Polycystic Ovary Syndrome
A hormonal disorder causing irregular periods, excess male hormones (acne, facial hair), and cysts on the ovaries, heavily linked to insulin resistance.
Emergency Management: Severe abnormal uterine bleeding requiring acute management (high-dose IV estrogen or D&C). Ovarian hyperstimulation syndrome (OHSS) if using injectable gonadotropins for fertility.
Polycystic Ovary Syndrome (PCOS) is a complex, heterogeneous endocrine and metabolic disorder of reproductive-age women. It is characterized by a combination of hyperandrogenism (clinical or biochemical), ovulatory dysfunction (oligo-anovulation), and polycystic ovarian morphology. It is a leading cause of female infertility.
Detailed Overview
PCOS is far more than a reproductive disorder; it is a profound metabolic condition. The core pathophysiologic driver in most patients is peripheral insulin resistance, leading to compensatory hyperinsulinemia. High insulin levels directly stimulate the ovarian theca cells to overproduce androgens and simultaneously decrease hepatic production of Sex Hormone-Binding Globulin (SHBG), further increasing free, active testosterone. This androgen excess disrupts follicular maturation, leading to multiple arrested cysts (polycystic ovaries) and failure to ovulate. Long-term, PCOS carries significant risks for type 2 diabetes, metabolic syndrome, cardiovascular disease, and endometrial hyperplasia/cancer.
Epidemiology & Demographics
The most common endocrine disorder in reproductive-aged women, affecting 6-12% of women worldwide. Prevalence is increasing parallel to global obesity rates.
Etiological Mechanism
Multifactorial. Involves complex genetic susceptibility interacting with environmental factors, primarily diet and lifestyle leading to obesity, which exacerbates underlying insulin resistance and androgen excess.
Primary Causes
Hypothalamic-pituitary axis dysregulation (increased GnRH pulse frequency causing high LH to FSH ratio), primary ovarian hyperandrogenism, and severe peripheral insulin resistance are the primary drivers.
Three main defects interact: 1) Insulin resistance: hyperinsulinemia stimulates theca cell androgen production and inhibits hepatic SHBG. 2) Ovarian dysfunction: excess androgens prematurely luteinize granulosa cells, arresting follicle growth (creating the 'cysts') and preventing ovulation. 3) Neuroendocrine defect: abnormally rapid GnRH pulses favor LH production over FSH. The high LH stimulates theca cells to produce more testosterone, while low FSH impairs the granulosa cells' ability to convert that testosterone to estradiol via aromatase. This creates a vicious cycle of hyperandrogenism and anovulation. The chronic unopposed estrogen (from peripheral conversion of androgens) without progesterone (due to anovulation) drives endometrial proliferation.
Diagnostic Criteria & Guidelines
Rotterdam Criteria (requires 2 out of 3, after exclusion of other etiologies): 1) Oligo- and/or anovulation. 2) Clinical and/or biochemical signs of hyperandrogenism. 3) Polycystic ovaries on ultrasound (≥20 follicles per ovary or ovarian volume ≥10 mL).
For cycle regulation/endometrial protection: Combined Oral Contraceptives (COCs) containing low-androgenic progestins (e.g., Ethinyl estradiol/Drospirenone). For metabolic support/insulin resistance: Metformin (titrated to 1500-2000 mg/day). For infertility: Letrozole (aromatase inhibitor) 2.5 mg/day on days 3-7 of cycle is the first-line ovulation induction agent.
Second-Line & Adjunctive Therapy
For refractory hirsutism: Antiandrogens such as Spironolactone 100-200 mg/day (MUST be prescribed with strict contraception due to risk of feminizing male fetuses). For infertility: Clomiphene citrate or injectable gonadotropins. For severe obesity: GLP-1 receptor agonists (e.g., Semaglutide) or bariatric surgery.
Surgical & Procedural Management
Laparoscopic ovarian drilling (diathermy) is a second-line treatment for women with clomiphene/letrozole-resistant PCOS to induce ovulation by destroying androgen-producing stroma.
Patient Counseling & Advice
Explain that PCOS is a lifelong condition requiring chronic management. Emphasize that while it is a major cause of infertility, ovulation can be successfully induced in most women when they are ready to conceive. Stress the critical importance of having at least 4 periods a year (induced via progestin withdrawal if necessary) to prevent uterine cancer. Discuss the high risk of diabetes and the need for rigorous lifestyle management.
Follow-Up & Monitoring Schedule
Annual screening for BP, BMI, and depression. A 2-hour OGTT and fasting lipid profile every 1-3 years. Monitor liver enzymes if on Metformin or suspected of having NAFLD.
Preventive Strategies
Cannot be prevented, but early lifestyle interventions (diet, exercise) in adolescents with a family history can significantly mitigate the development of severe phenotypes and metabolic complications.
Good for symptom control and fertility with appropriate medical management. Long-term prognosis depends heavily on the prevention and management of metabolic and cardiovascular comorbidities.