PCOS and PCOD - A Complete Clinical Overview

PCOS vs. PCOD: Terminology

• PCOD refers specifically to the ultrasound finding of polycystic-appearing ovaries (multiple small follicles). It is considered a milder, often reversible condition.
• PCOS is a broader endocrine syndrome - a diagnosis of multiple features including hyperandrogenism, ovulatory dysfunction, and/or polycystic ovarian morphology. It is NOT just about ovarian appearance on ultrasound.

What is PCOS?

• Hyperandrogenism (HA)
• Hirsutism
• Anovulatory infertility

Diagnostic Criteria (Rotterdam 2003 - Still Current)

1. HA + ovarian dysfunction + PCO morphology (classic full picture)
2. HA + ovarian dysfunction (no PCO on USS)
3. HA + PCO morphology (regular cycles)
4. Ovarian dysfunction + PCO morphology (no HA)

Conditions to Rule Out First

• Hyperprolactinemia
• Non-classic congenital adrenal hyperplasia (measure 17-OHP in all hirsute women)
• Cushing syndrome
• Androgen-secreting neoplasm (ovarian or adrenal)
• Thyroid disorder
• Hypo/hypergonadotropic disorders

Pathophysiology

1. Hyperandrogenism

• LH hypersecretion stimulates ovarian theca cells to overproduce androgens
• Basal LH elevated in ~2/3 of cases
• Elevated androgens: testosterone, DHEAS, androstenedione

2. Insulin Resistance (IR)

• Present in the majority of PCOS women regardless of obesity
• A unique post-receptor defect (diminished insulin receptor autophosphorylation) found in ~50% of women with PCOS
• IR leads to compensatory hyperinsulinemia, which:
  • Collaborates with LH to stimulate theca cell androgen production
  • Inhibits hepatic SHBG synthesis, increasing free (bioavailable) testosterone

3. Chronic Anovulation

• Follicular arrest due to androgen excess and abnormal gonadotropin secretion
• Multiple small antral follicles accumulate = polycystic appearance on USS

Clinical Features

Reproductive

• Irregular periods (oligomenorrhea/amenorrhea) - from menarche
• Anovulatory infertility
• Elevated risk of: miscarriage, gestational diabetes, gestational hypertension, preeclampsia, preterm birth

Hyperandrogenic

• Hirsutism (70% in the US; much less common in East Asian women due to lower 5α-reductase activity)
• Acne
• Male-pattern alopecia (androgenic alopecia)

Metabolic

• Obesity in >50% of women with PCOS (predominantly android/central obesity)
• Insulin resistance and compensatory hyperinsulinemia
• 30-45% of obese women with PCOS have glucose intolerance or type 2 diabetes
• Dyslipidemia, elevated cardiovascular risk
• Acanthosis nigricans - a skin marker of IR (vulva, axilla, nape of neck, inner thigh)
• HAIR-AN syndrome: Hyperandrogenism + Insulin Resistance + Acanthosis Nigricans (extreme form)

Psychological

• Depression in 35-40% (vs. ~10% in controls)
• Anxiety and eating disorders are common
• Poor body image, low self-esteem

Investigations

Management

1. Lifestyle Modification (ALL patients)

• Weight loss as little as 5% body weight can restore ovulation, reduce insulin, lower androgens, and improve SHBG
• Diet and exercise are first-line for overweight/obese women
• Recent systematic review (2025, PMID 39861440) confirms lifestyle intervention improves hormonal, metabolic, and reproductive outcomes

2. Not Trying to Get Pregnant

• Combined oral contraceptive pills (COCPs) - first-line: regulate cycles, increase SHBG, reduce free testosterone (takes 2-3 months for androgens to fall; hirsutism/acne improvement may take longer)
• If inadequate response after 6 months: add antiandrogens - spironolactone or flutamide
• Endometrial protection (prevent unopposed estrogen/endometrial hyperplasia):
  • Periodic progestins (medroxyprogesterone acetate 10 mg or progesterone 200 mg for 10-14 days every 3 months)
  • Levonorgestrel IUD

• Metformin - for prevention of cardiometabolic risk in overweight/obese; NOT recommended alone for endometrial protection, hyperandrogenism, or infertility

3. Wanting to Get Pregnant (Ovulation Induction)

4. Hirsutism-Specific

• Weight loss
• COCPs
• 5α-reductase inhibitors: finasteride
• Antiandrogens: spironolactone, cyproterone acetate, flutamide
• GnRH analogues
• Mechanical: temporary (shaving, waxing) or permanent (electrolysis, laser)

Long-Term Complications & Monitoring

• Endometrial carcinoma - chronic anovulation causes unopposed estrogen; endometrial biopsy if at increased risk (young PCOS women can develop well-differentiated stage I endometrial cancer as early as the second decade)
• Type 2 diabetes - screen with OGTT, especially if obese or family history
• Cardiovascular disease - lipid profile, BP, waist circumference
• Obstructive sleep apnea - refer if suspected
• Depression/anxiety - PHQ-2 screening at each visit
• Vitamin D - assess and supplement if deficient (common in this population)

Key Points Summary