What are the typical symptoms and signs of polycystic ovary syndrome (PCOS)?

Symptoms of Polycystic Ovary Syndrome (PCOS)

PCOS presents with three core symptom domains: menstrual irregularities (oligomenorrhea or amenorrhea), hyperandrogenic manifestations (hirsutism, acne, male-pattern balding), and metabolic disturbances (insulin resistance, weight gain, acanthosis nigricans). 1

Reproductive and Menstrual Symptoms

• Oligomenorrhea or amenorrhea is the hallmark menstrual presentation, typically beginning at menarche and persisting chronically due to anovulation 2, 3, 4
• Infertility results from chronic anovulation, with low mid-luteal phase progesterone levels (<6 nmol/L) confirming the absence of ovulation 2, 3
• Menstrual irregularity manifests as irregular bleeding patterns rather than complete absence of periods in most cases 4

Hyperandrogenic Dermatologic Manifestations

• Hirsutism occurs in approximately 75% of PCOS cases and represents the most visible androgenic symptom, with excessive terminal hair growth in male-pattern distribution 1, 5
• Acne develops due to elevated androgen levels stimulating sebaceous gland activity 2, 6, 5
• Male-pattern balding (androgenic alopecia) may occur but is less common than hirsutism 2
• Clitoromegaly can develop in severe hyperandrogenic states 2

Critical caveat: Rapid development of virilizing signs such as deepening voice, increased muscle mass, or severe temporal balding should prompt evaluation for androgen-secreting tumors rather than PCOS 4

Metabolic and Physical Examination Findings

• Obesity affects 51-74% of PCOS patients, with central/abdominal obesity being particularly common and exacerbating all other symptoms 1
• Acanthosis nigricans (dark, velvety skin patches in body folds) indicates insulin resistance and is a key physical examination finding 2
• Weight gain serves as a major trigger for PCOS development and symptom worsening in genetically susceptible women 2, 1
• Elevated waist-hip ratio reflects central adiposity patterns 2

Important distinction: When acanthosis nigricans is present, consider associated insulinoma or gastric adenocarcinoma, not just PCOS 2

Metabolic and Hormonal Features

• Insulin resistance and hyperinsulinemia affect 50-70% of women with PCOS, independent of obesity status 1, 5
• Fasting glucose/insulin ratio >4 suggests reduced insulin sensitivity 2, 3
• Type 2 diabetes risk is substantially elevated, with 31-40% of lean PCOS patients developing glucose intolerance 3
• Dyslipidemia includes elevated LDL cholesterol, elevated triglycerides, and decreased HDL cholesterol 2, 5
• Hypertension develops more frequently due to metabolic syndrome features 1, 5

Psychological and Quality of Life Symptoms

• Depression and anxiety are prevalent and significantly impact quality of life 1, 7
• Eating disorders occur more frequently in PCOS patients 1
• Emotional distress related to hirsutism, infertility, and body image concerns requires screening 3
• Bipolar disorder and binge eating disorder occur at higher rates 5

Laboratory and Imaging Findings (Not Symptoms but Diagnostic)

• Elevated testosterone levels (>2.5 nmol/L) on day 3-6 of cycle 2
• LH/FSH ratio >2 due to accelerated GnRH pulsatility 2, 3
• Pelvic ultrasound showing >10 peripheral cysts (2-8 mm diameter) with thickened ovarian stroma 2

Note for adolescents: Pelvic ultrasound findings are NOT needed for diagnosis in adolescent girls, who should be diagnosed based on menstrual irregularity, clinical hyperandrogenism, and/or hyperandrogenemia alone 6

Medication-Related Considerations

• Valproate (antiepileptic drug) can exacerbate PCOS or trigger PCOS-like symptoms including worsening hirsutism and elevated testosterone 2, 1
• Prevalence of PCOS in women with temporal lobe epilepsy ranges from 10-25%, even without antiepileptic drug use 2

Ethnic Variations

• East Asian women show highest metabolic syndrome prevalence despite lower BMI and less pronounced hyperandrogenic features compared to other ethnic groups 1