Polycystic Ovary Syndrome (PCOS): An Overview of Symptoms, Causes, and Therapeutic Approaches

Polycystic Ovary Syndrome (PCOS) is one of the most common and complex endocrine disorders affecting women of reproductive age worldwide. It is defined by three main features: hyperandrogenism, irregular ovulation, and polycystic ovarian morphology. PCOS has widespread effects on reproductive, metabolic, and psychological health.

Despite being recognized for decades, the exact cause of PCOS remains unclear, and its symptoms vary significantly between individuals. This makes both diagnosis and treatment challenging. PCOS is a leading cause of female infertility, largely due to anovulation. However, even when ovulation is restored, many women still require assisted reproductive technologies like IVF, suggesting deeper issues such as poor egg quality or altered endometrial receptivity. Beyond fertility, PCOS is linked to hormonal imbalance, insulin resistance, obesity, and mood disorders like anxiety and depression. Oxidative stress is increasingly seen as a major factor in its development, triggering inflammation and worsening symptoms.

The global prevalence of PCOS ranges from 5% to 15% among women aged 18–44. This wide range is influenced by changing diagnostic criteria, regional disparities in healthcare access, and limited awareness. Common symptoms include irregular periods, acne, hirsutism, and weight gain, often worsened by poor lifestyle habits. Over time, diagnostic definitions have evolved—from focusing on ovarian appearance to broader criteria like the Rotterdam criteria—leading to shifts in how PCOS is recognized and reported. Many women, especially in low-resource settings, remain undiagnosed or misdiagnosed, delaying early treatment and increasing the risk of long-term complications._1,2,3,4

PCOS often presents alongside metabolic issues like obesity, insulin resistance, and systemic inflammation. Treatments include lifestyle changes, medications such as metformin, and in some cases, bariatric surgery. Women with PCOS are also at higher risk for type 2 diabetes, cardiovascular diseases, and mental health issues. Despite extensive clinical research, few studies explore the lived experiences of women with PCOS. Understanding how patients cope with symptoms, interact with healthcare systems, and manage daily life is critical for providing holistic, patient-centre care._5,6,7,8,9

Another overlooked area is how PCOS affects body weight regulation. Many women with PCOS struggle with weight loss due to complex changes in appetite, metabolism, and energy balance. Additionally, exposure to endocrine-disrupting chemicals (e.g., bisphenols, parabens, triclosan) may disrupt hormonal balance and contribute to the development of PCOS. A majority of PCOS patients also meet the criteria for metabolic syndrome, which includes high blood pressure, abnormal cholesterol levels, and glucose intolerance. The shared link—insulin resistance makes PCOS a condition requiring long-term, multidisciplinary management._10,11

Adipose (fat) tissue dysfunction also plays a key role in PCOS by promoting inflammation, androgen excess, and insulin resistance. Genetic, environmental, and epigenetic factors influence these pathways, reinforcing the need to view PCOS as a lifelong metabolic and endocrine disorder.₁₂

Recently, natural compounds like myo-inositol (MI) and D-chiro-inositol (DCI) have shown promise in improving insulin sensitivity and restoring ovulation. These may serve as safer or complementary alternatives to standard treatments like metformin.₁₃

In summary, PCOS is a multisystem disorder that affects women well beyond fertility. Early diagnosis, individualized treatment, and continuous care are essential to reduce the risk of long-term complications. Addressing both medical and emotional aspects of the disorder will lead to more effective and compassionate healthcare.₁₄

Female Reproductive System: Anatomy and Physiology

The female reproductive system is a highly specialized group of organs that work in coordination to ensure the processes of sexual reproduction, menstruation, fertilization, pregnancy, and childbirth. It consists of distinct external and internal anatomical structures, each with unique physiological roles, all under the control of a finely regulated hormonal system.

Fig No. Internal Structure of ovary

Anatomy Overview

The external genitalia, collectively called the vulva, provide protection for the internal organs and play a key role in sexual arousal and lubrication. These include:

• Mons pubis: A fatty tissue layer that cushions the pubic bone.
• Labia majora and labia minora: Skin folds that protect the vaginal and urethral openings.
• Clitoris: A highly sensitive erectile organ involved in sexual stimulation.
• Vestibule: Contains the vaginal and urethral openings as well as the Bartholin’s glands, which secrete lubricating mucus.

The internal reproductive organs include:

• Vagina: A muscular, elastic canal that serves as the passageway for menstrual flow, intercourse, and childbirth.
• Uterus: A pear-shaped muscular organ where a fertilized egg implants and a fetus develops. It consists of the fundus (top), body (middle), and cervix (lower part that connects to the vagina).
• Fallopian tubes: Tubes that transport eggs from the ovaries to the uterus. Fertilization typically occurs here. Fimbriae at the ends help capture the ovum.
• Ovaries: Small, oval-shaped glands that produce ova (eggs) and secrete the female sex hormones estrogen and progesterone.

Physiology Overview

The physiological functions of the female reproductive system are governed by a monthly menstrual cycle, typically lasting around 28 days, and controlled by a complex hormonal feedback loop involving the hypothalamus, pituitary gland, and ovaries.

1. Menstrual Cycle Phases

• Menstrual Phase (Days 1–5): Shedding of the uterine lining (endometrium) through the vagina.
• Follicular Phase (Days 1–13): Stimulated by FSH (follicle-stimulating hormone), ovarian follicles grow and produce estrogen, which helps regenerate the endometrial lining.
• Ovulation (Day 14): A surge in LH (luteinizing hormone) causes the release of a mature egg from the ovary.
• Luteal Phase (Days 15–28): The ruptured follicle forms the corpus luteum, which secretes progesterone to maintain the endometrium. If no fertilization occurs, hormone levels drop, leading to menstruation.

2. Hormonal Regulation

The cycle is regulated by a hierarchical hormonal control system:

• Hypothalamus secretes GnRH (Gonadotropin-Releasing Hormone).
• Anterior pituitary gland releases FSH and LH in response.
• Ovaries produce estrogen and progesterone, which regulate endometrial changes, ovulation, and development of secondary sexual characteristics.

3. Fertilization and Pregnancy

• Fertilization typically occurs in the fallopian tube when sperm meets the ovum.
• The resulting zygote travels to the uterus and implants into the endometrial lining within 6–10 days.
• The hormone HCG (human chorionic gonadotropin), produced by the early embryo, maintains the corpus luteum and supports early pregnancy._15,16,17

PCOS (POLYCYSTIC OVARY SYNDROME):

Polycystic Ovary Syndrome (PCOS) is a prevalent endocrine disorder affecting women, particularly during their reproductive years. Epidemiological studies estimate that PCOS affects approximately 10–15% of women of reproductive age, with at least 7% of infertile women exhibiting clinical features of the syndrome. PCOS is recognized as a heterogeneous disorder characterized by a range of clinical manifestations that vary significantly among individuals.

Fig No. 2 polycystic ovary

Mechanism of Action of PCOS

Polycystic Ovary Syndrome (PCOS) develops through a multifaceted interaction of genetic, epigenetic, and environmental factors that disrupt normal hormonal homeostasis. A central hormonal abnormality in PCOS is an increased luteinizing hormone (LH) to follicle-stimulating hormone (FSH) ratio, which contributes to anovulation and heightened androgen production.

This hormonal imbalance also dysregulates the hypothalamic-pituitary-adrenal (HPA) axis, heightening the body's stress response and increasing susceptibility to mood disorders such as anxiety and depression.

Insulin resistance is another key pathological feature of PCOS. Despite elevated insulin production (hyperinsulinemia), peripheral tissues such as skeletal muscle and adipose tissue exhibit decreased sensitivity to insulin. This resistance stimulates further insulin secretion, creating a self-perpetuating cycle. Elevated insulin levels suppress hepatic production of sex hormone-binding globulin (SHBG), leading to increased levels of free circulating androgens. These androgens not only exacerbate insulin resistance but also drive the clinical manifestations of hyperandrogenism such as acne, hirsutism, and oligomenorrhea.

Thus, PCOS is a systemic condition marked by a feedback loop where hormonal and metabolic disturbances mutually reinforce one another, making the condition challenging to manage without a multifactorial treatment strategy._18,19,20

Clinical Features and Pathophysiology

PCOS is commonly associated with a triad of symptoms:

• Ovulatory dysfunction (e.g., irregular or absent menstrual cycles)
• Hyperandrogenism (e.g., hirsutism, acne, and androgenic alopecia)
• Polycystic ovarian morphology (as seen on ultrasound)

Insulin resistance is a central feature in many PCOS cases and is implicated in both the reproductive and metabolic abnormalities observed. This insulin resistance may lead to metabolic syndrome, a cluster of conditions—including abdominal obesity, dyslipidemia, hypertension, and glucose intolerance—that significantly elevate the risk of type 2 diabetes and cardiovascular disease. Although obesity exacerbates the clinical manifestations of PCOS, it is important to note that the syndrome also affects lean women, underscoring its multifactorial etiology.

Impact on Health and Quality of Life

Beyond reproductive implications such as infertility, PCOS can severely affect psychological well-being and long-term health outcomes. Mood disorders, including anxiety and depression, are more prevalent in women with PCOS. The chronic nature of the condition necessitates long-term management strategies to reduce both immediate and future risks.

Therapeutic Approaches

Currently, there is no definitive cure for PCOS; however, several therapeutic interventions are effective in managing its symptoms and associated comorbidities:

• Ovulation Induction: First-line pharmacologic treatment for anovulatory infertility is Clomiphene Citrate (CC). In CC-resistant cases, alternatives include gonadotropins, laparoscopic ovarian drilling, recombinant FSH (rFSH), or GnRH agonists.
• Management of Hyperandrogenism: Combined oral contraceptives are commonly used to reduce androgen levels. Other options include GnRH analogues and anti-androgens such as spironolactone and finasteride.
• Insulin Sensitization: Metformin, an insulin-sensitizing agent, improves insulin resistance and may help regulate menstrual cycles and promote ovulation.
• Lifestyle Modification: A cornerstone of PCOS management is sustained lifestyle intervention. Regular physical activity and a balanced diet have been shown to improve insulin sensitivity, aid in weight management, and reduce long-term cardiovascular risks.₂₁

Risk Factors of Polycystic Ovary Syndrome (PCOS)

Polycystic Ovary Syndrome (PCOS) is a multifaceted endocrine and metabolic disorder arising from the interplay of genetic, hormonal, metabolic, environmental, and psychological factors. Understanding the risk landscape is critical for early diagnosis, individualized management, and improved long-term outcomes.

Non-Genetic Factors

Environmental Toxins - Exposure to environmental toxins particularly endocrine-disrupting chemicals (EDCs) has been implicated in the pathogenesis of PCOS. These compounds, which include industrial pollutants, tobacco smoke, heavy metals (e.g., lead, mercury), and agricultural pesticides, disrupt endocrine homeostasis by mimicking or blocking hormonal signalling. Entry into the human body occurs via inhalation, dermal contact, or ingestion, ultimately affecting hormone receptor sensitivity and synthesis pathways, thereby exacerbating reproductive and metabolic abnormalities associated with PCOS.

Obesity and Dietary Patterns Obesity is a well-established risk factor that not only contributes to the onset of PCOS but also amplifies its clinical severity. Excess adiposity, especially visceral fat, exacerbates hyperandrogenism, insulin resistance, hirsutism, and menstrual irregularities. Modern sedentary lifestyles combined with energy-dense, nutrient-poor diets play a critical role in weight gain, metabolic dysregulation, and reproductive dysfunction. Even in non-obese individuals, unhealthy dietary patterns and poor physical activity levels can independently contribute to metabolic and reproductive manifestations of PCOS.

Genetic Factors

PCOS has a strong familial component, suggesting a heritable predisposition. Genome-wide association studies (GWAS) have identified several susceptibility genes, particularly those involved in steroidogenesis, insulin signalling, and gonadotropin action.

• Variants in the CYP11A1 and androgen receptor (AR) genes are linked to increased androgen biosynthesis.
• Alterations in the SHBG (Sex Hormone-Binding Globulin) gene may influence the bioavailability and action of circulating androgens.

Women with a first-degree relative diagnosed with PCOS are significantly more likely to develop the disorder, highlighting the importance of genetic screening in at-risk populations. A deeper understanding of these genetic contributors paves the way for targeted and precision-based interventions.

Hormonal Dysregulation

PCOS is fundamentally characterized by hyperandrogenism, often evidenced by elevated serum testosterone, 17-hydroxyprogesterone, and a raised Free Androgen Index (FAI). A hallmark of the condition is an elevated LH:FSH ratio, which disrupts normal folliculogenesis and ovulatory processes, leading to anovulation and polycystic ovarian morphology.

Additionally, insulin resistance (IR)present in up to 70% of women with PCOS contributes to hyperinsulinemia, which in turn:

• Stimulates ovarian androgen production,
• Reduces SHBG synthesis by the liver, increasing free androgens,
• Promotes adipocyte-derived inflammatory cytokines that exacerbate IR.

This complex endocrine dysfunction lies at the core of PCOS pathophysiology and contributes to its reproductive and metabolic sequelae.

Psychosocial and Emotional Factors

Emotional Disturbance

Psychological distress, including chronic stress, anxiety, and depression, has emerged as a significant modifiable risk factor in the onset and progression of PCOS. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis due to prolonged psychological stress can impair gonadotropin-releasing hormone (GnRH) pulsatility, exacerbating menstrual irregularities and hormonal imbalance.

The bidirectional relationship between emotional health and PCOS creates a self-perpetuating cycle whereby PCOS symptoms contribute to emotional disturbance, which in turn worsens endocrine function and metabolic health.

Stress, Anxiety, and Depression

Numerous studies have highlighted higher incidences of anxiety disorders, depression, mood instability, and sleep disturbances among women with PCOS. These conditions may arise secondary to poor self-image (due to acne, hirsutism, or infertility), but also act as contributing factors via neuroendocrine modulation particularly elevated cortisol levels which further disrupt insulin and androgen balance.

Holistic management strategies should therefore encompass mental health interventions alongside endocrine therapies to break this cycle and improve overall patient outcomes.

Family History

A positive family history especially among first-degree female relatives is a strong risk factor for developing PCOS. Familial aggregation suggests that hereditary and epigenetic mechanisms play a significant role in disease etiology. Studies report that daughters and sisters of affected individuals often share phenotypic traits such as irregular menstruation, insulin resistance, and hyperandrogenism.

Understanding familial patterns can facilitate early screening, risk stratification, and preventive lifestyle counselling in genetically predisposed populations.

Lifestyle Factors

Lifestyle behaviours, including poor nutrition, lack of exercise, smoking, and irregular sleep patterns, contribute significantly to the development and exacerbation of PCOS symptoms. Specific risk behaviours include:

• Diets high in saturated fats, refined sugars, and processed foods,
• Low intake of dietary fiber and micronutrients,
• Physical inactivity and sedentary routines,
• Smoking and sleep apnea (often associated with snoring), which may aggravate metabolic syndrome components.

Given the modifiable nature of these factors, structured lifestyle interventions focused on weight management, exercise, and dietary optimization are cornerstones of PCOS management and prevention._22,23

Clinical Diagnosis of PCOS

Diagnosing PCOS requires a comprehensive evaluation since no single test is definitive. The widely accepted Rotterdam criteria require the presence of at least two of the following three features:

1. Oligomenorrhea or Amenorrhea: Irregular or absent menstrual cycles, typically fewer than 9 periods per year or absence of menstruation for more than 3 months.
2. Clinical and/or Biochemical Hyperandrogenism: Manifestations include hirsutism, acne, androgenic alopecia, or elevated serum androgen levels.
3. Polycystic Ovarian Morphology (PCOM): Detected via transabdominal or transvaginal ultrasound, characterized by ≥12 follicles measuring 2–9 mm in diameter or increased ovarian volume (>10 mL).

To rule out other endocrine disorders and confirm the diagnosis, a PCOD panel is commonly performed, which includes testing levels of LH, FSH, TSH, Prolactin, and androgens (Testosterone, DHEAS, SHBG).

• Ultrasound: A transabdominal ultrasound is often the first imaging method used. In virginal or young patients, transvaginal ultrasound is avoided unless clinically necessary.
• Laparoscopy: In ambiguous cases or when surgical intervention is required, laparoscopy allows direct visualization and can be used for ovarian drilling or other corrective procedures.

Vitamin D deficiency, commonly observed in PCOS patients, may worsen clinical outcomes. Hence, screening for serum 25(OH)D levels is also recommended.

Early and accurate diagnosis is essential for preventing long-term complications such as infertility, metabolic syndrome, type 2 diabetes, and cardiovascular disease._24,25

Scientific Studies Supporting Allopathic Approaches in PCOS

The following table highlights selected studies involving both human and animal models that demonstrate the efficacy of conventional treatments in PCOS:

These studies highlight the importance of both clinical and preclinical models in understanding the pharmacodynamics, therapeutic effectiveness, and systemic impact of conventional drugs on PCOS-related pathophysiology._26,27,28,29

Treatment of PCOS

While PCOS is considered a chronic, incurable condition, its symptoms and long-term risks can be effectively managed through lifestyle modification, pharmacological therapy, and nutritional supplementation.

1. Lifestyle Management

Lifestyle intervention is the first-line approach, especially for overweight or obese patients:

• Weight Management: A modest weight loss of 5–10% can restore ovulatory cycles, reduce androgen levels, and improve insulin sensitivity.
• Balanced Diet: A low glycemic index (GI), anti-inflammatory diet rich in whole grains, vegetables, lean proteins, and healthy fats helps regulate insulin and androgen levels.
• Physical Activity: Regular aerobic and resistance exercises improve metabolic and cardiovascular health, reduce insulin resistance, and enhance psychological well-being.
• Sleep Hygiene & Stress Reduction: Quality sleep and stress management through yoga, mindfulness, or therapy support hormonal regulation and mental health.

2. Pharmacological Interventions

• Oral Contraceptive Pills (OCPs): Used to regulate menstrual cycles and reduce hyperandrogenism.
• Insulin Sensitizers (e.g., Metformin): Improve insulin resistance, regulate ovulation, and help with weight management.
• Anti-androgens (e.g., Spironolactone): Help treat hirsutism and acne when OCPs are insufficient.
• Ovulation Induction Agents (e.g., Letrozole, Clomiphene): Used in women trying to conceive.

3. Nutritional Supplementation

• Vitamin D: Correcting deficiency may improve insulin sensitivity and reproductive outcomes.
• Omega-3 Fatty Acids: Shown to reduce androgen levels and inflammation.
• Inositol (Myo- and D-chiro-inositol): Supports ovarian function and improves insulin sensitivity.

4. Behavioural and Supportive Therapies

Psychological counselling and support groups may benefit those suffering from anxiety, depression, or body image issues due to PCOS._30,31,32,33

Allopathic Treatment of Polycystic Ovary Syndrome (PCOS)

Allopathic or conventional medicine is one of the most widely used and evidence-based approaches for managing Polycystic Ovary Syndrome (PCOS). The goal of treatment is typically symptom-specific, addressing issues such as irregular ovulation, insulin resistance, hyperandrogenism, and associated metabolic dysfunctions.

Allopathic treatments remain an essential part of PCOS management, particularly for symptom control and fertility enhancement. However, patient-centered care that integrates pharmaceutical therapy with lifestyle changes and alternative remedies may offer the most balanced and effective approach for long-term health and quality of life in women with PCOS.

Allopathic medications are often prescribed as part of a comprehensive management plan that includes lifestyle modifications, dietary changes, and regular follow-up.

Commonly Prescribed Allopathic Medications

Limitations of Allopathic Therapy

While effective, conventional pharmacotherapy may be associated with:

• Side effects (e.g., gastrointestinal discomfort with metformin, ovarian hyperstimulation with clomiphene)
• Contraindications in certain populations (e.g., liver dysfunction with troglitazone)
• Need for long-term medication adherence
• Limited impact on root causes such as lifestyle and stress_34,35,36

Use of Herbal Drugs in the Management of Polycystic Ovary Syndrome (PCOS)_37,38,39,40

Polycystic Ovary Syndrome (PCOS) is a common endocrine disorder affecting women of reproductive age. While conventional medications such as hormonal contraceptives, metformin, and anti-androgens are widely used, many patients seek alternative therapies due to concerns about side effects and long-term use. Herbal medicines, derived from traditional systems like Ayurveda and Unani, are increasingly popular for their perceived safety, affordability, and holistic action on hormonal regulation, metabolism, and reproductive function.

Several medicinal plants have shown promising effects in reducing PCOS symptoms such as irregular menstruation, insulin resistance, obesity, and ovarian cysts. The table below summarizes key herbs commonly used in traditional medicine systems for PCOS management:

Table no.1 Use of Herbal Drugs in (PCOS)