Clinical review: Lifecycle of polycystic ovary syndrome (PCOS): from in utero to menopause

Abstract

Context: Polycystic ovary syndrome (PCOS) is diagnosed during the reproductive years when women present with 2 of 3 of the following criteria: 1) irregular menstrual cycles or anovulation, 2) hyperandrogenism, and 3) PCO morphology. However, there is evidence that PCOS can be identified from early infancy to puberty based on predisposing environmental influences. There is also increasing information about the PCOS phenotype after menopause. The goal of this review is to summarize current knowledge about the appearance of PCOS at different life stages and the influence of reproductive maturation and senescence on the PCOS phenotype.

Evidence: PubMed, the bibliography from the Evidence-Based PCOS Workshop, and the reference lists from identified manuscripts were reviewed.

Evidence synthesis: The current data suggest that daughters of women with PCOS have a greater follicle complement and mild metabolic abnormalities from infancy. PCOS is often diagnosed in puberty with the onset of hyperandrogenism and may be preceded by premature pubarche. During the reproductive years, there is a gradual decrease in the severity of the cardinal features of PCOS. Menopausal data suggest that the majority of women who had PCOS during their reproductive years continue to manifest cardiovascular risk factors. However, the majority do not present an increased risk for cardiovascular morbidity and mortality, perhaps because women with no history of PCOS may catch up after menopause.

Conclusion: The current data provide a comprehensive starting point to understand the phenotype of PCOS across the lifespan. However, limitations such as a bias of ascertainment in childhood, age-based changes during reproductive life, and the small numbers studied during menopause point to the need for additional longitudinal studies to expand the current knowledge.

Figure 1.

Log ovarian volume (Log Ov Vol) and follicle number (Foll Num) in women with PCOS and controls (Ctl). A and B, Log ovarian volume (A) and follicle number (B) in women with PCOS (n = 544; ●) and controls (n = 666; □) across reproductive age. Linear regression was performed for women with PCOS (solid line) and controls (dashed line). Data include those from a previous publication (50) and additional subjects recruited using the same criteria in the interim. Results are the same as previously published (50). The fall in follicle number is the same in women with PCOS and controls as suggested by the parallel fall in follicle number, but the number of follicles is higher in women with PCOS. Ovarian volume is higher in women with PCOS, and the slope of the line for ovarian volume is less steep than for controls (P < .05).