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Polycystic ovary syndrome

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Template:Short description Template:Redirect Template:Cs1 config Template:Use dmy dates Template:Infobox medical condition

Polycystic ovary syndrome, or polycystic ovarian syndrome, (PCOS) is the most common endocrine disorder in women of reproductive age.<ref name="Goodman2015">Template:Cite journal</ref> The name is a misnomer,<ref>Template:Cite journal</ref> as not all women with this condition develop cysts on their ovaries. The name originated from the observation of cysts which form on the ovaries of some women with this condition. However, this is not a universal symptom and is not the underlying cause of the disorder.<ref name="Dunaif2013">Template:Cite journal</ref><ref>Template:Cite journal</ref>

The primary characteristics of PCOS include hyperandrogenism, anovulation, insulin resistance, and neuroendocrine disruption.<ref name="Crespo2018">Template:Cite journal</ref> Women may also experience irregular menstrual periods, heavy periods, excess hair, acne, pelvic pain, difficulty getting pregnant, and patches of darker skin.<ref name="NICHD What are the symptoms of PCOS?" /><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Beyond its reproductive implications, PCOS is increasingly recognized as a multifactorial metabolic condition with significant long-term health consequences, including an elevated risk of cardiovascular disease and type 2 diabetes.<ref name="Teede e1321–e1322">Template:Cite journal</ref>

A review of international evidence found that the prevalence of PCOS could be as high as 26% among some populations, though ranges between 4% and 18% are reported for general populations.<ref>Template:Cite journal</ref><ref name="Lentscher et al 2021">Template:Cite journal</ref><ref>Template:Cite journal</ref> According to the World Health Organization (WHO), PCOS affects over 8-13% of reproductive-aged women.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name="Teede e1321–e1322" />

The exact cause of PCOS remains uncertain, and treatment involves management of symptoms using medication.<ref name="Lentscher et al 2021" />

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DefinitionEdit

Two definitions are commonly used:

NIH
In 1990, a consensus workshop sponsored by the NIH/NICHD suggested that a person has PCOS if they have all of the following:<ref name=emedicine_main>Template:EMedicine</ref>Template:PbTemplate:Numbered list
Rotterdam
In 2003, a consensus workshop sponsored by ESHRE/ASRM in Rotterdam indicated PCOS to be present if any two out of three criteria are met, in the absence of other entities that might cause these findings:<ref name=BMC2010 /><ref name="Azziz-2006">Template:Cite journal</ref><ref name=HumRep_Rotterdam>Template:Cite journal</ref>Template:PbTemplate:Numbered listTemplate:PbThe Rotterdam definition is wider, including many more women, the most notable ones being women without androgen excess. Critics say that findings obtained from the study of women with androgen excess cannot necessarily be extrapolated to women without androgen excess.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>
Androgen Excess PCOS Society
In 2006, the Androgen Excess PCOS Society suggested a tightening of the diagnostic criteria to all of the following:<ref name=BMC2010 />Template:PbTemplate:Numbered list

Signs and symptomsEdit

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Signs and symptoms of PCOS include irregular or no menstrual periods, heavy periods, excess body and facial hair, acne, pelvic pain, difficulty getting pregnant, and patches of thick, darker, velvety skin,<ref name="NICHD What are the symptoms of PCOS?">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> ovarian cysts, enlarged ovaries, excess androgens, and weight gain.<ref name="vice.com">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Associated conditions include type 2 diabetes, obesity, obstructive sleep apnea, heart disease, mood disorders, and endometrial cancer.<ref name="NIH2017Def" />

Common signs and symptoms of PCOS include the following:

  • Menstrual disorders: PCOS mostly produces oligomenorrhea (fewer than nine menstrual periods in a year) or amenorrhea (no menstrual periods for three or more consecutive months), but other types of menstrual disorders may also occur.<ref name=BMC2010 />
  • Infertility: This generally results directly from chronic anovulation (lack of ovulation).<ref name=BMC2010 />
  • High levels of masculinizing hormones: Known as hyperandrogenism, the most common signs are acne and hirsutism (male pattern of hair growth, such as on the chin or chest), but it may produce hypermenorrhea (heavy and prolonged menstrual periods), androgenic alopecia (increased hair thinning or diffuse hair loss), or other symptoms.<ref name=BMC2010 /><ref name="AMN">{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref> Approximately three-quarters of women with PCOS (by the diagnostic criteria of NIH/NICHD 1990) have evidence of hyperandrogenemia.<ref name="huang">Template:Cite journal</ref>

  • Metabolic syndrome: This appears as a tendency towards central obesity and other symptoms associated with insulin resistance, including low energy levels and food cravings.<ref name=BMC2010 /> Serum insulin, insulin resistance, and homocysteine levels are higher in women with PCOS.<ref name="FertSter_insulin">Template:Cite journal</ref>
  • Acne: A rise in testosterone levels increases the oil production within the sebaceous glands and clogs pores.<ref name=":0">Template:Cite book</ref> For many women, the emotional impact is great and quality of life can be significantly reduced.<ref name=":1">Template:Cite journal</ref>
  • Androgenic alopecia: Estimates suggest that androgenic alopecia affects 22% of PCOS sufferers.<ref name=":0" /> This is a result of high testosterone levels that are converted into the dihydrotestosterone (DHT) hormone. Hair follicles become clogged, making hair fall out and preventing further growth.<ref>Template:Cite book</ref>
  • Acanthosis nigricans (AN): A skin condition where dark, thick, and "velvety" patches can form.<ref name=":2">Template:Cite book</ref>
  • Polycystic ovaries: There are small cysts on one or both ovaries. Ovaries might enlarge and compress follicles surrounding the eggs. As a result, ovaries might fail to function regularly. This disease is related to the number of follicles per ovary each month, growing from the average range of 6–8 to double, triple, or more.Template:Citation needed Women with PCOS have a higher risk of multiple diseases including infertility, type 2 diabetes mellitus (DM-2), cardiovascular risk, metabolic syndrome, obesity, impaired glucose tolerance, depression, obstructive sleep apnea (OSA), endometrial cancer, and non-alcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH).<ref>Template:Cite book</ref>

Women with PCOS tend to have central obesity. Still, studies are conflicting as to whether visceral and subcutaneous abdominal fat is increased, unchanged, or decreased in women with PCOS relative to non-PCOS women with the same body mass index.<ref name="pmid25781555">Template:Cite journal</ref> In any case, androgens, such as testosterone, androstanolone (dihydrotestosterone), and nandrolone decanoate have been found to increase visceral fat deposition in both female animals and women.<ref name="pmid18615851">Template:Cite journal</ref>

Although 80% of PCOS presents in women with obesity, 20% of women diagnosed with the disease are non-obese or "lean" women.<ref>Template:Cite journal</ref> However, obese women who have PCOS have a higher risk of adverse outcomes, such as hypertension, insulin resistance, metabolic syndrome, and endometrial hyperplasia.<ref>Template:Cite journal</ref>

Even though most women with PCOS are overweight or obese, it is important to acknowledge that non-overweight women can also be diagnosed with PCOS. Up to 30% of women diagnosed with PCOS maintain a normal weight before and after diagnosis. "Lean" women still face the various symptoms of PCOS with the added challenges of having their symptoms properly addressed and recognized. Lean women often go undiagnosed for years and are usually diagnosed after struggles to conceive.<ref>Template:Cite journal</ref> Lean women are likely to have a missed diagnosis of diabetes and cardiovascular disease. These women also have an increased risk of developing insulin resistance, despite not being overweight. Lean women are often taken less seriously with their diagnosis of PCOS and also face challenges finding appropriate treatment options. This is because most treatment options are limited to approaches for losing weight and healthy dieting.<ref>Template:Cite journal</ref>

Hormone levelsEdit

Testosterone levels are usually elevated in women with PCOS.<ref name="MazzeStrockSimonson2007" /><ref name="pmid32462512">Template:Cite journal</ref> In a 2020 systematic review and meta-analysis of sexual dysfunction related to PCOS which included 5,366 women with PCOS from 21 studies, testosterone levels were analyzed and were found to be 2.34 nmol/L (67 ng/dL) in women with PCOS and 1.57 nmol/L (45 ng/dL) in women without PCOS.<ref name="pmid32462512" /> In a 1995 study of 1,741 women with PCOS, mean testosterone levels were 2.6 (1.1–4.8) nmol/L (75 (32–140) ng/dL).<ref name="pmid8567849">Template:Cite journal</ref> In a 1998 study which reviewed many studies and subjected them to meta-analysis, testosterone levels in women with PCOS were 62 to 71 ng/dL (2.2–2.5 nmol/L) and testosterone levels in women without PCOS were about 32 ng/dL (1.1 nmol/L).<ref name="pmid15251757">Template:Cite journal</ref> In a 2010 study of 596 women with PCOS which used liquid chromatography–mass spectrometry (LC–MS) to quantify testosterone, median levels of testosterone were 41 and 47 ng/dL (with 25th–75th percentiles of 34–65 ng/dL and 27–58 ng/dL and ranges of 12–184 ng/dL and 1–205 ng/dL) via two different labs.<ref name="pmid20826578">Template:Cite journal</ref> If testosterone levels are above 100 to 200 ng/dL, per different sources, other possible causes of hyperandrogenism, such as congenital adrenal hyperplasia or an androgen-secreting tumor, may be present and should be excluded.<ref name="pmid8567849" /><ref name="CarminaStanczykLobo2019">Template:Cite book</ref><ref name="MazzeStrockSimonson2007">Template:Cite book</ref>

Associated conditionsEdit

Warning signs may include a change in appearance. But there are also manifestations of mental health problems, such as anxiety, depression, and eating disorders.<ref name="vice.com" />Template:Medical citation needed

A diagnosis of PCOS suggests an increased risk of the following:

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|CitationClass=web }}</ref>Template:Better source needed The risk of ovarian cancer and breast cancer is not significantly increased overall, but women with PCOS were about three times more likely to develop endometrial cancer than other women.<ref name="BarryAzizia2014">Template:Cite journal</ref>

Some medical providers and groups consider PCOS to be an intersex condition because some sex hormones are outside the typical range.<ref>Tara Becker, Marshall Chin, and Nancy Bates (9 Mar 2022). "Measuring Sex, Gender Identity, and Sexual Orientation". National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. Washington DC: National Academies Press (US). 7, Measuring Intersex/DSD Populations. Archived from the original on 1 February 2025. Retrieved 12 February 2025.</ref> However, medical consensus, including the Endocrine Society and NIH, defines PCOS as an endocrine/metabolic disorder, not intersex, as it lacks congenital sex characteristic variations.<ref>Template:Cite journal</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>Template:Fv A 2023 study notes two transmasculine individuals self-identified as intersex without medical diagnosis, tying it to identity, not biology.<ref>Template:Cite journal</ref>

CauseEdit

PCOS is a heterogeneous disorder of uncertain cause.<ref name="Fauser2011">Page 836 (Section:Polycystic ovary syndrome) in: Template:Cite journal</ref><ref name="FertSter_molecular">Template:Cite journal</ref> There is some evidence that it is a genetic disease. Such evidence includes the familial clustering of cases, greater concordance in monozygotic compared with dizygotic twins and heritability of endocrine and metabolic features of PCOS.<ref name="Endo2006">Template:Cite journal</ref><ref name="Fauser2011" /><ref name="FertSter_molecular" /> There is some evidence that exposure to higher than typical levels of androgens and the anti-Müllerian hormone (AMH) in utero increases the risk of developing PCOS in later life.<ref>Template:Cite journal</ref>

It may be caused by a combination of genetic and environmental factors.<ref name="De2016">Template:Cite journal</ref><ref name="Endo2006" /><ref name="Du2015">Template:Cite journal</ref> Risk factors include obesity, a lack of physical exercise, and a family history of someone with the condition.<ref name="NICHD What causes PCOS?">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Diagnosis is based on two of the following three findings: anovulation, high androgen levels, and ovarian cysts.<ref name="NIH2017Def" /> Cysts may be detectable by ultrasound.<ref name="NICHD How do health care providers diagnose PCOS?">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Other conditions that produce similar symptoms include adrenal hyperplasia, hypothyroidism, and high blood levels of prolactin.<ref name="NICHD How do health care providers diagnose PCOS?" />

GeneticsEdit

The genetic component appears to be inherited in an autosomal dominant fashion with high genetic penetrance but variable expressivity in females; this means that each child has a 50% chance of inheriting the predisposing genetic variant(s) from a parent, and, if a daughter receives the variant(s), the daughter will have the disease to some extent.<ref name="FertSter_molecular" /><ref name="pmid11212071" /><ref name="AnnNYAS_thoughts" /><ref name="OMIM" /> The genetic variant(s) can be inherited from either the father or the mother, and can be passed along to both sons (who may be asymptomatic carriers or may have symptoms such as early baldness and/or excessive hair) and daughters, who will show signs of PCOS.<ref name="pmid11212071">Template:Cite journal</ref><ref name="OMIM">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The phenotype appears to manifest itself at least partially via heightened androgen levels secreted by ovarian follicle theca cells from women with the allele.<ref name="AnnNYAS_thoughts">Template:Cite journal</ref> The exact gene affected has not yet been identified.<ref name="Endo2006" /><ref name="FertSter_molecular" /><ref name="pmid15380142">Template:Cite journal</ref> In rare instances, single-gene mutations can give rise to the syndrome phenotype.<ref>Template:Cite journal</ref> Current understanding of the pathogenesis of the syndrome suggests, however, that it is a complex multigenic disorder.<ref>Template:Cite journal</ref>

The severity of PCOS symptoms appears to be largely determined by factors such as obesity.<ref name="Endo2006" /><ref name=BMC2010 /><ref name="pmid28416368">Template:Cite journal</ref> PCOS has some aspects of a metabolic disorder, since its symptoms are partly reversible. Even though considered as a gynecological problem, PCOS consists of 28 clinical symptoms.<ref>Template:Cite journal</ref>

Even though the name suggests that the ovaries are central to disease pathology, cysts are a symptom instead of the cause of the disease. Some symptoms of PCOS will persist even if both ovaries are removed; the disease can appear even if cysts are absent. Since its first description by Stein and Leventhal in 1935, the criteria of diagnosis, symptoms, and causative factors have been subject to debate. Gynecologists often see it as a gynecological problem, with the ovaries being the primary organ affected. However, recent insights show a multisystem disorder, with the primary problem lying in hormonal regulation in the hypothalamus, with the involvement of many organs. The term PCOS is used because there is a wide spectrum of symptoms possible. It is common to have polycystic ovaries without having PCOS; approximately 20% of European women have polycystic ovaries, but most of those women do not have PCOS.<ref name="Dunaif2013" />

EnvironmentEdit

PCOS may be related to or worsened by exposuresTemplate:Clarify during the prenatal period,<ref name="Hoeger-2014">Template:Cite journal</ref><ref name="Abbott-2005">Template:Cite journal</ref><ref name="Rasgon-2004">Template:Cite journal</ref> epigenetic factors, environmental impacts (especially industrial endocrine disruptors, such as bisphenol A and certain drugs)<ref name="Rutkowska-2014">Template:Cite journal</ref><ref name="Palioura-2013">Template:Cite journal</ref><ref name="Hu-2011">Template:Cite journal</ref> and the increasing rates of obesity.<ref name="Palioura-2013" />

Endocrine disruptors are defined as chemicals that can interfere with the endocrine system by mimicking hormones such as estrogen. According to the NIH (National Institute of Health), examples of endocrine disruptors can include dioxins and triclosan. Endocrine disruptors can cause adverse health impacts in animals.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Additional research is needed to assess the role that endocrine disruptors may play in disrupting reproductive health in women and possibly triggering or exacerbating PCOS and its related symptoms.<ref>Template:Cite journal</ref>

The study of epigenetic changes in PCOS in utero or after birth has become an emerging area of research. While extensive research is not currently available, some studies are looking into the connection between abnormal DNA methylation changes in various tissues and the development of PCOS.<ref name=":4">Template:Cite journal</ref>  Environmental exposure to endocrine disruptors such as phthalates could alter DNA methylation patterns, particularly in the ovaries, granulosa cells, and adipose tissue.<ref name=":4" />

One study observed early embryonic development of mice subjected to di--(2-ethylhexyl) phthalate (DEHP) and the results showed abnormal methylation patterns in the Stra8 gene involved in meiosis initiation.<ref name=":5">Template:Cite journal</ref> The gene for transcription factor Lhx8, involved in early follicular changes, was also impacted by DEHP when the neonatal mouse ovaries were analyzed. Together, these results showed DEHP induced epigenetic changes via DNA methylation to interfere with folliculogenesis, symptomatic of PCOS.<ref name=":5" /> Although DNA methylation in human embryonic development is not fully characterized, the animal model studies on epigenetic changes provide information to suggest that PCOS may have fetal origins.

Androgen excess is a central feature in the PCOS phenotype, and exposure in utero has shown PCOS-like features in adulthood. A study from 2014 induced DNA hypomethylation in the ovarian tissue of zebrafish exposed to androgens early in development.<ref name="ReferenceA">Template:Cite journal</ref> Glucose homeostasis alterations were also observed. Furthermore, these effects were carried into the next generation, suggesting that epigenetic changes caused by excess androgens in the fetus could be transgenerational.<ref name="ReferenceA"/>

PathogenesisEdit

Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of androgenic hormones, in particular testosterone, by either one or a combination of the following (almost certainly combined with genetic susceptibility):<ref name="AnnNYAS_thoughts" />

A majority of women with PCOS have insulin resistance and/or are obese, which is a strong risk factor for insulin resistance, although insulin resistance is a common finding among women with PCOS in normal-weight women as well.<ref name="Mor2015" /><ref name="BMC2010" /><ref name="FertSter_insulin" /> Elevated insulin levels contribute to or cause the abnormalities seen in the hypothalamic–pituitary–ovarian axis that lead to PCOS. Hyperinsulinemia increases GnRH pulse frequency,<ref name=DimantiDunaif2012>Template:Cite journal</ref> which in turn results in an increase in the LH/FSH ratio<ref name="DimantiDunaif2012" /><ref>Template:Cite journal</ref> increased ovarian androgen production; decreased follicular maturation; and decreased SHBG binding.<ref name=DimantiDunaif2012/> Furthermore, excessive insulin increases the activity of 17α-hydroxylase, which catalyzes the conversion of progesterone to androstenedione, which is in turn converted to testosterone. The combined effects of hyperinsulinemia contribute to an increased risk of PCOS.<ref name=DimantiDunaif2012/>

Adipose (fat) tissue possesses aromatase, an enzyme that converts androstenedione to estrone and testosterone to estradiol. The excess of adipose tissue in obese women creates the paradox of having both excess androgens (which are responsible for hirsutism and virilization) and excess estrogens (which inhibit FSH via negative feedback).<ref name="Rojas2014">Template:Cite journal</ref>

The syndrome acquired its most widely used name due to the common sign on ultrasound examination of multiple (poly) ovarian cysts. These "cysts" are in fact immature ovarian follicles. The follicles have developed from primordial follicles, but this development has stopped ("arrested") at an early stage, due to the disturbed ovarian function. The follicles may be oriented along the ovarian periphery, appearing as a 'string of pearls' on ultrasound examination.<ref>Template:Cite journal</ref>

PCOS may be associated with chronic inflammation,<ref name=Mediators_Inflammation>Template:Cite journal</ref> with several investigators correlating inflammatory mediators with anovulation and other PCOS symptoms.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Similarly, there seems to be a relation between PCOS and an increased level of oxidative stress.<ref name="pmid23303572">Template:Cite journal</ref>

DiagnosisEdit

Not every person with PCOS has polycystic ovaries (PCO), nor does everyone with ovarian cysts have PCOS; although a pelvic ultrasound is a major diagnostic tool, it is not the only one.<ref name=emedicine_imaging /> The diagnosis is fairly straightforward using the Rotterdam criteria, even when the syndrome is associated with a wide range of symptoms.<ref>Template:Cite journal</ref>

  • Polycystic ovary.jpg

    Transvaginal ultrasound scan of polycystic ovary

  • PCO polycystic ovary.jpg

    Polycystic ovary as seen on sonography

Differential diagnosisEdit

Other causes of irregular or absent menstruation and hirsutism, such as hypothyroidism, congenital adrenal hyperplasia (21-hydroxylase deficiency) (which may cause excessive body hair, deep tone voice and others symptoms similar to hyperandrogenism), Cushing's syndrome, hyperprolactinemia (leading to anovulation), androgen-secreting neoplasms, and other pituitary or adrenal disorders, should be investigated.<ref name=BMC2010 /><ref name=HumRep_Rotterdam /><ref name=emedicine_workup />

Assessment and testingEdit

Standard assessmentEdit

  • History-taking, specifically for menstrual patterns, obesity, hirsutism, and acne. A clinical prediction rule found that these four questions can diagnose PCOS with a sensitivity of 77.1% (95% confidence interval [CI] 62.7%–88.0%) and a specificity of 93.8% (95% CI 82.8%–98.7%).<ref name="pmid17872783">Template:Cite journal</ref>
  • Gynecologic ultrasonography, specifically looking for small ovarian follicles. These are believed to be the result of disturbed ovarian function with failed ovulation, reflected by the infrequent or absent menstruation that is typical of the condition. In a normal menstrual cycle, one egg is released from a dominant follicle – in essence, a cyst that bursts to release the egg. After ovulation, the follicle remnant is transformed into a progesterone-producing corpus luteum, which shrinks and disappears after approximately 12–14 days. In PCOS, there is a so-called "follicular arrest"; i.e., several follicles develop to a size of 5–7 mm, but not further. No single follicle reaches the preovulatory size (16 mm or more). According to the Rotterdam criteria, which are widely used for the diagnosis of PCOS,<ref name=Mor2015/> 12 or more small follicles should be seen in a suspect ovary on ultrasound examination.<ref name=emedicine_main /> More recent research suggests that there should be at least 25 follicles in an ovary to designate it as having polycystic ovarian morphology (PCOM) in women aged 18–35 years.<ref name="DewaillyLujan2013">Template:Cite journal</ref> The follicles may be oriented in the periphery, giving the appearance of a 'string of pearls'.<ref name="O'Brien2011">Template:Cite book</ref> If a high-resolution transvaginal ultrasonography machine is not available, an ovarian volume of at least 10 ml is regarded as an acceptable definition of having polycystic ovarian morphology, rather than follicle count.<ref name="DewaillyLujan2013" />
  • Laparoscopic examination may reveal a thickened, smooth, pearl-white outer surface of the ovary. (This would usually be an incidental finding if laparoscopy were performed for some other reason, as it would not be routine to examine the ovaries in this way to confirm a diagnosis of PCOS.)<ref>Template:Cite journal</ref>
  • Serum (blood) levels of androgens, including androstenedione and testosterone may be elevated.<ref name="BMC2010" /> Dehydroepiandrosterone sulfate (DHEA-S) levels above 700–800 μg/dL are highly suggestive of adrenal dysfunction because DHEA-S is made exclusively by the adrenal glands.<ref name="pmid18844715">Template:Cite journal</ref><ref name=emedicine_workup>Template:EMedicine</ref> The free testosterone level is thought to be the best measure,<ref name=emedicine_workup /><ref name="pmid17603706">Template:Cite journal</ref> with approximately 60 per cent of PCOS patients demonstrating supranormal levels.<ref name="huang" />

Some other blood tests are suggestive but not diagnostic. The ratio of LH (luteinizing hormone) to FSH (follicle-stimulating hormone), when measured in international units, is elevated in women with PCOS. Common cut-offs to designate abnormally high LH/FSH ratios are 2:1<ref name=Banaszewska2003/> or 3:1<ref name=emedicine_workup /> as tested on day 3 of the menstrual cycle. The pattern is not very sensitive; a ratio of 2:1 or higher was present in less than 50% of women with PCOS in one study.<ref name=Banaszewska2003>Template:Cite journal</ref> There are often low levels of sex hormone-binding globulin,<ref name=emedicine_workup /> in particular among obese or overweight women.<ref>Template:Cite book</ref> Anti-Müllerian hormone (AMH) is increased in PCOS, and may become part of its diagnostic criteria.<ref name="pmid26691645">Template:Cite journal</ref><ref name="pmid24430863">Template:Cite journal</ref><ref name="BroerBroekmans2014">Template:Cite journal</ref>

Glucose tolerance testingEdit

  • Two-hour oral glucose tolerance test (GTT) in women with risk factors (obesity, family history, history of gestational diabetes)<ref name=BMC2010 /> may indicate impaired glucose tolerance (insulin resistance) in 15–33% of women with PCOS.<ref name=emedicine_workup /> Frank diabetes can be seen in 65–68% of women with this condition.<ref>Template:Cite journal</ref> Insulin resistance can be observed in both normal weight and overweight people, although it is more common in the latter (and in those matching the stricter NIH criteria for diagnosis); 50–80% of people with PCOS may have insulin resistance at some level.<ref name=BMC2010 />
  • Fasting insulin level or GTT with insulin levels (also called IGTT). Elevated insulin levels have helped predict response to medication and may indicate women need higher doses of metformin or a second medication to significantly lower insulin levels. Elevated blood sugar and insulin values do not predict who responds to an insulin-lowering medication, low-glycemic diet, and exercise. Many women with normal levels may benefit from combination therapy. A hypoglycemic response in which the two-hour insulin level is higher and the blood sugar lower than fasting is consistent with insulin resistance. A mathematical derivation known as the HOMAI, calculated from the fasting values in glucose and insulin concentrations, allows a direct and moderately accurate measure of insulin sensitivity (glucose-level x insulin-level/22.5).<ref>Template:Cite book</ref>

Stem cell modelsEdit

Human embryonic stem cells (hESCs) derived from the inner cell mass of blastocyst-stage embryos of women with PCOS have shown abnormal lipid metabolism, consistent with the pathophysiology of the disease.<ref name=":6">Template:Cite journal</ref> When the hESCs are differentiated into adipocytes, gene expression data from these fat cells reveal a downregulation or a decrease in genes linked to glucose, lipid, and steroid metabolism.<ref>Template:Cite journal</ref> Despite the significant findings provided by hESC research to understand the earliest stages of PCOS development, there are limitations in studying human embryos due to legal prohibitions and ethical concerns.

Recent studies have successfully developed in vitro PCOS disease models through Induced pluripotent stem cell technology (iPSC).<ref name=":6" /> Similar to hESCs, iPSC cells can be derived from patients and can differentiate into various cell types. Using adult somatic cells, iPSCs can reprogram the cells into a pluripotent state, which can then be specified to replicate PCOS-like traits. Furthermore, 3D “organoid” models of female reproductive tissue, such as the uterus and ovaries, produced from iPSCs, present a powerful way to stimulate the development of reproductive disorders such as PCOS in vitro.<ref name=":6" />

File:IPSC Model for PCOS.png
Induced pluripotent stem cell model for PCOS research

Although not widely utilized, some researchers have explored the use of this biotechnology to model PCOS. One study that characterized the link between obesity and PCOS reprogrammed PCOS-derived urine epithelial cells into adipocytes and found that iPSC lines had greater glucose consumption along with lower insulin response compared to controls.<ref>Template:Cite journal</ref> These are results consistent with symptoms of the disease. Studies on iPSCs have also contributed significantly to understanding the behavior of ovarian granulosa cells, which maintain follicular development and secrete steroid hormones.<ref>Template:Cite journal</ref> The transcriptome data from the PCOS-derived iPSCs indicate dysfunctions in folliculogenesis and disruptions in the oocyte microenvironment.

Current growing data shows a strong association between mitochondrial malfunction and PCOS. iPSCs from PCOS patients have provided some evidence of impairments in glycolytic and mitochondrial functions.<ref name=":6" /> Interestingly, these cells exhibited a higher number of copies of mitochondrial DNA compared to the control. This may support the idea that mitochondrial biosynthesis is elevated in these patients as a compensatory response to the aberrations seen in the metabolic processes.<ref name=":6" />

iPSC models have great advantages over the ethical concerns in hESC research. One challenge to using this technology is controlling or assessing the intra-human variability, especially with a multifaceted disease such as PCOS. Nonetheless, these stem cell models are a valuable approach to gaining more insights into the disease.

ManagementEdit

PCOS has no cure.<ref name="NICHD Is there a cure for PCOS?">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Treatment may involve lifestyle changes such as weight loss and exercise.<ref name=Mor2015>Template:Cite journal</ref><ref name=Gia2009>Template:Cite journal</ref> Recent research suggests that daily exercise including both aerobic and strength activities can improve hormone imbalances.<ref name=":3" />

Birth control pills may help with improving the regularity of periods, excess hair growth, and acne.<ref name="NIH2014Tx1" /> Combined oral contraceptives are especially effective and used as the first line of treatment to reduce acne and hirsutism and regulate the menstrual cycle. This is especially the case in adolescents.<ref name=":3" />

Metformin, GLP-1, and anti-androgens may also help.<ref name="NIH2014Tx1" /> Other typical acne treatments and hair removal techniques may be used.<ref name="NIH2014Tx1">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Efforts to improve fertility include weight loss, metformin, and ovulation induction using clomiphene or letrozole.<ref name="NIH2014Tx2" /> In vitro fertilization is used by some in whom other measures are not effective.<ref name="NIH2014Tx2">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Certain cosmetic procedures may also help alleviate symptoms in some cases. For example, the use of laser hair removal, electrolysis, or general waxing, plucking, and shaving are all effective methods for reducing hirsutism.<ref name=":2" /> The primary treatments for PCOS include lifestyle changes and the use of medications.<ref name="Diagnosis and treatment of polycyst">Template:Cite journal</ref>

Goals of treatment may be considered under these categories:Template:Citation needed

In each of these areas, there is considerable debate as to the optimal treatment. One of the major factors underlying the debate is the lack of large-scale clinical trials comparing different treatments. Smaller trials tend to be less reliable and hence may produce conflicting results. General interventions that help to reduce weight or insulin resistance can be beneficial for all these aims because they address what is believed to be the underlying cause.<ref>Template:Cite journal</ref> As PCOS appears to cause significant emotional distress, appropriate support may also be useful.<ref name="pmid22824735">Template:Cite journal</ref>

DietEdit

Where PCOS is associated with being overweight or obese, successful weight loss is the most effective method of restoring normal ovulation/menstruation. The American Association of Clinical Endocrinologists guidelines recommend a goal of achieving 10–15% weight loss or more, which improves insulin resistance and allTemplate:Clarify hormonal disorders.<ref name="AACE2016">Template:Cite journal</ref> Still, many women find it very difficult to achieve and sustain significant weight loss. Insulin resistance itself can cause increased food cravings and lower energy levels, which can make it difficult to lose weight on a regular weight-loss diet. A scientific review in 2013 found similar improvements in weight, body composition and pregnancy rate, menstrual regularity, ovulation, hyperandrogenism, insulin resistance, lipids, and quality of life to occur with weight loss, independent of diet composition.<ref name=Moran2013>Template:Cite journal</ref> Still, a low GI diet, in which a significant portion of total carbohydrates is obtained from fruit, vegetables, and whole-grain sources, has resulted in greater menstrual regularity than a macronutrient-matched healthy diet.<ref name="Moran2013" />

Reducing the intake of food groups that cause inflammation, such as dairy, sugars, and simple carbohydrates, can be beneficial.<ref name=":2" />

A mediterranean diet is often very effective due to its anti-inflammatory and anti-oxidative properties.<ref name=":3">Template:Cite book</ref>

It has been suggested that vitamin D deficiency may play some undetermined role in the development of the metabolic syndrome, and that treatment might be beneficial.<ref name=emedicine_treatment /><ref name="pmid24044903">Template:Cite journal</ref> However, a systematic review of 2015 found no evidence that vitamin D supplementation reduced or mitigated metabolic and hormonal dysregulations in PCOS.<ref name="pmid26061015">Template:Cite journal</ref> As of 2012, interventions using dietary supplements to correct metabolic deficiencies in people with PCOS had been tested in small, uncontrolled and nonrandomized clinical trials; the resulting data are insufficient to recommend their use.<ref>Template:Cite journal</ref>

MedicationsEdit

Medications for PCOS include oral contraceptives and metformin. The oral contraceptives increase sex hormone binding globulin production, which increases the binding of free testosterone. This reduces the symptoms of hirsutism caused by high testosterone and regulates return to normal menstrual periods.<ref name=emedicine_treatment /> Anti-androgens such as finasteride, flutamide, spironolactone, and bicalutamide do not show advantages over oral contraceptives, but could be an option for people who do not tolerate them.<ref>Template:Cite journal</ref> Finasteride is the only oral medication for the treatment of androgenic alopecia, that is FDA approved.<ref name=":2" />

Metformin is a medication commonly used in type 2 diabetes mellitus to reduce insulin resistance and is used off label (in the UK, US, AU, and EU) to treat insulin resistance seen in PCOS. In many cases, metformin also supports ovarian function and a return to normal ovulation.<ref name=emedicine_treatment /><ref name=Lord>Template:Cite journal</ref> A newer insulin resistance medication class, the thiazolidinediones (glitazones), have shown equivalent efficacy to metformin, but metformin has a more favorable side effect profile.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> The United Kingdom's National Institute for Health and Clinical Excellence recommended in 2004 that women with PCOS and a body mass index above 25 be given metformin when other therapy has failed to produce results.<ref name="NICE2004">Template:NICE</ref><ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Metformin may not be effective in every type of PCOS, and therefore there is some disagreement about whether it should be used as a general first-line therapy.<ref name="pmid19697191">Template:Cite journal</ref> In addition to this, metformin is associated with several unpleasant side effects: including abdominal pain, metallic taste in the mouth, diarrhoea and vomiting.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Metformin is thought to be safe to use during pregnancy (pregnancy category B in the US).<ref>Template:Cite journal</ref> A review in 2014 concluded that the use of metformin does not increase the risk of major birth defects in women treated with metformin during the first trimester.<ref name="CassinaDona2014">Template:Cite journal</ref> Liraglutide may reduce weight and waist circumference in people with PCOS more than other medications.<ref>Template:Cite journal</ref> The use of statins in the management of underlying metabolic syndrome remains unclear.<ref name="Diagnosis and treatment of polycyst" />

It can be difficult to become pregnant with PCOS because it causes irregular ovulation. Medications to induce fertility when trying to conceive include the ovulation inducer clomiphene or pulsatile leuprorelin. Evidence from randomised controlled trials suggests that in terms of live birth, metformin may be better than placebo, and metformin plus clomiphene may be better than clomiphene alone, but that in both cases women may be more likely to experience gastrointestinal side effects with metformin.<ref>Template:Cite journal</ref>

InfertilityEdit

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Some individuals with PCOS may have difficulty getting pregnant since their bodies do not produce the hormones necessary for regular ovulation.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> PCOS might also increase the risk of miscarriage or premature delivery. However, it is possible to have a normal pregnancy.Template:Citation needed

For women who do, anovulation or infrequent ovulation is a common cause and PCOS is the main cause of anovulatory infertility.<ref>Template:Cite journal</ref> Other factors include changed levels of gonadotropins, hyperandrogenemia, and hyperinsulinemia.<ref name="Qiao2011">Template:Cite journal</ref> Like women without PCOS, women with PCOS that are ovulating may be infertile due to other causes, such as tubal blockages due to a history of sexually transmitted diseases.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

For overweight anovulatory women with PCOS, weight loss and diet adjustments, especially to reduce the intake of simple carbohydrates, are associated with the resumption of natural ovulation.<ref>Template:Cite journal</ref> Digital health interventions are particularly effective in providing combined therapy to manage PCOS through both lifestyle changes and medication.<ref>Template:Cite journal</ref>

Femara is an alternative medicine that raises FSH levels and promotes the development of the follicle.<ref name=":2" />

For those women that, after weight loss, are still anovulatory, or for anovulatory lean women, ovulation induction using the medications letrozole or clomiphene citrate are the principal treatments used to promote ovulation.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Clomiphene can cause mood swings and abdominal cramping for some.<ref name=":2" />

Previously, the anti-diabetes medication metformin was a recommended treatment for anovulation, but it appears less effective than letrozole or clomiphene.<ref>Template:Cite journal</ref><ref>Template:Cite journalTemplate:Primary source inline</ref>

For women not responsive to letrozole or clomiphene and diet and lifestyle modification, there are options available including assisted reproductive technology procedures such as controlled ovarian hyperstimulation with follicle-stimulating hormone (FSH) injections followed by in vitro fertilisation (IVF).<ref>Template:Cite journal</ref>

Though surgery is not commonly performed, the polycystic ovaries can be treated with a laparoscopic procedure called "ovarian drilling" (puncture of 4–10 small follicles with electrocautery, laser, or biopsy needles),<ref>Template:Cite journal</ref> which often results in either resumption of spontaneous ovulations<ref name=emedicine_treatment /> or ovulations after adjuvant treatment with clomiphene or FSH.<ref>Template:Cite journal</ref> (Ovarian wedge resection is no longer used as much due to complications such as adhesions and the presence of frequently effective medications.) There are, however, concerns about the long-term effects of ovarian drilling on ovarian function.<ref name=emedicine_treatment />

In a small UK randomized trial, bariatric surgery led to more spontaneous ovulations than behavioral interventions combined with medical therapy in adult women with PCOS, raising the prospect that surgery could enhance prospects of spontaneous fertility.<ref>Template:Cite journal</ref>

Mental healthEdit

Women with PCOS are far more likely to have depression than women without. Symptoms of depression might be heightened by certain physiological manifestations of this disease such as hirsutism or obesity that can lead to low self-esteem or poor body image.<ref name=":1" />  Researchers suggest that there be mental health screenings performed in tandem with PCOS assessment to identify these complications early and treat them accordingly.<ref name="Berni_2018">Template:Cite journal</ref>

PCOS is associated with other mental health-related conditions besides depression such as anxiety, bipolar disorder, and obsessive–compulsive disorder.<ref name=":1" /> Additionally, it has been found to significantly increase the risk of eating disorders.<ref name="Berni_2018" />  Screening for these mental health conditions will also be helpful in the treatment of PCOS.

Lifestyle changes for people with PCOS have been proven to be difficult due to a lack of intrinsic motivation, altered risk perception, or other PCOS-related barriers. However, self-management techniques and behavior change can be taught in a multidisciplinary approach to support women with PCOS in managing their symptoms.<ref>Template:Cite journal</ref>

Hirsutism and acneEdit

Template:Further When appropriate (e.g., in women of childbearing age who require contraception), a standard contraceptive pill is frequently effective in reducing hirsutism.<ref name=emedicine_treatment /> Progestogens such as norgestrel and levonorgestrel should be avoided due to their androgenic effects.<ref name=emedicine_treatment /> Metformin combined with an oral contraceptive may be more effective than either metformin or the oral contraceptive on its own.<ref>Template:Cite journal</ref>

In the case of taking medication for acne, Kelly Morrow-Baez PHD, in her exposition titled Thriving with PCOS, informs that it "takes time for medications to adjust hormone levels, and once those hormone levels are adjusted, it takes more time still for pores to be unclogged of overproduced oil and for any bacterial infections under the skin to clear up before you will see discernible results." (p. 138) <ref name=":2" />

Other medications with anti-androgen effects include flutamide,<ref name=flutamide>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> and spironolactone,<ref name=emedicine_treatment /> which can improve hirsutism. Metformin can reduce hirsutism, perhaps by reducing insulin resistance, and is often used if there are other features such as insulin resistance, diabetes, or obesity that are likely to respond to metformin. Eflornithine (Vaniqa) is a medication that is applied to the skin in cream form, and acts directly on the hair follicles to inhibit hair growth. It is usually applied to the face.<ref name=emedicine_treatment /> 5-alpha reductase inhibitors (such as finasteride and dutasteride) may also be used;<ref name=emedicine_medications>Template:EMedicine</ref> they work by blocking the conversion of testosterone to dihydrotestosterone (the latter of which is responsible for most hair growth alterations and androgenic acne).

Although these agents have shown significant efficacy in clinical trials (for oral contraceptives, in 60–100% of individuals<ref name=emedicine_treatment />), the reduction in hair growth may not be enough to eliminate the social embarrassment of hirsutism or the inconvenience of plucking or shaving. Individuals vary in their response to different therapies. It is usually worth trying other medications if one does not work, but medications do not work well for all individuals.<ref>Template:Cite journal</ref>

Menstrual irregularityEdit

If fertility is not the primary aim, then menstruation can usually be regulated with a contraceptive pill.<ref name=emedicine_treatment>Template:EMedicine</ref> The purpose of regulating menstruation, in essence, is for the patient's convenience, and perhaps their sense of well-being; there is no medical requirement for regular periods, as long as they occur sufficiently often.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

If a regular menstrual cycle is not desired, then therapy for an irregular cycle is not necessarily required. Most experts say that, if a menstrual bleed occurs at least every three months, then the endometrium (womb lining) is being shed sufficiently often to prevent an increased risk of endometrial abnormalities or cancer.<ref name=verity_risks>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> If menstruation occurs less often or not at all, some form of progestogen replacement is recommended.<ref name=emedicine_medications />

Alternative medicineEdit

A 2017 review concluded that while both myo-inositol and D-chiro-inositols may regulate menstrual cycles and improve ovulation, there is a lack of evidence regarding effects on the probability of pregnancy.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> A 2012 and 2017 review have found myo-inositol supplementation appears to be effective in improving several of the hormonal disturbances of PCOS.<ref name="pmid22296306">Template:Cite journal</ref><ref>Template:Cite journal</ref> Myo-inositol reduces the amount of gonadotropins and the length of controlled ovarian hyperstimulation in women undergoing in vitro fertilization.<ref>Template:Cite journal</ref> A 2011 review found not enough evidence to conclude any beneficial effect from D-chiro-inositol.<ref name="pmid21142777">Template:Cite journal</ref> There is insufficient evidence to support the use of acupuncture, current studies are inconclusive and there's a need for additional randomized controlled trials.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

EpidemiologyEdit

PCOS is the most common endocrine disorder among women between the ages of 18 and 44.<ref name="BMC2010">Template:Cite journal</ref> It affects approximately 2% to 20% of this age group depending on how it is defined.<ref name="NICHD What causes PCOS?" /><ref name=Lub2013>Template:Cite book</ref> When someone is infertile due to lack of ovulation, PCOS is the most common cause and could guide to patients' diagnosis.<ref name=NIH2017Def/> The earliest known description of what is now recognized as PCOS dates from 1721 in Italy.<ref name="Kovacs2007">Template:Cite book</ref> Template:TOC limit

The prevalence of PCOS depends on the choice of diagnostic criteria. The World Health Organization estimates that it affects 116 million women worldwide as of 2010 (3.4% of women).<ref name="LancetEpi2012">Template:Cite journal</ref> Another estimate indicates that 7% of women of reproductive age are affected.<ref>Template:Cite journal</ref> Another study using the Rotterdam criteria found that about 18% of women had PCOS, and that 70% of them were previously undiagnosed.<ref name=BMC2010/> Prevalence also varies across countries due to a lack of large-scale scientific studies; India, for example, has a purported rate of 1 in 5 women having PCOS.<ref>Template:Cite news</ref>

Few studies have investigated the racial differences in cardiometabolic factors in women with PCOS.<ref>Template:Cite journal</ref> There is also limited data on the racial differences in the risk of metabolic syndrome and cardiovascular disease in adolescents and young adults with PCOS.<ref>Template:Cite journal</ref> The first study to comprehensively examine racial differences discovered notable racial differences in risk factors for cardiovascular disease. African American women were found to be significantly more obese, with a significantly higher prevalence of metabolic syndrome compared to white adult women with PCOS.<ref>Template:Cite journal</ref> It is important for the further research of racial differences among women with PCOS, to ensure that every person that is affected by PCOS has the available resources for management.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref>

Ultrasonographic findings of polycystic ovaries are found in 8–25% of women non-affected by the syndrome.<ref>Template:Cite journal</ref><ref name="clayton">Template:Cite journal</ref><ref name="pmid8053879">Template:Cite journal</ref><ref name="pmid9091329">Template:Cite journal</ref> 14% women on oral contraceptives are found to have polycystic ovaries.<ref name="clayton" /> Ovarian cysts are also a common side effect of levonorgestrel-releasing intrauterine devices (IUDs).<ref>Template:Cite journal</ref>

HistoryEdit

Historical descriptions of PCOS symptoms date back to ancient Greece, where Hippocrates described women with "thick, oily skin and absence of menstruation."<ref>Template:Cite journal</ref>

In modern times, the condition was first described in 1935 by American gynecologists Irving F. Stein Sr. and Michael L. Leventhal, from whom its original name of Stein–Leventhal syndrome is taken.<ref name=emedicine_imaging>Template:EMedicine</ref><ref name=emedicine_main /> Stein and Leventhal first described PCOS as an endocrine disorder in the United States, and since then, it has become recognized as one of the most common causes of oligo-ovulatory infertility among women.<ref name="BarryAzizia2014" />

The earliest published description of a person with what was later recognized as PCOS was in 1721 in Italy.<ref name="Kovacs2007" /> Cyst-related changes to the ovaries were described in 1844.<ref name="Kovacs2007" />

EtymologyEdit

Other names for this syndrome include polycystic ovarian syndrome, polycystic ovary disease, functional ovarian hyperandrogenism, ovarian hyperthecosis, sclerocystic ovary syndrome, and Stein–Leventhal syndrome. The eponymous last option is the original name; it is now used, if at all, only for the subset of women with all the symptoms of amenorrhea with infertility, hirsutism, and enlarged polycystic ovaries.<ref name="emedicine_imaging" />

Most common names for this disease derive from a typical finding on medical images, called a polycystic ovary. A polycystic ovary has an abnormally large number of developing eggs visible near its surface, looking like many small cysts.<ref name="emedicine_imaging" />

Society and cultureEdit

In 2005, 4 million cases of PCOS were reported in the US, costing $4.36 billion in healthcare costs.<ref>Template:Cite journal</ref> In 2016 out of the National Institute of Health's research budget of $32.3 billion for that year, 0.1% was spent on PCOS research.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Among women aged between 14 and 44, PCOS is conservatively estimated to cost $4.37 billion per year.<ref name="Azziz-2006" />

As opposed to women in the general population, women with PCOS experience higher rates of depression and anxiety. International guidelines and Indian guidelines suggest psychosocial factors should be considered in women with PCOS, as well as screenings for depression and anxiety.<ref name="Chaudhari-2018">Template:Cite journal</ref> Globally, this aspect has been increasingly focused on because it reflects the true impact of PCOS on the lives of patients. Research shows that PCOS adversely impacts a patient's quality of life.<ref name="Chaudhari-2018" /><ref name="pmid39429741">Template:Cite journal</ref>

Public figuresEdit

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See alsoEdit

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ReferencesEdit

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Further readingEdit

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External linksEdit

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