Synonyms
Subdivisions
General Discussion
Polycystic ovarian syndrome (PCOS) is a common hormonal disorder affecting women of reproductive age. It leads to the overproduction of androgens, hormones typically higher in men but also present in women. One study showed that in women without PCOS, the median testosterone levels were 24 nanograms per deciliter (ng/dL), with a range of 10-59 ng/dL. Women with PCOS were found to have a median testosterone level of 49 ng/dL (range: 16-125 ng/dL). However, there is no universally accepted range of androgen levels that is diagnostic of PCOS, as normal androgen levels in women can vary.1 Healthcare providers can often diagnose PCOS based on their clinical judgement and the patient’s symptoms, without requiring additional testing like bloodwork or ultrasound. PCOS is characterized by an excess of androgens (that can present with acne or male-pattern hair growth), oligo-anovulation (menstrual cycles >35 days apart, or fewer than 8 menses/year), and/or polycystic-appearing ovaries (ovaries that have small fluid-filled pockets on their surface) on an ultrasound exam.2 Though PCOS affects between 8 and 13% of reproductive-age women, it is estimated that up to 70% of affected women remain undiagnosed.3 It is important for women to understand the signs and symptoms of PCOS so that they can seek medical attention when necessary and make more informed healthcare decisions.
The implications of PCOS are wide-ranging but may be serious. Women with PCOS are twice as likely to develop metabolic syndrome, which includes obesity, insulin resistance (like prediabetes), dyslipidemia (elevated “bad” cholesterol), and heart and liver disease.4 In addition to the physical consequences of PCOS, the symptoms that characterize the disorder can contribute to psychological distress and sexual dysfunction.5
Less is known about the effects of PCOS on sexual health, though several studies have identified a correlation between PCOS and lower quality of life, depression, anxiety, poor body image, low self-esteem, and disordered eating. These factors, in turn, have been identified as risk factors for sexual dysfunction and reduced sexual satisfaction.5 A 2018 meta-analysis found that women with PCOS reported small impairments in arousal, lubrication, orgasm, and sexual satisfaction, despite the presence of extra androgens (which one would generally associate with improved sexual function). Whether these findings are related to the endocrine (hormone-related) effects of PCOS, the emotional and psychological effects, or a combination of the three is unknown.6
Signs & Symptoms
- Irregular menstrual cycles
- Infertility
- Weight gain and obesity, especially around the midsection
- Hirsutism (excessive hair growth on unexpected areas of the body, such as the face or chest)
- Acne
- Oily skin
- Acanthosis nigricans (a condition that causes the skin to develop velvety, dark patches, commonly appearing in skin folds)
- Androgenic alopecia (male-pattern hair-loss and baldness)
People with PCOS are also at higher risk of developing the following:
- Type 2 diabetes
- Hypertension
- High cholesterol
- Heart disease
- Endometrial cancer
- Pregnancy loss
Causes
The exact cause of PCOS is poorly understood. Genetic, environmental, and lifestyle factors likely influence its course. For example, a high intake of saturated fats, refined carbohydrates, and low fiber are associated with increased risk and severity of PCOS.7,8 Bisphenol A (BPA) and phthalates—chemicals used in the production of plastics—are endocrine disruptors, meaning they interfere with the body's hormone system. These chemicals have also been implicated in the pathogenesis of this condition.9 Additionally, chronic stress, poor sleep, and low socioeconomic status are associated with higher rates of PCOS or more severe symptoms.7
Affected Populations
PCOS is the most common endocrine disease in women, affecting up to 13% of reproductive-age women. Symptoms of PCOS can present soon after a young girl’s first period (around 11 or 12 years of age) or later in life (20-40 years of age).
Diagnosis
The diagnosis of PCOS is based on the Rotterdam criteria, which require the presence of at least two of the following three features: (1) hyperandrogenism as evidenced either by clinical findings (such as acne or male-pattern baldness) or biochemical hyperandrogenism identified via bloodwork; (2) ovulatory dysfunction, which typically results in irregular menstrual cycles; or (3) polycystic ovaries, identified via ultrasound. Clinical evaluations are often sufficient to diagnose PCOS, but it is also important to consider alternate causes of hyperandrogenism in females, such as congenital adrenal hyperplasia (CAH), which can present very similarly. When in doubt, a 17-hydroxyprogesterone blood level can distinguish between the two, with levels significantly higher in women with CAH.10
Standard Therapies
The treatment of PCOS involves the mitigation of bothersome symptoms as well as the prevention of metabolic syndrome. Lifestyle changes including diet, exercise, and weight loss can improve symptoms of PCOS. Pharmacologic interventions can be used to normalize hormone levels. For women who are not actively trying to conceive, combination oral contraceptives can decrease androgen production, regulate estrogen, make menstruation regular, and provide contraception. Women struggling with PCOS-related infertility may benefit from medications such as clomiphene, letrozole, metformin, or gonadotropins to aid in ovulation. Spironolactone, which blocks the effects of androgens on the skin, may also be considered for dermatologic complaints related to PCOS (hirsutism and acne). Hair removal through electrolysis, laser or other topical methods, and a variety of acne treatments including over the counter options may also be considered. Women with PCOS experiencing sexual dysfunction can find medical and educational resources through The Androgen Excess and PCOS Society, ACOG, and PCOS Challenge. There are also a variety of support groups and community forums such as PCOS Diva. The International Society for the Study of Women’s Sexual Health (ISSWSH) is a professional organization with a directory of healthcare providers specializing in women’s sexual health.
Investigational Therapies
Support Available
Visit the PCOS Awareness Association website at https://www.pcosaa.org/ to learn more about PCOS, connect with providers and community members, and find more resources.
References
- Keefe CC, Goldman MM, Zhang K, Clarke N, Reitz RE, Welt CK. Simultaneous measurement of thirteen steroid hormones in women with polycystic ovary syndrome and control women using liquid chromatography-tandem mass spectrometry. PloS One. 2014;9(4):e93805. doi:10.1371/journal.pone.0093805
- Christ JP, Cedars MI. Current Guidelines for Diagnosing PCOS. Diagnostics. 2023;13(6):1113. doi:10.3390/diagnostics13061113 https://www.mdpi.com/2075-4418/13/6/1113
- Polycystic ovary syndrome. Accessed May 5, 2024. https://www.who.int/news-room/fact-sheets/detail/polycystic-ovary-syndrome
- Chen W, Pang Y. Metabolic Syndrome and PCOS: Pathogenesis and the Role of Metabolites. Metabolites. 2021;11(12):869. doi:10.3390/metabo11120869 https://www.mdpi.com/2218-1989/11/12/869
- Kalhor M, Mohammadi E, Shahali S, Amini L, Moghaddam-Banaem L. Sexual and reproductive health aspects in women with polycystic ovary syndrome: An integrative review. Int J Reprod Biomed. 2022;20(9):723-738. doi:10.18502/ijrm.v20i9.12062 https://kneopen.com/ijrm/article/view/12062/19782/
- Pastoor H, Timman R, Klerk C de, Bramer WM, Laan ET, Laven JS. Sexual function in women with polycystic ovary syndrome: a systematic review and meta-analysis. Reprod Biomed Online. 2018;37(6):750-760. doi:10.1016/j.rbmo.2018.09.010 https://www.sciencedirect.com/science/article/pii/S1472648318304863
- Merkin SS, Phy JL, Sites CK, Yang D. Environmental determinants of polycystic ovary syndrome. Fertil Steril. 2016;106(1):16-24. doi:10.1016/j.fertnstert.2016.05.011
- Mizgier M, Jarząbek-Bielecka G, Formanowicz D, et al. Dietary and Physical Activity Habits in Adolescent Girls with Polycystic Ovary Syndrome (PCOS)-HAstudy. J Clin Med. 2021;10(16):3469. doi:10.3390/jcm10163469 https://www.mdpi.com/2077-0383/10/16/3469
- Urbanetz LAML, Soares-Junior JM, dos Santos Simões R, Maciel GAR, Baracat MCP, Baracat EC. Bisphenol A and polycystic ovary syndrome in human: A systematic review. Int J Gynecol Obstet. 2024;166(1):190-203. doi:10.1002/ijgo.15349
- Papadakis G, Kandaraki EA, Tseniklidi E, Papalou O, Diamanti-Kandarakis E. Polycystic Ovary Syndrome and NC-CAH: Distinct Characteristics and Common Findings. A Systematic Review. Front Endocrinol. 2019;10:388. doi:10.3389/fendo.2019.00388 https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2019.00388/full
