The clinical features of polycystic ovary syndrome include the following [4].

• Menstrual disorders: Patients with polycystic ovary syndrome usually present with oligomenorrhea or amenorrhea. The irregularities usually appear around the time of menarche.
• Infertility: This usually results from anovulation. In addition, the risk of recurrent miscarriages is also up to 50 to 60% higher in these women.
• Metabolic disorder: At least 40% of the women presenting with polycystic ovary syndrome are obese. Central obesity is associated with other symptoms like insulin resistance [5].
• Hirsutism and acne: High levels of masculinizing hormones in women with polycystic ovary syndrome result in the common signs of acne and hirsutism. Other signs include androgenic alopecia and acanthosis nigricans.
• Sometimes, the disease may be asymptomatic.

• Weight Gain

  Along with irregular periods, the first signs of PCOS may be the growth of facial and male-patterned body hair, thinning scalp hair, acne, and weight gain. Weight gain, however, is not always present. Normal-weight women can also have PCOS. [hormone.org]

  Treatment options for Ms R, including those that may affect her weight gain, are reviewed and implications for future fertility are discussed. [ncbi.nlm.nih.gov]

• Virilization

  Virilizing tumor: Women who present with symptoms of severe virilization or those who have a rapid onset of symptoms should have a thorough evaluation for a virilizing tumor. [clinicaladvisor.com]

  Typically, high androgen levels are associated with increased virilization. [ncbi.nlm.nih.gov]

  Convert to ICD-10-CM : 256.4 converts directly to: 2015/16 ICD-10-CM E28.2 Polycystic ovarian syndrome Approximate Synonyms Isosexual virilization Polycystic ovarian syndrome Virilization, isosexual Clinical Information A complex disorder characterized [icd9data.com]

  Clinical signs include amenorrhea, oligomenorrhea, infertility, obesity, hirsutism, and virilism. [icd10data.com]

• Abdominal Obesity

  The aim of present study was to analyze the effect of abdominal obesity expressed using waist/hip ratio (WHR) in patients with polycystic ovary syndrome on metabolic parameters. [ncbi.nlm.nih.gov]

  Physical examination also can detect high blood pressure and increased abdominal obesity as risk factors for diabetes and cardiovascular disease in individuals who are overweight. [obgyn.ucla.edu]

• Coronary Atherosclerosis

  Young obese women with polycystic ovary syndrome have evidence of early coronary atherosclerosis. J Clin Endocrinol Metab. 2007; 92 :4609–4614. [ PubMed ] [ Google Scholar ] 95. Talbott EO, Zborowski JV, Rager J, Stragand JR. [ncbi.nlm.nih.gov]

• Pathologist

  Conference Series LLC Ltd welcomes all the Obstetrics Gynecologists, Reproductive Endocrinologist, Pathologists, Research scholars, Industrial professionals and student delegates from biomedical and healthcare sectors to be a part of the esteemed PCOS [pcosaa.conferenceseries.com]

• Deepening of Voice

  […] of voice and increased muscle mass Persistent acne and oily skin ( seborrhoea ) Hidradenitis suppurativa (acne inversa), an inflammatory condition that results in boil-like lumps in the armpits, groin and under the breasts Acanthosis nigricans : dark [dermnetnz.org]

• Pelvic Mass

  However, it is indicated if clinical findings are suggestive of a virilizing tumor (eg, rapid progression, clitoromegaly, pelvic mass, or a total testosterone level >200 ng/dL) or disorder of sex development. [pediatrics.aappublications.org]

• Hypertension

  RESULTS: PCOS was related to hypertensive disorders in pregnancy with a relative risk (RR) of 1.62 (95% CI 1.09-2.42). [ncbi.nlm.nih.gov]

  In the current issue of Hypertension, Chen et al2 attempt to dissect the role that androgens may play in mediating the hypertension in young women with PCOS. [ahajournals.org]

  PCOS and hypertensive disorders in pregnancy Hypertensive disorders of pregnancy include: i. new onset of hypertension during pregnancy (or gestational hypertension which is defined as new-onset hypertension in pregnancy after 20 weeks of gestation), [intechopen.com]

• Hirsutism

  Idiopathic hirsutism: The decision to attribute symptoms to idiopathic hirsutism is always difficult. Certainly women with a family history of hirsutism are at increased risk. [clinicaladvisor.com]

  […] dysfunction and hirsutism: 1) Women without menstrual dysfunction or hirsutism. [dx.doi.org]

  Context: Hirsutism often occurs in women with polycystic ovary syndrome (PCOS). [ncbi.nlm.nih.gov]

  Hirsutism and Acne Efornithine cream applied topically reduces hirsutism and acne. Cryproterone acetate is an anti-androgenic contraceptive pill that may also be helpful in the reduction of acne and hirsutism. [symptoma.com]

  […] used to assess improvements in the level of self‐reported hirsutism. [doi.org]

• Alopecia

  Logistic regression analysis showed that there were significant associations between sexual function score and the literacy, alopecia, and infertility. [ncbi.nlm.nih.gov]

  They had alopecia totalis, with sparse scalp hair and absent eye lashes. [jpma.org.pk]

  OCPs as monotherapy are not very effective in arresting mild to moderate alopecia or hirsutism and are preferably combined with an anti-androgen to achieve a better response when targeting hirsutism and alopecia. [doi.org]

  Balding, also called androgenic alopecia refers to the loss or thinning of scalp hair. Hirsutism, acne or androgenic alopecia can be the result of increased production of male hormone, called androgens, in women with PCOS. [cedars-sinai.edu]

  Alopecia Syndrome Search GEO for disease gene expression data for Hypogonadotropic Hypogonadism-Frontoparietal Alopecia Syndrome. [malacards.org]

• Acne Vulgaris

  Hidradenitis suppurativa, like acne vulgaris, may be a feature of hyperandrogenism. Obesity may be associated with both hidradenitis suppurativa and PCOS. We describe a possible association between PASH syndrome and PCOS. [ncbi.nlm.nih.gov]

  Harper, Use of Oral Contraceptives for Management of Acne Vulgaris, Dermatologic Clinics, 34, 2, (159), (2016). Alison M. Layton, E. Anne Eady and Christos C. Zouboulis, Acne, Rook's Textbook of Dermatology, Ninth Edition, (1-78), (2016). [doi.org]

  Moderate-severe inflammatory acne vulgaris unresponsive to topical medications is an indication to test for hyperandrogenemia. [pediatrics.aappublications.org]

  vulgaris as an indication to test for hyperandrogenemia) Often, a 17-hydroxyprogesterone test is also done to screen adolescents for nonclassic congenital adrenal hyperplasia. [msdmanuals.com]

• Hypertrichosis

  J Clin Endocrin Metab. 2008;93:1105–1120. 35 Hirsutism must be distinguished from hypertrichosis, which is defined as generalized excessive vellus hair growth distributed in a nonsexual pattern, for example, predominantly on forearms or lower legs. [pediatrics.aappublications.org]

  Note: The use of eflornithine has been studied only on the face and adjacent involved areas under the chin of individuals with hypertrichosis; therefore, limit use of this drug to these areas. [emedicine.medscape.com]

• Amenorrhea

  A 20-year-old nulligravid woman had been suffering from oligomenorrhea, amenorrhea, and moderate hirsutism since the age of 18 years. [ncbi.nlm.nih.gov]

  English polycystic ovary syndrome syndrome characterized by hyperandrogenism, polycystic ovaries, hirsutism, oligomenorrhea or amenorrhea, anovulation and excessive body weight Multicystic ovaries PCOS Polycystic Ovarian disease Polycystic ovaries Polycystic [wikidata.org]

• Oligomenorrhea

  We report the case of an obese 18-year-old Caucasian women with hirsutism and oligomenorrhea. Abdominal palpation revealed a voluminous firm mass. Hormonal evaluation documented severe hyperandrogenism. [ncbi.nlm.nih.gov]

  also put some women at an increased risk of developing diabetes mellitus (1) NICHD (1990) Diagnostic Criteria for PCOS is: Clinical Hyperandrogenism (Ferriman-Gallwey Score >8) or Biochemical Hyperandrogenism (Elevated Total/Free Testosterone) AND Oligomenorrhea [gpnotebook.co.uk]

  English polycystic ovary syndrome syndrome characterized by hyperandrogenism, polycystic ovaries, hirsutism, oligomenorrhea or amenorrhea, anovulation and excessive body weight Multicystic ovaries PCOS Polycystic Ovarian disease Polycystic ovaries Polycystic [wikidata.org]

• Clitoromegaly

  Although infrequent, some clinical symptoms must be carefully searched for, since they draw the clinician’s attention toward a severe disease: (a) rapidly growing hirsutism, with other signs of virilization such as clitoromegaly, temporal balding, voice [web.archive.org]

  Occasionally, clitoromegaly, increased muscle mass, deep voice (more usually, these are signs of more severe hyperandrogenism syndromes). [patient.info]

  Hyperandrogenemia (elevated free testosterone, free androgen index, or DHEA levels) and/or clinical evidence of androgen excess (hirsutism, acne, clitoromegaly, male body habitus) are present in up to 80% of affected women.[6] Polycystic ovaries are defined [medscape.com]

• Vaginal Bleeding

  PCOS symptoms include: excess hair growing on your face, chest, stomach or back (hirsutism) thinning hair or baldness (alopecia) irregular periods or no periods at all abnormal vaginal bleeding difficulty falling pregnant or not falling pregnant at all [healthdirect.gov.au]

  Often, a biopsy of the uterine lining (endometrial biopsy) is done to make sure no cancer is present, particularly if women have abnormal vaginal bleeding. [msdmanuals.com]

  You might also notice acne, excessive hair growth on the face or other parts of the body, weight gain, and occasionally prolonged vaginal bleeding. [whattoexpect.com]

• Secondary Amenorrhea

  Here, we present a case of ACTH-dependent pituitary macroadenoma (Cushing's disease) resulting in secondary amenorrhea mimicking polycystic ovary syndrome (PCOS). [ncbi.nlm.nih.gov]

  Symptoms of PCOS include changes in the menstrual cycle, such as: Not getting a period after you have had one or more normal ones during puberty ( secondary amenorrhea ) Irregular periods that may come and go, and be very light to very heavy Other symptoms [nlm.nih.gov]

  Symptoms of PCOS include changes in the menstrual cycle, such as: Not getting a period after you have had one or more normal ones during puberty (secondary amenorrhea) Irregular periods that may come and go, and be very light to very heavy Other symptoms [medlineplus.gov]

The diagnosis of polycystic ovary syndrome is based on history, general physical examination, laboratory investigations and radiographic studies [6].

On history and examination, there are certain obvious findings such as menstrual irregularities, obesity, acne, hirsutism and subfertility.

The patients must have two out of three features given below:

1. Amenorrhea/oligomenorrhea
2. Clinical or biochemical hyperandrogenism
3. Polycystic ovaries on ultrasound

A transvaginal ultrasound is main diagnostic tool to establish diagnosis of polycystic ovaries. The criteria for the definite diagnosis are eight or more subcapsular follicular cysts less than 10mm in diameter and increased ovarian stroma. The follicles may be oriented in periphery giving the appearance of a “string of pearls”.

Laparoscopic examination may also reveal a thickened, smooth, pearl-white outer surface of ovary.

Laboratory testing includes high serum levels of androgens including testosterone. The ratio of lutenizing hormone to follicle stimulating hormone is also elevated in women with polycystic ovary syndrome.

• Hyperinsulinemia

  KEYWORDS: body mass index; hyperinsulinemia; irisin; meta-analysis; polycystic ovary syndrome [ncbi.nlm.nih.gov]

• Hyperglycemia

  Thus, ROS generation from MNCs in response to hyperglycemia may serve as an inflammatory trigger for the induction of insulin resistance in PCOS. We examined ROS generation in MNCs of patients with PCOS before and after hyperglycemia. [doi.org]

  ROS generation from MNCs in response to hyperglycemia is increased in PCOS independent of obesity. [ncbi.nlm.nih.gov]

• Androgens Increased

  […] elevated serum androgens (increased A and/or T concentrations) and 155 (47%) showed elevated LH levels. [ncbi.nlm.nih.gov]

  These tests are used to detect increased levels of androgens and other hormones. [stanfordchildrens.org]

  As a result, the production of male hormones (androgens) increases. High levels of male hormones increase the risk of metabolic syndrome (with high blood pressure, high cholesterol levels, and resistance to the effects of insulin). [msdmanuals.com]

• Insulin Increased

  PCOS is seriously underdiagnosed Emma Kapotes/Rd.com About 7 million U.S. women have polycystic ovary syndrome (PCOS), which results when excess insulin increases the production of androgens (male hormones). [rd.com]

  When cells can’t use insulin properly, the body’s demand for insulin increases. The pancreas makes more insulin to compensate. Extra insulin triggers the ovaries to produce more male hormones. Obesity is a major cause of insulin resistance. [healthline.com]

  Insulin levels reduce the amount of IGFBP which in turn increases the amount of circulating IGF. IGF has been shown to induce LH receptors increasing LH levels, again suggesting an interaction between insulin resistance, LH and EC [81]. [intechopen.com]

• Estrogen Increased

  Also, some of the male hormones may be converted to estrogen, increasing estrogen levels. Not enough progesterone is produced to balance the increased level of estrogen. [msdmanuals.com]

Medical management of polycystic ovary syndrome has the following four goals [7].

• Restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer
• Restoration of fertility
• Lowering of insulin resistance
• Treatment of hirsutism and acne

Diet

Since polycystic ovary syndrome is associated with obesity, a significant reduction in weight is the most effective method in restoring ovulation and normal menstrual cycles. A high carbohydrate diet which can be obtained from fruits, vegetables and whole grain sources may be helpful. Moreover, treatment with essential vitamins (particularly vitamin D) and micronutrients may also be indicated.

Medications

A number of drugs which are helpful in the management of polycystic ovary syndrome are listed below.

• Combined oral contraceptive pills (COCP): They are helpful in regulating menstruation.
• Cyclical oral progesterone: They are also used for the regulation of menstruation.
• Clomiphene: This can be used to induce ovulation when subfertility is present [8].
• Metformin: This is beneficial in a subset of patients with polycystic ovary syndrome that have hyperinsulinemia and cardiovascular risk factors. It is less effective than clomiphene for ovulation induction and it does not improve pregnancy outcome [9] [10]. It should be discontinued when pregnancy is detected.

Hirsutism and Acne

• Efornithine cream applied topically reduces hirsutism and acne.
• Cryproterone acetate is an anti-androgenic contraceptive pill that may also be helpful in the reduction of acne and hirsutism.
• Metformin improves parameters of insulin resistance, hyperandrogenism, anovulation and acne in polycystic ovary syndrome.
• GnRH analogues with low-dose hormone replacement therapy should be reserved for women that are intolerant to other therapies.
• Surgical treatments such as laser or electrolysis may also be considered when other treatments fail to provide a good response.

Women with polycystic ovary syndrome are at an increased risk for endometrial hyperplasia, endometrial carcinoma, miscarriages, strokes, autoimmune thyroiditis and cardiovascular events. However, no known association with breast or ovarian cancer has yet been found.

Early diagnosis and treatment may reduce the risk of some of these disorders, particularly type 2 diabetes mellitus and cardiovascular diseases.

The etiology of polycystic ovary syndrome is not completely clear but there is often a family history. Since polycystic ovary syndrome is a hormonal disorder, the disease is more often associated with peripheral insulin resistance and hyperinsulinism. Obesity may also contribute to such abnormalities [2].

Moreover, family history of anovulation and increased androgen levels (testosterone and androstenedione) may also lead to polycystic ovary syndrome.

Polycystic ovary syndrome most commonly affects females of reproductive age group with a prevalence of 4-12%. Up to 10% of the cases are diagnosed during gynecological visits. The World Health Organization estimates that it affects 116 million women worldwide.

According to one study, a great ethnic variability in hirsutism is observed. Asian women, for instance, have much less hirsutism as compared to white women. The prevalence rate of hirsutism in southern Chinese women is found to be 10.5%. Similarly in women with hirsutism, investigators found a significant increase in incidence of menstrual irregularities, acne, acanthosis nigricans and polycystic ovaries.

In polycystic ovary syndrome, the ovaries are stimulated to release excess amounts of male hormones, particularly testosterone. It is suggested that there is an increase in the serum level of free IGF-1 that stimulates ovarian androgen production. There is also an excessive release of luteinizing hormone by the anterior pituitary gland [3].

Moreover, most of the women presenting with polycystic ovary syndrome are obese and have insulin resistance. The elevated insulin level causes abnormalities of hypothalamic-pituitary axis that lead to the development of polycystic ovary syndrome. In obese women, adipose tissue possesses aromatase, an enzyme that converts androstenedione to estrone, and testosterone to estradiol. Thus, the excess of adipose tissue in obese women results in the increased production of both androgens (responsible for hirsutism, acne and virilization) and estrogens.

Polycystic ovary syndrome has a strong genetic evidence and has been found to be associated with a specific FMR1 sub-genotype in the heterozygous females.

Polycystic ovary disease cannot be prevented but early diagnosis and treatment helps prevent long term complications such as diabetes and heart diseases. The use of high fiber diet is also helpful.

Polycystic ovary syndrome (PCOS) is an ovarian dysfunction with the cardinal features of hyperandrogenism and polycystic ovary morphology. The disease is characterized by menstrual irregularities, hirsutism and obesity. It is a common hormonal disorder among the females of reproductive age and is associated with increased risk of type 2 diabetes and cardiovascular events [1].

Polycystic ovary syndrome is one of the most common hormonal disorders of the female gender. The patients usually present with menstrual disturbances, acne and increased facial hair. The disease runs in families, usually affecting females of reproductive age group. Early diagnosis and treatment helps restore fertility and also reduces the risks of complications.

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