Overview
Recognizing the Clinical Pattern
A 27 year old reports cycles every 45 to 60 days, progressive facial hair, and acne.
A 27-year-old reports cycles every 45 to 60 days, progressive facial hair, and acne. Her pelvic ultrasound shows increased follicle number, but the scan does not diagnose PCOS by itself. The diagnosis depends on the combination of findings and the exclusion of conditions that can imitate them. Polycystic ovary syndrome is a heterogeneous endocrine disorder. Its clinical expression may be dominated by irregular ovulation, androgen excess, metabolic risk, or several of these together. Ovarian morphology is neither necessary nor sufficient in every adult. The underlying physiology helps explain the pattern. Altered gonadotropin-releasing hormone pulsatility may produce relatively increased luteinizing hormone signalling, while ovarian and adrenal androgen production rises. Insulin resistance can lead to compensatory hyperinsulinaemia; insulin then further stimulates ovarian androgen production and suppresses hepatic sex hormone-binding globulin. The result is a larger free-androgen fraction. Follicular development stalls, ovulation becomes infrequent, and the endometrium may be exposed to prolonged unopposed oestrogen. The experienced clinician first clarifies the menstrual pattern and looks for the tempo of androgen symptoms. Gradual hirsutism, acne, and irregular cycles fit PCOS. Rapid virilization, marked voice change,...