Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is a common endocrine and metabolic disorder affecting women of reproductive age. It is characterized by a combination of ovulatory dysfunction, hyperandrogenism, and polycystic ovarian morphology, though not all women present with every feature.

Epidemiology:

• Affects ~6–12% of women of reproductive age (varies by diagnostic criteria).
• Leading cause of anovulatory infertility.

Etiology & Pathophysiology:

• The exact cause is multifactorial: genetic, hormonal, and environmental.
• Key mechanisms:
• Insulin resistance & hyperinsulinemia → stimulates ovarian androgen production.
• Hyperandrogenism → hirsutism, acne, alopecia, anovulation.
• Disrupted HPO (hypothalamic–pituitary–ovarian) axis → abnormal LH:FSH ratio, impaired follicular development.

Diagnostic Criteria:

The most widely used is the Rotterdam Criteria (2003): at least 2 out of 3:

1. Oligo-ovulation or anovulation (irregular or absent cycles).
2. Clinical and/or biochemical signs of hyperandrogenism (e.g., hirsutism, acne, elevated testosterone).
3. Polycystic ovaries on ultrasound (≥12 follicles 2–9 mm or ovarian volume >10 mL).

(Other causes must be excluded, such as thyroid disorders, hyperprolactinemia, or congenital adrenal hyperplasia.)

Clinical Features:

• Menstrual/ovulatory dysfunction: oligomenorrhea, amenorrhea, infertility.
• Hyperandrogenism: hirsutism, acne, male-pattern hair loss.
• Metabolic manifestations: insulin resistance, obesity (especially central), increased risk of type 2 diabetes.
• Long-term risks: endometrial hyperplasia/cancer (due to chronic anovulation), dyslipidemia, cardiovascular disease.

Investigations:

• Hormonal profile: ↑ androgens, ↑ LH:FSH ratio (sometimes), rule out mimicking conditions.
• Ultrasound pelvis: “string of pearls” appearance of multiple small follicles.
• Metabolic evaluation: fasting glucose, HbA1c, lipid profile.

Management:

Treatment is individualized depending on patient’s symptoms and fertility goals.

1. Lifestyle modification:
   • Weight loss (5–10%) improves ovulation and insulin sensitivity.
   • Regular exercise, balanced diet (low GI, high fiber).
2. Pharmacological management:
   • Menstrual irregularity / hyperandrogenism:
   • Combined oral contraceptives (COCs) regulate cycles, reduce hirsutism/acne.
   • Anti-androgens (spironolactone, finasteride) if needed.
   • Insulin resistance:
   • Metformin improves metabolic profile and may restore ovulation.
   • Infertility:
   • Ovulation induction agents (letrozole, clomiphene citrate).
   • Assisted reproductive techniques if resistant.
3. Cosmetic measures for hirsutism:
   • Laser hair removal, electrolysis, topical eflornithine.