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.

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.

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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