Polycystic ovary syndrome

Polycystic Ovary Syndrome (Polycystic Ovary Syndrome, PCOS)

1) Disease Description (Causes and Symptoms)

• Core pathophysiology: Dysfunction of the hypothalamic-pituitary-ovarian (HPO) axis combined with insulin resistance/hyperinsulinemia and hyperandrogenemia causes chronic anovulation or oligo-ovulation. Polycystic ovarian morphology on ultrasound may also be present.
• Main causes (multifactorial): Genetic predisposition + insulin resistance, androgen excess, and abnormal hormone secretion (not a single cause).
• Main symptoms: Menstrual abnormalities (irregular menstruation due to amenorrhea, oligomenorrhea, or anovulation), infertility, hirsutism, acne, weight gain (central obesity), pruritus, abnormal vaginal bleeding, etc.
• Risk of complications: Type 2 diabetes and insulin resistance, metabolic syndrome, obesity, increased risk of cardiovascular disease, and increased risk of endometrial hyperplasia and, in the long term, endometrial cancer.
• Key diagnostic points: Rotterdam criteria — at least 2 of the following 3 criteria: 1) Oligo/anovulation, 2) Clinical or biochemical evidence of hyperandrogenism (hirsutism/male-pattern hair loss/elevated blood testosterone), 3) Polycystic ovarian morphology on ultrasound. Other causes (thyroid disease, hyperprolactinemia, nonclassic congenital adrenal hyperplasia, Cushing syndrome, androgen-secreting tumors, etc.) must be excluded.

2) Treatment Methods (Standard Treatment · Medications · Procedures/Surgery · Lifestyle Management · Precautions)

• Lifestyle management (first-line treatment): Weight loss (a 5–10% reduction in body weight may improve menstruation and ovulation), regular exercise, and dietary modification (a low-calorie, low-refined-carbohydrate diet is recommended). Lifestyle intervention aimed at improving underlying metabolic and cardiovascular risks is essential.
• Medication treatment
  • Menstrual regulation and management of hyperandrogenic symptoms: Combined oral contraceptives (COCs) are the first-line choice (induce cyclic bleeding and suppress androgens). Spironolactone (an antiandrogen) may additionally be used (contraindicated during pregnancy).
  • Improvement of insulin resistance: Metformin — improves weight and metabolic parameters and may help regulate menstruation in some patients. It is not a direct first-line ovulation-induction drug as a conventional infertility treatment.
  • Ovulation induction (when pregnancy is desired): Letrozole (an aromatase inhibitor) is currently recommended as first-line therapy (with a higher pregnancy achievement rate than clomiphene). Clomiphene citrate is used as an alternative or in combination. Gonadotropin stimulation therapy (follicle-stimulating hormone) or in vitro fertilization (IVF) are second- or third-line options.
  • Management of endometrial hyperplasia and cancer risk: Protect the endometrium with progestins (given cyclically or through an LNG-IUS (Mirena)).
  • Topical treatment: Topical medications for acne and hirsutism (retinoids, antibiotics) and hair-removal procedures (hair removal, laser treatment), etc.
• Procedures/Surgery: Ovarian drilling is used rarely (when medication treatment fails). Assisted reproductive technology (IVF) may be considered.
• Monitoring/Testing: Regular testing of glycated hemoglobin, OGTT, lipids, blood pressure, weight, and endometrial thickness (in cases of prolonged amenorrhea) is recommended.
• Precautions
  • Spironolactone, retinoids, statins, etc. are contraindicated during pregnancy, and pregnancy plans should be confirmed in women of childbearing age.
  • Prolonged amenorrhea increases the risk of endometrial hyperplasia and cancer → endometrial evaluation is necessary.
  • Check for medication side effects (vomiting, headache, risk of thrombosis, etc.) and drug interactions.

3) Checklist Before an Outpatient Visit (Including Items to Bring · Example Questions)

• Items/materials to bring
  • List of recently used medications/supplements (including dosage and time of administration)
  • Copies of recent test results (hormone tests, blood glucose and lipid tests, pelvic ultrasound, etc.)
  • Menstrual history (the past 6–12 months), records of weight changes, and temperature records (if basal body temperature has been monitored)
  • Whether pregnancy is desired and whether contraception is being used
  • Family history (diabetes, PCOS, infertility, cardiovascular disease)
  • Photographs of the skin and body hair (hirsutism) (helpful for medical evaluation)
  • Body measurements (if possible, recent weight, height, and waist circumference)
• Information to tell the healthcare provider in advance at the outpatient visit (example questions)
  • “How has your recent menstrual cycle changed?” / “When was the first day of your last menstrual period?”
  • “Do you want to become pregnant?” / “Are you currently using contraception?”
  • “Are you taking spironolactone, metformin, or birth control pills?”
  • “How have your weight changes or the progression of your body hair and acne changed over time?”

4) Examples of General Questions to Ask the Doctor

• What are the main side effects of this medication (e.g., oral contraceptives, spironolactone, or metformin)?
• What is the prognosis for my symptoms (irregular menstruation, hirsutism, and infertility)?
• What tests should I have, and how often, to reduce my risk of diabetes or cardiovascular disease?
• What is the safest and most effective approach when planning a pregnancy?

5) Examples of Condition-Specific Questions (1–2)

• I want to become pregnant. Which medication is currently recommended as first-line therapy for ovulation induction (letrozole vs. clomiphene), and what are the expected recovery period and success rate?
• I have had prolonged amenorrhea. Is an evaluation of the endometrium (thickness) necessary? Which progestin regimen do you recommend to protect the endometrium?

(The choice of diagnosis and treatment varies depending on the individual’s symptoms, test results, desire for pregnancy, and underlying conditions. Please determine an accurate evaluation and treatment plan in consultation with a healthcare provider.)