic challenge. Reproductive BioMedicine Online 8(6), 644-648. https://doi.org/10.1016/S1472-6483(10)61644-6

[2] Barber, T. M., Wass, J. A. H., McCarthy, M. I., & Franks, S. (2007). Metabolic characteristics of women with polycystic ovaries and oligo-amenorrhoea but normal androgen levels: implications for the management of polycystic ovary syndrome. Clinical Endocrinology 66(4), 513-517. https://doi.org/10.1111/j.1365-2265.2007.02764.x

[3] Barber, T. M., Hanson, P., Weickert, M. O., & Franks, S. (2019). Obesity and polycystic ovary syndrome: Implications for pathogenesis and novel management strategies. Clinical Medicine Insights Reproductive Health, 13. https://doi.org/10.1177/1179558119874042

[4] Bromberger, A. (2022). Why women face difficulty receiving PCOS diagnoses. Global Reproductive Health at Duke. https://dukecenterforglobalreproductivehealth.org/2022/12/26/why-women-face-difficulty-receiv ing-pcos-diagnoses/

[5] Douglas, K. M., Fenton, A. J., Eggleston, K., & Porter, R. R. (2022). Rate of polycystic ovary syndrome in mental health disorders: a systematic review. Archives of Women’s Mental Health 25, 9–19. https://doi.org/10.1007/s00737-021-01179-4

[6] Horst, G. J. (2010). Estrogen in the limbic system. Hormones of the Limbic System 82, 319-338. https://doi.org/10.1016/S0083-6729(10)82017-5

[7] Johnston, M. A. (2007). Bearded women in early modern England. SEL Studies in English Literature 1500-1900 47(1), 1-28. https://dx.doi.org/10.1353/sel.2007.0004.

[8] Joo, Y. Y., Actkins, K., Pacheco, J. A., Basile, O. A., Carroll, R., Crosslin, D. R., Day, F., Denny, J. C., Edwards, D. R. V., Hakonarson, H., Harley, J. B., Hebbring, S. J., Ho, K., Jarvik, G. P., Jones, M., Karaderi, T., Mentch, F.D., Meun, C., Namjou, B., . . . International PCOS Consortium (2020). A polygenic and phenotypic risk prediction for polycystic ovary syndrome evaluated by phenome-wide association studies. The Journal of Clinical Endocrinology & Metabolism 105(6), 1918–1936. https://doi.org/10.1210/clinem/dgz326

[9] Lebovitz, H. E. (2001). Insulin resistance: Definition and consequences. Experimental and Clinical Endocrinology & Diabetes 2001 109(2), S135-S148. https://doi.org/10.1055/s-2001-18576

[10] Rosenfield, R. L. & Ehrmann, D. A., (2016). The pathogenesis of polycystic ovary syndrome (PCOS): The hypothesis of PCOS as functional ovarian hyperandrogenism revisited. Endocrine Reviews 37(5), 467–520. https://doi.org/10.1210/er.2015-1104

[11] Ruth, K. S., Day, F. R., Tyrrell, J., Thompson, D. J., Wood, A. R., Mahajan, A., Beaumont, R. N., Wittemans, L., Martin, S., Busch, A. S., Erzurumluoglu, A. M., Hollis, B., O’Mara, T. A., The Endometrial Cancer Association Consortium, McCarthy, M. I., Langenburg, C., Easton, D. F., Wareham, N. J., Burgess, S., Murray, A., . . . Perry, J. R. B. (2020). Using human genetics to understand the disease impacts of testosterone in men and women. Nature Medicine 26, 252–258. https://doi.org/10.1038/s41591-020-0751-5

[12] Sharma, S. & Sharma, S. (2020). Obesity epidemic: Striking the younger age group. Medical Journal of Dr. D.Y. Patil Vidyapeeth 13(4), 333-334. https://doi.org/10.4103/mjdrdypu.mjdrdypu_307_19

[13] Stener-Victorin, E. & Deng, Q. (2021). Epigenetic inheritance of polycystic ovary syndrome — Challenges and opportunities for treatment. Nature Reviews Endocrinology 17, 521-533. https://doi.org/10.1038/s41574-021-00517-x

[14] Tay, C. T., Hart, R. J., Hickey, M., Moran, L. J., Earnest, A. & Doherty, D. A. (2020). Updated adolescent diagnostic criteria for polycystic ovary syndrome: Impact on prevalence and longitudinal body mass index trajectories from birth to adulthood. BMC Med 18(1), 389. https://doi.org/10.1186/s12916-020-01861-x

[15] U.S. Centers for Disease Control and Prevention (2024). About insulin resistance and type-2 diabetes. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/about/insulin-resistance-type-2-diabetes.html

[16] U.S. Centers for Disease Control and Prevention (2025). Epigenetics, health, and disease. Centers for Disease Control and Prevention. https://www.cdc.gov/genomics-and-health/epigenetics/index.html

[17] Wild, R. A., (2002). Long-term health consequences of PCOS. Human Reproduction Update 8(3), 231–241. https://doi.org/10.1093/humupd/8.3.231

[18] Witchel, S. F., Azziz, R., & Oberfield, S. E. (2022). History of polycystic ovary syndrome, premature adrenarche, and hyperandrogenism in pediatric endocrinology. Hormone Research in Paediatrics 95(6), 557–567. https://doi.org/10.1159/000526722