PCOS (Polycystic Ovary Syndrome): Symptoms, Diagnosis and Modern Treatment

Polycystic Ovary Syndrome (PCOS) is one of the most common hormonal and metabolic disorders in women of reproductive age, affecting approximately 8–13% of this population worldwide. Beyond its visible features — irregular periods, hirsutism, acne and weight gain — PCOS also increases the long-term risk of insulin resistance, type 2 diabetes and cardiovascular disease. With accurate diagnosis and an individualised treatment plan, symptoms can be controlled and long-term risks substantially reduced.

PCOS versus PCOM: an important distinction

Recent guidelines — most notably the 2023 International PCOS Guideline (Teede et al.) — have clarified the difference between two often-confused concepts:

• PCOM (Polycystic Ovarian Morphology): A finding on ultrasound of multiple small follicles (≥20 per ovary) or an increased ovarian volume (>10 mL). It is only an imaging sign. Around 20–30% of healthy women with regular menstrual cycles can display PCOM.
• PCOS (Polycystic Ovary Syndrome): A clinical syndrome that requires the presence of additional clinical criteria such as ovulatory dysfunction or hyperandrogenism.

In other words, a "polycystic-appearing ovary" is not the same as "polycystic ovary syndrome". PCOM is only one of the possible criteria for PCOS. The 2023 guideline additionally allows anti-Müllerian hormone (AMH) to replace ultrasound in adults, and permits diagnosis without ultrasound in adolescents when regular cycles and clear hyperandrogenism are both present.

What causes PCOS?

There is no single cause. Genetic predisposition, insulin resistance, low-grade inflammation and increased ovarian androgen production interact to produce the syndrome. A family history of PCOS, type 2 diabetes or premature cardiovascular disease increases risk. Obesity worsens the clinical picture, but PCOS also occurs in lean women (approximately 20% of cases).

Symptoms of PCOS

1. Menstrual irregularity and anovulation

The most common presenting complaint. Cycles may be longer than 35 days (oligomenorrhoea), fewer than eight cycles per year, or absent altogether (amenorrhoea). Because ovulation is impaired, spontaneous conception is more difficult.

2. Signs of hyperandrogenism

• Hirsutism: Male-pattern hair growth on the face, chin, chest, abdomen and back.
• Acne: Persistent adult-onset or post-adolescent acne, typically along the jawline, chin and back.
• Androgenic alopecia: Thinning of the hair along the frontal hairline and crown.

3. Weight gain and features of insulin resistance

Central (abdominal) weight gain, difficulty losing weight, post-meal drowsiness and cravings, and dark, velvety skin patches on the neck or axillae (acanthosis nigricans) are clinical markers of insulin resistance, present in around 70% of women with PCOS.

4. Infertility

PCOS is the most common cause of anovulatory infertility. However, PCOS does not equal infertility — with appropriate treatment the majority of women can conceive.

5. Psychological symptoms

Depression, anxiety and disordered eating are 2–3 times more frequent in women with PCOS than in the general population and should be assessed as part of care.

Diagnosis: the Rotterdam criteria

A diagnosis of PCOS requires at least two of the following three criteria, after excluding other conditions that produce a similar picture:

1. Ovulatory dysfunction: Oligo- or anovulation, evidenced by irregular cycles or a low mid-luteal progesterone.
2. Clinical or biochemical hyperandrogenism: Hirsutism or acne, or elevated serum free testosterone.
3. PCOM or elevated AMH: Polycystic ovarian morphology on ultrasound, or an age-appropriate elevated AMH level (2023 guideline update).

Conditions that must be excluded

• Thyroid dysfunction (TSH)
• Hyperprolactinaemia (prolactin)
• Non-classic congenital adrenal hyperplasia (17-OH-progesterone)
• Cushing syndrome and androgen-secreting tumours (rare)

Which investigations are needed?

• Hormonal profile: LH, FSH, oestradiol, prolactin, TSH, free testosterone, DHEAS, 17-OH-progesterone
• AMH (particularly when ultrasound is inconclusive)
• Fasting glucose, insulin, HbA1c and, when indicated, oral glucose tolerance test
• Lipid profile (total cholesterol, LDL, HDL, triglycerides)
• Vitamin D and liver enzymes
• Transvaginal or abdominal pelvic ultrasound

Treatment of PCOS

Treatment is not a single prescription. It is individualised to the patient's goals: fertility, cycle regulation, control of skin and hair symptoms, and reduction of long-term metabolic risk.

1. Lifestyle modification: the foundation

In overweight women with PCOS, losing as little as 5–10% of body weight can restore ovulation, reduce insulin resistance and improve hirsutism and acne. A Mediterranean-style diet, low-glycaemic carbohydrates, adequate protein and at least 150 minutes per week of moderate-intensity exercise are the mainstay.

2. Combined oral contraceptives

First-line treatment for women not currently seeking pregnancy. They regulate the menstrual cycle, reduce androgen levels and markedly improve hirsutism and acne. They also reduce the risk of endometrial hyperplasia associated with chronic anovulation.

3. Metformin

Used in women with insulin resistance, impaired glucose tolerance or high risk of type 2 diabetes. It supports weight control and may improve cycle regularity. It is not first-line for ovulation induction alone but can be combined with letrozole in selected cases.

4. Anti-androgen therapy

Spironolactone, cyproterone acetate or finasteride can be added for severe hirsutism and androgenic alopecia. These agents are teratogenic and must always be prescribed alongside effective contraception.

5. Ovulation induction (for women seeking pregnancy)

• Letrozole: Now the first-line agent for PCOS-related anovulatory infertility, with higher live-birth rates than clomiphene citrate.
• Clomiphene citrate: A long-established alternative.
• Gonadotropins: Low-dose injectable therapy for women who do not respond to oral agents; requires close follicular monitoring.
• In vitro fertilisation (IVF): Recommended when other approaches fail or when additional infertility factors coexist.
• Laparoscopic ovarian drilling: A surgical option in selected patients.

6. Local treatment of skin symptoms

Laser hair removal and electrolysis are effective adjuncts for hirsutism. Topical retinoids, benzoyl peroxide, and in resistant cases oral isotretinoin, are used for acne.

Long-term health risks in PCOS

PCOS is not confined to the reproductive years — it is a metabolic condition that persists after menopause. It is associated with:

• Type 2 diabetes (3–7 times higher risk than the general population)
• Cardiovascular disease and hypertension
• Metabolic syndrome and non-alcoholic fatty liver disease
• Obstructive sleep apnoea
• Endometrial cancer (due to prolonged unopposed oestrogen exposure)
• Gestational diabetes and pre-eclampsia during pregnancy
• Depression and anxiety

Regular monitoring of glucose, lipid profile, blood pressure and gynaecological health is therefore essential in every woman diagnosed with PCOS.

PCOS and pregnancy

With the right treatment, most women with PCOS can conceive. Because the risks of gestational diabetes, pregnancy-induced hypertension and pre-eclampsia are elevated, closer antenatal surveillance is recommended. Pre-conception weight optimisation and folic acid supplementation are important.

PCOS diagnosis and treatment in Adana

PCOS is not a diagnosis that can be made from a single laboratory value — it requires careful clinical assessment, ultrasound and integrated interpretation of hormonal results. Op. Dr. Sadık Kükrer offers individualised evaluation of menstrual irregularity, hirsutism, weight and insulin resistance, and fertility planning for women with PCOS in Adana. International patients are welcome to arrange a comprehensive assessment if symptoms persist or current treatment is not achieving the desired result.