What are the symptoms and treatment options for Polycystic Ovary Syndrome (PCOS)?

Symptoms and Treatment Options for Polycystic Ovary Syndrome (PCOS)

The primary symptoms of PCOS include irregular or absent menstrual cycles, clinical and/or biochemical signs of hyperandrogenism (such as hirsutism and acne), and polycystic ovaries on ultrasound examination. 1 Treatment should focus on lifestyle modifications, particularly weight loss, along with appropriate pharmacological interventions to manage specific symptoms and prevent long-term complications.

Common Symptoms of PCOS

Menstrual Irregularities

• Oligomenorrhea (infrequent menstruation) or amenorrhea (absence of menstruation) due to chronic anovulation 2, 1
• Irregular menstrual cycles that may begin during early pubertal years 3

Signs of Hyperandrogenism

• Hirsutism (excessive hair growth in a male pattern distribution) 2, 3
• Acne 1, 3
• Balding or male pattern hair loss 2
• Clitoromegaly (in severe cases) 2

Metabolic Features

• Obesity or increased abdominal adiposity 2, 4
• Acanthosis nigricans (darkened, velvety skin patches in body folds) - a sign of insulin resistance 2
• Insulin resistance, affecting 50-70% of women with PCOS 5

Reproductive Issues

• Infertility due to anovulation 1, 5
• Polycystic ovaries on ultrasound (multiple small follicles) 1

Diagnostic Approach

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

• Oligo- or anovulation
• Clinical and/or biochemical signs of hyperandrogenism
• Polycystic ovaries on ultrasound 1, 3

Important Laboratory Tests

• Thyroid-stimulating hormone (to rule out thyroid disease) 2
• Prolactin levels (to exclude hyperprolactinemia) 2
• Total testosterone or bioavailable/free testosterone (to assess hyperandrogenism) 2
• Two-hour oral glucose tolerance test (to screen for diabetes and insulin resistance) 2
• Fasting lipid profile (to evaluate for dyslipidemia) 2

Treatment Options

Lifestyle Modifications

• Weight loss of 5-10% has been shown to significantly improve PCOS symptoms, including menstrual irregularities and ovulation rates 1, 2
• Regular exercise program, even without weight loss, can have positive effects 2
• Dietary modifications focusing on balanced nutrition 6

Pharmacological Management for Women Not Attempting Conception

• Combination oral contraceptive pills (COCs) - first-line therapy for:

  • Regulating menstrual cycles 2
  • Providing endometrial protection 2
  • Suppressing androgen secretion 2
  • Managing acne and hirsutism 1

• Progestin therapy (e.g., medroxyprogesterone acetate):

  • Alternative for endometrial protection 2
  • Suppresses circulating androgen levels 2

• Anti-androgen medications for hirsutism:

  • Spironolactone 2, 1
  • Finasteride 2, 1
  • Topical eflornithine hydrochloride cream (FDA-approved for hirsutism) 2

• Insulin-sensitizing agents:

  • Metformin - improves insulin sensitivity, may help with ovulation and metabolic parameters 2
  • Thiazolidinediones (pioglitazone, rosiglitazone) - may improve insulin sensitivity but tend to increase weight 2

Management for Women Seeking Pregnancy

• Weight control and regular exercise as first-line approach 2

• Ovulation induction medications:

  • Letrozole (aromatase inhibitor) - first-line treatment for PCOS-related anovulation 1
  • Clomiphene citrate - approximately 80% of women ovulate with this treatment, and half of these conceive 2
  • Low-dose gonadotropins if clomiphene fails - provides higher monofollicular development with lower risk of ovarian hyperstimulation 2
  • Metformin may improve ovulation rates 2, 5

• Surgical options:

  • Laparoscopic ovarian drilling - benefit is undetermined according to ACOG 2

Screening and Prevention of Complications

• Metabolic screening:

  • All women with PCOS should be screened for type 2 diabetes with fasting glucose and 2-hour glucose tolerance test 2
  • Regular screening for dyslipidemia with complete fasting lipid profile 2
  • Calculation of BMI and waist-hip ratio 2

• Cardiovascular risk assessment:

  • Women with PCOS have increased risk factors for cardiovascular disease 2, 5
  • Regular blood pressure monitoring 5

• Mental health assessment:

  • Screen for depression, anxiety, and other mental health disorders which occur more frequently in women with PCOS 5

Common Pitfalls and Caveats

• PCOS diagnosis in adolescents requires careful consideration as normal pubertal development can mimic some PCOS features 3

• Other causes of androgen excess must be excluded before diagnosing PCOS, including:

  • Cushing's syndrome
  • Androgen-secreting tumors
  • Congenital adrenal hyperplasia
  • Thyroid disorders
  • Hyperprolactinemia 2

• Insulin-sensitizing agents are not FDA-approved specifically for PCOS treatment 2

• Combined approaches (e.g., antiandrogen plus ovarian suppression) may be more effective for hirsutism than single-agent therapy 2