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Polycystic Ovary Syndrome (PCOS)

Mar 30, 2025

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Polycystic Ovary Syndrome (PCOS)

Overview

  • Definition: A collection of symptoms due to multiple abnormally developing follicles in the ovaries.
  • Classification: Known as an endocrinopathy, affecting the hormonal system.
  • Prevalence: Most common endocrinopathy in females of reproductive age; affects between 6-13% of females.
  • Mechanism: Not well understood, but involves the hypothalamic-pituitary-ovarian axis.

Causes and Mechanisms

  • Hypothalamic-Pituitary Axis:
    • Hypothalamus releases GnRH (gonadotropin-releasing hormone).
    • Stimulates anterior pituitary to produce FSH (follicle-stimulating hormone) and LH (lutenizing hormone).
    • FSH and LH cause ovaries to produce androgens.
  • Hyperandrogenism:
    • Hypothalamus produces rapid pulses of GnRH, increasing LH to FSH ratio.
    • Ovaries produce more androgens, especially testosterone.
    • Adrenal glands become more sensitive to ACTH, releasing more androgens.
  • Insulin Resistance:
    • Androgens contribute to insulin resistance.
    • Insulin promotes androgen production, perpetuating a cycle.
    • Insulin reduces SHBG (sex hormone-binding globulin), increasing free androgens.
  • Genetic Component:
    • Heritability is around 70%, with exact genes yet unidentified.

Clinical Features

  • Hyperandrogenism Symptoms:
    • Hirsutism: Excessive hair growth in male-like pattern (face, back, chest).
    • Acne: Affects ~20% due to increased sebum production.
    • Weight Gain: Result of higher glucose levels and increased appetite.
    • Higher risk of type 2 diabetes and cardiovascular issues.
  • Menstrual Irregularities:
    • Infrequent periods (< 8 per year), oligo/anovulation.
    • Most common cause of infertility in young females.
    • Risks include gestational diabetes, preeclampsia, miscarriage, macrosomia.

Diagnosis

  • Rotterdam Criteria: Requires 2 out of 3 features in adults (all 3 in teenagers):
    1. Clinical or biochemical hyperandrogenism.
    2. Oligo/anovulation.
    3. Polycystic ovaries on ultrasound.
  • Blood Tests: Rule out other causes (e.g., adrenal hyperplasia, hypothyroidism).
  • Additional Evaluations: Blood sugar levels, lipid profiles.

Management

  • Weight Loss:
    • 5-7% weight loss can restore ovulation in ~80%.
    • Reduces hyperandrogenism symptoms and cardiovascular risks.
  • Medications:
    • Oral contraceptives: Reduce GnRH secretion, increase SHBG, prevent endometrial cancer.
    • Metformin: Variable evidence, used for insulin resistance.
    • Aromatase Inhibitors (e.g., Letrozole): Increase live birth rates.
    • Anti-androgens (e.g., Finasteride, Spironolactone): Symptomatic control.
    • Antibiotics, retinoids: For acne.

Summary

PCOS is a complex condition requiring a multi-faceted approach for management, focusing on symptom reduction, fertility maximization, and complication prevention.

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