PCOS: Overview of risk factors, symptoms and treatment options

PCOS: Overview of risk factors, symptoms and treatment options

Overview

Polycystic Ovary Syndrome (PCOS) is one of the most common endocrine disorder affecting women of reproductive age, characterized by a combination of metabolic issues and underlying hormonal imbalances.  PCOS is a condition that inherently alters the way ovaries function. It affects approximately 1 in 10 women worldwide and is one of the leading causes of infertility. A concerning fact is that more than 70% of affected women are undiagnosed further challenging proper treatment. PCOS can affect girls soon after puberty, but it may also develop during the late teens or early twenties.

Risk factors

While the exact risk factors are still unknown, there are many common and well known risk factors:

  1. Family history has been known to be associated with PCOS development suggesting a strong genetic component. 
  2. Obesity which often aggravates insulin resistance is often a common risk factor.
  3. Insulin resistance (even without obesity) is both a risk factor as well a feature in women suffering from PCOS.
  4. Sedentary lifestyle contributes to obesity as well as insulin resistance.
  5. Hormonal imbalance especially androgen excess is reported in 60-70% of women suffering from PCOS.
  6. Low birth weight has been also connected to increased incidence of PCOS. For example, a birth weight of <2.5 kg confers a 76% higher likelihood of PCOS development later in life.
  7. While smoking is not directly a cause for PCOS, there is direct evidence establishing worsening of underlying symptoms in women suffering from PCOS.
  8. Numerous studies have found a correlation between Vitamin D insufficiency and onset of PCOS symptoms especially insulin resistance.

Many of the above risk factors often don’t exist in isolation but work together to aggravate PCOS. For example obesity, sedentary lifestyle and lack of vitamin D could create positive feedback loop that keep worsening PCOS symptoms.

Symptoms

1. Menstrual Irregularities: Oligomenorrhea (infrequent menstrual periods) or amenorrhea (absence of menstruation) are common in PCOS patients.

2. Hyperandrogenism (Excess Androgens):

  • Clinical signs include hirsutism (excessive, coarse hair growth on face, chest, abdomen, back).
  • Acne and oily skin due to androgen excess.
  • Androgenic alopecia or hair loss has also been implicated as a symptom in PCOS.

3. Polycystic ovaries:

  • Presence of 12 or more follicles in each ovary measuring 2–9 mm in diameter or increased ovarian volume (>10 cm³) detected by ultrasound.

4. Infertility:

  • Anovulation or irregular ovulation can lead to difficulty conceiving.

5. Metabolic symptoms:

  • Insulin resistance leading to increased risk of type 2 diabetes and metabolic syndrome.
  • Weight gain and difficulty losing weight; obesity is common but not universal.

6. Psychological symptoms:

  • Higher prevalence of anxiety, depression, and reduced quality of life in women with PCOS.

7. Other Symptoms:

  • Skin changes such as acanthosis nigricans (dark, velvety patches commonly in neck and armpits) indicating insulin resistance.
  • Sleep apnea, especially in obese women with PCOS.

Treatment

1. Lifestyle Modification 

  • Weight management:
    • Even a 5–10% reduction in body weight improves insulin sensitivity, ovulation, and reduces androgen levels.
    • Focus on a balanced diet (low glycemic index, reduce calories if overweight) and regular physical activity.
  • Exercise: 
    • Improves insulin resistance and menstrual regularity independent of weight loss.

2. Pharmacological Treatments

  • Combined Oral Contraceptives (COCs):
    • Regulate menstrual cycles.
    • Reduce androgen levels and improve symptoms like hirsutism and acne.

  • Ovulation Induction Agents:
    1. To regulate menstrual cycles and induce ovulation:
      • Clomiphene citrate
      • Letrozole: Increasingly preferred over Clomiphene due to higher pregnancy rates and fewer side effects.
      • Metformin: Used alone or with Clomiphene to improve insulin sensitivity and ovulation, especially in women with insulin resistance.
      • Gonadotropins: Injectable hormones used if oral agents fail.

    2. To address insulin resistance and metabolic risks:
      • Metformin
        i. Improves insulin sensitivity.
        ii. May help restore menstrual regularity and support weight loss.
        iii. Used especially in overweight/obese women or those with impaired glucose tolerance.

    3. To reduce hyperandrogenism symptoms (hirsutism, acne):
      • Anti-androgens:
        i. Spironolactone, finasteride, or flutamide can reduce androgen effects.
        ii. Usually combined with COCs to prevent pregnancy due to teratogenic risk. (Rosenfield, 2007)
      • Topical treatments:
        i. Eflornithine cream to slow facial hair growth.

      3. Surgical Treatment

      • Ovarian drilling (laparoscopic ovarian drilling):
        • Considered when medical ovulation induction fails.
        • Minimally invasive procedure to reduce androgen production and induce ovulation.
           (Amer et al., 2018)

      4. Psychological Support

      • Screening and treatment for anxiety, depression, and body image issues.
      • Counseling and cognitive behavioral therapy (CBT) often recommended to counter the decrease in quality of life because of PCOS.

      5. Long-term Monitoring and Management

      • Regular screening for metabolic syndrome, diabetes, and cardiovascular risk factors.
      • Monitoring bone health, especially if amenorrhea persists.

      While there is no specific cure for PCOS, its symptoms can be managed effectively through lifestyle and medical interventions. One of the simplest and most effective remedies is lifestyle modification. Weight loss through a balanced diet and regular exercise can significantly improve hormone balance, insulin sensitivity, and menstrual regularity. Even a modest reduction in body weight (5–10%) can help restore ovulation and improve symptoms.

      References:

      1. https://www.cdc.gov/diabetes/basics/pcos.html
      2. https://www.mayoclinic.org/diseases-conditions/pcos
      3. https://www.womenshealth.gov/a-z-topics/polycystic-ovary-syndrome
      4. https://www.nichd.nih.gov/health/topics/pcos
      5. Legro RS, et al. (2013). Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. https://doi.org/10.1210/jc.2013-2350
      6. Mohan A, Haider R, Fakhor H, Hina F, Kumar V, Jawed A, Majumder K, Ayaz A, Lal PM, Tejwaney U, Ram N, Kazeem S. Vitamin D and polycystic ovary syndrome (PCOS): a review. Ann Med Surg (Lond). 2023 Jun 5;85(7):3506-3511. doi: 10.1097/MS9.0000000000000879. PMID: 37427232; PMCID: PMC10328709.
      7. Azziz R, et al. (2016). "Polycystic Ovary Syndrome." Nature Reviews Disease Primers, 2:16057. https://doi.org/10.1038/nrdp.2016.57
      8. Teede HJ, et al. (2018). "Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome." Human Reproduction, 33(9), 1602–1618. https://doi.org/10.1093/humrep/dey256
      9. Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004 Jan;19(1):41-7. doi: 10.1093/humrep/deh098. PMID: 14688154.
      10. Moran LJ, Ko H, Misso M, Marsh K, Noakes M, Talbot M, Frearson M, Thondan M, Stepto N, Teede HJ. Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines. J Acad Nutr Diet. 2013 Apr;113(4):520-45. doi: 10.1016/j.jand.2012.11.018. Epub 2013 Feb 16. PMID: 23420000.
      11. Legro RS, et al. (2014). "Letrozole versus Clomiphene for Infertility in the Polycystic Ovary Syndrome." New England Journal of Medicine, 371(2), 119-129. https://doi.org/10.1056/NEJMoa1313517
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