From the Guidelines
Infertility is the classic presentation complication of Polycystic Ovary Syndrome (PCOS) in a patient with a Body Mass Index (BMI) of 25, rather than Diabetes Mellitus (DM). The most recent and highest quality study, 1, published in 2024, highlights the complex pathophysiology of PCOS, including the interaction of altered hypothalamic–pituitary–ovarian function and concomitant hyperinsulinemia/insulin resistance with promotion of androgen excess. This study emphasizes the importance of addressing reproductive, psychological, and metabolic health in PCOS management.
Key Points:
- PCOS is characterized by heterogeneous features, including reproductive, psychological, and metabolic sequelae, with a prevalence of 8%–13% according to the Rotterdam criteria 1.
- Insulin resistance (IR) plays a crucial role in many symptoms of PCOS, regardless of BMI, and affects both lean and overweight women with PCOS 1.
- The hormonal dysregulation in PCOS significantly impacts reproductive function, leading to chronic anovulation, irregular menstrual cycles, and impaired follicular development, resulting in infertility 1.
- Approximately 70-80% of women with PCOS experience fertility issues, making it the most common endocrine cause of female infertility.
- While diabetes mellitus (DM) is associated with PCOS, particularly in patients with higher BMI values and longer disease duration, infertility represents the more classic and immediate complication of PCOS, even in patients with a BMI of 25.
Management:
- Treatment for PCOS-related infertility typically begins with weight control and a regular exercise program, followed by medication such as clomiphene citrate if needed 1.
- Lifestyle modification, including diet and exercise, is essential for PCOS management, but pharmacotherapy may be necessary as an adjunct to lifestyle approaches to optimize weight loss success and efficacy in obesity 1.
From the Research
Presentation of Polycystic Ovary Syndrome (PCOS)
- The classic presentation complication of PCOS in a patient with a Body Mass Index (BMI) of 25 is more likely to be related to infertility rather than Diabetes Mellitus (DM) 2, 3, 4, 5.
- Infertility is a prevalent presenting feature of PCOS, with approximately 75% of women suffering from infertility due to anovulation, making PCOS the most common cause of anovulatory infertility 3.
- PCOS is a leading cause of female infertility, impacting up to 40% of cases, and is characterized by hyperandrogenism, chronic anovulation, and polycystic ovarian morphology 5.
Relationship between PCOS and Diabetes Mellitus (DM)
- While PCOS is linked to metabolic comorbidities like hepatic steatosis, glucose intolerance, dyslipidemia, type 2 diabetes mellitus (T2DM), and hypertension, the primary presentation complication in a patient with a BMI of 25 is more likely to be related to infertility 5.
- The increased risk of developing adverse obstetric complications, including gestational diabetes mellitus, has been suggested to occur independently of obesity as well as in populations without assisted reproductive techniques 6.
Treatment of Infertility in PCOS
- Lifestyle modifications, such as weight loss, physical exercise, and stop smoking, are of the utmost importance in improving fertility outcomes in women with PCOS 3, 4, 5.
- Clomiphene citrate and letrozole are commonly used as first-line pharmacological treatments for ovulation induction in women with PCOS, with letrozole being considered a more effective option 2, 3, 5.
- Gonadotropins and laparoscopic ovarian surgery are usually second-line ovulation induction therapies, while in vitro fertilization (IVF) is considered a third-line therapy where first- or second-line ovulation induction therapies have failed 3, 4, 5.