Polycystic Ovary Syndrome

Definition/diagnostic criteria Polycystic Ovary Syndrome (PCOS) is a heterogeneous disorder characterised by a combination of clinical and biochemical signs of hyperandrogenism, ovulatory dysfunction and polycystic ovaries. Diagnostic criteria do vary, but one widely accepted version is the Rotterdam criteria, in which the diagnosis of PCOS should be made based on the presence of at least two of the following three criteria: oligo- or anovulation, clinical and/or biochemical signs of hyperandrogenism, and polycystic ovaries on ultrasound.

Epidemiology Prevalence estimates vary widely (between 2 and 26%) but there is agreement that it is underdiagnosed, as many women may not seek medical advice. There is a wide ethnic variation in prevalence, and it is more common in women of South Asian and Black Caribbean descent.

Diagnosis
Clinical features: Women with PCOS may present with a range of symptoms, including menstrual irregularity, signs of androgen excess such as hirsutism, acne and male-pattern balding, and obesity. It is also associated with insulin resistance and may present with symptoms suggestive of type 2 diabetes mellitus.

Investigations: The following assessments should be performed for an accurate diagnosis of PCOS: a detailed medical history, a clinical examination including body mass index (BMI) and waist circumference, serum hormone levels (including LH, FSH, total testosterone and sex hormone-binding globulin), and a pelvic ultrasound to assess the ovaries.

Typical abnormalities found in women with PCOS include elevated LH to FSH ratio, raised levels of testosterone, and the presence of 12 or more follicles in one or both ovaries or increased ovarian volume (>10ml).

Treatment Treatment is tailored to the individual’s symptoms and reproductive goals. Weight management through diet and exercise is the first-line approach as it can improve endocrine profiles and ovulation rates. Pharmacological treatments include combined oral contraceptives to regulate menstrual cycles and manage hirsutism. For those seeking fertility, clomiphene citrate is the first-line pharmacotherapy. Metformin is used particularly in those with impaired glucose tolerance or type 2 diabetes. For hirsutism, topical treatments, such as eflornithine cream, may be recommended.

Prognosis The long-term prognosis for women with PCOS is variable and can include an increased risk of type 2 diabetes, cardiovascular disease and endometrial cancer. However, with appropriate management of symptoms and comorbidities, many women with PCOS can maintain a good quality of life. Fertility issues can often be addressed with treatment, although some women may require assisted reproductive technologies.