What is Polycystic Ovary Syndrome (PCOS)?

What is Polycystic Ovary Syndrome (PCOS)?

Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder affecting 8-13% of reproductive-age women, characterized by a combination of reproductive, endocrine, metabolic, and psychosocial symptoms that require diagnosis based on the Rotterdam criteria. 1, 2

Diagnostic Criteria

According to the Rotterdam criteria, PCOS diagnosis requires two of the following three criteria:

1. Oligo- or anovulation (irregular or absent menstrual cycles)
2. Clinical and/or biochemical signs of hyperandrogenism (excess male hormones)
3. Polycystic ovaries on ultrasound (specific morphological appearance)

With the exclusion of other relevant disorders 1

Ultrasound Criteria for PCOM:

• ≥20 follicles per ovary measuring 2-9mm and/or ovarian volume ≥10ml 2
• Transvaginal approach preferred if sexually active and acceptable to patient 2
• Important: Ultrasound should NOT be used for diagnosis in those with gynecological age <8 years due to high incidence of multi-follicular ovaries 2

Clinical Presentation

PCOS presents with various symptoms across different body systems:

Reproductive Symptoms:

• Irregular or absent menstrual cycles
• Infertility (accounts for approximately 80% of anovulatory infertility) 3
• Polycystic ovaries

Endocrine Symptoms:

• Hirsutism (excess body hair in male-pattern distribution)
• Acne
• Androgenic alopecia (male-pattern hair loss)
• Elevated testosterone levels 2

Metabolic Features:

• Insulin resistance
• Abdominal obesity
• Impaired glucose tolerance or type 2 diabetes
• Dyslipidemia 4, 5

Pathophysiology

PCOS is a heterogeneous disorder with complex pathophysiology:

• Hormonal imbalance: Characterized by hyperandrogenism and insulin resistance 4
• Ovarian dysfunction: Multiple small antral follicles form due to hormonal imbalance 4
• Metabolic dysfunction: Insulin resistance leads to compensatory hyperinsulinemia, which stimulates ovarian androgen production 5
• Genetic factors: Evidence suggests PCOS might be a complex multigenic disorder 5
• Environmental influences: Diet, lifestyle factors, and possibly prenatal exposures play important roles 4, 5

Associated Health Risks

Women with PCOS face increased risks for:

• Metabolic disorders: Type 2 diabetes, metabolic syndrome 2
• Cardiovascular disease: Higher risk due to metabolic abnormalities 2, 5
• Cancer: Increased risk for endometrial cancer (OR 2.79) and ovarian cancer (OR 2.52) in women under 54 years 2
• Psychological disorders: Higher prevalence of anxiety, depression, and eating disorders 2
• Pregnancy complications: Including gestational diabetes and preeclampsia 6

Management Approach

Management of PCOS should address the specific symptoms and long-term health risks:

1. Lifestyle modifications: First-line treatment focusing on diet, exercise, and behavioral strategies 2

   • At least 150 minutes of physical activity per week is recommended 3
   • Exercise improves insulin sensitivity, reproductive function, and psychological well-being 3

2. Pharmacological treatments:

   • Hormonal treatments (e.g., combined oral contraceptives) for menstrual irregularity and hyperandrogenism
   • Insulin-sensitizing agents like metformin for metabolic abnormalities 2
   • Anti-androgens for hirsutism and other androgenic symptoms

3. Regular screening:

   • Glucose tolerance testing
   • Lipid profiles
   • Blood pressure monitoring
   • Mental health assessment 2

Common Pitfalls in PCOS Management

• Delayed diagnosis: Symptoms often begin during puberty but may be overlooked 6
• Incomplete evaluation: Failure to screen for metabolic complications
• Focusing only on fertility: Neglecting long-term health risks beyond reproductive years
• Inappropriate use of ultrasound: Using ultrasound for diagnosis in adolescents within 8 years of menarche 2
• Inadequate differential diagnosis: Not ruling out other causes of hyperandrogenism and menstrual irregularities 2

PCOS is a lifelong condition that requires ongoing management across different life stages, with treatment priorities shifting from reproductive concerns in younger women to metabolic and cardiovascular health in older women 6.