The exact cause of PCOS remains multifactorial, involving genetic, hormonal, and environmental influences.

1. Genetic Predisposition

• Family history significantly increases the risk (especially if mother or sister has PCOS or diabetes).
• Multiple genes influence androgen production, insulin action, and ovarian follicle development.

2. Hormonal Imbalance

• Elevated androgens (male hormones) such as testosterone interfere with follicular development and ovulation.
• Luteinizing hormone (LH) is often elevated relative to follicle-stimulating hormone (FSH), disrupting normal ovulation.

3. Insulin Resistance

• Excess insulin stimulates the ovaries to produce more androgens.
• Contributes to weight gain, acne, and anovulation.

4. Lifestyle and Environmental Factors

• Sedentary lifestyle, obesity, poor diet, and stress exacerbate symptoms.
• Early puberty, low birth weight, and exposure to endocrine-disrupting chemicals may also contribute.

The hallmark of PCOS is a complex interaction between the hypothalamic–pituitary–ovarian (HPO) axis, insulin resistance, and hyperandrogenism.

1. Hypothalamic–Pituitary Dysfunction: Increased GnRH pulse frequency leads to elevated LH and low FSH, promoting androgen production in the theca cells of the ovaries.
2. Hyperandrogenism: High androgen levels inhibit follicular maturation, resulting in anovulation and multiple small follicular cysts on the ovaries.
3. Insulin Resistance: Insulin acts synergistically with LH to stimulate androgen synthesis and suppress hepatic production of sex hormone–binding globulin (SHBG), leading to more free testosterone.
4. Ovarian Changes: The ovaries become enlarged, with multiple immature follicles (not true cysts), giving the characteristic “polycystic” appearance on ultrasound.

PCOS manifests with a spectrum of reproductive, dermatologic, and metabolic symptoms that vary among individuals.

1. Menstrual and Reproductive Symptoms

• Irregular or absent menstrual periods (oligomenorrhea or amenorrhea).
• Infertility due to anovulation. Difficulty conceiving or maintaining pregnancy.

2. Hyperandrogenic Symptoms

• Excess facial or body hair (hirsutism).
• Acne and oily skin.
• Thinning scalp hair (androgenic alopecia).

3. Metabolic Symptoms

• Weight gain or difficulty losing weight.
• Central (abdominal) obesity.
• Insulin resistance and glucose intolerance.

4. Psychological Manifestations

• Mood swings, anxiety, depression, and reduced self-esteem

There is no single definitive test for PCOS.

Diagnosis is typically based on clinical findings, laboratory tests, and imaging, following the Rotterdam criteria, which require at least two of the following three features:

1. Oligo- or anovulation (irregular or absent periods).
2. Clinical or biochemical signs of hyperandrogenism.
3. Polycystic ovaries on ultrasound (≥12 small follicles per ovary and/or ovarian volume >10 mL).

Laboratory Tests:

• Serum total and free testosterone – elevated in PCOS.
• LH/FSH ratio – often >2:1.
• Prolactin and TSH – to rule out other endocrine disorders.
• Fasting glucose and insulin – to assess insulin resistance.
• Lipid profile – for cardiovascular risk

Imaging:

• Pelvic ultrasound: Reveals enlarged ovaries with multiple peripheral follicles (“string of pearls” appearance).

There is no cure for PCOS, but symptoms can be effectively managed through lifestyle changes, medications, and targeted therapies depending on the woman’s goals — whether it’s restoring menstruation, improving fertility, or managing metabolic and cosmetic concerns.

1. Lifestyle Modification — The Foundation of Management

• Weight loss (5–10%) significantly improves ovulation and insulin sensitivity.
• Regular aerobic exercise and strength training.
• Balanced diet: low glycemic index foods, high fiber, lean proteins, and omega-3 fats.
• Stress reduction through mindfulness and sleep optimization.

2. Pharmacological Therapy

a. Insulin-Sensitizing Agents

• Metformin improves insulin sensitivity, lowers androgen levels, and restores menstrual regularity.
• Beneficial for women with obesity, insulin resistance, or prediabetes.

b. Hormonal Regulation

• Combined oral contraceptive pills (COCs):
• Suppress LH and ovarian androgen production.
• Regulate menstrual cycles and reduce acne/hirsutism.
• Common combinations: ethinylestradiol + cyproterone acetate or drospirenone.

c. Anti-Androgenic Agents

• Spironolactone, flutamide, or finasteride reduce excess hair and acne.
• Must be used with contraception due to teratogenicity.

d. Ovulation Induction (for Fertility)

• Letrozole (aromatase inhibitor) – first-line for inducing ovulation.
• Clomiphene citrate – traditional first-line oral agent.
• Gonadotropin therapy or IVF for resistant cases.

e. Metabolic Management

• Statins for dyslipidaemia.
• Inositol supplements (myo-inositol, D-chiro-inositol) support insulin sensitivity and ovulation naturally.

3. Emerging and Supportive Therapies Nutraceuticals:

Omega-3 fatty acids, vitamin D, and chromium improve metabolic parameters.

Acupuncture: May aid menstrual regulation and stress reduction. Weight management medications or bariatric surgery in cases of severe obesity. “Ovarian-Protective” Approach:Similar to the “chondroprotective” or “neuroprotective” strategies in other therapeutic areas, this concept focuses on preserving ovarian function and metabolic balance through insulin-sensitizing, antioxidant, and anti-inflammatory interventions that protect long-term fertility and endocrine health.

If left unmanaged, PCOS can lead to serious long-term health issues, including:

• Infertility and recurrent miscarriage.
• Type 2 diabetes mellitus.
• Metabolic syndrome and hypertension.
• Dyslipidemia and cardiovascular disease.
• Endometrial hyperplasia or cancer due to prolonged unopposed oestrogen exposure.
• Sleep apnoea and depression.

While PCOS cannot always be prevented due to genetic predisposition, its symptoms and complications can be minimized through:

• Maintaining a healthy weight and regular exercise.
• Balanced diet to prevent insulin resistance.
• Regular menstrual tracking and early gynaecological check-ups.
• Managing stress and getting adequate sleep.

Consult a healthcare provider if you experience:

• Irregular or absent menstrual cycles.
• Excessive hair growth, acne, or hair thinning.
• Unexplained weight gain or difficulty losing weight.
• Difficulty conceiving after 6–12 months of trying.
• Symptoms of depression or anxiety.
• Early diagnosis and intervention can restore hormonal balance, preserve fertility, and reduce long-term metabolic risks.

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• Rotterdam ESHRE/ASRM Consensus. Revised 2003 diagnostic criteria for PCOS.
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• Goodman NF, et al. American Association of Clinical Endocrinologists guideline for PCOS. Endocr Pract. 2015;21:1291–1300.
• Teede HJ, et al. International Evidence-Based Guideline for the Assessment and Management of PCOS. 2018.