PCOS: Symptoms, Diagnosis, and Evidence-Based Treatment Options

PCOS: Symptoms, Diagnosis, and Treatment

Polycystic ovary syndrome (PCOS) is the most common hormonal disorder in women of reproductive age, affecting 6-12% of women (approximately 5 million in the US). Despite its prevalence, it takes an average of 2 years and 3 doctors to receive a diagnosis.

What Is PCOS?

PCOS is a complex endocrine disorder characterized by:

1. Excess androgen (male hormone) production
2. Ovulatory dysfunction (irregular or absent ovulation)
3. Polycystic ovaries on ultrasound (though not required for diagnosis)

The name is somewhat misleading — the "cysts" are actually immature follicles, and not all women with PCOS have them on ultrasound.

Diagnostic Criteria (Rotterdam Criteria)

PCOS is diagnosed when 2 of 3 criteria are met:

1. Irregular or absent periods (oligomenorrhea or amenorrhea)
2. Clinical or biochemical signs of excess androgens
3. Polycystic ovaries on ultrasound

Other causes (thyroid disease, hyperprolactinemia, congenital adrenal hyperplasia) must be excluded.

Symptoms

Menstrual irregularities:

• Periods fewer than 8 per year
• Cycles longer than 35 days
• Absent periods (amenorrhea)

Signs of excess androgens:

• Hirsutism (excess hair on face, chest, abdomen — affects 70% of PCOS patients)
• Acne (particularly hormonal pattern — jawline, chin)
• Androgenic alopecia (female pattern hair loss)

Metabolic features:

• Insulin resistance (affects 70-80% of PCOS patients)
• Weight gain, particularly abdominal
• Difficulty losing weight
• Acanthosis nigricans (dark, velvety skin patches in skin folds)

Other:

• Infertility (PCOS is the most common cause of anovulatory infertility)
• Sleep apnea (3x more common in PCOS)
• Mood disorders (depression and anxiety are more prevalent)

Long-Term Health Risks

PCOS is associated with increased risk of:

• Type 2 diabetes (4-7x higher risk)
• Cardiovascular disease
• Endometrial cancer (from chronic anovulation and unopposed estrogen)
• Metabolic syndrome

Treatment

Lifestyle modification (first-line for most symptoms):

Even 5-10% weight loss in overweight women with PCOS can restore ovulation, reduce androgen levels, and improve metabolic markers. Low-glycemic diet and regular exercise are most effective.

Hormonal contraceptives:

Combined oral contraceptives (estrogen + progestin) regulate periods, reduce androgen levels, and protect the endometrium. First-line for women not trying to conceive.

Metformin:

Improves insulin sensitivity; reduces androgen levels; can restore ovulation. Particularly useful for metabolic PCOS.

Spironolactone:

Anti-androgen; reduces hirsutism and acne. Used with contraception (teratogenic).

For fertility:

• Letrozole (first-line ovulation induction; superior to clomiphene)
• Clomiphene citrate
• Gonadotropins
• IVF if other treatments fail

Inositol:

Myo-inositol and D-chiro-inositol supplements have evidence for improving insulin sensitivity and ovulation in PCOS. Considered safe.

Medical Disclaimer

PCOS diagnosis and management requires evaluation by a gynecologist or endocrinologist. Treatment should be individualized based on symptoms and reproductive goals.