Polycystic ovarian syndrome (PCOS) is a type of reproductive disorder in which excessive amounts of androgens (male hormones such as testosterone) are produced by the ovaries. The cause of PCOS is not completely known, and ongoing research is being conducted to further understand the condition.

Women with PCOS usually have the following symptoms:

• Irregular menstrual cycles
  
  
• Polycystic ovaries (enlarged ovaries containing tiny cysts)
  
  
• Abnormal levels of insulin as well as insulin resistance (cells require greater amounts of insulin to use the carbohydrates from the diet)
  
  
• Hirsutism (excessive hair growth throughout the face and body)
  
  
• Excessive weight gain
  
  
• Acne
  
  
• Male-pattern hair thinning
  
  
• Acanthosis nigricans (darkening of the skin around the areas of the neck, arms, breasts or thighs)
  
  
• Skin tags (small pieces of excess skin around the armpit or neck area)

In addition, PCOS may put women at risk for more serious health complications such as:

• Diabetes
• Infertility
• Heart disease
• High blood pressure (hypertension)
• High blood cholesterol
• Obesity
• Uterine cancer

Some of the symptoms of PCOS are similar to other conditions, including androgen-secreting tumors and Cushing syndrome. Therefore, diagnosis of PCOS usually involves first ruling out these conditions. A number of medical tests may be performed for this purpose but there is no single test to diagnose PCOS. Many patients present with variations of the typical symptoms making it difficult to diagnose this condition.

Because of the variable nature of the syndrome, the American Society for Reproductive Medicine (ASRM) and the European Society for Human Reproduction and Embryology (ESHRE) redefined the guidelines for PCOS diagnosis. To be diagnosed with PCOS, a woman must have two of the following symptoms:

• Irregular or absent ovulation
• Elevated levels of androgens
• Polycystic ovaries

PCOS is a lifelong condition, and there is no known method of prevention. The condition resolves spontaneously only in rare cases. A number of treatments are available to relieve its symptoms and prevent the risk of more serious complications. Treatment of PCOS varies depending on whether the patient wishes to become pregnant (e.g., medications for birth control or fertility). Medications traditionally used in diabetes treatment may also be recommended for insulin resistance (when cells in the body do not respond normally to insulin circulating in the blood). This condition is the reason some women with PCOS have excessive amounts of insulin. In addition, patients are advised to achieve and maintain a healthy weight. In some cases, surgery may be an option.  

Polycystic ovarian syndrome (PCOS) is a disorder that affects the endocrine system. With PCOS, the normal hormone cycles are disrupted, causing interference with a woman’s ovulation cycle. Hormones are responsible for various functions throughout the body, including regulating a woman’s reproductive functions (e.g., normal development of eggs in the ovaries). It is not completely understood why or how the hormone cycles are disrupted by PCOS.

PCOS is a syndrome rather than a disease. A syndrome is a group of symptoms that collectively compose a condition or disease. The following characteristics are present in most women with PCOS:

• A genetic component. Many women with PCOS have female family members who exhibit symptoms and/or complications related to the disorder (e.g., irregular menstruation, excessive body hair growth, diabetes).
  
  
• Excess levels of insulin in the blood (hyperinsulinemia). Insulin is a hormone produced by the pancreas that allows the cells to absorb and use glucose for energy. When a person is insulin resistant, the cells throughout the body do not respond normally to insulin circulating in the blood. Insulin resistance causes hyperinsulinemia in women with PCOS. Hyperinsulinemia, in turn, may lead to glucose intolerance or type 2 diabetes.
  

  

• Excess levels of the luteinizing hormone (LH) secreted by the pituitary gland in the brain. Too much LH interferes with normal ovarian function. High levels of both LH and insulin stimulate the ovary to produce excessive male hormones (androgens). When the LH remains elevated and does not have a mid cycle surge or increase this also affects the release of the egg from the ovary.
  
  
• Abnormalities in the ovaries and adrenal glands, both of which are a significant factor in the syndrome.
  
  
• Abnormalities in the central nervous system. Cases of both hypothalamic and pituitary gland dysfunction have been reported.

The hormonal imbalance associated with PCOS brings about many signs and symptoms, including irregularities in the menstrual cycle (e.g., infrequent periods, amenorrhea), problems with the metabolic and cardiovascular systems and problems conceiving.

In addition, PCOS may result in the growth of many small cysts (fluid-filled sacs) in the ovaries that later become enlarged. Polycystic ovaries are enlarged ovaries that contain more than 12 follicular cysts, tiny follicles in the range of a quarter to half an inch (0.6 to 1.3 centimeters) in diameter. The hormonal changes may also result in the constant growth of the lining of the uterus (endometrium), which increases a woman’s risk of uterine cancer over time.

PCOS may be referred to as Stein Leventhal syndrome, named for the physicians who first encountered the disease. In 1935, Dr. Irving Stein and Dr. Michael Leventhal reported on a group of women with amenorrhea, infertility, hirsutism and enlarged polycystic ovaries. Though research into this condition has continued since that time, little is known about the nature and causes of PCOS.

Until very recently, the most widely accepted definition of PCOS was based upon diagnostic criteria recommended in 1990. The criteria classified it as a disorder characterized by chronic hyperandrogenism (high levels of testosterone and/or other androgens) and chronic anovulation (absence of ovulation) in the absence of other specific causes of these problems. But further research led to an international consensus in 2003 that expanded the diagnostic criteria to include women who exhibit any two of the following:

• Infrequent ovulation or anovulation
• Chronic hyperandrogenism
• Polycystic-appearing ovaries on ultrasound

If left untreated, the consequences of PCOS can put women at risk for:

• Heart disease
  
  
• High blood pressure (hypertension) and pregnancy-induced hypertension
  
  
• High cholesterol
  
  
• Type 2 diabetes and gestational diabetes
  
  
• Endometrial cancer (a type of uterine cancer)
  
  
• Infertility
  
  
• Obesity
  
  

• Sleep apnea (a condition in which a person’s breathing stops and restarts several times during sleep)

PCOS is one of the most common hormonal disorders among women of childbearing age, which is considered from the onset of puberty or menstruation until menopause. According to the American Society for Reproductive Medicine (ASRM), about 5 percent of women in the United States have PCOS.

PCOS should be considered a factor in young girls who exhibit hirsutism, menstrual irregularities and/or obesity. If PCOS is diagnosed and treated early, the risk of developing the more serious complications (e.g., type 2 diabetes, uterine cancer) in adulthood is greatly reduced.

Even though the hormonal imbalance that produces the symptoms of polycystic ovarian syndrome (PCOS) is becoming better understood, the disorder’s actual cause is unknown.

Research suggests a link between PCOS and excess insulin in the blood. Many women with PCOS have a family history of diabetes. Insulin is a hormone produced in the pancreas that enables body cells to use glucose (blood sugar) for energy. Women with PCOS have a decreased sensitivity to insulin, also known as insulin resistance. Through several mechanisms, excess insulin is believed to boost the production of androgens (male hormones) in the ovaries. This, in turn, brings about many of the symptoms associated with PCOS, such as excessive weight gain and excessive hair growth throughout the body.

Research has indicated that PCOS may be hereditary. Many women afflicted with PCOS have a family history of complications commonly associated with the disorder. Their relatives need not have been diagnosed with PCOS, but they may have experienced related problems. These conditions could include irregular periods, absence of menstruation (amenorrhea), an inability to become pregnant, excess androgen production, insulin resistance, diabetes, obesity and/or hirsutism.

PCOS is less common among women as they get older and is extremely uncommon after menopause, although cases have been reported.

Signs and symptoms of polycystic ovarian syndrome (PCOS) may first appear around the time of puberty. But for most women, signs do not become noticeable until their early teens. The most common symptoms are:

• Hirsutism. A growth of coarse body hair in a male pattern, which may appear on the chin, upper lip, neck, sideburn area, chest, nipple area and the lower abdomen along the midline.
  
  
• Irregular or infrequent periods.
  
  
• Prolonged premenstrual syndrome (PMS) symptoms, such as bloating, pelvic pain, headaches, mood swings and/or depression.
  
  
• Excessive weight gain.
  
  
• Acne and/or oily skin. Particularly severe acne, especially if it persists into adulthood.
  
  
• Polycystic ovaries. Enlarged ovaries containing more than 12 follicular cysts, tiny follicles in the range of a quarter to half an inch in diameter (0.6 to 1.3 centimeters).
  
  
• Hair loss or male-pattern hair thinning.
  
  
• Acanthosis nigricans (AN). Darkening of the skin around the areas of the neck, arms, breasts, or thighs. AN is usually indicative of insulin resistance as well.
  
  
• Skin tags. Small pieces of excess skin around the armpit or neck area.   

Symptoms of PCOS vary among women. Some women may have very little acne, whereas others have severe acne, facial hair growth or hair loss in the scalp. Also, many women do not show any visible signs of the disease.

It is important to note that there are a number of other conditions that may cause similar symptoms, such as thyroid problems (e.g., hypothyroidism, hyperthyroidism). Because of this, it is essential that patients exhibiting symptoms consult a physician to rule out other conditions and determine an appropriate treatment plan.

There is no single test to diagnose polycystic ovarian syndrome (PCOS), which makes diagnosis difficult. However, the American Society for Reproductive Medicine (ASRM) and European Society for Human Reproduction and Embryology (ESHRE) have agreed on guidelines for PCOS diagnosis. To be diagnosed with PCOS, a woman must exhibit two of the following:

• Irregular or absent ovulation
  
  
• Elevated levels of androgens (male hormones such as testosterone)
  
  
• Enlarged ovaries containing 12 or more follicles each (polycystic ovaries) diagnosed by ultrasound

A physician will first evaluate the physical symptoms and obtain a woman’s medical history, including her menstrual history and family history. This is followed by a physical examination, including a pelvic examination, typically conducted by an obstetrician-gynecologist (ObGyn). 

Other tests may be performed to either aid in the diagnosis of PCOS or to rule out other conditions that may cause similar symptoms. These may include:

• Blood tests. Laboratory examinations of blood samples to measure blood levels of the following:
  
  
• • Thyroid hormone. Symptoms of low thyroid function are similar to those of PCOS.
    
    
  • Prolactin hormone. Excess levels of this hormone stimulate milk production and often result in irregular or absent periods, which is also a symptom of hyperprolactinemia.
    
    
  • Male hormones (androgens). Excessive levels of these hormones often cause “male-like” characteristics, such as excess body and/or facial hair (hirsutism).
    
    
  • Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels. A high ratio of LH to FSH (typically three to one) is indicative of PCOS.
    
    
  • Insulin and glucose (blood sugar) levels (usually a morning fasting level is required). Excess levels of these are also indicative of insulin resistance or type 2 diabetes.
    
    
  • Lipids (cholesterol and triglyceride levels). Excessive levels of these may result in high blood pressure.
    
    
  The best time to be tested for PCOS is in the morning shortly after the start of the menstrual cycle. Therefore, a physician may prescribe medication to induce menstruation. Birth control medications might make the tests difficult to interpret because they affect hormonal imbalance. The patient may be referred to a specialist for interpretation of the blood test results, such as an endocrinologist or reproductive endocrinologist.
  
  
• Ultrasound. An imaging test that uses sound waves to produce a picture of the body’s organs and structures, the woman may receive a pelvic ultrasound or transvaginal ultrasound. These tests may be used to check for the presence of the characteristic images that depict polycystic ovaries or to determine if the lining of the uterus has thickened. Although ultrasounds can help confirm a PCOS diagnosis, they are not always accurate because not all women that have cysts have PCOS and not all women with PCOS have polycystic ovaries. The images produced by the ultrasound should be examined by a physician experienced with their interpretations.
  
  
• Endometrial biopsy. The removal of a tissue sample from the uterine lining for laboratory analysis. It may be used to detect any precancerous and cancerous conditions that can cause abnormal bleeding.

Because PCOS encompasses a broad spectrum of symptoms, it is considered a diagnosis of exclusion. This means that physicians will first rule out other conditions with similar symptoms such as:

• High prolactin hormone levels (hyperprolactinemia)
  
  
• Excess adrenal hormones
  
  
• Cushing syndrome (a disorder of overactivity of the adrenal gland)
  
  
• Androgen-secreting tumors in the ovaries
  
  
• Thyroid problems (e.g., autoimmune thyroiditis, hypothyroidism, hyperthyroidism)
  
  
• Eating disorders

If a woman is diagnosed with PCOS, she should be tested and treated for other complications that may be associated with it, such as insulin resistance, heart disease, high blood pressure, hirsutism, type 2 diabetes and uterine cancer.

Polycystic ovarian syndrome (PCOS) is a lifelong condition. Although there is no cure at this time, treatments are available to manage the condition, relieve its symptoms and reduce the risk of related complications.

If any of the more serious complications associated with PCOS are present, such as diabetes, heart disease or uterine cancer, physicians will immediately begin aggressive treatment of these conditions. In some cases, treatment for these conditions can be long-term.

Any PCOS treatment plan should include:

• Weight management. Obesity or unwanted weight gain are commonly associated with PCOS. Patients are encouraged to consult with a physician and/or registered dietician to formulate a weight control plan tailored to their specific needs. This plan should include an exercise regimen for the healthy management of weight. According to the American Society for Reproductive Medicine (ASRM), losing as little as 5 to 10 percent of total body weight may help women resume normal ovulation. In addition, a healthy diet and regular exercise are the best ways to prevent long-term consequences of PCOS such as cardiovascular disease and diabetes.
  
  
• Removal of unwanted body hair. It is not medically necessary to remove the unusual hair growth associated with PCOS (hirsutism). However, many women choose to take advantage of options such as electrolysis, waxing or laser therapy for aesthetic reasons.
  
  
• Quitting smoking (if applicable). Smoking increases the risk of complications commonly associated with PCOS (e.g., heart disease). It is also beneficial for women who want to become pregnant.
  
  
• Regular gynecological examinations. Yearly visits to a gynecologist for pelvic exams are an important part of PCOS treatment. They can detect early signs of either ovarian cancer or uterine cancer, which is a risk for women who have irregular periods or do not menstruate.
  

  

For women with PCOS who are trying to conceive, treatment varies and may include:

• Ovulation drugs. Medications that stimulate ovulation. The main fertility issue that affects women with PCOS is the lack of ovulation. Therefore, ovulation medications are the first line of treatment for women with PCOS who wish to become pregnant. For women with PCOS, the ovulation drug most commonly used is clomiphene citrate. A second, more aggressive therapy may be used, involving injectable drugs called gonadotropins. These drugs trigger ovulation in almost all women with PCOS and can lead to pregnancy in most cases. Potential side effects of gonadotropins may include hot flashes, vaginal dryness and loss of bone density, among others. In addition, all ovulation drugs may put PCOS patients at an increased risk for multiple births.
  
  
• Antidiabetic agents. Medications that increase the body’s sensitivity to insulin normally used in the treatment of type 2 diabetes. This type of treatment may be prescribed with clomiphene if clomiphene therapy alone does not result in pregnancy. Metformin is also prescribed for women with PCOS who are not trying to conceive. The drug can treat two other common symptoms of PCOS, weight gain and insulin resistance.
  
  
• Laparoscopic ovarian drilling. An outpatient surgery that involves the use of electrical or laser energy to burn holes in enlarged follicles on the surface of the ovaries. This type of surgery stimulates ovulation, regulates the menstrual cycle and increases a patient’s chances of becoming pregnant. However, the procedure is only used if other, less invasive methods fail because it increases the risk of pelvic adhesions, which can cause chronic pelvic pain. For women who smoke, this type of surgery may not be successful.
  
  
• In-vitro fertilization (IVF). Another option for women with PCOS who are trying to conceive is IVF. This procedure involves retrieving mature eggs from a woman, fertilizing them with a man’s sperm in a laboratory and implanting the embryos in the uterus three to five days after fertilization. IVF is sometimes recommended by physicians to reduce the chance of having multiple births, which is higher when using ovulation drugs.

For women not trying to conceive, treatment usually centers on restoring a normal menstrual cycle and may include:

• Birth control pills, typically incorporating estrogen and progestin. These also help reduce the risk of endometrial cancer.
  
  
• Corticosteroids (steroids used to suppress androgen production by the adrenal glands).
  
  
• Anti-androgens (e.g., spironolactone, flutamide).
  
  
• Gonadotrophin-releasing hormone (GnRH) agonists (e.g., leuprolide). These suppress the production of sex hormones, and induce a temporary menopause in premenopausal women. However, GnRH agonists may have significant side effects, such as hot flashes and bone demineralization, and are usually prescribed for no longer than six months.

These types of medications also reduce skin problems such as acne, and may cut down on hirsutism for as long as they are taken.

Because the primary cause of PCOS is unknown, there are no known prevention methods. However, early detection of PCOS is critical. It is important for a young woman to visit a gynecologist after her first menstruation (menarche) and maintain a regular gynecological checkup schedule. Treatment that begins at an early age has a better chance of preventing the more serious risks associated with the disorder.

The link between insulin resistance and polycystic ovarian syndrome (PCOS) is leading researchers to examine the effects of medications used in diabetes treatment on patients with this hormonal imbalance.

There is promising evidence that shows the use of metformin (a type of insulin sensitizer) to be highly successful in regulating the menstrual cycle and lowering body mass index (BMI). It may also help overall cholesterol levels and increase ovulation and fertility, although some studies show that traditional fertility medications such as clomiphene are more effective in achieving pregnancy.

Research is also continuing in other disease areas for which women with PCOS have an increased risk, such as cardiovascular disease and metabolic syndrome. Cardiac risk factors such as increased LDL cholesterol and cardiac calcium levels are being studied in PCOS patients and how much those increased levels contribute to heart disease.

For the most part, research is still being conducted to better understand the underlying causes of PCOS. In addition, treatment using natural progesterone and laser therapy to improve ovulation are being studied in women. Ongoing studies are starting to confirm the belief that women with this hormonal imbalance who obtain proper treatment can live healthier lives, and may even have healthy pregnancies.