Do you need a polycystic ovary on ultrasound to diagnose PCOS?

No. The Rotterdam criteria require any two of three findings (ovulatory dysfunction, hyperandrogenism, polycystic ovaries on ultrasound). Many patients meet criteria without an ultrasound finding. An ultrasound is most useful when the diagnosis is uncertain or fertility is on the roadmap.

Can you have PCOS at a normal weight?

Yes. About 20% of women with PCOS have a normal BMI. The "lean PCOS" phenotype is well-described and frequently missed because the standard screen assumes obesity. Biology, not appearance, drives the diagnosis.

Is metformin the right first-line for PCOS?

Metformin helps insulin resistance, modestly helps cycles, and is inexpensive. For patients with significant insulin resistance, it is often a good first move. For patients with mild insulin resistance and primarily hormonal symptoms, oral contraceptives or spironolactone may be a better fit. The decision depends on what is most disruptive.

What about GLP-1 medications for PCOS?

GLP-1s (semaglutide, tirzepatide) have meaningful metabolic effects in PCOS patients with insulin resistance and weight as part of the picture. The data is still developing but is moving in a clearly positive direction. We prescribe them thoughtfully when the indication is real.

Can you reverse PCOS?

PCOS is not "reversed" in the traditional sense, but the symptoms can be managed to the point of near-resolution for many patients, particularly with weight loss, training, and treatment of insulin resistance. The underlying genetic and physiologic predisposition does not go away, but the clinical picture can become very mild.

What is the long-term cardiometabolic risk in PCOS?

Women with PCOS have substantially elevated risk of type 2 diabetes, metabolic syndrome, and probably cardiovascular disease, even at normal weight. Long-arc primary care should include cardiometabolic monitoring (HbA1c, lipids with ApoB, blood pressure) starting in the 20s, not waiting until standard age cutoffs.

What is the role of nutrition in PCOS?

A protein-floor (around 1.2-1.6 g/kg/day for most adults) approach with adequate fiber and attention to refined carbohydrates is the framework that has the best evidence. Specific diets (low-carb, Mediterranean, ketogenic) all work for some patients; the right one is the one the patient can sustain. We do not push a single restrictive plan.

How does Philadelphia's healthcare landscape affect PCOS care?

PCOS frequently falls between specialties in Philadelphia. OB-GYN handles cycles, dermatology handles skin, endocrinology handles metabolic disease, and reproductive endocrinology handles fertility. No one practice is responsible for the integrated picture. A direct primary care practice with time to coordinate and hold the long-arc plan is the missing piece for many patients.

What does the long-arc plan look like at Fishtown Medicine?

Year-by-year: annual cardiometabolic reassessment, ongoing optimization of insulin resistance, symptom-driven treatment adjustments, fertility support when relevant, and screening for diabetes and cardiovascular risk that recognizes the elevated PCOS-related risk profile. The plan updates as the patient moves through different life stages.

Do you need a polycystic ovary on ultrasound to diagnose PCOS?

No. The Rotterdam criteria require any two of three findings (ovulatory dysfunction, hyperandrogenism, polycystic ovaries on ultrasound). Many patients meet criteria without an ultrasound finding. An ultrasound is most useful when the diagnosis is uncertain or fertility is on the roadmap.

Can you have PCOS at a normal weight?

Yes. About 20% of women with PCOS have a normal BMI. The "lean PCOS" phenotype is well-described and frequently missed because the standard screen assumes obesity. Biology, not appearance, drives the diagnosis.

Is metformin the right first-line for PCOS?

Metformin helps insulin resistance, modestly helps cycles, and is inexpensive. For patients with significant insulin resistance, it is often a good first move. For patients with mild insulin resistance and primarily hormonal symptoms, oral contraceptives or spironolactone may be a better fit. The decision depends on what is most disruptive.

What about GLP-1 medications for PCOS?

GLP-1s (semaglutide, tirzepatide) have meaningful metabolic effects in PCOS patients with insulin resistance and weight as part of the picture. The data is still developing but is moving in a clearly positive direction. We prescribe them thoughtfully when the indication is real.

Can you reverse PCOS?

PCOS is not "reversed" in the traditional sense, but the symptoms can be managed to the point of near-resolution for many patients, particularly with weight loss, training, and treatment of insulin resistance. The underlying genetic and physiologic predisposition does not go away, but the clinical picture can become very mild.

What is the long-term cardiometabolic risk in PCOS?

Women with PCOS have substantially elevated risk of type 2 diabetes, metabolic syndrome, and probably cardiovascular disease, even at normal weight. Long-arc primary care should include cardiometabolic monitoring (HbA1c, lipids with ApoB, blood pressure) starting in the 20s, not waiting until standard age cutoffs.

What is the role of nutrition in PCOS?

A protein-floor (around 1.2-1.6 g/kg/day for most adults) approach with adequate fiber and attention to refined carbohydrates is the framework that has the best evidence. Specific diets (low-carb, Mediterranean, ketogenic) all work for some patients; the right one is the one the patient can sustain. We do not push a single restrictive plan.

How does Philadelphia's healthcare landscape affect PCOS care?

PCOS frequently falls between specialties in Philadelphia. OB-GYN handles cycles, dermatology handles skin, endocrinology handles metabolic disease, and reproductive endocrinology handles fertility. No one practice is responsible for the integrated picture. A direct primary care practice with time to coordinate and hold the long-arc plan is the missing piece for many patients.

What does the long-arc plan look like at Fishtown Medicine?

Year-by-year: annual cardiometabolic reassessment, ongoing optimization of insulin resistance, symptom-driven treatment adjustments, fertility support when relevant, and screening for diabetes and cardiovascular risk that recognizes the elevated PCOS-related risk profile. The plan updates as the patient moves through different life stages.

PCOS Care in Philadelphia, PA | Fishtown Medicine

TL;DR30-second take

PCOS in Philadelphia is most often managed piecemeal: an OB-GYN for cycles and fertility, a dermatologist for acne and hair, an endocrinologist for insulin resistance if it gets escalated. The underlying biology is one integrated picture - insulin resistance driving androgen excess driving the symptoms - and primary care done well is the right place to manage it. Fishtown Medicine pulls the workup together: fasting insulin, HbA1c, androgen panel, cycle history, and a plan that addresses metabolic health, hormonal symptoms, and fertility on the same page.

PCOS gets diagnosed in three settings: at the dermatologist's office for acne and hirsutism, at the OB-GYN's office for irregular cycles and infertility, or at the endocrinologist's office once the insulin resistance has caught up. Each specialist treats their slice. The patient ends up with topical retinoids, oral contraceptives, sometimes metformin, sometimes spironolactone, and a list of follow-up appointments that do not talk to each other.

The biology underneath those three slices is one story. PCOS is driven by insulin resistance and elevated androgens that reinforce each other. The cycle changes, the skin changes, the hair changes, the weight changes, the mood changes, and the cardiometabolic risk all flow from that central engine. Managing them piecemeal works fine for some patients and badly for others. The integrated view is the point of primary care.

The Rotterdam criteria and what they mean

Diagnosis is based on the Rotterdam criteria: any two of the following three.

Ovulatory dysfunction - irregular or absent periods, or documented anovulation.
Hyperandrogenism - clinical (acne, hirsutism, male-pattern hair loss) or biochemical (elevated testosterone, DHEA-S, or androstenedione).
Polycystic ovaries on ultrasound - 12 or more follicles per ovary or increased ovarian volume.

Importantly: PCOS is a diagnosis of exclusion. Thyroid disease, hyperprolactinemia, congenital adrenal hyperplasia, Cushing's syndrome, and androgen-secreting tumors all need to be ruled out before settling on PCOS.

What a real PCOS workup includes

For someone presenting with possible PCOS, the workup we run is:

Cycle history with attention to age at menarche, longest stretch without a cycle, prior pregnancies and outcomes, contraceptive history.
Androgen panel. Total testosterone, free testosterone, SHBG, DHEA-S. Sometimes androstenedione and 17-hydroxyprogesterone (the latter to rule out non-classical congenital adrenal hyperplasia).
Metabolic panel. Fasting insulin, fasting glucose, HbA1c. The HOMA-IR calculation from fasting insulin and glucose is one of the most useful single screens for insulin resistance. Sometimes an oral glucose tolerance test.
Lipid panel with ApoB. Cardiometabolic risk in PCOS is elevated even at normal weight.
TSH and free T4, prolactin. Rule out thyroid disease and hyperprolactinemia.
CBC and comprehensive metabolic panel.
Vitamin D, ferritin. Often suboptimal and contribute to fatigue and hair symptoms.
Pelvic ultrasound when the diagnosis is uncertain or fertility is on the roadmap.

Beyond labs, we go through skin, hair, energy, mood, sleep, weight trajectory, and family history. A focused exam looks for acanthosis nigricans (a sign of significant insulin resistance), hirsutism distribution, and acne.

What treatment actually looks like

Treatment in PCOS is layered and depends on what is most disruptive for the patient and whether fertility is on the roadmap.

For metabolic health and insulin resistance:

Resistance training and a protein-floor approach to nutrition. The single most underused intervention in PCOS care. The metabolic improvements from training and adequate protein intake are substantial and often change how much medication is needed.
Metformin. Improves insulin resistance, modestly helps cycles, helps with weight. Generic and inexpensive.
GLP-1 medications (Ozempic, Mounjaro). Newer addition. For patients with significant insulin resistance and weight component, the metabolic improvements are meaningful and sometimes substantial. Used thoughtfully, not reflexively.
Inositol (myo-inositol or combined myo and D-chiro inositol). Modest data, low downside, popular with many patients.

For hormonal symptoms (acne, hirsutism, cycles when fertility is not the goal):

Combined oral contraceptives. Reduce androgens, regularize cycles, manage acne.
Spironolactone. Anti-androgen, effective for acne and hirsutism. Often paired with a contraceptive because of teratogenic potential.
Topical treatments for acne (retinoids, benzoyl peroxide) in coordination with dermatology when needed.

For fertility:

Fishtown Medicine

A 90-minute conversation with Dr. Ash. A written plan you can actually follow.

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Lifestyle and weight management (when weight is in the picture) often restore ovulation alone.
Letrozole or clomiphene to induce ovulation. Letrozole is now the first-line per ACOG.
Metformin sometimes layered in.
Coordinated referral to reproductive endocrinology when first-line interventions do not work.

ℹ NOTE

The biggest under-recognized PCOS phenotype in Philadelphia primary care is the "lean PCOS" patient. Normal BMI, regular-ish cycles, but persistent acne and elevated androgens and elevated fasting insulin. They get told "you don't look like you have PCOS" and miss the workup. The diagnosis is made on biology, not appearance.

How PCOS care works at Fishtown Medicine

First visit is 90 minutes. We build the full picture, decide on the labs, and discuss what is most disruptive to address first. Many patients come having already had pieces of the workup; we fill in what is missing rather than re-running everything.

Follow-up is at 6-8 weeks for first results conversation, then at 3-6 month intervals for treatment adjustments. Once the picture is stable, annual reassessment with attention to metabolic and cardiovascular trajectory.

We coordinate with dermatology, OB-GYN, and reproductive endocrinology when relevant. The primary care relationship holds the integrated picture and the long-arc plan.

What it costs

Membership at Fishtown Medicine covers all visits and ongoing management; see pricing for current rates. All visits and direct messaging access are covered. PCOS medications (metformin, spironolactone, oral contraceptives, letrozole, GLP-1s) are billed through pharmacy with insurance or cash pricing. Labs are billed separately at the cheapest of insurance or cash. Ultrasounds and reproductive endocrinology referrals are billed through their respective practices.

Key Takeaways

PCOS is one connected biology, not three separate problems. Primary care done well holds the integrated picture.
Diagnosis is based on the Rotterdam criteria; ultrasound is not required.
"Lean PCOS" is real and frequently missed.
Treatment depends on what is most disruptive: metabolic, hormonal, or fertility.
Long-term cardiometabolic monitoring should start in the 20s for women with PCOS.

Metabolic Health in Philadelphia - the insulin resistance side of the picture.
Hormone Optimization in Philadelphia - the broader hormones framing.
GLP-1 Weight Loss in Philadelphia - one of the newer metabolic tools.
PCOS Pillar - the deeper clinical guide.
Fertility Pillar - the fertility side of PCOS care.
Direct Primary Care in Philadelphia - the membership context.
TRT (Testosterone Replacement Therapy) - the safe, monitored TRT approach
Menopause Care - evidence-based menopause management
Perimenopause Care - the often-missed transition that needs proactive care
Thyroid Treatment - thyroid optimization beyond TSH alone

Fishtown Medicine | Services

2418 E York St, Philadelphia, PA 19125(267) 360-7927 hello@fishtownmedicine.comHSA/FSA Eligible

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Frequently Asked Questions

Common Questions

Deep-Dive Questions

We start with what is most disruptive for the patient and most likely to improve. For patients where cycles and fertility are the priority, we focus on ovulation and metabolic optimization. For patients where acne and hair are the priority, we focus on androgens. For patients where metabolic health is the dominant issue, we focus on insulin resistance with training, nutrition, metformin, and sometimes GLP-1s. The framing is integrated, but the first move is symptom-driven.

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Start your intake

Dr. Ash reads every intake himself, and answers questions personally - usually within a few hours.

TL;DR30-second take

The Rotterdam criteria and what they mean

Diagnosis is based on the Rotterdam criteria: any two of the following three.

Ovulatory dysfunction - irregular or absent periods, or documented anovulation.
Hyperandrogenism - clinical (acne, hirsutism, male-pattern hair loss) or biochemical (elevated testosterone, DHEA-S, or androstenedione).
Polycystic ovaries on ultrasound - 12 or more follicles per ovary or increased ovarian volume.

What a real PCOS workup includes

For someone presenting with possible PCOS, the workup we run is:

Cycle history with attention to age at menarche, longest stretch without a cycle, prior pregnancies and outcomes, contraceptive history.
Androgen panel. Total testosterone, free testosterone, SHBG, DHEA-S. Sometimes androstenedione and 17-hydroxyprogesterone (the latter to rule out non-classical congenital adrenal hyperplasia).
Metabolic panel. Fasting insulin, fasting glucose, HbA1c. The HOMA-IR calculation from fasting insulin and glucose is one of the most useful single screens for insulin resistance. Sometimes an oral glucose tolerance test.
Lipid panel with ApoB. Cardiometabolic risk in PCOS is elevated even at normal weight.
TSH and free T4, prolactin. Rule out thyroid disease and hyperprolactinemia.
CBC and comprehensive metabolic panel.
Vitamin D, ferritin. Often suboptimal and contribute to fatigue and hair symptoms.
Pelvic ultrasound when the diagnosis is uncertain or fertility is on the roadmap.

What treatment actually looks like

Treatment in PCOS is layered and depends on what is most disruptive for the patient and whether fertility is on the roadmap.

For metabolic health and insulin resistance:

Resistance training and a protein-floor approach to nutrition. The single most underused intervention in PCOS care. The metabolic improvements from training and adequate protein intake are substantial and often change how much medication is needed.
Metformin. Improves insulin resistance, modestly helps cycles, helps with weight. Generic and inexpensive.
GLP-1 medications (Ozempic, Mounjaro). Newer addition. For patients with significant insulin resistance and weight component, the metabolic improvements are meaningful and sometimes substantial. Used thoughtfully, not reflexively.
Inositol (myo-inositol or combined myo and D-chiro inositol). Modest data, low downside, popular with many patients.

For hormonal symptoms (acne, hirsutism, cycles when fertility is not the goal):

Combined oral contraceptives. Reduce androgens, regularize cycles, manage acne.
Spironolactone. Anti-androgen, effective for acne and hirsutism. Often paired with a contraceptive because of teratogenic potential.
Topical treatments for acne (retinoids, benzoyl peroxide) in coordination with dermatology when needed.

For fertility:

Fishtown Medicine

A 90-minute conversation with Dr. Ash. A written plan you can actually follow.

Start your intake

Lifestyle and weight management (when weight is in the picture) often restore ovulation alone.
Letrozole or clomiphene to induce ovulation. Letrozole is now the first-line per ACOG.
Metformin sometimes layered in.
Coordinated referral to reproductive endocrinology when first-line interventions do not work.

ℹ NOTE

How PCOS care works at Fishtown Medicine

We coordinate with dermatology, OB-GYN, and reproductive endocrinology when relevant. The primary care relationship holds the integrated picture and the long-arc plan.

What it costs