Polycystic ovary syndrome, or PCOS, is a hormone disorder common among women of reproductive age that can cause menstrual irregularities and infertility, along with other clinical symptoms such as insulin resistance, obesity and acne. While elevated androgens (or male sex hormones) are generally recognised as a cardinal feature of PCOS, its clinical presentation varies from person to person. Even its name is misleading, since not all women with PCOS even present with polycystic ovaries.
PCOS is ultimately a complicated disorder of interacting hormonal, metabolic, genetic and environmental factors. These factors can influence reproductive function by directly affecting the reproductive ‘control centre’ in the brain, but also by affecting the function of other organ systems. Because there are many factors that potentially impact the development and presentation of PCOS, and because not all factors affect each individual, it becomes very difficult to establish a ‘one-size-fits-all’ model of PCOS. This diverse phenotypic presentation of PCOS not only makes it difficult to characterise and diagnose, but also difficult to treat.
To be diagnosed with PCOS, which is done using the modified Rotterdam criteria, 2 out of the following 3 diagnostic features must be met: 1) irregular menstrual cycles (known as oligo- or anovulation), 2) clinical and/or biochemical hyperandrogenism (which may include assessment of hyperandrogenic features like hirsutism and/or involve measuring androgen levels in the blood), and 3) a polycystic appearance of the ovaries on ultrasound. However, other considerations must be taken into account as well, such as ethnic variation and metabolic disease risk. While there may be some underlying commonalities among women with PCOS, each patient requires an individualised treatment plan that specifically targets the clinical features and comorbidities that threaten their health and self-esteem. Timely implementation of these interventions, which include education and counselling, lifestyle changes and medical treatments, is paramount to the overall management of PCOS, its associated comorbidities, and the enhancement of quality of life for these patients.
Going forward, it is also important that research into the causes, mechanisms and treatment of PCOS take in to account the variety of ways in which PCOS presents. For example, in patients with PCOS who also have metabolic comorbidities, considering the role of high insulin levels in both the pathophysiology and treatment of PCOS is extremely important, whereas it may be less relevant in patients who don’t present with a metabolic phenotype. Therefore, taking into consideration the complexities of PCOS, and recognising which hormone, genetic, environmental and lifestyle factors are at play is extremely important when it comes to both understanding the pathophysiology of and identifying the most effective treatment(s) for different PCOS 'subtypes'.
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