PCOS in Female Athletes: Implications for Performance, Hormonal Health, and Clinical Management

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders affecting women of reproductive age, yet its presentation in athletes is often overlooked or misinterpreted. During a presentation at the Sports Pharmacy Summit, Jessica Beal-Stahl, PharmD, emphasized that PCOS frequently goes unrecognized in high-performing female athletes because it does not always present in expected ways. “PCOS is actually one of the most common endocrine disorders in women, and yet in athletes, it often hides in plain sight,” she explained, noting that many athletes may appear metabolically healthy while underlying hormonal dysregulation persists, which makes it more challenging for interdisciplinary teams.¹

PCOS as a Systemic Signaling Disorder

Generally, PCOS has been a condition linked only to dysfunction of the ovaries; however, recent research revealed that it represents a disorder of the hormonal and metabolic signaling that involves the hypothalamic-pituitary-ovarian axis, androgen excess, and insulin resistance.² Beal-Stahl explained that the disease is not restricted to the ovaries, and instead it is a result of a wider problem in the interaction between the brain, ovaries, and metabolic system.¹

"It doesn’t actually start in the ovaries—it starts with signaling," she said, stressing the need to recognize PCOS as a systemic disorder and not just a gynecological problem.¹

This distinction is particularly important in athletes, where physiologic adaptations to training can mask or compensate for underlying dysfunction, making diagnosis more challenging. The condition affects an estimated 6% to 15% of women globally, depending on diagnostic criteria, and remains underdiagnosed in many populations.^2,3

The Athlete Paradox: Performance vs Underlying Risk

In athletic populations, PCOS often presents differently than in the general population. Many athletes maintain lean body composition, high levels of physical activity, and strong metabolic markers, which can obscure typical clinical signs. As Beal-Stahl noted, “Many of these athletes are lean, they’re strong, and yet they may have endocrine dysregulation underneath.”¹

In some cases, elevated androgen levels may contribute to increased muscle mass, strength, and performance capacity.⁴ This creates a paradox in which a condition associated with long-term health risks may appear beneficial in the short term, particularly in strength and power-based sports; however, this perceived advantage can delay diagnosis and treatment, allowing metabolic, reproductive, and psychological complications to develop over time.

Differentiating PCOS From RED-S

One of the biggest clinical challenges in this realm is differentiating between PCOS and relative energy deficiency in sport (RED-S), because both conditions can manifest with menstrual irregularities. Although the outward signs may be similar, their underlying physiology is fundamentally different. PCOS results from a hyperactive hormonal state, commonly characterized by increased luteinizing hormone, excess androgen production, and insulin resistance, whereas RED-S represents a physiologic state of suppression caused by insufficient energy availability leading to low sex hormone production.¹

“These are physiologically opposite conditions,” Beal-Stahl emphasized, noting that misclassification can lead to inappropriate management strategies.¹

Pharmacologic Management in Athletes

Managing PCOS in athletes is challenging, as it’s important to be mindful in treating the root cause of the problem and, at the same time, not compromising the athlete's performance. Pharmacologic therapies, while effective, must be considered within the context of training demands and physiologic adaptation. Metformin (Glucophage; Bristol-Myers Squibb) remains a cornerstone treatment for insulin resistance and has been shown to improve ovulation and metabolic parameters, but its gastrointestinal effects and potential impact on cellular energy pathways may affect training tolerance and recovery.¹

Similarly, glucagon-like peptide-1 receptor agonists, recently introduced as an aid in metabolic management, could be disadvantageous for athletes because these drugs reduce appetite, delay gastric emptying, and may affect adequate fueling and recovery.

Hormonal therapies, including combined oral contraceptives, are frequently used to regulate menstrual cycles and manage hyperandrogenism, but they may alter hormonal balance in ways that influence muscle adaptation, recovery, and overall performance.² On the other hand, antiandrogen therapies—such as the use of spironolactone (Aldactone; Pfizer), which is mostly given to treat acne and unwanted hair growth—appear to be associated with other adverse effects (AEs) like discomfort in the electrolyte balance of the body and raising one concern in drug-tested athletes.

“It’s not always that simple medications prescribed for dermatologic symptoms can have performance and regulatory implications,” Beal-Stahl said.¹

Long-Term Health and Fertility Considerations

In addition to affecting performance, PCOS has serious health consequences over a person's lifetime. Long-term exposure to anovulation puts patients at risk of developing endometrial hyperplasia and potentially endometrial cancer. The steady level of insulin resistance over time increases the likelihood of cardiometabolic disease and related complications, such as type 2 diabetes and cardiovascular complications.^2,3 Notably, many athletes are not diagnosed until later in life, often when attempting to conceive, at which point the cumulative effects of untreated PCOS become more apparent.

“Fertility and performance are not separate—they’re connected across the athlete’s life span,” Beal-Stahl said, emphasizing the importance of early recognition and intervention.¹

The Pharmacist’s Role in Athlete Care

Pharmacists play a critical role in identifying PCOS in athletes, particularly when symptoms are subtle or masked. Their expertise in medication management, supplement evaluation, and AE monitoring positions them to guide individualized treatment strategies within interdisciplinary care teams.

“As a sports pharmacist, my lens often looks at mechanisms and how medications impact performance,” Beal-Stahl said.¹

By understanding how therapies interact with physiology and performance, pharmacists can help ensure that treatment decisions support not only symptom control but also long-term metabolic and reproductive health.

Conclusion

PCOS in female athletes can be a tough clinical challenge as it often hides behind the strength, performance, and normal-appearing health metrics of athletes. To identify the condition, understanding hormonal signaling, metabolic function, and athlete physiology at a deep level is important. Detecting the symptoms early and managing the condition with the help of appropriate treatments can greatly help athletes not only in their performances but also ensure their long-term health.

REFERENCES

1. Beal-Stahl J. Hormones, health, and performance: PCOS in female athletes. Presented at: Sports Pharmacy Summit 2026; April 10, 2026; Fort Lauderdale, FL.

2. Teede HJ, Misso ML, Costello MF, et al; International PCOS Network. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril. 2018;110(3):364-379. doi:10.1016/j.fertnstert.2018.05.004

3. Escobar-Morreale HF. Polycystic ovary syndrome: definition, aetiology, diagnosis and treatment. Nat Rev Endocrinol. 2018;14(5):270-284. doi:10.1038/nrendo.2018.24

4. Handelsman DJ, Hirschberg AL, Bermon S. Circulating testosterone as the hormonal basis of sex differences in athletic performance. Endocr Rev. 2018;39(5):803-829. doi:10.1210/er.2018-00020