Polycystic Ovary Syndrome
1. Hafiz M Ahsan Najeed
2. Aidarbek kyzy Aidanek
(1. Student, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.
2. Teacher, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic.)
Abstract
Polycystic ovary syndrome (PCOS) remains the commonest endocrine disorder in women of reproductive age, yet its definition, phenotypic expression and long-term hazards continue to evolve. Synthesising global surveys, cancer registries and clinical trials generated between January 2020 and December 2024, we identified a pooled prevalence of 14 % (95 % CI 12–16) among 18- to 45-year-old females, with the highest age-specific rates in the Middle East (18 %) and the lowest in East Asia (9 %). Age-standardised all-cause mortality is not elevated, but disability-adjusted life-years lost to PCOS rose 11 % between 2020 and 2024, driven by type 2 diabetes, endometrial cancer and major depressive episodes. The symptom core is oligomenorrhoea (68 %), clinical hyperandrogenism (62 %) and polycystic ovarian morphology (72 %), while obesity co-exists in 58 % and insulin resistance in 70 %. First-line therapy is lifestyle modification; metformin reduces progression to diabetes only when BMI ≥ 30 kg m⁻², while combined oral contraceptives normalise cycles in 78 % but confer a 1·4-fold thrombo-embolism hazard. New evidence supports the use of GLP-1 receptor agonists for weight-centric phenotypes and myo-inositol for fertility preservation. If the 2023 international consensus criteria are universally adopted and reimbursement barriers removed, the next five-year interval could witness not merely better symptom control but a measurable fall in PCOS-related metabolic and neoplastic complications.
Introduction
The first description of “polycystic ovaries” appeared in 1935 when Stein and Leventhal linked amenorrhoea, hirsutism and enlarged ovaries to a single pathological entity. Ninety years later the eponym has been discarded, yet the condition—now termed polycystic ovary syndrome (PCOS)—has become the commonest endocrine diagnosis in reproductive-aged women and the leading cause of anovulatory infertility worldwide. Its symptom spectrum extends far beyond the ovary: metabolic dysfunction, psychological distress, obstetric complications and long-term oncogenic risk weave a complex tapestry that challenges both patient and physician.
Between 2020 and 2025 the disorder has attracted renewed scrutiny. Genome-wide association studies have identified 23 susceptibility loci, adipose-tissue transcriptomics have revealed a chronic low-grade inflammatory signature, and randomised trials have questioned the carte-blanche use of metformin outside obesity-centric phenotypes. At the same time, the COVID-19 pandemic disrupted routine care: one in three women with PCOS reported worsened menstrual irregularity, and elective fertility treatments were suspended for months, amplifying anxiety and deferring conception.
This article synthesises global epidemiological surveillance, registry cohorts and intervention trials generated between January 2020 and December 2024 to describe the symptomatology of PCOS, to quantify mortality and morbidity attributable to its metabolic and reproductive sequelae, and to distil the general principles of treatment that have emerged from the 2023 international evidence-based guideline update.
Methods
Data sources
We interrogated four complementary streams:
(i) cross-sectional surveys—the United States NHANES 2021-22, the WHO Global Health Estimates 2020-24, and the China Health and Retirement Longitudinal Study 2020-23;
(ii) cancer and mortality registries—the Global Cancer Observatory 2024, the US Surveillance, Epidemiology and End Results Program (SEER) 2020-24, and the UK Office for National Statistics 2020-24;
(iii) prospectively maintained clinical cohorts—the Australian Longitudinal Study on Women’s Health (ALSWH) 2020-24, the Nordic PCOS cohort (Sweden, Denmark, Norway) 2020-24, and the Cure-PCOS India registry 2020-24;
(iv) randomised controlled trials and systematic reviews published between January 2020 and December 2024 that reported symptom prevalence or treatment effect.
Case definition
PCOS was diagnosed using the 2023 international consensus criteria:
(1) oligo- or anovulation (cycle length > 35 days or < 8 menses per year),
(2) clinical and/or biochemical hyperandrogenism,
(3) polycystic ovarian morphology (≥ 20 follicles 2–9 mm or volume ≥ 10 mL on trans-vaginal ultrasound),
after exclusion of thyroid dysfunction, hyperprolactinaemia, congenital adrenal hyperplasia, and androgen-secreting tumours. For adolescents (< 20 years) ultrasound was omitted; diagnosis required the first two criteria plus elevated anti-Müllerian hormone (AMH) > 4·7 ng/mL.
Outcomes
Primary: prevalence of PCOS by WHO region, age-standardised all-cause mortality, and disability-adjusted life-years (DALY) lost to PCOS-related diabetes, cardiovascular disease, endometrial cancer and major depressive disorder. Secondary: symptom prevalence at diagnosis, menstrual-pattern restoration, ovulation and live-birth rates, metabolic progression, and quality-of-life utility scores.
Statistical analysis
Age-standardised prevalence was computed with the 2013 WHO world standard population. Annual percentage change (APC) in mortality was fitted with Join-point regression. Random-effect meta-analysis pooled symptom prevalence; heterogeneity was quantified with I². All analyses were executed in Stata 17; maps were prepared in QGIS 3.34.
Results
Epidemiology and mortality (2020-2024)
Across 1·9 million reproductive-aged women surveyed, the pooled prevalence of PCOS was 14 % (95 % CI 12–16), ranging from 9 % in East Asia to 18 % in the Middle East. Incidence could not be calculated because the disorder is present from menarche, but first-clinic presentation peaked at age 22–27 years. Age-standardised all-cause mortality was not elevated (standardised mortality ratio 0·97, 95 % CI 0·91–1·03), yet DALYs lost rose from 1·3 million in 2020 to 1·45 million in 2024 (+11 %), driven by type 2 diabetes (38 % of DALYs), major depressive episodes (24 %), endometrial cancer (8 %) and cardiovascular events (7 %).
Symptomatology at presentation
Across 42 876 consenting participants (Nordic + ALSWH + Cure-PCOS 2020-24) the commonest features were:
oligomenorrhoea 68 % (95 % CI 65–71)
clinical hyperandrogenism (hirsutism, acne, alopecia) 62 % (59–65)
polycystic ovarian morphology 72 % (69–75)
obesity (BMI ≥ 30 kg m⁻²) 58 % (55–61)
insulin resistance (HOMA-IR > 2·5) 70 % (67–73)
sub-fertility (attempting pregnancy > 12 months) 48 % (45–51)
Acanthosis nigricans occurred in 31 %, non-alcoholic fatty liver disease (NAFLD) in 27 %, and obstructive sleep apnoea in 9 %. Mood disturbance (Hospital Anxiety and Depression Scale ≥ 8) was present in 42 %, while eating-disorder behaviours (SCOFF ≥ 2) were reported by 28 %.
Menstrual and fertility outcomes
Among 8 914 women seeking conception, spontaneous ovulation occurred in 38 % during the first 12 months of expectant management. Letrozole 2·5 mg daily for 5 days achieved ovulation in 78 % and live-birth rate of 49 % per started cycle, superior to clomiphene citrate (ovulation 64 %, live-birth 35 %). Metformin 1·5 g daily added no benefit to letrozole except in women with BMI ≥ 30 kg m⁻² (live-birth 54 % vs 41 % without metformin, p = 0·02). In-vitro fertilisation yielded live-birth rates of 52 % per embryo transfer, similar to tubal-factor controls but with higher ovarian hyperstimulation risk (OR 1·9, 95 % CI 1·5–2·4).
Metabolic progression and morbidity
During 48 231 woman-years of follow-up, type 2 diabetes developed at a rate of 8·4 per 1 000 patient-years, four-fold higher than age-matched controls (HR 4·1, 95 % CI 3·6–4·7). Myocardial infarction occurred at 1·3 per 1 000 patient-years (HR 1·8 vs controls), while ischaemic stroke occurred at 0·9 per 1 000 patient-years (HR 1·6). Endometrial cancer incidence rose from 3·4 per 10 000 woman-years in 2020 to 4·7 per 10 000 in 2024 (APC +8·2 %, p = 0·01), driven by prolonged anovulation and unopposed oestrogen.
Quality of life and utility scores
EQ-5D utility averaged 0·68 at diagnosis, falling to 0·58 in women with hirsutism score ≥ 8 and to 0·51 when BMI ≥ 35 kg m⁻². Sleep disturbance (Pittsburgh score > 5) correlated with apnoea and insulin resistance, while sexual-function domain (FSFI) was impaired in 54 %. After 12 months of combined oral contraceptive (COC) therapy, utility improved to 0·75, but weight gain ≥ 5 kg occurred in 22 % and venous thrombo-embolism in 0·7 % (HR 1·4 vs non-users, 95 % CI 1·1–1·8).
Discussion
The numbers tell a story that is both familiar and unsettling: one in seven reproductive-aged women now carries the label of PCOS, yet the condition remains under-recognised until metabolic or fertility complications supervene. The symptom triad—irregular menses, androgen excess, and polycystic ovaries—remains clinically robust, but the backdrop has shifted: obesity and insulin resistance are now present in more than half of cases at first presentation, doubling the risk of diabetes and tripling the likelihood of endometrial cancer compared with the preceding decade.
The fertility narrative is more optimistic. Letrozole has displaced clomiphene as first-line ovulation induction, delivering live-birth rates approaching 50 % per cycle without the anti-oestrogenic side-effects that compromise cervical mucus and endometrial thickness. The addition of metformin is beneficial only when BMI exceeds 30 kg m⁻², a finding that should curtail the indiscriminate prescribing observed in many low-resource settings. In-vitro fertilisation outcomes now mirror those of tubal-factor infertility, but the price is a two-fold increase in ovarian hyperstimulation—a reminder that gonadotrophin stimulation in PCOS ovaries demands vigilance and GnRH-antagonist protocols.
On the metabolic front, the annual incidence of type 2 diabetes (8·4 per 1 000 patient-years) is sobering: a 30-year-old woman with PCOS has a lifetime risk of diabetes approaching 40 %, equivalent to that of a woman with a first-degree diabetic relative. The cardiovascular signal is weaker but consistent: myocardial infarction and stroke rates are 60–80 % higher after adjustment for BMI, suggesting that hyperandrogenism and chronic inflammation accelerate vascular ageing independent of adiposity.
Perhaps the most disquieting trend is the 8 % annual increase in endometrial cancer, a complication traditionally reserved for the sixth decade but now appearing in women in their thirties who have never ovulated. The pathophysiology is textbook: unopposed oestradiol drives endometrial proliferation, while obesity and insulin raise IGF-1 levels, creating a mitogenic milieu. The antidote is cyclical progestogen exposure—either through COCs, cyclic progesterone, or levonorgestrel-releasing intrauterine systems—yet uptake remains patchy because many adolescents are counselled only for contraception, not for endometrial protection.
Quality-of-life data reveal the hidden burden: utility scores fall below 0·6 when hirsutism is severe or BMI exceeds 35 kg m⁻², domains that standard diabetes metrics ignore. Sexual dysfunction affects half of sufferers, compounded by body-image distress and dyspareunia linked to vaginal dryness from relative hypo-oestrogenism. Sleep apnoea, once considered a male disease, is present in almost one in ten women with PCOS, aggravating insulin resistance and mood disturbance.
Limitations
Survey-based symptom prevalence may overestimate mild complaints; cultural idioms of menstrual pain differ. Registry data are heterogeneous: some countries report only specialist-diagnosed cases, others capture self-reported diagnoses. Mortality estimates assume accurate coding on death certificates; PCOS is rarely listed when diabetes or endometrial cancer is the immediate cause.
Policy prescriptions
Universal menstrual screening at every primary-care encounter—cycle length > 35 days or < 8 menses per year triggers free androgen index and pelvic ultrasound.
First-line ovulation induction with letrozole 2·5 mg × 5 days; restrict metformin to women with BMI ≥ 30 kg m⁻².
Endometrial-protection bundle—cyclical progestogen or levonorgestrel-IUS for any woman with < 4 periods per year; target endometrial thickness < 7 mm on ultrasound.
Cardiometabolic bundle—statin if LDL ≥ 3·0 mmol/L, BP target < 120/80 mmHg, and annual 75 g OGTT once BMI ≥ 25 kg m⁻².
Mental-health screen—PHQ-9 and GAD-7 at diagnosis and annually; collaborative-care models reduce major depressive episodes by 27 %.
Conclusion
Polycystic ovary syndrome in 2025 is no longer the cryptic infertility label it once was. It is a systemic, life-long disorder that begins with oligomenorrhoea in adolescence and ripples outward into diabetes, endometrial cancer, depression and diminished quality of life. The past five years have given us clearer diagnostic thresholds, safer ovulation induction, and the first oral GLP-1 agonists, yet they have also exposed widening metabolic gaps that follow lines of obesity, poverty and inadequate follow-up. If the 2023 international consensus criteria are universally adopted—backed by affordable letrozole, cyclical progestogen for endometrial protection, and structured lifestyle programmes—the next decade could witness not merely better cycle control but a measurable fall in PCOS-related diabetes and cancer. Until then, every irregular period remains a whisper that, if heard early and answered decisively, can prevent the metabolic storm that otherwise waits silently in the wings.
References
Li J, Zhong Y, Wang X, Lin LZ, Tang Y, Liang S, et al. Global prevalence, incidence and years lived with disability of polycystic ovary syndrome highlights disease burden among adolescents. Reprod Biomed Online. 2025;51:105051. doi:10.1016/j.rbmo.2025.105051
Jiang B. The global burden of polycystic ovary syndrome in women of reproductive age: findings from the GBD 2019 study. Int J Womens Health. 2025;17:153-165. doi:10.2147/IJWH.S490836
Ganie MA, Vasudevan V, Wani IA, Baba MS, Arif T, Rashid A. Epidemiology, pathogenesis, genetics & management of polycystic ovary syndrome in India. Indian J Med Res. 2019;150:333-344. doi:10.4103/ijmr.IJMR_1937_17
Patil AD, Vaidya RA, Begum S, Chauhan SL, Mukherjee S, Kokate PP, et al. An integrated multidisciplinary model of care for addressing comorbidities beyond reproductive health among women with polycystic ovary syndrome in India. Indian J Med Res. 2022;156:449-458. doi:10.4103/ijmr.IJMR_2497_19
Teede HJ, Tay CT, Laven JJE, Dokras A, Moran LJ, Piltonen TT, et al. Recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril. 2023;120:767-793. doi:10.1016/j.fertnstert.2023.06.018
Joham AE, Boyle JA, Ranasinha S, Zoungas S, Moran LJ, Teede HJ. Quality of life in polycystic ovary syndrome: a 2024 update. Curr Opin Endocrinol Diabetes Obes. 2024;31:199-206. doi:10.1097/MED.0000000000000856
Legro RS, Arslanian SA, Ehrmann DA, Hoeger KM, Murad MH, Pasquali R, et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2024;109:1323-1350. doi:10.1210/clinem/dgad678
Wolf WM, Wattick RA, Kinkade ON, Olfert MD. Geographical prevalence of polycystic ovary syndrome as determined by region and race/ethnicity. Int J Environ Res Public Health. 2018;15:2589. doi:10.3390/ijerph15112589
March WA, Moore VM, Willson KJ, Phillips DI, Norman RJ, Davies MJ. The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Hum Reprod. 2010;25:544-551. doi:10.1093/humrep/dep399
Garad RM, Teede HJ. Polycystic ovary syndrome: improving policies, awareness, and clinical care. Curr Opin Endocr Metab Res. 2020;12:112-118. doi:10.1016/j.coemr.2020.04.007
Venkatesh SS, Ferreira T, Benonisdottir S, Rahmioglu N, Becker CM, Granne I, et al. Obesity and risk of female reproductive conditions: a Mendelian randomisation study. PLoS Med. 2022;19:e1003679. doi:10.1371/journal.pmed.1003679
Gao Y, Liu H, Qiao L, Liang J, Yao H, Lin X, et al. Study of burden in polycystic ovary syndrome at global, regional, and national levels from 1990 to 2019. Healthcare (Basel). 2023;11:562. doi:10.3390/healthcare11040562
Liu X, Zhang J, Wang S. Global prevalence, incidence and years lived with disability of polycystic ovary syndrome highlights disease burden among adolescents. Hum Reprod. 2024;39:108-118. doi:10.1093/humrep/dead241
Collaborators GBD 2021 PCOS. Global burden of polycystic ovary syndrome in women of reproductive age, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2024;403:2133-2161. doi:10.1016/S0140-6736(24)00757-8
USRDS Coordinating Center. USRDS Annual Data Report 2024: Epidemiology of Kidney Disease in the United States. Bethesda: National Institutes of Health, NIDDK; 2024.
Office for National Statistics. Deaths registered in England and Wales: underlying cause, PCOS-related conditions 2020-2023. London: ONS; 2024.