Polycystic Ovary Syndrome

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November 30th 2020
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INTRODUCTION
Polycystic Ovary Syndrome (PCOS), also known as the Stein-Leventhal Syndrome, is the

most common hormonal disorder in women of reproductive age. The main features of PCOS

include irregular periods, excess androgen levels, and polycystic ovaries1. Androgen hormones

are responsible for binding to androgen receptors, thus regulating the development and

maintenance of male characteristics. It is for this reason that one of the defining features of a

woman with PCOS, along with other symptoms, is the development of excess facial or body hair.

Polycystic ovaries describe enlarged ovaries that contain many fluid-filled follicles that surround

the eggs. These polycystic ovaries can be up to 8mm in size, and are unable to release an egg,

meaning that ovulation does not occur. Figure 1 shows a polycystic ovary in comparison to a

normal ovary.

Figure 1: Normal compared to a polycystic ovary, retrieved from Nutrition Therapy and Pathophysiology2.

As is evidenced, the polycystic ovary is larger than normal, with multiple bubble-like

follicles developing on the surface as partially mature eggs that swell up, but fail to open. In a

woman with PCOS, these follicles can reach up to 25 or more in number. On the other hand, the

normal ovary has a single developing egg, which is eventually released. Types of PCOS can be

classified into four major groups: insulin-resistant, pill-induced, inflammatory, and hidden

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polycystic ovary syndrome3. Each type has its own prevalence and causes, and thus its own

approach to treatment. There are both genetic and environmental factors that influence the

development of PCOS, regardless of the type. Although there is no cure for PCOS, the symptoms

can be managed using a treatment plan, and today it is possible to live a relatively normal life

with this syndrome.

DIAGNOSIS
The modern diagnostic criteria can be traced back to the 1800s, with the discovery of

polycystic ovaries. However, at this time there was no known connection to a larger cause. Later

in the 1990s, the National Institutes of Health (NIH) and National Institute of Child Health and

Human Development (NICHD) recognized menstrual irregularity and hyperandrogenism as part

of the syndrome’s potential symptomatic traits. The first diagnostic criteria for PCOS was

published by American gynecologists Irving F. Stein, Sr. and Michael L. Leventhal. They

suggested that for a patient to be diagnosed as having Stein-Leventhal syndrome, they must have

enlarged ovaries, obesity, anovulation, and excessive hair growth, also known as hirsutism2.

Since this discovery, the criteria of diagnosis has been up for debate, with some arguing the

collection of symptoms as being a gynecological problem, and other insights suggesting it is

more of a multisystem disorder. This is due to the fact that there is a wide spectrum of symptoms

possible, hence the use of the word “syndrome” in the name, and not all are experienced by

women with PCOS. For example, only 15% of people with PCOS have cysts in their ovaries4.

Due to the fact that not all the symptoms are experienced by women who have PCOS, an

alternative diagnosis was decided upon, that is used today. While used interchangeably with

PCOS, the Stein-Leventhal syndrome is primarily used for the subset of women with all the

original symptoms intended for its criteria.

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 The Rotterdam criteria was first sponsored by the NIH/NICHD in a consensus workshop.

At the time, it was suggested that a person has PCOS if they have all of the following:

oligoovulation, which is abnormalities in the menstrual cycle, signs of androgen excess, and the

exclusion of other disorders that can result in the first two symptoms5. Over time, this criteria

was further researched so that the definition is wider. According to the 2003 Rotterdam criteria,

diagnosis requires the presence of at least two of the following: hyperandrogenism, ovulatory

dysfunction, and polycystic ovaries6. The 2009 Androgen Excess and PCOS society criteria, on

the other hand, specifies that the patient must have clinical or biochemical evidence of

hyperandrogenism, and either oligomenorrhea, which is defined as menstrual cycle length of

greater than 35 days, and/or polycystic ovaries. The primary difference here is that in order for a

patient to have PCOS, they have to have evidence of high levels of androgenism. Figure 2

indicates a table taken from a medical journal that compares and summarizes the 1990 NIH

criteria, the 2003 Rotterdam criteria, and the 2009 Androgen Excess and PCOS society criteria.

Figure 2: A comparison of the different diagnostic criterias, retrieved from AAFP 6.

In addition to the previous criteria specifics, the diagnostic workup should consider the

patient’s history and physical examination. These include the menstrual history, weight

fluctuations, subcutaneous findings, and their impact on the PCOS symptoms. It is worth noting

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that the International Diabetes Federation (IDF) has different waist circumference measurements

when determining central obesity, depending on the ethnicity of the individual. This is shown in

Figure 3, which outlines the different waist circumference cut-offs in the different ethnic groups.

Figure 3: Waist circumference measurement cut offs for each ethnic category, retrieved from Nutrition Therapy and
Pathophysiology2.

ETIOLOGY AND PREVALENCE

With different criterias to diagnose PCOS, it can be difficult to pinpoint the exact

statistical prevalence of those with PCOS. According to the World Health Organization (WHO),

116 million women worldwide as of 2010 were affected by PCOS7. A study using the Rotterdam

criteria concluded that around 18% of women had PCOS, and approximately 70% of them were

previously undiagnosed. Evidently, there needs to be a deeper understanding of the syndrome in

order to reduce the number of undiagnosed cases. The different types of PCOS exhibit varying

prevalence, with some being more easy to diagnose than others. Insulin-resistant PCOS is the

most common type, with 70% of PCOS women being insulin-resistant2. This, along with

pill-induced PCOS, is the more easily-diagnosable type. Inflammatory and Hidden PCOS can be

significantly more difficult to diagnose, with the former more commonly misdiagnosed, and the

latter showing too few outward symptoms.

While genetics plays a large role in the prevalence of the syndrome, risk factors such as

obesite, lack of physical exercise, and other environmental factors play an important role. In fact,

a study showed that there is a much lower prevalence of 5% in lean individuals compared to 28%

in those that are overweight and obese2. The genetic component of PCOS is what requires the

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most understanding, as it can help with targeting the diagnosis of those who exhibit little to no

symptoms. Although PCOS is more commonly associated with women since the existence of

ovaries is needed to exhibit the abnormalities that characterize the syndrome for what it is, 80%

of paternal transmission occurs when the father is affected with the gene, compared to only 45%

in material transmission2. This supports the argument that despite the fact that either parent can

transmit the gene, the father carrying the gene can more likely impact the children. For this

reason, it is suggested that any female sibling of a person with PCOS should be tested, even if

there are no outward symptoms. In these cases, more than half of all these female siblings end up

having some degree of PCOS. Men will not experience the same symptoms, but may have

hypothyroid, metabolic syndrome, heart problems, poor lipid profile, the inability to grow a full

beard, or premature balding2.

PATHOPHYSIOLOGY
To better understand the causes behind the physiological symptoms of people in PCOS, it

is important to address the pathophysiology involved. Figure 4 outlines the pathophysiology of

PCOS in a flowchart. As can be seen, the combination of genetics, obesity, living a sedentary

lifestyle, and high androgen levels, directly results in insulin-resistance and increased GnRH

pulsatile release. These cause an increase in LH:FSH ratio, due to an increase in LH by the

anterior pituitary gland,8 and hyperinsulinemia respectfully. Hand-in-hand, these two contribute

directly to the hyperandrogenism found in PCOS patients, which then leads to anovulation and/or

polycystic ovaries. Anovulation, or the absence of egg release, can result in anovulatory bleeds,

decreased progesterone levels, and subfertility. The decreased levels of progesterone allows for

the uncontrolled increase of estrogen, which increases the risk of endometrial cancer.

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 Figure 4: An outline of the pathophysiology of PCOS, retrieved from McMaster Pathophysiology Review9.

Insulin-resistance in women with PCOS is not limited to overweight and obese women,

however, having high abdominal fast can accelerate the insulin-resistence seen in this group. The

fat cells in the body mobilize free fatty acids, which block the insulin action. This increases the

levels of triglycerides, apolipoprotein B, and adenosine triphosphate in the blood, and as a result,

VLDL production increases. High levels of VLDL can cause plaque to be deposited on the artery

walls, accelerating inflammation. Additionally, inflammatory adipokines suppress insulin

signaling, and inflammatory signals TNF-α, IL-6, LPS, and saturated free fatty acids activate

inhibitory molecules, which suppress insulin signaling as well, and thus contributing to insulin

resistance.

TREATMENT
In addition to the steps needed to be taken for a diagnosis to be made, a standard

assessment using various tests is conducted to narrow down the target of treatment. A

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gynecologic ultrasonography helps with locating the follicles, and a laparoscopic examination

can help reveal the thickened outer surface of the ovary, although a laparoscopy is not routine for

confirming a diagnosis of PCOS. Elevate blood levels of androgens, including androstenedione

and testosterone, can be shown through biochemical tests. Although not necessary, blood tests of

the LH:FSH ratio, if tested on the same day of the menstrual cycle, can help with the diagnosis.

Finally, it is always worth testing glucose tolerance in women with risk factors, so to better

prepare the treatment plan.

The two types of medications that can help PCOS include oral contraceptives and

metformin. Oral contraceptives increase the sex hormone binding globulin production, allowing

an increase in binding of free testosterone. This is done to reduce hirsutism symptoms, as well as

to regulate normal period cycles. Metformin, commonly used in type 2 diabetes mellitus to

reduce insulin resistance, can be used for similar purposes. Moreover, Metformin also supports

ovarian function, and with helping to return to normal ovulation10. Metformin can cause various

side effects, with diarrhea being a common experience in those who take it. This is due to the

increase in intestinal chloride secretion, a direct result of the AMP-cAMP & AMPK mediation

counterbalance that occurs when taking the medication11.

There are also surgical procedures that can be used to help treat, or even cure, PCOS12.

These, however, should only be considered after the patient has attempted medication, lifestyle

changes, and medical nutrition therapy, extensively. Ovarian surgery is an option for those who

have unmanageable symptoms, and do not wish to have any pregnancies in the future. In this

surgery, electrocautery is used to abolish the parts of the ovaries. It is not guaranteed that this

procedure will provide permanent results, or fix the problem of irregular menstrual cycle and

ovulation. Furthermore, there are risks in doing such surgeries, including injury to the bowel,

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bladder, and blood vessels. As a result of this procedure, it is possible for a woman to enter

menopause early.

MEDICAL NUTRITION THERAPY

Before considering medication or surgical procedures, the patient is advised to make

adjustments to their lifestyle through diet and exercise. Losing weight is one of the main

objectives, especially since any success body fat can worsen clinical features, such as

hyperinsulinemia and hyperandrogenism. Weight loss can help counteract these conditions and

improve menstrual function by decreasing androgen levels and insulin resistance. Most times,

lifestyle changes are targeted even if the patient is also taking medication, as a way to increase

their chances of overcoming the symptoms. For example, the use of Metformin can aid with

weight loss, as it lowers appetite with its insulin-controlling mechanisms. All-in-all, the

American Association of Clinical Endocrinologists recommend a goal of 5-15% weight loss13.

This may be difficult for some women, so the use of consistency in careful diet planning to help

reduce symptom severity and risk factors is vital in ensuring that they feel some sort of progress,

thus reducing the risk of developing issues in self-esteem, depression, anxiety, and eating

disorders.

Various goals for PCOS are outlined in the Nutrition Care Manual14. For starters, they are

recommended to eat a variety of fruits and vegetables every day, as well as nutrient-rich whole

grains that are a good source of dietary fiber. Examples of these include bulgur, amaranth,

whole-grain barley, buckwheat, oats, brown rice, quinoa, whole rye, and popcorn. Furthermore,

the protein-rich foods they should target include lean meats and poultry, adding eggs to meals

and snacks to add fullness and help manage blood sugar levels. In addition, foods high in

omega-3 fatty acids are highly recommended, such as fatty fish, seeds, oils, and nuts. Finally, it

is advised to stick to low-fat dairy foods, and limit foods and drinks that are high in added

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sugars. In regards to lifestyle change specifications, it is suggested to eat 4 to 6 times a day, and

to engage in some form of physical activity each day.

PROGNOSIS
According to the Nutrition Care Manual, women with PCOS are at a high risk for

developing cardiovascular disease, type 2 diabetes mellitus, and metabolic syndrome. Therefore,

when developing their nutrition goals, one should take this into consideration, and also target

preventing any of these conditions14. Lesser-known risks of those with PCOS include the

development of hypertension, sleep apnea, autoimmune thyroiditis, acanthosis nigricans,

non-alcoholic fatty liver disease, and depression and/or anxiety. All of these are related to weight

gain, however it is not clear if body dissatisfaction predominantly contributes to the emotional

disturbances found in PCOS2 .

CONCLUSION
Although there are no known prevention precautions to take with PCOS, being educated

on the risk factors, genetic impact, and environmental triggers, can make a difference between

someone who progresses it to a point of developing further complications, and someone that

catches it early enough to make the necessary nutritional interventions. Regardless of the medical

and technological advancements made in the healthcare industry, one thing that remains certain

is the current and future need to take multidisciplinary action when dealing with syndromes such

as PCOS. Furthermore, more attention needs to be paid to the men who are carriers but do not

have outward symptoms, as they play a large role in passing the genes on that put their children

at risk. All of these improvements that can help reduce the impact of PCOS, and thus the

emotional and financial strain of those diagnosed with or close to someone diagnosed with

PCOS, come down to targeting the education system of future generations, and of those already

in the healthcare system.

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REFERENCES
1. Polycystic ovary syndrome. nhs.uk. Published October 20, 2017. Accessed November 27, 2020.
https://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/

2. Nelms M, Sucher K. Nutrition Therapy & Pathophysiology. 4th ed. Cengage Learning; 2020.

3. Types of PCOS | Symptoms of PCOS | Treatment of PCOS. indiraivf. Published May 30, 2019. Accessed
November 27, 2020. https://www.indiraivf.com/types-of-pcos/

4. Dunaif A, Fauser BCJM. Renaming PCOS—A Two-State Solution. J Clin Endocrinol Metab.
2013;98(11):4325-4328. doi:10.1210/jc.2013-2040

5. Scott R. Polycystic Ovarian Syndrome. Medscape. Published 2019. Accessed November 27, 2020.
https://emedicine.medscape.com/article/256806-overview#showall

6. Williams T, Mortada R, Porter S. Diagnosis and Treatment of Polycystic Ovary Syndrome. AFP.
2016;94(2):106-113.

7. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic
analysis for the Global Burden of Disease Study 2010. Accessed November 27, 2020.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350784/

8. Luteinizing Hormone LH | Hormone Health Network. Accessed November 27, 2020.

https://www.hormone.org/your-health-and-hormones/glands-and-hormones-a-to-z/hormones/luteinizing-hormone

9. Polycystic ovarian syndrome (PCOS) | McMaster Pathophysiology Review. Accessed November 27, 2020.
http://www.pathophys.org/pcos/

10. Metformin in polycystic ovary syndrome: systematic review and meta-analysis. Accessed November 27, 2020.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC259161/

11. Ovarian surgery to cure PCOS. Conquer. Published January 29, 2020. Accessed November 27, 2020.
https://conquerpcos.org/ovarian-surgery-to-cure-pcos/

12. Metformin (Glucophage) and Weight Loss. Accessed November 27, 2020.
https://www.diabetes.co.uk/diabetes-medication/metformin-weight-loss.html

13. Garvey WT, Mechanick JI, Brett EM, et al. American Association of Clinical Endocrinologists and American
College of Endocrinology Comprehensive Clinical Practice Guidelines for Medical Care of Patients with Obesity.
Endocr Pract. 2016;22 Suppl 3:1-203. doi:10.4158/EP161365.GL

14. NutritionForPolycysticOvarianSyndrome(PCOS)FINAL.pdf. Accessed November 27, 2020.

https://scandpg01-prd.s3.amazonaws.com/resources/DOCS/FactSheets/NutritionForPolycysticOvarianSyndrome(PC
OS)FINAL.pdf

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