Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women of reproductive age, affecting approximately 8-13% of women worldwide. Despite its prevalence, it remains underdiagnosed, with up to 70% of affected women unaware they have the condition.
What Is PCOS?
PCOS is a complex hormonal disorder characterized by a combination of signs and symptoms related to anovulation (lack of regular ovulation) and hyperandrogenism (excess male hormones). Despite its name, not all women with PCOS have ovarian cysts.
The Rotterdam Criteria for Diagnosis
To be diagnosed with PCOS, you must have at least two of these three criteria:
- Oligo- or anovulation: Irregular or absent periods (cycles longer than 35 days or fewer than 8 periods per year)
- Clinical or biochemical hyperandrogenism: Signs like acne, hirsutism (excess hair growth), or elevated testosterone levels
- Polycystic ovaries on ultrasound: 12 or more follicles in either ovary, or increased ovarian volume
Importantly, other conditions that cause similar symptoms (thyroid disorders, hyperprolactinemia, congenital adrenal hyperplasia) must be ruled out.
Understanding the Hormonal Picture
Key Hormone Findings in PCOS
- Elevated LH with normal or low FSH: The LH:FSH ratio is often greater than 2:1
- Elevated androgens: Total testosterone, free testosterone, and DHEA-S may be elevated
- Elevated AMH: Higher-than-expected AMH levels reflect the increased number of antral follicles
- Insulin resistance: Elevated fasting insulin and glucose, even when fasting glucose appears normal
The Insulin Connection
Insulin resistance is present in 50-70% of women with PCOS, regardless of body weight. Elevated insulin stimulates the ovaries to produce more androgens, creating a vicious cycle. This metabolic component significantly increases the risk of:
- Type 2 diabetes (women with PCOS have a 4-7x higher risk)
- Cardiovascular disease
- Non-alcoholic fatty liver disease
- Metabolic syndrome
PCOS Phenotypes
Not all PCOS is the same. Researchers have identified four phenotypes:
- Classic PCOS (Type A): All three Rotterdam criteria—highest metabolic risk
- Classic PCOS (Type B): Hyperandrogenism + anovulation, without polycystic ovaries
- Ovulatory PCOS (Type C): Hyperandrogenism + polycystic ovaries, but regular ovulation
- Non-hyperandrogenic PCOS (Type D): Anovulation + polycystic ovaries, without hyperandrogenism—mildest phenotype
Comprehensive Testing for PCOS
A thorough evaluation should include:
- Hormones: LH, FSH, total and free testosterone, DHEA-S, SHBG, 17-hydroxyprogesterone
- Metabolic markers: Fasting glucose, fasting insulin, HbA1c, lipid panel
- Thyroid function: TSH, free T4
- Prolactin
- AMH (often elevated in PCOS)
Evidence-Based Management
Lifestyle Modifications (First-Line)
Even modest weight loss (5-10%) can restore ovulation, improve insulin sensitivity, and reduce androgen levels. Key recommendations:
- Low glycemic index diet: Reduces insulin spikes and helps with weight management
- Regular exercise: Both aerobic and resistance training improve insulin sensitivity
- Adequate sleep: Poor sleep worsens insulin resistance
Medical Treatments
- Metformin: Improves insulin sensitivity, may restore ovulation, helps with weight management
- Combined oral contraceptives: Regulate periods, reduce androgens, protect the endometrium
- Anti-androgens: Spironolactone for hirsutism and acne (not safe during pregnancy)
- Fertility treatments: Letrozole or clomiphene for ovulation induction when pregnancy is desired
Long-Term Health Considerations
Women with PCOS should be monitored for:
- Type 2 diabetes (glucose tolerance testing every 1-3 years)
- Cardiovascular risk factors (lipids, blood pressure)
- Depression and anxiety (2-3x more common in PCOS)
- Obstructive sleep apnea (especially if overweight)
- Endometrial health (unopposed estrogen increases cancer risk)
Early diagnosis and comprehensive management can significantly reduce these long-term risks and improve quality of life.
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