What is Polycystic Ovary Syndrome (PCOS)?

Polycystic Ovary Syndrome (PCOS)

Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women, affecting 8-13% of this population, characterized by the presence of at least two of three Rotterdam criteria: oligo/anovulation, clinical or biochemical hyperandrogenism, and polycystic ovary morphology on ultrasound. 1

Definition and Diagnostic Criteria

PCOS diagnosis requires the presence of at least two of the following three Rotterdam criteria:

• Oligo/anovulation (irregular menstrual cycles)
• Clinical or biochemical hyperandrogenism (hirsutism, acne, male-pattern hair loss)
• Polycystic ovary morphology on ultrasound (≥20 follicles per ovary measuring 2-9mm and/or ovarian volume ≥10ml)

Important diagnostic considerations:

• Polycystic ovary morphology alone is insufficient for diagnosis 1
• Other etiologies of these symptoms must be excluded before confirming PCOS
• Ultrasound should be performed with appropriate technology (transvaginal approach with ≥8MHz transducer preferred) 1

Pathophysiology

PCOS has a complex pathophysiology involving:

• Insulin resistance (present in 50-70% of women with PCOS) 2
• Hyperinsulinemia contributing to hyperandrogenism through effects on the pituitary, liver, and ovaries 3
• Genetic and environmental factors 4
• Insulin resistance occurs irrespective of BMI, affecting both lean and overweight women 3
• Obesity further exacerbates insulin resistance and worsens all PCOS symptoms 3

Clinical Manifestations

PCOS presents with various symptoms:

• Menstrual irregularities (oligomenorrhea or amenorrhea)
• Hyperandrogenism (hirsutism, acne, male-pattern hair loss)
• Infertility
• Metabolic complications (insulin resistance, dyslipidemia, glucose intolerance)
• Psychological issues (depression, anxiety, mood disorders) 1, 4

Associated Health Risks

Women with PCOS have increased risk for:

• Type 2 diabetes mellitus and dysglycemia 4
• Metabolic syndrome and cardiovascular disease 3
• Endometrial cancer (at least twofold increased risk) 4
• Ovarian cancer (OR 2.52 in women under 54 years) 1
• Psychological disorders including depression, anxiety, and binge eating disorder 2
• Obstructive sleep apnea 4

Management Approach

Management of PCOS should focus on addressing:

1. Lifestyle modifications - First-line treatment for all women with PCOS 3

   • Multicomponent intervention including diet, exercise, and behavioral strategies
   • Focus on weight management and healthy lifestyle behaviors
   • No specific diet is recommended over others

2. Metabolic health

   • Metformin for patients with insulin resistance 4
   • Regular screening for cardiovascular risk factors including hypertension and dyslipidemia 1
   • Screening for glucose intolerance and type 2 diabetes

3. Menstrual irregularities and hyperandrogenism

   • Oral contraceptives as first-line therapy for women not seeking pregnancy 4
   • Antiandrogens (e.g., spironolactone) as second-line agents, typically added to oral contraceptives 4

4. Fertility concerns

   • Letrozole is first-line therapy for ovulation induction in women seeking pregnancy 4
   • Other options include clomiphene, metformin, gonadotropins, and assisted reproductive technologies 2

Monitoring and Follow-up

• Regular assessment of menstrual cycle regularity
• Periodic evaluation for hyperandrogenic symptoms
• Screening for cardiovascular disease risk factors
• Evaluation for mood disorders and sleep apnea
• Planned transition to adult care providers for adolescents with PCOS 1

Special Considerations

• Ethnic variations exist in PCOS presentation, with East Asian women having higher prevalence of metabolic syndrome despite lower BMI and less hyperandrogenic features 3
• Psychological factors such as anxiety, depression, and eating disorders are prevalent in PCOS and require attention 3
• Healthcare providers should consider cultural sensitivities and weight-related stigma when addressing lifestyle interventions 3

PCOS is a lifelong condition with evolving symptoms throughout a woman's reproductive lifespan and beyond, requiring ongoing monitoring and management of both reproductive and metabolic health.