1.1. The etiology is widely unknown but PCOS is known as a complex endocrine and metabolic disorder that can be triggered by diet, lifestyle, genetics, gut dysbiosis, alterations in neuroendocrine, and obesity (Singh et al., 2023).
1.2. Sadeghi et al. (2022) stated that one of known underlying causes of PCOS is a high ratio or luteinizing hormone (LH) to follicle-stimulating hormone (FSH) and an increase in gonadotropin-releasing hormone (GnRH) (2022).
1.3. Women who have PCOS are at an increased risk of developing serious conditions such as type 2 diabetes mellitus and cancer. Insulin resistance and metabolic syndrome increases the risk of type 2 diabetes and cardiovascular disease (Singh et al., 2023).
1.4. Endometrial hyperplasia causes the lining of the uterus to thicken and increases the risk of developing endometrial cancer (Sadeghi et al., 2022).
2. Pathophysiology
2.1. PCOS is a hyperandrogenic state paired with oligo-anovulation that is inexplicable by any other disorder (Rasquin et al., 2022).
2.2. Two-thirds of PCOS presentations have functional ovarian hyperandrogenism (FOH) characterized by inappropriate androgen secretion and an over-response of 17-hydroxyprogesterone (17-OHP) to gonadotropin simulation (Rasquin et al., 2022).
2.3. The remaining one-third has atypical FOH lack of overresponse of 17-OHP but the elevation of testosterone can help to suppress the adrenal androgen production (Rasquin et al., 2022).
2.4. Insulin excess is know to sensitize the ovary to luteinizing hormone (LH). Theca cells also have overexpression of steroidogenic enzymes and proteins that are involved in androgen synthesis. The granulosa cells also prematurely luteinize as a result of the excess androgen and insulin levels (Rasquin et al., 2022).
2.5. The hormonal dysregulation of the ovaries alters the gonadotropin-releasing hormone (GnRH0 and can lead to an increase in LH in FSH secretion (Rasquin et al., 2022).
2.6. Elevated serum androgens are converted to estrones in the stromal cells of the adipose tissue. This process can be augmented in obese PCOS patients and cause rapid overproduction of estradiol (Rasquin et al., 2022).
3. Treatment/Management
3.1. Since symptoms may be different for each individual experiencing PCOS, management and treatment is tailored to the patient’s phenotype of manifestations (Singh et al., 2023).
3.2. Medical therapy for irregular menstruation include oral contraceptive pills, combine oral contraceptives, progestins and progesterone (Singh et al., 2023).
3.3. Medical therapy for insulin resistance and diabetes include insulin-sensitizing drugs such as metformin and thiazolidinediones (Singh et al., 2023).
3.4. Medical treatment for fertility include ovulation induction such as clomiphene citrate and metformin. Gonadotrophins such as FSH/LH/hCG and assisted reproductive technology such as In Vitro Fertilization (IVF) (Singh et al., 2023).
3.5. Medical therapy for depression such as antidepressants and antianxiety drugs (Singh et al., 2023).
3.6. Lifestyle Management changes such as a diet incorporating low glycemic index foods and increasing physical activity to aid in glucose reuptake by the skeletal muscles to lower elevated glucose levels and deter further storage of adipose tissue from high glucose level (Singh et al., 2023).
3.7. Alternative medicine methods include licorice root, maca, vitex, chasteberry and inositol (Singh et al., 2023).
3.8. Medical therapy for acne, hirsutism and hair loss such as antiandrogens, sebum-reducing cream (Singh et al., 2023).
4.4. Biochemical Hyperandrogenism: Elevated serum androgen levels (Total or free serum T level, Androstenedione, DHEAS)
4.5. Polycystic ovaries: greater than or equal to 12 follicles of 2-9 mm diameter cysts
4.6. Reproductive manifestations: Infertility (primary infertility is when a patient has never achieved a pregnancy and secondary infertility is when at least one prior pregnancy has been achieved (Sadeghi et al., 2022) Endometrial cancer: hyperplasia of endometrial cells
4.7. Endocrine features: Insulin resistance (Homeostatic model assessment- insulin resistance - impaired sensitivity to insulin mediated glucose disposal)
4.8. Psychological features: Anxiety and depression
4.9. Physical features: Excessive weight gain that is difficult to lose due to the hyperinsulinemia which causes an increase in hunger, promotes adipose storage and inhibits breakdown of adipose tissue (Sadeghi et al., 2022).
5. Lab Results/Diagnostics
5.1. PCOS is a condition that cannot be diagnosed conclusively with blood tests, cultures and biopsies (Sadeghi et al., 2022).
5.2. A differential diagnosis is needed for PCOS by excluding hyperprolactinemia, thyroid disease, Cushing’s syndrome, and congenital hyperplasia of adrenal glands (Sadeghi et al., 2022)
5.3. Rotterdam Criteria was created as a joint consensus statement in 2003 by 27 PCOS experts which broadened the phenotypical expressions of PCOS to include any two out three key characteristics: oligo-amenorrhea, hyperandrogenism, and polycystic-appearing ovaries on ultrasonography (Sadeghi et al., 2022).
6. Prevalence of disease statistics
6.1. The prevalence of PCOS worldwide have been found to be between 2-26%. The disparities in geographic reporting rates can be linked to differences in diagnosis criteria, awareness of disease risk factors, access to medical care and socioeconomic factors (Deswal et al., 2020).
6.2. Deswal et al. (2020) also mentioned evidence that race and ethnicity affect the clinical presentations of PCOS based on genetic differences.
7. Morbidity
7.1. PCOS places women at higher risk of developing cardiovascular disease, hypertension and diabetes. There are deficits in the data of women with PCOS in their postmenopausal ages. Furthermore, when compared to the control group there were insignificant differences between the prevalence of breast cancer, gynecological cancer, glucose and insulin levels (Forslund et al., 2022).
7.2. There is a lack of research surrounding the correlation between morbidity rates from diseases such as cardiovascular disease, diabetes and gynecological cancers and having PCOS as a comorbidity (Forsulan et al., 2022).
8. Patient Education
8.1. Patient’s should be educated on the increased risks that having PCOS has on their future health status. Healthy weight management can help to regulate menstrual cycle, insulin resistance and cholesterol levels. Weight management can also relieve the symptoms of excess hair growth and acne (Singh et al., 2023).
