Polycystic ovary syndrome

Polycystic ovary syndrome affects a substantial proportion of women of reproductive age and is among the more misunderstood diagnoses in medicine, starting with its name.

What it is and is not

The "cysts" are not cysts — they are ordinary immature follicles, present in larger numbers than usual, visible on ultrasound.

Their presence alone is not the condition; a considerable number of women have polycystic-appearing ovaries and no syndrome at all.

The syndrome is defined by a combination of features, and international guidance uses criteria requiring two of the following three: irregular or absent ovulation; clinical or biochemical signs of excess androgens; and polycystic ovarian morphology on ultrasound — with other causes excluded.

Notably, ultrasound is not required for diagnosis if the first two features are present, and is not recommended within several years of menarche because multifollicular ovaries are normal in adolescence.

The features

Irregular, infrequent or absent periods, reflecting irregular ovulation.

Signs of androgen excess: hirsutism, acne, and scalp hair thinning, with the presentation varying considerably between ethnic groups.

Difficulty conceiving, since ovulation is unpredictable or absent.

Weight gain and difficulty losing weight in many though not all — a substantial minority of women with the condition are of normal weight, and the assumption otherwise delays their diagnosis.

And frequently, symptoms of insulin resistance including skin changes such as darkened velvety patches at the neck and axillae.

The metabolic dimension

The part most often left out of the explanation.

Insulin resistance is present in a large proportion of women with the condition, independently of weight, and it is central to the mechanism: high insulin drives ovarian androgen production and reduces sex hormone binding globulin, raising free testosterone further.

Which is why the condition is associated with increased risk of type 2 diabetes, gestational diabetes, dyslipidaemia and metabolic syndrome, and why guidelines recommend metabolic screening at diagnosis and periodically thereafter.

It is also associated with increased endometrial cancer risk where periods are very infrequent, because the endometrium is exposed to oestrogen without regular progesterone opposition — which is why inducing a bleed periodically is recommended when cycles are very long.

Management

Directed at whichever features matter most to the individual, since there is no treatment for the syndrome as a whole.

For irregular cycles and endometrial protection: combined hormonal contraception, cyclical progestogen, or a hormonal intrauterine device.

For androgen symptoms: combined hormonal contraception, anti-androgen medication in some cases, topical treatments, and cosmetic approaches including laser hair reduction, which is effective and expensive.

Improvement takes months, since hair growth cycles are slow, which is worth knowing before concluding a treatment has failed.

For fertility: ovulation induction, most commonly with letrozole, which current guidance favours over clomifene on the basis of better live birth rates; then gonadotrophins or assisted conception where needed.

Most women with the condition can conceive with appropriate treatment.

For metabolic risk: physical activity and dietary change, which improve insulin sensitivity independently of weight loss, and metformin, which has a role in some situations.

Even modest weight loss where relevant produces measurable improvement in ovulation and symptoms.

Diet and supplements

An area saturated with claims.

No specific diet has been shown superior to others; what matters appears to be sustainability and overall dietary quality, with attention to glycaemic load being reasonable given the insulin picture.

Inositol supplements have a body of evidence suggesting effects on ovulation and insulin measures, with quality varying and guidelines describing the evidence as insufficient to recommend routinely — which is a more honest position than either the enthusiasm or the dismissal.

Many other supplements marketed for the condition have no meaningful evidence.

The psychological load

Frequently unaddressed and clinically significant.

Rates of depression, anxiety and disordered eating are higher in this population, and body image concerns relating to weight and hirsutism are common.

Guidelines now explicitly recommend screening for mood disorders at diagnosis.

Diagnostic experience itself is a recognised problem: surveys consistently report long delays, multiple clinicians, and dissatisfaction with the information provided.

What changes over time

Worth knowing, since it is rarely explained.

Cycles frequently become more regular with age as ovarian follicle numbers decline.

Androgen symptoms often improve.

The metabolic risks do not go away and warrant continued attention.

And the condition is associated with a somewhat later menopause on average, which is one of the few pieces of good news in the standard explanation.

General information only, not medical advice. Consult a qualified clinician about diagnosis and management of PCOS.