Symptoms of Polycystic Ovary Syndrome (PCOS) in Women
PCOS presents with three core symptom domains—menstrual irregularities, hyperandrogenic manifestations, and metabolic disturbances—with at least two domains required for diagnosis. 1
Menstrual and Reproductive Symptoms
- Oligomenorrhea or amenorrhea is the hallmark menstrual presentation, resulting from chronic anovulation due to arrested follicular development at 2-8mm diameter. 2, 1
- Infertility or subfertility occurs secondary to anovulation, with mid-luteal phase progesterone levels <6 nmol/L confirming the absence of ovulation. 3, 2
- Menstrual cycles become irregular during adolescence and young adulthood, often serving as the first presenting symptom. 4
Hyperandrogenic Dermatologic Manifestations
- Hirsutism affects approximately 75% of women with PCOS and represents the most visible androgenic symptom, manifesting as excess terminal hair growth in male-pattern distribution (face, chest, abdomen, back). 1, 5
- Acne develops from androgen-driven sebaceous gland hyperactivity and may persist beyond typical adolescent years. 5, 4
- Male-pattern alopecia (androgenic hair loss) occurs on the scalp, particularly at the crown and frontal regions. 5, 4
The pathophysiology underlying these dermatologic features involves accelerated GnRH pulsatility driving excessive LH secretion, which stimulates ovarian theca cells to overproduce testosterone, while hyperinsulinemia directly amplifies androgen production and suppresses SHBG, increasing free testosterone levels. 1
Metabolic and Body Composition Symptoms
- Obesity is present in 74% of women with PCOS in recent cohorts (increased from 51% in the 1990s), with weight gain serving as a major trigger for disease development in genetically susceptible women. 2, 1
- Central/abdominal obesity (waist-hip ratio >0.9) exacerbates metabolic, reproductive, and psychological features of the syndrome. 3, 1
- Insulin resistance and hyperinsulinemia manifest clinically even in lean women, though symptoms worsen with obesity. 2, 1, 6
- Acanthosis nigricans (dark, velvety skin patches in body folds) serves as a physical marker of insulin resistance. 3
Metabolic Syndrome Features
- Type 2 diabetes or glucose intolerance develops at higher rates, with fasting glucose >7.8 mmol/L indicating diabetes. 2, 1, 6
- Dyslipidemia presents with elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides. 1, 6
- Hypertension occurs more frequently than in age-matched controls. 1, 6
- Nonalcoholic fatty liver disease should be screened for as part of metabolic evaluation. 5
Psychological and Quality of Life Symptoms
- Anxiety and depression are prevalent and significantly impact quality of life in women with PCOS. 1, 7
- Eating disorders occur more commonly in this population. 1, 5
- Body image concerns related to hirsutism, acne, obesity, and hair loss contribute to psychological distress. 5, 7
Additional Clinical Manifestations
- Sleep apnea occurs more commonly in women with PCOS and should be screened for, particularly in obese patients. 5
- Endothelial dysfunction and subclinical atherosclerosis develop as markers of cardiovascular disease risk. 2, 1
Important Clinical Caveats
Certain medications, particularly valproate, can trigger or exacerbate PCOS symptoms including worsening hirsutism. 2, 1 Clinicians should review medication lists when evaluating suspected PCOS.
Ethnic variation exists in symptom presentation: East Asian women show highest metabolic syndrome prevalence despite lower BMI and less prominent hyperandrogenic features compared to other ethnic groups. 1
Physical inactivity and unhealthy dietary patterns actively contribute to symptom progression, making lifestyle factors both triggers and perpetuators of the syndrome. 2, 8