What Is Polycystic Ovary Syndrome?
Polycystic Ovary Syndrome (PCOS) is the most prevalent endocrine disorder in women of reproductive age, affecting 8-13% of this population. Despite the name, PCOS is not defined by the presence of "cysts" in the ovaries — the ovarian follicles visualized on ultrasound are immature antral follicles, not true cysts.
PCOS is a heterogeneous syndrome characterized by hyperandrogenism (excess male hormones), ovulatory dysfunction (irregular cycles or anovulation), and metabolic alterations (insulin resistance, cardiovascular risk). Not all patients present all components.
Beyond reproductive consequences, PCOS is associated with an increased risk of type 2 diabetes, metabolic syndrome, cardiovascular disease, hepatic steatosis, and psychological disorders (anxiety, depression, body-image disturbance). It is a disease requiring long-term management and a multidisciplinary approach.
Hyperandrogenism
Androgen excess is the central feature of PCOS, causing acne, hirsutism, and alopecia, and contributing to ovulatory dysfunction.
Insulin Resistance
Present in 50-70% of women with PCOS, independent of weight. It is the main metabolic risk factor and amplifies hyperandrogenism.
Psychological Impact
Anxiety, depression, and body-image disturbance are significantly more prevalent in PCOS and should be actively assessed.
Pathophysiology
The pathophysiology of PCOS involves a vicious cycle between ovarian hyperandrogenism and hyperinsulinemia. The ovaries of women with PCOS produce excess androgens (mainly testosterone and androstenedione) due to intrinsic hyperactivity of the theca cells, which appears to have a genetic basis.
Insulin resistance aggravates the picture: elevated insulin levels directly stimulate androgen production by ovarian theca cells and suppress hepatic SHBG (sex hormone-binding globulin) production, increasing the free and biologically active fraction of androgens.
In the hypothalamic-pituitary axis, GnRH pulsatility increases, favoring LH secretion over FSH. The LH excess further stimulates androgen production, while the relative FSH deficiency prevents adequate follicular maturation — follicles develop partially but do not reach ovulation, resulting in the multiple antral follicles seen on ultrasound.
Symptoms
The clinical presentation of PCOS is heterogeneous. Symptoms can range from mild menstrual irregularity to a full picture with marked hyperandrogenism, infertility, and metabolic disorders. Symptoms typically appear in adolescence, after menarche.
Clinical Manifestations of PCOS
- 01
Menstrual irregularity
Oligomenorrhea (cycles > 35 days) or amenorrhea (absence of menstruation for > 3 months). Reflects chronic anovulation.
- 02
Hirsutism
Excessive male-pattern hair growth (face, chest, abdomen, back). Present in 60-70% of women with PCOS.
- 03
Persistent acne
Acne that persists beyond adolescence or with hormonal distribution (jaw, chin, neck). Responds poorly to topical treatments alone.
- 04
Androgenetic alopecia
Diffuse thinning at the crown, sparing the frontal hairline. Less common than hirsutism, but equally impactful.
- 05
Weight gain
Tendency toward weight gain and difficulty losing it, especially in the abdomen (visceral adiposity).
- 06
Anovulatory infertility
PCOS is the most common cause of infertility from anovulation. Responds well to ovulation induction in most cases.
- 07
Acanthosis nigricans
Velvety skin darkening in folds (neck, armpits, groin). A clinical marker of insulin resistance.
Diagnosis
The diagnosis of PCOS is based on the Rotterdam criteria (2003), which require at least 2 of 3 criteria after exclusion of other causes of hyperandrogenism. International guidelines from 2023 reaffirmed these criteria with diagnostic refinements.
🏥Rotterdam Criteria for PCOS (2 of 3)
- 1.Clinical hyperandrogenism (hirsutism, acne, alopecia) and/or biochemical hyperandrogenism (elevated total or free testosterone)
- 2.Ovulatory dysfunction: oligomenorrhea (cycles > 35 days) or amenorrhea
- 3.Polycystic ovarian morphology on ultrasound: >= 12 follicles measuring 2-9mm per ovary or ovarian volume > 10 mL (updated criterion: >= 20 follicles with modern transducers)
- 4.Mandatory exclusion: hyperprolactinemia, thyroid dysfunction, congenital adrenal hyperplasia, Cushing syndrome, androgen-secreting tumors
DIAGNÓSTICO DIFERENCIAL
Differential Diagnosis
Hyperprolactinemia
- Spontaneous galactorrhea
- Amenorrhea with elevated prolactin
- No hyperandrogenism
- Headache and visual changes — macroprolactinoma
Testes Diagnósticos
- Serum prolactin
- Pituitary MRI
Adjunctive to pharmacologic treatment; evidence of prolactin-level modulation
Congenital Adrenal Hyperplasia
- Severe hyperandrogenism
- Elevated 17-OH progesterone
- Symptom onset in childhood or puberty
- Marked hyperandrogenism with clitoromegaly
Testes Diagnósticos
- 17-OH progesterone (basal and ACTH-stimulated)
- DHEA-S
Does not replace specific corticosteroid therapy; may complement symptom management
Cushing Syndrome
- Central obesity with purple striae
- Hypertension and osteoporosis
- Elevated urinary cortisol
- Very elevated urinary cortisol
- Signs of glucocorticoid excess
Testes Diagnósticos
- 24-hour urinary free cortisol
- Dexamethasone suppression test
- Pituitary/adrenal MRI
Has no role in the treatment of Cushing syndrome
Hypothyroidism
Read more →- Fatigue, weight gain, constipation, hair loss
- Irregular menstrual cycles
- Elevated TSH
Testes Diagnósticos
- TSH and free T4
Adjunctive to thyroid hormone therapy; ANS modulation
Androgen-Producing Tumors
- Rapidly progressive hyperandrogenism onset
- Virilization (clitoromegaly, deep voice)
- Testosterone above 200 ng/dL
- Rapid virilization — endocrinologic emergency
Testes Diagnósticos
- Total and free testosterone
- DHEA-S
- Ovarian and adrenal ultrasound or MRI
Has no role in the treatment of androgen-secreting tumors
Hyperprolactinemia
Hyperprolactinemia is the main differential diagnosis for PCOS in women with amenorrhea and infertility. While PCOS is characterized by excess LH and androgens, hyperprolactinemia suppresses the gonadotropic axis through a distinct mechanism — excess prolactin inhibits GnRH pulsatility.
The distinction is laboratory-based: elevated prolactin with normal androgens points to hyperprolactinemia. Prolactin measurement should be a mandatory part of the workup for any menstrual irregularity. Cabergoline treatment normalizes prolactin and restores ovulation in 80-90% of cases.
Non-Classic Congenital Adrenal Hyperplasia
Non-classic congenital adrenal hyperplasia (late-onset form) can present very similarly to PCOS — with menstrual irregularity, hyperandrogenism, and polycystic ovaries on ultrasound. It is caused by partial 21-hydroxylase enzyme deficiency, resulting in 17-OH progesterone accumulation.
Screening uses basal 17-OH progesterone measurement. Values above 2 ng/mL warrant ACTH stimulation testing for confirmation. Corticosteroid treatment (hydrocortisone) is specific and differs from PCOS treatment — so diagnostic differentiation is clinically relevant.
Androgen-Producing Tumors
Although rare, androgen-producing ovarian or adrenal tumors should be excluded when hyperandrogenism is severe and rapid in onset. Testosterone values above 150-200 ng/dL or markedly elevated DHEA-S, especially with virilization (voice deepening, clitoromegaly), require urgent imaging.
In classic PCOS, testosterone rarely exceeds 150 ng/dL and frank virilization is uncommon. Any woman with disproportionate hyperandrogenism should be evaluated by an endocrinologist before any treatment for PCOS.
Treatment
PCOS treatment is directed at each patient's specific symptoms and metabolic risks. Lifestyle modifications — balanced diet and regular exercise — are the foundation of treatment for all patients, especially those with overweight and insulin resistance.
Lifestyle (Foundation of Treatment)
Losing 5-10% of body weight significantly improves ovulation, hyperandrogenism, and metabolic profile. Aerobic plus resistance exercise, 150 min/week. Mediterranean or low-glycemic-index diet.
Hormonal Contraceptives
For menstrual regulation and treatment of hyperandrogenism (acne, hirsutism). Prefer progestins with antiandrogenic action (cyproterone, drospirenone). They protect the endometrium from hyperplasia.
Insulin Sensitizers
Metformin (1500-2000mg/day) improves insulin sensitivity, regularizes cycles, and may aid weight loss. Myo-inositol (4g/day) is an alternative with fewer gastrointestinal effects.
Ovulation Induction (for Fertility)
Letrozole (aromatase inhibitor) is first-line. Clomiphene citrate is an alternative. Low-dose gonadotropins for refractory cases. IVF when other options fail.
Acupuncture as Treatment
Acupuncture is studied in PCOS with a focus on menstrual cycle regulation, improved ovulation, and reduced hyperandrogenism. Experimental studies suggest that electroacupuncture may influence ovarian sympathetic nervous system activity, one of the hypothesized mechanisms for effects on follicular function — but the clinical impact of these changes remains uncertain.
Randomized clinical trials — including a multicenter study published in JAMA — have investigated the effect of acupuncture on ovulation and pregnancy rate in women with PCOS. Results are mixed: while some smaller studies suggest improvement in ovulatory frequency and androgen levels, the JAMA study did not show a significant benefit on live birth rate compared with sham acupuncture.
Acupuncture may contribute as complementary therapy for stress control, improved insulin sensitivity, and autonomic nervous system regulation. Its most plausible role in PCOS is adjunctive, not primary.
Prognosis
PCOS is a chronic condition that evolves throughout life. Clinical hyperandrogenism (hirsutism, acne) tends to improve with age, while metabolic risk (diabetes, cardiovascular disease) increases, especially without lifestyle intervention.
Regarding fertility, most women with PCOS can become pregnant with adequate treatment. Letrozole induces ovulation in 60-80% of cycles and yields a live birth rate of 25-30% per cycle in selected women.
Long-term metabolic follow-up is essential. Regular screening for diabetes, dyslipidemia, and metabolic syndrome should be part of follow-up for every woman with PCOS, regardless of body weight.
Myths and Facts
Myth vs. Fact
PCOS means having cysts in the ovaries
The "cysts" are actually immature antral follicles — normal structures in exaggerated number. The name of the syndrome is historically imprecise and causes confusion.
Only obese women have PCOS
PCOS affects women of all body weights. 20-30% of women with PCOS are lean. Insulin resistance can be present regardless of weight.
Women with PCOS cannot become pregnant
Most women with PCOS can become pregnant with treatment. PCOS is the most treatable cause of anovulatory infertility. Ovulation induction is highly effective.
PCOS is just a gynecologic problem
PCOS is a systemic disease with long-term metabolic, cardiovascular, and psychological implications. It requires lifelong multidisciplinary follow-up.
When to Seek Help
Women with menstrual irregularity, hirsutism, persistent acne, or difficulty becoming pregnant should seek evaluation for PCOS. Early diagnosis allows interventions that reduce long-term metabolic risk.
Frequently Asked Questions
PCOS is the most common endocrine disorder in women of reproductive age, affecting 6-15% of them. It is characterized by anovulation or oligo-ovulation, clinical or biochemical hyperandrogenism, and polycystic-appearing ovaries on ultrasound. Diagnosis requires at least 2 of the 3 Rotterdam criteria.
The proposed mechanisms — investigated mainly in experimental studies — include modulation of the hypothalamic-pituitary-ovarian axis and the autonomic nervous system, with potential influence on LH levels and insulin sensitivity. These are mechanistic hypotheses, not proven clinical effects in all patients. Acupuncture's role in PCOS is complementary, not primary.
There is no consensus on the ideal protocol. Swedish studies used an average of 14 sessions over 4 months as a research design, with some hormonal outcomes observed over time; extrapolation to Brazilian clinical practice requires individual assessment by the physician acupuncturist and integration with gynecologic follow-up.
No. Acupuncture does not replace metformin, hormonal contraceptives, or ovulation inducers in patients with formal indication for these treatments. Any change or discontinuation of medication should be decided exclusively by the responsible gynecologist or endocrinologist. Acupuncture's role is adjunctive — possibly contributing to stress control, sleep quality, and general symptoms — not an alternative to established pharmacologic therapy.
No. PCOS is the most treatable cause of anovulatory infertility. With ovulation induction (clomiphene citrate, letrozole, gonadotropins), pregnancy rates are satisfactory. Women with PCOS who do not respond to simple induction may benefit from IVF. The reproductive prognosis is generally good with adequate treatment.
Yes. Women with PCOS have a 4 to 8-fold higher risk of developing type 2 diabetes and increased cardiovascular risk due to insulin resistance, dyslipidemia, and chronic inflammation. Lifestyle measures (diet, exercise) are fundamental for reducing long-term metabolic risk.
The evidence is heterogeneous. Some trials suggest improvement in hormonal markers and menstrual frequency, while the largest randomized trial (Wu et al., JAMA 2017) found no significant benefit of acupuncture on hard reproductive outcomes (live births) compared with sham acupuncture. International guidelines do not recommend acupuncture as primary treatment for PCOS; its use, when indicated, is complementary.
Yes, significantly. A 5-10% reduction in body weight in overweight women with PCOS may restore ovulation in 55-100% of cases, reduce androgens, and improve insulin sensitivity. Weight loss is frequently the highest-impact intervention available for overweight women with PCOS.
There is no definitive cure. PCOS is a chronic condition that persists after menopause as metabolic syndrome. Treatment controls symptoms and reduces risks. Some women see significant improvement with weight loss. Research on genetic modulation and gut microbiota may open future perspectives.
The gynecologist is the primary specialist for PCOS. In cases with significant insulin resistance or diabetes, an endocrinologist should be included. For infertility, a reproductive medicine specialist is indicated. The physician acupuncturist can integrate care as a complement to the hormonal and metabolic approach.
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