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Polycystic ovary syndrome (PCOS) is a complex endocrine and metabolic condition. Although global prevalence rates vary due to factors such as differing diagnostic criteria and substantial geographic differences in medical care access and health education, this disorder is estimated to affect 4 to 20% of reproductive-age women worldwide.¹ In the United States, prevalence is estimated up to 12%,² and recent reporting indicates the economic burden of PCOS is approximately $8 billion annually in 2020 USD when combining costs for both  immediate and long-term health complications.³

Despite being a common hormone disorder in women of reproductive age, the variation in PCOS phenotypes and symptomology often leads to delayed or underdiagnosis.^4,5 Reports also indicate that the clinical phenotype of PCOS shows a wide variation depending on a patient’s race and ethnicity.^1,6,7 In addition, some patients who receive a PCOS diagnosis report a high level of dissatisfaction with their health care. In one survey of primarily non-Hispanic white women between the ages of 18 and 35 (n=759) who received a PCOS diagnosis, 57.3% were dissatisfied with overall care, with 98.2% searching for additional PCOS information on the internet.⁴ And unfortunately, not all patients experiencing PCOS symptoms seek care, potentially unaware that treatments, including lifestyle approaches, may provide some symptom relief.

PCOS Health Risks

PCOS has been associated with chronic inflammation,^8,9 insulin resistance,¹⁰ and an overall increase in health risks. Common comorbidities include infertility, hypertension, type 2 diabetes, depression, anxiety, sleep apnea, menstrual irregularities, and more.^10,11 A 2020 systematic review of 23 cohort studies found that in addition to an increased risk of hypertension and type 2 diabetes, women with PCOS also showed higher serum concentrations of total cholesterol, lower serum concentrations of high-density lipoprotein-C, and increased risks of non-fatal cerebrovascular disease events compared to women without PCOS.¹² Women with PCOS are also more likely to have anxiety or depression,¹³ even when compared with controls with the same BMI.¹⁴ Additional studies suggest an association between PCOS and metabolic syndrome in adolescents, with those adolescents with PCOS showing three times greater odds of having metabolic syndrome compared to controls.¹⁵

Diagnosis & Treatment Approaches

Early PCOS diagnosis and personalized treatments may substantially help to reduce long-term health impacts, and in a primary care practice, patients with this condition are common. One national estimate reported a mean yearly rate of over 500,000 PCOS-related visits among women ages 11 to 60.¹⁶

Where would you start if Joelle, a 25-year-old female, came to you reporting years of cystic acne and irregular and painful periods? What if that patient also had an elevated BMI with high abdominal adiposity, elevated testosterone, prediabetes, and a single cyst found in a pelvic ultrasound? Functional medicine offers effective tools to help organize a patient’s health story and diagnose and personalize interventions. As an example, for Joelle, a comprehensive functional medicine physical exam is one tool that may aid in an accurate diagnosis, as acanthosis nigricans and hirsutism are common physical findings in patients with PCOS.Expand your physical exam skills

Recent clinical trials continue to show that lifestyle modifications, including diet and exercise, help patients with PCOS alleviate some PCOS symptoms and may help reduce ongoing health risks by improving metabolic profiles.^17,18 A recent Cochrane review also concluded that lifestyle interventions may improve androgen levels and reduce weight and BMI in women with PCOS.¹⁹ A 2021 meta-analysis that included 11 clinical trials found that both aerobic and resistance training interventions for women with PCOS demonstrated significant improvements in depression and anxiety symptoms in addition to positive improvements in their health-related quality of life.²⁰

Other interventions and approaches such as traditional Chinese medicine and acupuncture continue to show promise as adjunctive treatments for PCOS.²¹ While further large-scale trials are still needed, a 2020 meta-analysis of 10 randomized controlled trials (n=737 patients with PCOS) showed significant decreases in BMI and waist to hip ratio in the acupuncture treatment groups compared to controls, in addition to significant improvements in fasting plasma glucose, insulin sensitivity, and triglyceride measurements.²²

Accurate diagnosis followed by multimodal interventions may not only help patients like Joelle with immediate concerns but also help to improve their health in the long-term. Learn more about the complexities of hormonal balance and creating effective and personalized treatment approaches for your patients at IFM’s Hormone Advanced Practice Module (APM).

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References

1. Deswal R, Narwal V, Dang A, Pundir C. The prevalence of polycystic ovary syndrome: a brief systematic review. J Hum Reprod Sci. 2020;13(4):261-271. doi:10.4103/jhrs.JHRS_95_18.
2. PCOS (polycystic ovary syndrome) and diabetes. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/basics/pcos.html#:~:text=PCOS%20is%20one%20of%20the,US%20women%20of%20reproductive%20age. . Reviewed March 24, 2020. Accessed February 22, 2022.
3. Riestenberg C, Jagasia A, Markovic D, Buyalos RP, Azziz R. Health care-related economic burden of polycystic ovary syndrome in the United States: pregnancy-related and long-term health consequences. J Clin Endocrinol Metab. 2022;107(2):575-585. doi:10.1210/clinem/dgab613.
4. Hoyos LR, Putra M, Armstrong AA, et al. Measures of patient dissatisfaction with health care in polycystic ovary syndrome: retrospective analysis. J Med Internet Res. 2020;22(4):E16541. doi:10.2196/16541.
5. Al Wattar BH, Fisher M, Bevington L, et al. Clinical practice guidelines on the diagnosis and management of polycystic ovary syndrome: a systematic review and quality assessment study. J Clin Endocrinol Metab. 2021;106(8):2436-2446. doi:10.1210/clinem/dgab232.
6. Engmann L, Jin S, Sun F, et al. Racial and ethnic differences in the polycystic ovary syndrome metabolic phenotype. Am J Obstet Gynecol. 2017;216(5):493. doi:10.1016/j.ajog.2017.01.003.
7. Sendur SN, Yildiz BO. Influence of ethnicity on different aspects of polycystic ovary syndrome: a systematic review. Reprod Biomed Online. 2021;42(4):799-818. doi:10.1016/j.rbmo.2020.12.006.
8. Aboeldalyl S, James C, Seyam E, Ibrahim EM, Shawki HE-D, Amer S. The role of chronic inflammation in polycystic ovarian syndrome-a systematic review and meta-analysis. Int J Mol Sci. 2021;22(5):2734. doi:10.3390/ijms22052734.
9. Abraham Gnanadass S, Divakar Prabhu Y, Valsala Gopalakrishnan A. Association of metabolic and inflammatory markers with polycystic ovarian syndrome (PCOS): an update. Arch Gynecol Obstet. 2021;303(3):631-643. doi:10.1007/s00404-020-05951-2.
10.  Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2013;6(1):1-13. doi:10.2147/CLEP.S37559.
11.  Sirmans SM, Parish RC, Blake S, Wang X. Epidemiology and comorbidities of polycystic ovary syndrome in an indigent population. J Investig Med. 2014;62(6):868-874. doi:10.1097/01.JIM.0000446834.90599.5d.
12.  Wekker V, van Dammen L, Koning A, et al. Long-term cardiometabolic disease risk in women with PCOS: a systematic review and meta-analysis. Hum Reprod Update. 2020;26(6):942-960. doi:10.1093/humupd/dmaa029.
13.  Wang Y, Ni Z, Li K. The prevalence of anxiety and depression of different severity in women with polycystic ovary syndrome: a meta-analysis. Gynecol Endocrinol. 2021;37(12):1072-1078. doi:10.1080/09513590.2021.1942452.
14.  Cooney LG, Lee I, Sammel MD, Dokras A. High prevalence of moderate and severe depressive and anxiety symptoms in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod. 2017;32(5):1075-1091. doi:10.1093/humrep/dex044.
15.  Fu L, Xie N, Qu F, Zhou J, Wang F. The association between polycystic ovary syndrome and metabolic syndrome in adolescents: a systematic review and meta-analysis. Reprod Sci. Published online February 2, 2022. doi:10.1007/s43032-022-00864-8.
16.  Sanchez N. Suitability of the national health care surveys to examine behavioral health services associated with polycystic ovary syndrome. J Behav Health Serv Res. 2018;45(2):252-268. doi:10.1007/s11414-016-9543-6.
17.  Kazemi M, McBreairty LE, Chizen DR, Pierson RA, Chilibeck PD, Zello GA. A comparison of a pulse-based diet and the therapeutic lifestyle changes diet in combination with exercise and health counselling on the cardio-metabolic risk profile in women with polycystic ovary syndrome: a randomized controlled trial. Nutrients. 2018;10(10):E1387. doi:10.3390/nu10101387.
18.  Dietz de Loos ALP, Jiskoot G, Timman R, Beerthuizen A, Busschbach JJV, Laven JSE. Improvements in PCOS characteristics and phenotype severity during a randomized controlled lifestyle intervention. Reprod Biomed Online. 2021;43(2):298-309. doi:10.1016/j.rbmo.2021.05.008.
19.  Lim SS, Hutchison SK, Van Ryswyk E, Norman RJ, Teede HJ, Moran LJ. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev. 2019;3(3):CD007506. doi:10.1002/14651858.CD007506.pub4.
20.  Patten RK, Pascoe MC, Moreno-Asso A, Boyle RA, Stepto NK, Parker AG. Effectiveness of exercise interventions on mental health and health-related quality of life in women with polycystic ovary syndrome: a systematic review. BMC Public Health. 2020;21(1):2310. doi:10.1186/s12889-021-12280-9.
21.  Hu J, Shi W, Xu J, et al. Complementary and alternative medicine for the treatment of abnormal endometrial conditions in women with PCOS: a systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med. 2021;2021:5536849. doi:10.1155/2021/5536849.
22.  Zheng R, Qing P, Han M, et al. The effect of acupuncture on glucose metabolism and lipid profiles in patients with PCOS: a systematic review and meta-analysis of randomized controlled trials. Evid Based Complement Alternat Med. 2021;2021:5555028. doi:10.1155/2021/5555028.