Review Paper

Polycystic Ovarian Disease or Polycystic Ovarian

Syndrome: How to Identify and Manage- A Review
Neha Minocha

School of Medical and Allied Sciences, K.R. Mangalam University, Sohna Road, Gurugram, Haryana, India.

Abstract
PCOD or PCOS is a reproductive and metabolic disorder concerned with the ovaries. An ovary is an active organ that changes its form,
appearance, and shape according to its hormonal ambiance. PCOD or PCOS is a condition in which ovary of women of childbearing age is
enlarged and starts producing an excessive amount of male hormones (androgens) and is the main cause of infertility, diabetes, irregular
menstrual periods, and hirsutism. No exact cause of the disease has been found yet but the change in lifestyle, change in dietary needs, lack
of exercise, and the most important of all, i.e. stress level induces the disease. There are medicines, which can induce an artificial menstrual
cycle and regulate the level of hormones and ultimately treat the three signs of PCOS i.e. Acne, Hirsutism, and Obesity.

Keywords: PCOD, PCOS, ovulatory dysfunction, hyperandrogenaemia, hirsutism

INTRODUCTION
PCO (Polycystic ovary) is a condition and PCOS
(Polycystic ovary syndrome) is a symptom [1, 2]. A pattern of
symptoms belonging to a particular disease is defined as a
syndrome [3]. Ovary of normal women who is in the age of
her reproductive years has a volume of around 4-6 ml of
each ovary and have a folded structure like a walnut, but if a
woman is diagnosed with PCOS, her ovaries get enlarged
and bulky with having more than 10 ml of volume, thus it
starts producing a high quantity of androgens [4-10].

Normal ovulating ovaries contain fluid-filled sacs called

follicles, with variations in size from 1 to 30 millimeters,
which depends on the phase of the menstrual cycle. The
individual sac or follicle contains a tiny egg, which never
matures enough to trigger ovulation. While in the polycystic Fig 2: Inside view of Polycystic ovaries
ovary, there are more than 12 small follicles, measuring 2 to
9 millimeters in diameter, and are usually arranged in a
‘pearl-necklace’ manner around the periphery [11]. So, as the Address for correspondence: Neha Minocha, , School of
name suggests, poly means many, in polycystic ovary Medical and Allied Sciences, K.R. Mangalam University,
syndrome there are many small cysts like sacs that are filled Sohna Road, Gurugram, Haryana, India.
with fluids and grown inside the ovaries and they do not Email: neha.minocha @ krmangalam.edu.in
need to be removed surgically.
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How to cite this article: Minocha, N. Polycystic Ovarian Disease or

Polycystic Ovarian Syndrome: How to Identify and Manage- A
Review. Arch Pharma Pract 2020;11(2):102-6.

Normal Ovary Polycystic Ovary

Fig 1: Normal & polycystic ovary

© 2020 Archives of Pharmacy Practice 1 102

 Neha Minocha et al.: Polycystic Ovarian Disease or Polycystic Ovarian Syndrome: How to Identify and Manage- A Review

Features also it was not recognized. In 1844, Chereau described the

The vital features of PCOS are excessive production of male sclerocystic changes in ovaries yet it was not recognized
hormones and having many cysts in the ovaries. However, a until Stein and Leventhal had comprehensive research on it
[13]
few common problems that women diagnosed with PCOS .
may include the following:
• Hirsutism: the presence of excess hair on the body In 1985, another research was carried out by Adams and his
• irregular or missing periods colleagues and they noticed polycystic ovaries with an
• heavy periods excessive number of follicles and termed that condition
• acne, oily skin, and other skin related problems multifollicularity. According to them, polycystic ovaries are
• hair loss and hair thinning from the scalp those in which there is the presence of more than 10 cysts
• insulin resistance having 2–8 mm diameter and are peripherally arranged [13].
• fertility problems
• body weight-related issues [3]. ETIOLOGY: The exact etiology of PCOS or PCOD is yet to
be explicated; nevertheless there is noticeable inherent
But these features do not rely on if a patient may have resistance towards insulin, even if the women are slender [14,
15]
polycystic ovaries or may have PCOS. In 2003, a meeting . Following hyperinsulinemia (increase in insulin level),
was held by experts and they revised their concern about the which increases the production of androgen; there is a
PCOS, which later on they get their work published in 2004, decrease in protein binding, which ultimately increases the
which concluded: ‘PCOS is a syndrome of ovarian level of free androgen. Due to the above-mentioned
dysfunction and its basic features include hyperandrogenism hormonal imbalance, there are noticeable alterations in the
and polycystic morphology’ [6]. appearance of the ovary, disturbing its function and hurts
fertility [16-19].
History
Polycystic ovaries were described as early as the 19th Insulin resistance concerning PCOS is further worsened by
century but it was not until 1935 that syndrome was obesity [20]. Obesity is having a two-directional relationship
identified and subsequently named for Stein and Leventhal, with PCOS, with women gaining weight regularly,
who first associated with amenorrhea, obesity, and hirsutism exacerbates PCOS occurrence and its severity. PCOS reacts
with polycystic ovaries in seven patients and thus PCOS well to exercise and having a change in the dietary plan,
syndrome was initially termed as Stein–Leventhal syndrome both of which reduce insulin resistance [16].
[12, 13]
.
Some features highlighted by findings that androgen
Before their research, dating back in 1721, young married secretion is stimulated by insulin via ovarian theca, which
women, infertile and moderately obese had their ovaries of suppresses (SHBG) sex hormone-binding globulin and, thus,
larger size and bulky than normal were identified but then enhances free circulating testosterone [12]. However, insulin
resistance is not considered a universal feature of PCOS [21].

Fig 3: The etiological, hormonal and clinical features of PCOS

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 Neha Minocha et al.: Polycystic Ovarian Disease or Polycystic Ovarian Syndrome: How to Identify and Manage- A Review

Pathophysiology Certain causes of disordered ovulation, hirsutism, and

As mentioned above, the fundamental pathophysiological acne are listed below:
defect concerning PCOS is not known, but some of the• Genetic
important features include resistance to insulin, excess• Nutritional
production of androgen, and transformed gonadotropin• Intrauterine
dynamics [22]. Organs that are affected by PCOS are a• Hormonal
woman’s ovaries, it is the reproductive organ through which• Fat, insulin, skin sensitivity [26].
estrogen and progesterone hormones are produced and
ultimately menstrual cycle is regulated. It is a myth that Diagnosis:
women do not need for male hormones but the fact is Since PCOS is a syndrome and cannot be diagnosed by
ovaries produce a negotiable amount of male hormones that single diagnostic criteria, it is identified by any two out of
we call as androgens. In PCOD, there are elevated levels of the following three clinical criteria, because women having
Luteinizing Hormone, which is three times higher than PCOD may have:
Follicle Stimulating Hormone, which ultimately leads to• Oligomenorrhoea (irregular or prolonged menstrual cycles)
increased production of testosterone by the ovaries leading
• Hyperandrogenism (excessive production of androgens)
to the growth of facial hair and acne [23].
• The polycystic appearance of the ovaries (multiple follicles
in the ovary)
It is also associated with an imbalance in glucose and insulin
dysfunction, which leads to obesity, diabetes, a rise in Oligomenorrhoea is a condition when there is a skip of more
cholesterol level, and an increase in blood pressure. Thus than 3 menstrual cycles or we can say that irregular
increased production of androgen blocks the ovulation menstrual cycle. There are several blood tests, which are
process and causes follicular atresia (Growth of follicles is done to check the menstrual irregularities and these are
arrested), before the pre-ovulatory phase. Also, if women levels of Luteinising Hormone (LH), Follicle Stimulating
take a diet, which is high in carbohydrate and fat content Hormone (FSH), TSH, and Prolactin, which is known as
then weight gain resulting from dietary plan seems to PCOD panel as all these laboratory tests are done under
exacerbate the signs of PCOS. Women having PCOD are at PCOD Panel. Hyperandrogenism is when there is excess
high risk of developing diabetes, cardiovascular diseases, production of androgens, which is exposed by acne, oily
infertility, and endometrial cancer [24, 25]. skin, and excess hair on the face, chest, and stomach [6, 16, 30].
While in some cases, women face hair thinning and
baldness, but it could be a sign of underactive thyroid,
Cause
malnutrition, iron or zinc deficiency, stress, sickness or a
No exact cause of PCOD or PCOS has been found yet, but
problem of PCOS also. Polycystic ovaries mean when there
yes there are certain points, which correlate the cause of
are several present small sized follicles around the periphery
PCOD and these are the patient’s family history (genetic),
or near the ovarian surface which is diagnosed by
her change in lifestyle, lack of daily routine exercise,
ultrasonography [11, 31]. If there is a reverse ratio of FSH: LH
changes in dietary habits, loss of work-life balance,
(3:1), then it may be PCOD. Endocrine features related to
exposure to environmental pollution, exposure to mobile
the diagnosis of PCOS include an elevated level of certain
phone radiations, and the most important of all is stress
[26] hormones like androgens, luteinizing hormone, prolactin,
. Stress levels in humans are increasing day by day and,
and estrogen [32]. A lowering of vitamin D level also
thus, it has now developed as one of the primary causes of
exacerbates PCOD [16].
PCOD, which can ultimately lead to a rise in blood
pressure (hypertension), diabetes mellitus (most
commonly Type-2 diabetes), increased risk of A doctor must be able to see the ovaries while investigating
uterine cancer and many cardiovascular diseases [22, 24, 25, for polycystic ovaries and this can be done by using
27]
. Researchers are still trying to discover if any gene is abdominal ultrasound, vaginal ultrasound and/or
responsible or might be linked to PCOS or PCOD. Some laparoscopy. In abdominal ultrasound, a map of the area
women, who are obese, having severe excess body hair being scanned by using soundwaves and investigate the
and raised blood levels, yet have a perfectly regular ovaries. Though this method is painless ovaries are not
menstrual period [26]. And many women are thin but have visible so vaginal ultrasound or laparoscopy is done to have
PCOS, which reminds that the exact cause or the exact a clear look at the ovaries. Vaginal ultrasound is not done in
story about PCOS is not confirmed. When women eat lots unmarried women, because it can be done using a vaginal
of carbohydrates the level of insulin in the body is probe, which is gently inserted into the vagina and placed
increased, which increases the level of testosterone and right next to the wall of the ovary to get a clear look at the
decreases SHBG (a protein to which testosterone attaches) prominence of cysts. While laparoscopy, a cut in the naval is
level in ovaries and liver respectively. Changes in made and an extremely small telescope is allowed to enter
testosterone and SHBG levels elevate free testosterone through the cut and allow the surgeon to have a clear and
levels, which ultimately leads to irregular periods and skin complete look at ovaries, uterus, and fallopian tubes, and so
problems [28, 29]. on. With the help of laparoscopy, the doctor can get a good-
quality picture of the desired part [33].

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 Neha Minocha et al.: Polycystic Ovarian Disease or Polycystic Ovarian Syndrome: How to Identify and Manage- A Review

Treatment Recent advances in the management of pcos

There are many views regarding the treatment of PCOS, PCOS appears to be a heterogeneous condition and whose
some say it cannot be treated as it is a life-long disorder and initial management of diagnosis of PCOS or PCOD will
some concluded that having a change in lifestyle and having depend on the clinical problems (anovulation or hirsutism).
hormonal treatment can work well with PCOS [28].• Hirsutism: The backbone of managing PCOS largely
Consequences related to health concerning PCOS are depends on hair removal techniques. In some cases, this may
diverse and may include non-functioning or dysfunction of still be the choice of treatment if fertility is sought. In the
certain organs, so it is the utmost thing to get treated off this 1960s, antiandrogen therapy was introduced in which
disorder and have a stress-free life. If a woman is obese, she spironolactone, cyproterone acetate, and more recently
may have a deficiency of vitamin-D, because obesity is flutamide are successfully used in treating symptoms of
directly linked with a decrease in the level of vitamin-D and hyperandrogenism, which also includes acne. To induce
that person may likely get osteoporosis or rickettsia [16]. regular withdrawal of bleeding in patients having PCOS,
Thus, the very first step in the treatment changes in lifestyle. antiandrogens are usually prescribed with a low-dose oral
There are certain lifestyle management strategies, which contraceptive.
work well in PCOS: •
• Prevent getting obese or being over-weight (having• Anovulation: In 1958, the first human pituitary FSH was
weight management) used to induce ovulation in anovulatory women but it was
• Modification in dietary routine by having a low- stopped afterward because it was causing severe
carbohydrate diet complication rates to both fetus and mother. Afterward, in
• Regular physical activity or regular exercise 1961, Greenblatt and his associates stated positive induction
• Modification in behavior of ovulation using clomiphene citrate, which is chemically
• Stress -free lifestyle related to the non-steroidal estrogen chlorotrianisene.
• Reduce the intake of fast food Clomiphene citrate was used because it was inexpensive and
• Reduce intake of processed food had low toxicity with fewer side effects. Likewise, after
• Reduce the intake of alcoholic beverages several approaches like the introduction of GnRH analogs
• Regular check on vitamin-D level [16, 26, 34] were developed but all of them possess serious problems.
•
Recent medicines used in regulating PCOS: The next medical treatment was ovulation induction with
Certain medicines are used globally to regulate PCOS and metformin, an insulin-sensitizing agent, which decreases the
the first line of pills that are used to prevent hirsutism, acne, insulin level and lowers the level of circulating total and free
and irregular menstrual periods are oral contraceptives. Oral androgen with a result in improving clinical sequelae of
contraceptives are the pills, which are appropriately hyperandrogenism.
composed of hormones and they start an artificial menstrual
cycle in women so as she can get a withdrawal bleeding.• Weight loss: In modern society, changes in the dietary
Contraceptive Pills come in a pack of 21 active tablets, and routine can increase the proportion of obesity among women
some then have seven days of inactive tablets as a reminder and also the symptoms of PCOS as an excess of body fat
to have a seven-day break from the medication. These pills emphasize insulin resistance. Obese women with PCOD
also possess good treatment for excess hair and acne have irregular ovulation and hyperandrogenism and thus
because they contain a small dose of male hormone making treatment less effective and less efficient. Weight
blockers. These pills result in very low levels of free loss will lead to certain improvements in management [36].
testosterone in the body. While having these pills, one
cannot get pregnant. In the market, there are many brands of Remedies
the pills available and these are: • Lifestyle modification
• Diane-35 (contain a small amount of synthetic• Dietary changes
progestin, CPA) • Insulin-lowering drugs
• Yasmin (contain a small amount of synthetic• Oral contraceptives
progestin) • Weight loss
• Marvelon • Progestin therapy
• Femoden-ED • Medicines for hirsutism
• Microgynon • Fertility medications.

Some drugs that contain CPA Cyproterone acetate, are CONCLUSION

enormously useful drugs for the management of severe PCOD or PCOS is a reproductive disorder in which
androgen-excess disorders. CPA is an androgen-blocker— women’s ovary gets enlarged and starts producing an
which means it suppresses the ovarian production of excessive amount of male hormones (androgens) and is the
testosterone—and it is a progestin, so it protects the uterus main cause of infertility, diabetes, irregulation in menstrual
against cancer and lightens menstrual periods. It is usually periods, and hirsutism. The pathophysiologic defect is not
given with estrogens [35]. known yet, but certain vital features are known, which

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