Polycystic Ovary Syndrome Overview

Updated: 19-October-2024

Introduction

Polycystic ovary syndrome (PCOS), also known as polycystic ovarian syndrome, is a common endocrine condition that affects how a woman’s ovaries work. Described as a low-grade chronic inflammatory state, due to decreased progesterone and elevated estrogen levels, it is responsible for approximately 85% of cases of irregular periods in women.

The exact prevalence is unknown due to a lack of awareness amongst the community, however it is estimated to affect between 5 to 15% of women.¹ A higher prevalence of PCOS is common in population studies where higher incidence of obesity and diabetes exist.²

The 3 main features of PCOS are:

• Irregular periods. This means the ovaries are not regularly releasing eggs (menstrual cycle length > 35 days or < 22 days).
• Excess androgen. Male dominant hormones which may cause excess acne, facial or body hair and male pattern baldness (serum total testosterone > 2 nmol/L).
• Polycystic ovaries. An increased number of antral follicles causing enlarged ovaries (specifically 20 or more antral follicles 2 to 9μm in diameter or ovarian volume > 10mL).

If you have at least 2 of these features, your Doctor may diagnose you with PCOS in the absence of other possible causes (e.g. adrenal disorder³, hyperthyroidism⁴, hyperprolactinoma⁵, androgen secreting tumours in rare cases).

In fact non-obese women with polycystic ovaries but no symptoms (irregular cycles, acne, facial or body hair) have a similar ‘time to pregnancy’ compared to women without polycystic ovaries.⁶

On the other hand women with elevated androgen levels are at greater risk of having children with neuropsychiatric disorders, particularly attention deficit hyperactivity disorder, autism spectrum disorder, Tourette’s disorder and chronic tic disorder.⁷

Even though hyperandrogenism and menstrual dysfunction is common in women with PCOS they are not associated. Studies show that the severity of menstrual dysfunction, in women with PCOS, is closely linked to the degree of insulin resistance (dynamic state) rather than androgen levels.^8,9,10 Therefore correcting elevated insulin levels first (and androgens second) is most likely to restore regular menstrual cycles.

To understand PCOS, we need to go back to the very beginning. Approximately 3 months prior to ovulation, tiny sacs each containing an egg, known as follicles begin to grow. This growth and release is predominantly regulated by the female hormones estrogen and progesterone. However during this early stage of growth women with elevated levels of testosterone experience two to three times the normal number of follicle arrest. This is what gives the appearance of small cysts in the ovaries under ultrasound and hence the name polycystic ovaries.

Interestingly normal puberty in girls cause many of the features of PCOS, such as irregular periods, elevated androgen levels, increased luteinizing hormone (LH), insulin resistance and polycystic ovaries. This is one of the reasons why a Doctor might not send a young woman for ultrasound diagnosis, particularly if it has been less than 8 years since the woman began menstruating.¹¹

In short, women with PCOS normally have problems with fertility because ovulation occurs intermittently or stops entirely and endometrial receptivity is altered.¹² To make matters worse, women with PCOS commonly exhibit high levels of insulin (i.e. 65-80% insulin resistant) irrespective of BMI.^13,14 Insulin resistance worsens menstrual cycles and makes it difficult for women trying to lose weight.¹⁵

Fortunately as women get older (> 30), the prevalence of polycystic ovaries tends to decrease, along with androgen levels, causing the return of normal menstrual cycles in some women.^16,17,18,19 However embryo quality also decreases with age such that immediate treatment is normally recommended over a wait and see approach.

Symptoms of Polycystic Ovary Syndrome

Polycystic ovary syndrome does not usually produce symptoms until part way through puberty when the ovaries begin to produce hormones in significant amounts.

These symptoms can include:

• periods that are infrequent, irregular or absent (oligomenorrhea or polymenorrhoea ²⁰)
• difficulty getting pregnant (due to irregular or absent ovulation)
• male pattern hair growth
• darkened, thickened armpit skin (acanthosis nigricans)
• thinning hair and hair loss
• oily skin or acne
• weight gain or obesity ²¹
• bloating ²²

Risks Associated with Polycystic Ovary Syndrome

Women diagnosed with Polycystic Ovary Syndrome are also at higher risk of other complications which can complicate the trying to conceive journey.

These risks include:

• Endocrine disorders
• Cardiovascular disease
• Gestational diabetes, Impaired glucose tolerance, Type 2 diabetes
• Liver disease
• Kidney stones
• Endometrial cancer
• Infection
• Pregnancy complications
• Inflammatory disorders
• Cognitive impairment
• Mental disorders
• Obstructive sleep apnea
• Asthma

Causes of Polycystic Ovary Syndrome

The exact cause of PCOS is currently unknown, however researchers are slowly piecing together the puzzle which may involve elevated androgen levels in utero, high sucrose diets consumed prepuberty and or gene mutations.^23,24,25

Diagnosis of Polycystic Ovary Syndrome

Women are diagnosed with PCOS if they have any combination of irregular periods, excess androgen and polycystic ovaries.

However, correct diagnosis of PCOS is a multi-step process to rule out other possible causes (e.g. adrenal disorder, hyperthyroidism, hyperprolactinoma, androgen secreting tumours in rare cases). This process involves:

• Physical examination
• Blood tests
• Ultrasound scan

Treatment of Polycystic Ovary Syndrome

Currently there is no official cure for PCOS, however many of the symptoms and underlying effects of PCOS can be improved and sometimes normalised.

Understanding your unique type of PCOS is paramount to effective management long term, as is a peer support group to lean on for good mental health.²⁶

Although women with PCOS are traditionally diagnosed as type A, B, C or D, recent genetic analysis suggests PCOS only has 3 unique subtypes: reproductive, indeterminate, and metabolic.²⁷

As shown above, each subtype involves different biological pathways and environmental factors. This explains why no single treatment option is 100% successful.

Treatment options for PCOS fall into 3 categories:

• Natural
• Conventional
• Fertility

Natural treatment of PCOS includes: exercise, diet, weight loss, stress management, environmental changes, and supplements.

Although natural treatment options are often combined with conventional treatments. Conventional treatment of PCOS normally involves medication. However in cases where medication (and lifestyle modification) has failed, the doctor may recommend surgery (bariatric/metabolic).

Nevertheless, women with PCOS trying to conceive naturally sometimes need fertility treatment (a.k.a. medically assisted reproduction). This normally consists of medication with or without assisted reproductive technologies (IVF, IVM), and in some cases surgery (Laparoscopic Ovarian Drilling, Bariatric).

References

1. Johnson, M H, (2018). Essential Reproduction, 8th Edition. https://www.wiley.com/en-au/Essential+Reproduction%2C+8th+Edition-p-9781119246398 ↩︎
2. Dubey P, et al. (2021). Prevalence of at-risk hyperandrogenism by age and race/ethnicity among females in the United States using NHANES III. https://www.ejog.org/article/S0301-2115(21)00153-6/abstract ↩︎
3. Gourgari E, et al. (2016). Bilateral Adrenal Hyperplasia as a Possible Mechanism for Hyperandrogenism in Women With Polycystic Ovary Syndrome. https://academic.oup.com/jcem/article/101/9/3353/2806623 ↩︎
4. Ueshiba H, et al. (1997). Serum androgen levels in hyperthyroid women. https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0029-1211779 ↩︎
5. Goyal A and Ganie M A, (2018). Idiopathic Hyperprolactinemia Presenting as Polycystic Ovary Syndrome in Identical Twin Sisters: A Case Report and Literature Review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6145756/ ↩︎
6. Hassam M A and Killick S R, (2003). Ultrasound diagnosis of polycystic ovaries in women who have no symptoms of polycystic ovary syndrome is not associated with subfecundity or subfertility. https://www.fertstert.org/article/S0015-0282(03)01010-0/fulltext ↩︎
7. Cesta A E, et al. (2019). Maternal polycystic ovary syndrome and risk of neuropsychiatric disorders in offspring: prenatal androgen exposure or genetic confounding? https://www.cambridge.org/core/journals/psychological-medicine/article/maternal-polycystic-ovary-syndrome-and-risk-of-neuropsychiatric-disorders-in-offspring-prenatal-androgen-exposure-or-genetic-confounding/67AE5515F9EAB54938DA63782991D169 ↩︎
8. Niu J, et al. (2023). Association between insulin resistance and abnormal menstrual cycle in Chinese patients with polycystic ovary syndrome. https://ovarianresearch.biomedcentral.com/articles/10.1186/s13048-023-01122-4 ↩︎
9. Li X, et al. (2022). The Degree of Menstrual Disturbance Is Associated With the Severity of Insulin Resistance in PCOS. https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2022.873726/full ↩︎
10. Ezeh U, et al. (2021). Menstrual dysfunction in polycystic ovary syndrome: association with dynamic state insulin resistance rather than hyperandrogenism. https://www.fertstert.org/article/S0015-0282(20)32758-8/fulltext ↩︎
11. Legro R S, et al. (2013). Diagnosis and Treatment of Polycystic Ovary Syndrome: An Endocrine Society Clinical Practice Guideline. https://academic.oup.com/jcem/article/98/12/4565/2833703 ↩︎
12. Wang C, et al. (2022). Impact of metabolic disorders on endometrial receptivity in patients with polycystic ovary syndrome. https://www.spandidos-publications.com/10.3892/etm.2022.11145 ↩︎
13. DeUgarte C M, et al. (2005). Prevalence of insulin resistance in the polycystic ovary syndrome using the homeostasis model assessment. https://www.fertstert.org/article/S0015-0282(05)00373-0/fulltext ↩︎
14. Hussein S, et al. (2023). Insulin level, lipid profile, and HOMA index in lean and obese patients with polycystic ovary syndrome. https://medandlife.org/all-issues/2023/issue-8-2023/original-article-issue-8-2023/insulin-level-lipid-profile-and-homa-index-in-lean-and-obese-patients-with-polycystic-ovary-syndrome/ ↩︎
15. Lionett S, et al. (2021). Absent Exercise-Induced Improvements in Fat Oxidation in Women With Polycystic Ovary Syndrome After High-Intensity Interval Training. https://www.frontiersin.org/journals/physiology/articles/10.3389/fphys.2021.649794/full ↩︎
16. Keizerswaard J, et al. (2022). Changes in individual polycystic ovary syndrome phenotypical characteristics over time: a long-term follow-up study. https://www.fertstert.org/article/S0015-0282(22)00049-8/fulltext ↩︎
17. Jacewicz-Swiecka M, et al. (2021). The Effect of Ageing on Clinical, Hormonal and Sonographic Features Associated with PCOS—A Long-Term Follow-Up Study. https://www.mdpi.com/2077-0383/10/10/2101 ↩︎
18. Carmina E, et al. (2012). A 20-Year Follow-up of Young Women With Polycystic Ovary Syndrome. https://journals.lww.com/greenjournal/abstract/2012/02000/a_20_year_follow_up_of_young_women_with_polycystic.10.aspx ↩︎
19. Elting M W, et al. (2000). Women with polycystic ovary syndrome gain regular menstrual cycles when ageing. https://academic.oup.com/humrep/article/15/1/24/702011 ↩︎
20. Ganie M A, et al. (2023). Pre-polycystic ovary syndrome and polymenorrhoea as new facets of polycystic ovary syndrome (PCOS): Evidences from a single centre data set. https://onlinelibrary.wiley.com/doi/10.1111/cen.14964 ↩︎
21. Lerner A, et al. (2020). Androgen Reduces Mitochondrial Respiration in Mouse Brown Adipocytes: A Model for Disordered Energy Balance in Polycystic Ovary Syndrome. https://www.mdpi.com/1422-0067/22/1/243 ↩︎
22. Jain T, et al. (2021). Characterization of polycystic ovary syndrome among Flo app users around the world. https://rbej.biomedcentral.com/articles/10.1186/s12958-021-00719-y ↩︎
23. de Melo G B, et al. (2021). Early Exposure to High-Sucrose Diet Leads to Deteriorated Ovarian Health. https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2021.656831/full ↩︎
24. Abbott D H, et al. (2018). Accelerated Episodic Luteinizing Hormone Release Accompanies Blunted Progesterone Regulation in PCOS-like Female Rhesus Monkeys (Macaca Mulatta) Exposed to Testosterone during Early-to-Mid Gestation. https://karger.com/nen/article/107/2/133/220347/Accelerated-Episodic-Luteinizing-Hormone-Release ↩︎
25. Moore A M, et al. (2015). Enhancement of a robust arcuate GABAergic input to gonadotropin-releasing hormone neurons in a model of polycystic ovarian syndrome. https://www.pnas.org/doi/full/10.1073/pnas.1415038112 ↩︎
26. Ranasinghe B A, et al. (2021). The impact of peer-led support groups on health-related quality of life, coping skills and depressive symptomatology for women with PCOS. https://www.tandfonline.com/doi/full/10.1080/13548506.2021.2019805 ↩︎
27. Dapas M and Dunaif A, (2022). Deconstructing a Syndrome: Genomic Insights Into PCOS Causal Mechanisms and Classification. https://academic.oup.com/edrv/article/43/6/927/6506411 ↩︎