polycystic ovary syndrome polycystic ovary syndrome polycystic ovary syndrome, or pcos, is the most common endocrine disorder in women of reproductive age. the syndrome is named after cysts which form on the ovaries of some people with this condition, though this is not a universal symptom, and not the underlying cause of the disorder. polycystic ovary syndromeother nameshyperandrogenic anovulation (ha), stein-leventhal syndromea polycystic ovaryspecialtygynecology, endocrinologysymptomsirregular menstrual periods, heavy periods, excess hair, acne, pelvic pain, difficulty getting pregnant, patches of thick, darker, velvety skincomplicationstype 2 diabetes, obesity, obstructive sleep apnea, heart disease, mood disorders, endometrial cancerdurationlong termcausesgenetic and environmental factorsrisk factorsobesity, not enough exercise, family historydiagnostic methodbased on anovulation, high androgen levels, ovarian cystsdifferential diagnosisadrenal hyperplasia, hypothyroidism, high blood levels of prolactintreatmentweight loss, exercisemedicationbirth control pills, metformin, anti-androgensfrequency2% to 20% of women of childbearing age women with pcos may experience irregular menstrual periods, heavy periods, excess hair, acne, pelvic pain, difficulty getting pregnant, and patches of thick, darker, velvety skin. the primary characteristics of this syndrome include: hyperandrogenism, anovulation, insulin resistance, and neuroendocrine disruption. a review of international evidence found that the prevalence of pcos could be as high as 26% among some populations, though ranges between 4% and 18% are reported for general populations. the exact cause of pcos remains uncertain, and treatment involves management of symptoms using medication. definition two definitions are commonly used: nih in 1990 a consensus workshop sponsored by the nih/nichd suggested that a person has pcos if they have all of the following: oligoovulation signs of androgen excess (clinical or biochemical) exclusion of other disorders that can result in menstrual irregularity and hyperandrogenism rotterdam in 2003 a consensus workshop sponsored by eshre/asrm in rotterdam indicated pcos to be present if any two out of three criteria are met, in the absence of other entities that might cause these findings: oligoovulation and/or anovulation excess androgen activity polycystic ovaries (by gynecologic ultrasound) the rotterdam definition is wider, including many more women, the most notable ones being women without androgen excess. critics say that findings obtained from the study of women with androgen excess cannot necessarily be extrapolated to women without androgen excess. androgen excess pcos society in 2006, the androgen excess pcos society suggested a tightening of the diagnostic criteria to all of the following: excess androgen activity oligoovulation/anovulation and/or polycystic ovaries exclusion of other entities that would cause excess androgen activity signs and symptoms signs and symptoms of pcos include irregular or no menstrual periods, heavy periods, excess body and facial hair, acne, pelvic pain, difficulty getting pregnant, and patches of thick, darker, velvety skin, ovarian cysts, enlarged ovaries, excess androgen, weight gain and hirsutism. associated conditions include type 2 diabetes, obesity, obstructive sleep apnea, heart disease, mood disorders, and endometrial cancer. further information: infertility in polycystic ovary syndrome common signs and symptoms of pcos include the following: menstrual disorders: pcos mostly produces oligomenorrhea (fewer than nine menstrual periods in a year) or amenorrhea (no menstrual periods for three or more consecutive months), but other types of menstrual disorders may also occur. infertility: this generally results directly from chronic anovulation (lack of ovulation). high levels of masculinizing hormones: known as hyperandrogenism, the most common signs are acne and hirsutism (male pattern of hair growth, such as on the chin or chest), but it may produce hypermenorrhea (heavy and prolonged menstrual periods), androgenic alopecia (increased hair thinning or diffuse hair loss), or other symptoms. approximately three-quarters of women with pcos (by the diagnostic criteria of nih/nichd 1990) have evidence of hyperandrogenemia. metabolic syndrome: this appears as a tendency towards central obesity and other symptoms associated with insulin resistance, including low energy levels and food cravings. serum insulin, insulin resistance, and homocysteine levels are higher in women with pcos. polycystic ovaries: ovaries might get enlarged and comprise follicles surrounding the eggs. as result, ovaries might fail to function regularly. this disease is related to the number of follicles per ovary each month growing from the average range of 6-8 to double, triple or more. women with pcos tend to have central obesity, but studies are conflicting as to whether visceral and subcutaneous abdominal fat is increased, unchanged, or decreased in women with pcos relative to non-pcos women with the same body mass index. in any case, androgens, such as testosterone, androstanolone (dihydrotestosterone), and nandrolone decanoate have been found to increase visceral fat deposition in both female animals and women. although 80% of pcos presents in women with obesity, 20% of women diagnosed with the disease are non-obese or "lean" women. however, obese women that have pcos have a higher risk of adverse outcomes, such as hypertension, insulin resistance, metabolic syndrome, and endometrial hyperplasia. even though most women with pcos are overweight or obese, it is important to acknowledge that non-overweight women can also be diagnosed with pcos. up to 30% of women diagnosed with pcos maintain a normal weight before and after diagnosis. "lean" women still face the various symptoms of pcos with the added challenges of having their symptoms properly addressed and recognized. lean women often go undiagnosed for years, and usually are diagnosed after struggles to conceive. lean women are likely to have a missed diagnosis of diabetes and cardiovascular disease. these women also have an increased risk of developing insulin resistance, despite not being overweight. lean women are often taken less seriously with their diagnosis of pcos, and also face challenges finding appropriate treatment options. this is because most treatment options are limited to approaches of losing weight and healthy dieting. hormone levels testosterone levels are usually elevated in women with pcos. in a 2020 systematic review and meta-analysis of sexual dysfunction related to pcos which included 5,366 women with pcos from 21 studies, testosterone levels were analyzed and were found to be 2.34 nmol/l (67 ng/dl) in women with pcos and 1.57 nmol/l (45 ng/dl) in women without pcos. in a 1995 study of 1,741 women with pcos, mean testosterone levels were 2.6 (1.1–4.8) nmol/l (75 (32–140) ng/dl). in a 1998 study which reviewed many studies and subjected them to meta-analysis, testosterone levels in women with pcos were 62 to 71 ng/dl (2.2–2.5 nmol/l) and testosterone levels in women without pcos were about 32 ng/dl (1.1 nmol/l). in a 2010 study of 596 women with pcos which used liquid chromatography–mass spectrometry (lc–ms) to quantify testosterone, median levels of testosterone were 41 and 47 ng/dl (with 25th–75th percentiles of 34–65 ng/dl and 27–58 ng/dl and ranges of 12–184 ng/dl and 1–205 ng/dl) via two different labs. if testosterone levels are above 100 to 200 ng/dl, per different sources, other possible causes of hyperandrogenism, such as congenital adrenal hyperplasia or an androgen-secreting tumor, may be present and should be excluded. associated conditions warning signs may include a change in appearance. but there are also manifestations of mental health problems, such as anxiety, depression, and eating disorders. a diagnosis of pcos suggests an increased risk of the following: endometrial hyperplasia and endometrial cancer (cancer of the uterine lining) are possible, due to overaccumulation of uterine lining, and also lack of progesterone, resulting in prolonged stimulation of uterine cells by estrogen. it is not clear whether this risk is directly due to the syndrome or from the associated obesity, hyperinsulinemia, and hyperandrogenism. insulin resistance/type 2 diabetes. a review published in 2010 concluded that women with pcos have an elevated prevalence of insulin resistance and type 2 diabetes, even when controlling for body mass index (bmi). pcos is also associated with higher risk for diabetes. high blood pressure, in particular if obese or during pregnancy depression and anxiety dyslipidemia – disorders of lipid metabolism – cholesterol and triglycerides. women with pcos show a decreased removal of atherosclerosis-inducing remnants, seemingly independent of insulin resistance/type 2 diabetes. cardiovascular disease, with a meta-analysis estimating a 2-fold risk of arterial disease for women with pcos relative to women without pcos, independent of bmi. strokes weight gain miscarriage sleep apnea, particularly if obesity is present non-alcoholic fatty liver disease, particularly if obesity is present acanthosis nigricans (patches of darkened skin under the arms, in the groin area, on the back of the neck) autoimmune thyroiditis the risk of ovarian cancer and breast cancer is not significantly increased overall. cause pcos is a heterogeneous disorder of uncertain cause. there is some evidence that it is a genetic disease. such evidence includes the familial clustering of cases, greater concordance in monozygotic compared with dizygotic twins and heritability of endocrine and metabolic features of pcos. there is some evidence that exposure to higher than typical levels of androgens and the anti-müllerian hormone (amh) in utero increases the risk of developing pcos in later life. it may be caused by a combination of genetic and environmental factors. risk factors include obesity, a lack of physical exercise, and a family history of someone with the condition. diagnosis is based on two of the following three findings: anovulation, high androgen levels, and ovarian cysts. cysts may be detectable by ultrasound. other conditions that produce similar symptoms include adrenal hyperplasia, hypothyroidism, and high blood levels of prolactin. genetics the genetic component appears to be inherited in an autosomal dominant fashion with high genetic penetrance but variable expressivity in females; this means that each child has a 50% chance of inheriting the predisposing genetic variant(s) from a parent, and, if a daughter receives the variant(s), the daughter will have the disease to some extent. the genetic variant(s) can be inherited from either the father or the mother, and can be passed along to both sons (who may be asymptomatic carriers or may have symptoms such as early baldness and/or excessive hair) and daughters, who will show signs of pcos. the phenotype appears to manifest itself at least partially via heightened androgen levels secreted by ovarian follicle theca cells from women with the allele. the exact gene affected has not yet been identified. in rare instances, single-gene mutations can give rise to the phenotype of the syndrome. current understanding of the pathogenesis of the syndrome suggests, however, that it is a complex multigenic disorder. due to the scarcity of large-scale screening studies, the prevalence of endometrial abnormalities in pcos remains unknown, though women with the condition may be at increased risk for endometrial hyperplasia and carcinoma as well as menstrual dysfunction and infertility. the severity of pcos symptoms appears to be largely determined by factors such as obesity. pcos has some aspects of a metabolic disorder, since its symptoms are partly reversible. even though considered as a gynecological problem, pcos consists of 28 clinical symptoms. even though the name suggests that the ovaries are central to disease pathology, cysts are a symptom instead of the cause of the disease. some symptoms of pcos will persist even if both ovaries are removed; the disease can appear even if cysts are absent. since its first description by stein and leventhal in 1935, the criteria of diagnosis, symptoms, and causative factors are subject to debate. gynecologists often see it as a gynecological problem, with the ovaries being the primary organ affected. however, recent insights show a multisystem disorder, with the primary problem lies in hormonal regulation in the hypothalamus, with the involvement of many organs. the term pcos is used due to the fact that there is a wide spectrum of symptoms possible. it is common to have polycystic ovaries without having pcos; approximately 20% of european women have polycystic ovaries, but most of those women do not have pcos. environment pcos may be related to or worsened by exposures during the prenatal period, epigenetic factors, environmental impacts (especially industrial endocrine disruptors, such as bisphenol a and certain drugs) and the increasing rates of obesity. endocrine disruptors are defined as chemicals that can interfere with the endocrine system by mimicking hormones such as estrogen. according to the nih (national institute of health), examples of endocrine disruptors can include dioxins and triclosan. endocrine disruptors can cause adverse health impacts in animals. additional research is needed to assess the role that endocrine disruptors may play in disrupting reproductive health in women and possibly triggering or exacerbating pcos and its related symptoms. pathogenesis polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of androgenic hormones, in particular testosterone, by either one or a combination of the following (almost certainly combined with genetic susceptibility): the