"You can’t have PCOS anymore, you’re too old." "You were just estrogen dominant." "It was probably just your birth control messing with your cycle." If you’ve heard any of these before, you’re not alone—but they’re not the full story. Polycystic Ovary Syndrome (PCOS) is one of the most misunderstood and underdiagnosed hormonal conditions in women, especially as we move into midlife. As a lifestyle medicine physician and menopause specialist, I see so many women in their 40s and 50s who were never properly diagnosed, or who were told their PCOS “resolved” after their twenties. But the truth is, PCOS is not just a reproductive disorder—it’s a lifelong metabolic and neuroendocrine condition that can shape how you experience perimenopause, menopause, and the decades beyond. Let’s dive into what PCOS really looks like, why so many smart, high-functioning women have been missed or misdiagnosed, and how we can support your hormones, metabolism, and nervous system at midlife and beyond. What Is PCOS, Really? Polycystic Ovary Syndrome is a condition of hormonal imbalance, typically involving irregular or absent ovulation, higher levels of androgens (like testosterone or DHEA), and signs like acne, hirsutism, or hair thinning. It’s diagnosed using the Rotterdam criteria, which require two out of three of the following: Irregular cycles or lack of ovulation Elevated androgens (on labs or symptoms) Polycystic-appearing ovaries on ultrasound But here’s the thing: you don’t need to look like a textbook case to have PCOS. And you don’t have to be overweight, either. Many women I see had irregular periods in their teens or early 20s, were put on birth control to "regulate" them, and never thought about it again. But under the surface, they may still be dealing with insulin resistance, metabolic dysfunction, and the downstream effects of decades of low ovulatory progesterone. PCOS in High-Functioning, Chronically Stressed Women I want to name a pattern I see over and over again in my clinic: high-performing, deeply thoughtful, often anxious women with a history of: Childhood trauma or emotional neglect Chronic stress, perfectionism, or people-pleasing tendencies Neurodivergence or sensory sensitivity Head injuries or subtle brain trauma Long histories of surviving on willpower alone These women may have had "normal" labs, been told their hormones were fine, and still feel awful—tired, inflamed, emotionally fragile, or completely burned out. Their PCOS may have never been diagnosed, or it may present now as midlife metabolic dysfunction, vasomotor instability, or nervous system dysregulation. And because PCOS is so often framed as a fertility problem, it gets missed entirely after age 35. PCOS Doesn’t Magically Go Away After Menopause Yes, ovulation stops. But PCOS is not just about ovulation. Women with a history of PCOS: Often go through perimenopause with more erratic hormone fluctuations May retain higher levels of androgens than peers Often experience insulin resistance, stubborn weight gain, and mood swings Are at higher risk for type 2 diabetes, cardiovascular disease, fatty liver, and dementia You may also experience a sudden onset of classic estrogen-deficiency symptoms after years of feeling "estrogen dominant": vaginal dryness, poor sleep, brain fog, hot flashes, or joint pain. This hormonal shift can feel disorienting—especially if you were previously told that you had too much estrogen or testosterone. So Yes, You Might Still Need Hormones One of the most common questions I get is: "If I had PCOS or high estrogen before, why would I ever take hormones in menopause?" Here’s why: PCOS doesn’t protect you from the effects of estrogen and progesterone deficiency You may still have low progesterone, especially if you had anovulatory cycles for years Testosterone levels decline sharply after menopause, even in women with a PCOS history And importantly, many women who thrived on higher testosterone levels in their younger years may feel the effects of that decline even earlier—sometimes in late perimenopause rather than after menopause. This can look like a sudden drop in motivation, mental clarity, libido, or muscle tone. While your labs may still appear "in range," they may be low for you, based on where your body functioned best in your 20s or 30s. This is why a personalized approach matters—because it’s not just about numbers on a chart, but about how you feel in your body. Hormone therapy can help with symptoms, muscle mass, cognition, and overall metabolic health Of course, it has to be individualized. But fear of hormones due to your "PCOS past" should not be a reason to avoid evidence-based treatment that could dramatically improve your quality of life. Where Do We Start? I always begin with: 1. Lifestyle foundations: Balanced blood sugar (this is critical) Resistance training and muscle-building Nervous system regulation (because stress is metabolic) Sleep, circadian health, and gut support 2. Supportive supplements (individualized): Inositol (myo + d-chiro), magnesium, omega-3s, sometimes berberine or NAC 3. Hormone support (when appropriate): Bioidentical progesterone for sleep, mood, and cycle regulation Estradiol and testosterone for quality of life and long-term disease prevention Vaginal estrogen for GSM, even in women with a PCOS history Final Thoughts If you have PCOS or suspect you might—even if no one ever told you that you did—you deserve midlife care that goes deeper. You deserve a plan that honors your past hormone story and supports the road ahead. At Wondercreek Health, I don’t just treat numbers on a lab report. I listen to your lived experience, your history, your intuition. PCOS is real. Your symptoms are real. And there is help.