Polycystic Ovarian Syndrome (PCOS)

What Is PCOS?

PCOS is characterised by a combination of hormonal imbalances (elevated androgens), ovarian dysfunction (irregular ovulation), and metabolic disturbances (insulin resistance). The name polycystic refers to the appearance of multiple small follicles on the ovaries when viewed with ultrasound, although not everyone with PCOS has visible cysts.

Key Diagnostic Criteria

Clinicians typically use the Rotterdam criteria (2003), which require at least two of the following three features:

• Oligo or anovulation: Infrequent or absent menstrual periods.
• Hyperandrogenism: Clinical (acne, hirsutism, malepattern hair loss) or biochemical (high testosterone, DHEAS).
• Polycystic ovarian morphology: 12 follicles 29mm in diameter or ovarian volume>10cm on ultrasound.

Other conditions that mimic PCOS (thyroid disease, hyperprolactinemia, congenital adrenal hyperplasia) must be excluded before confirming the diagnosis.

Common Signs & Symptoms

• Irregular menstrual cycles (e.g., 8 periods per year).
• Excess facial or body hair (hirsutism).
• Acne, especially adultonset.
• Thinning scalp hair (androgenic alopecia).
• Weight gain or difficulty losing weight, often central obesity.
• Darkened patches of skin (acanthosis nigricans) indicating insulin resistance.
• Infertility or difficulty conceiving.

Underlying Causes

The exact cause of PCOS is unknown, but several mechanisms interact:

• Genetics: Firstdegree relatives have a higher risk, suggesting polygenic inheritance.
• Insulin resistance: Elevated insulin levels can stimulate ovarian androgen production and suppress sexhormonebinding globulin (SHBG), increasing free testosterone.
• Hormonal dysregulation: Abnormal LH to FSH ratios, increased GnRH pulse frequency, and altered adipokine levels contribute to ovarian dysfunction.
• Environmental factors: Earlylife nutrition, exposure to endocrinedisrupting chemicals, and lifestyle (sedentary behaviour, highglycaemic diet) may modulate risk.

Health Risks Associated With PCOS

Beyond reproductive concerns, PCOS can increase the likelihood of several longterm conditions:

• Type2 diabetes and metabolic syndrome.
• Cardiovascular disease (hypertension, dyslipidaemia).
• Endometrial hyperplasia or cancer due to prolonged unopposed estrogen.
• Mood disorders anxiety and depression are more prevalent.
• Sleep apnoea, especially in overweight individuals.

Management Strategies

Because PCOS is heterogeneous, treatment is personalised and often targets multiple goals: regularising periods, reducing androgenic symptoms, improving insulin sensitivity, and supporting fertility when desired.

Lifestyle Interventions

• Weight management: A modest 510% reduction in body weight can restore ovulation and improve insulin resistance.
• Diet: Lowglycaemic, highfiber meals; adequate protein; reduction of refined sugars and saturated fats.
• Exercise: Combination of aerobic (150min/week) and resistance training enhances insulin sensitivity.

Pharmacological Options

• Combined oral contraceptives (COCs): Firstline for menstrual regulation and androgen control.
• Antiandrogens (e.g., spironolactone): Reduce hirsutism and acne; used with contraception.
• Insulinsensitising agents:
  • Metformin lowers insulin, may aid ovulation and weight loss.
  • Thiazolidinediones rarely used due to sideeffects.
• Fertilityinducing drugs:
  • Clomiphene citrate firstline ovulation induction.
  • Letrozole increasingly preferred for higher pregnancy rates.
  • Gonadotropins or IVF for refractory cases.
• Hairremoval therapies: Laser, electrolysis, or topical eflornithine for persistent hirsutism.
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Psychological Support

Screening for depression, anxiety, and bodyimage concerns is recommended. Counseling, CBT, or support groups can improve quality of life.

Frequently Asked Questions

Can PCOS be cured?

There is currently no cure. Symptoms can be managed effectively, and many women experience remission of some features with appropriate lifestyle and medical therapy.

Do I need to be overweight to have PCOS?

No. While obesity worsens insulin resistance and is common in PCOS, lean individuals can also meet diagnostic criteria.

Is pregnancy possible with PCOS?

Yes. Up to 7080% of women with PCOS can conceive with treatment, ranging from lifestyle changes and oral agents to assisted reproductive technologies.

Should I avoid pregnancy if I have PCOS?

Pregnancy is safe when managed appropriately. However, uncontrolled PCOS increases risks of gestational diabetes and preeclampsia, so preconception counselling is advisable.

How often should I have followup appointments?

Typically every 612months to monitor menstrual patterns, metabolic parameters (glucose, lipids, blood pressure), and any evolving symptoms.

Resources & Further Reading

• American College of Obstetricians and Gynecologists (ACOG) PCOS guidelines
• Endocrine Society Clinical practice guidelines for PCOS
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) PCOS fact sheet
• Polycystic Ovary Syndrome Association Support and education for patients.