PCOS : 10 Essential Facts Every Woman Should Know

Introduction

Polycystic Ovarian Syndrome (PCOS) formerly known as Stein Leventhal syndrome, is one of the most common hormonal disorders affecting women of reproductive age group. Although the condition was once named for the presence of “Polycystic Ovaries” the term can be misleading. The so called cysts are not true path, logically cyst, but rather multiple immature or added ovarian follicle that failed to develop normal. In fact many woman with PCOS, do not have the policy appearance over on the ultrasound

PCOS is one of the most common reason of hirsutism (Excess Facial and Body hair) and one of the leading causes of chronic anovulation, which can result in irregular menstrual period and infertility. Beyond reproductive health, PCOS is also closely linked to insulin resistance, Pre-diabetes, Type 2 Diabetes, obesity and increased risk of cardiovascular syndrome,making erly diagnosis and proper management essential.

Risk factor

Obesity

Insulin resistance

Female with metabolic Syndrome

Diabetes mellitus type two and type one

Pre-mature adrenarche

Mexican or Australian people, and sometimes the South Asian people are predisposed

History of 1st degree relative with PCOS

Few anti ecliptic drug which is a higher risk of PCOS like valproic acid.

Pathogenesis

The exact cause of PCOS remains incompletely understood, but excess ovarian androgen production is a central feature of the disorder. In most women with PCOS serum testosterone levels are mild to moderately elevated, typically range below 200 ng/dL. Markedly higher androgen level should prompt evaluation for other causes, such as androgen secreting ovarian tumour or adrenal tumour.

The excess estrogen are produced primary by the Theca cells of the ovaries with a insulin resistance and elevated leutenizing hormone further stimulating the androgen synthesis. This increased androgen level disrupt the normal follicular development. Instead of maturing into a dominant follicle and ovulating, many undergo growth arrest, resulting in multiple small immature follicle within the ovaries.

The arrested follicular development leads to chronic and ovulation, causing irregular menstrual cycle, infertility, and many of the characteristic clinical features of PCOS, including its Hirsutism and acne

The diagnosis of PCOS is commonly establish based on the criteria which is discussed below.

Hirsutism vs Virilisation

	Hirsutism	Virilisation
Androgen Level	Mildly Elevated	Excessive Elevated
Seen in	PCOS / PMOS	Androgen Producing Tumor
Fearures	Coarse male pattern terminal hair around Lips, Chin, Chest, Linea Nigra, Alopecia	Clitoromegaly Increased Muscle mass Deepening of Voice
Score System	Modified Ferriman Gallwey Score	Prader Score

General Lab Reports

LDL- increased

HDL- decreased

Testosterone- > 70 but <200

DHEA- elevated

LH- elevated

Sex Hormone Binding Globulin (SHBG)- decreased bue to increased Testosterone

Rotterdam Criteria

Any 2 of the following 3 should be present

Increased androgen level
Ovary dysfunction as amenorrhea or oligomenorrhea
USG- one or both the ovaries with >12 follicle with size <1 cm and volume >10 ml

The USG shows in “necklace pattern” of the ovaries with PCOS

What can be associated with Hirsutism

PCOS / PMOS

Idiopathic Hirsutism

Late onset CAH

Androgen secreting Ovarian Tumor

Hirsutism vs CAH

	Hirsutism	CAH
17 hydroxy-progesterone	Norma	Markedly Elevated
Testosterone	Elevated	Elevated
DHEA	Mildly Elevated	May be Elevated
LH:FSH ratio	Elevated (>2:1)	Normal
ACTH Stimulation test	Not required	Confirm Diagnosis

One quick way to differentiate them is, in CAH, its early onset of hirsutism and in PCOS, its rather a Rapid Onset

17-OH Progesterone Value

<200 ng/dL – Rule out CAH

200-800 ng/dL – Perform ACTH stimulation test to evaluate CAH

>800 ng/dL – Confirms CAH

Testosterone Values

<70 ng/dL – Usually Normal

70-150 ng/dL – Mild Elevation, commonly seen in PCOS

>150 ng/dL – Consider Androgen Secreting Ovarian Tumor

Insulin Resistance

It is seen almost 70 to 80% of the patients. This further stimulate the Theca cell to produce androgen. Insulin resistance is associated with-

Hyperandrogenism

Diabetes mellitus

Acanthosis Nigricana

Obese PCOS vs Thin PCOS

	OBESE FEMALE PCOS	THINN FEMALE PCOS
Insulin Resistance	Present	Presemt
Amenorrhea	Less Common	More Common
Estrogen level	High	Normal
Progesterone level	Low	Low

Future Pregnancy Related Complications

Infertility due to anovulation.

Increased Abortion due to decreased progesterone

Pregnancy induced Hypertension

Gestational Diabetes

Still Birth

Complications of the Female with PCOS / PMOS

Menstrual irregularity

Hirsutism

Alopecia

Infertility

Insulin Resistance

Dyslipidemia

High Blood Pressure

Coronary Artery Disease

Diabetes Mellitus

Metabolic X syndrome

Endometrial Cancer

Ovarian Cancer

Mood disorder like Anxiety or Depression

How to Treat PCOS?

1st Line Treatment – lifestyle modification.

Even if 5% weight lost can lead to ovulatory recycle. When an obese patient comes with PCOS, She is first recommended to loose her weight first with Lifestyle Modification.

Hypocaloric diet with Brisk walking and exercise is mostly recommended by doctors. Fat loss has a multidimensional advantages. It not only deceases central fat but also improve the insulin sensitivity. Weight loss improves the PCOS by increasing Sex Hormone Binding Globulin and further decrease the Androgen or Free testosterone level in body.

If the patient decides to go directly for Bariatric Surgery to loose weight, she should delay her pregnancy for next 1 to 2 years, because rapid weight loss can be dangerous for the baby’s health and IUGR or Nutritional Deprivation may happen to the Fetus.

DOC – OCP/ Oral Combined Pills.

The progesterone inside the OCP should be 3rd or 4th Generation, because of thier Least Androgenic Side Effect.

Management of PCOS with Menstrual Irregularities

Patients coming with PCOS along with Menstrual Problem should also take OCP. They should consume OCP for 3 weeks and then stop for 1 week.

OCP are mostly started on Day 3 to Day 5 of the cycle and continued for 3 weeks. It increases the Estrogen and Progesterone levels in body for 3 weeks, and then when stopped results in Menstruation.

Progesterone reduces the LH which acts on Theca cell to produce Androgen. So OCP increases progesterone and reduces LH further reducing Androgen and Hirsutism is treated.

Management of PCOS With Insulin Resistance

When a patient comes with Impaired Glucose test or Increased Fasting Glucose or Acanthosis Nigricans.

Drug – Metformin. 850 BD or 500 TDS is prescribed mostly.

Management of PCOS with Hirsutism

Based on Ferriman-Gallwey scoring system Hirsutism may be divided into 3 parts

Mild – Score <10

Moderate – Score >10

Severe – Score >15

Patient With Mild Hirsutism are asked to Shave, pluck, wax or Laser if needed.

Moderate and Severe Hirsutism mainly treated with Medicines. The main treatment is to use OCP where the Progesterone is 4th Generation for their Anti Androgenic behaviour. Estrogen in OCP binds with the Sex Hormone Binding Globulins and reduces the free Testosterone . Progesterone provides negative feedback on LH, with in turn reduces Androgen.

But, Estrogen leads to increase in clotting factors in body, so if a patient suffering from ThromboEmbolism, Direct Estrogen is not given, rather a drug with Progesterone with Estrogen action, name “Nor-ethi-drone”, is prescribed.

If patient with Hirsutism not getting relief with OCP even after using 6 months continuously, 2nd line management is started along with OCP with Spiranolactone, Flutamide, Ketoconazole, these has Anti Androgenic behaviour.

Management of PCOS with Infertility

Patients with PCOS suffering from Infertility mainly due to Anovulation. Even if she ovulates, the egg quality is very poor. The following drugs are given

1st Line Drug

Letrozole, Clomiphen Citrate.

Letrozol is mainly used in Infertility due to PCOS. In other types of infertility, Clomiphen is more commonly used.

2nd Line Drug

HMG (May lead to Ovarian Hyperstimulation Syndrome)

3rd Line Drug

Pulsatile GnRH, IVF

Summery of Management

PCOS +

Obesity- Lifestyle Modifications
Irregular Menstrual- OCP
Insulin Resistance- Metformin
Hirsutism- OCP, Flutamide, Spiranolactone
Infertility – Letrozol, Clomiphen Citrate.

Conclusions

Polycystic Ovary Syndrome (PCOS) or PMOS is a complex endocrine and metabolic disorder that affects much more than the ovaries. It commonly presents with irregular menstrual cycles, hirsutism, acne, infertility, and features of insulin resistance, while also increasing the long-term risk of type 2 diabetes, metabolic syndrome, cardiovascular disease, and endometrial cancer.

Early diagnosis using the Rotterdam criteria, along with appropriate laboratory evaluation, helps exclude other causes of hyperandrogenism and ensures timely treatment.

Lifestyle modification and weight reduction remain the foundation of management, with medications tailored to the patient’s primary concern, such as oral contraceptive pills for menstrual irregularities and hirsutism, metformin for insulin resistance, and letrozole for infertility.

Because PCOS is a lifelong condition, regular follow-up, healthy lifestyle habits, and individualised treatment are essential to improve reproductive, metabolic, and overall long-term health outcomes.