Polycystic Ovarian Syndrome Clinical Presentation

Updated: Nov 27, 2023
  • Author: Richard Scott Lucidi, MD, FACOG; Chief Editor: Richard Scott Lucidi, MD, FACOG  more...
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The family history of patients with polycystic ovarian syndrome (PCOS) may include the following:

  • Menstrual disorders

  • Adrenal enzyme deficiencies

  • Hirsutism

  • Infertility

  • Obesity and metabolic syndrome

  • Diabetes

Menstrual abnormalities

Patients with PCOS have abnormal menstruation patterns attributed to chronic anovulation. (The patient usually has a history of menstrual disturbance dating back to menarche.) Some women have oligomenorrhea (ie, menstrual bleeding that occurs at intervals of 35 days to 6 months, with < 9 menstrual periods per year) or secondary amenorrhea (an absence of menstruation for 6 months). Dysfunctional uterine bleeding and infertility are the other consequences of anovulatory menstrual cycles. The menstrual irregularities in PCOS usually present around the time of menarche.

A retrospective study by Maslyanskaya et al reported that PCOS was the most common etiology seen in adolescent patients hospitalized for abnormal uterine bleeding (accounting for 33% of 125 hospital admissions). [40]


Hyperandrogenism clinically manifests as excess terminal body hair in a male distribution pattern. Hair is commonly seen on the upper lip, on the chin, around the nipples, and along the linea alba of the lower abdomen. Some patients have acne and/or male-pattern hair loss (androgenic alopecia).

Other signs of hyperandrogenism (eg, clitoromegaly, increased muscle mass, voice deepening) are more characteristic of an extreme form of PCOS termed hyperthecosis. These signs and symptoms could also be consistent with androgen-producing tumors, exogenous androgen administration, or virilizing congenital adrenal hyperplasia.

Premature adrenarche is a common occurrence and, in some cases, may represent a precursor to PCOS. Hirsutism and obesity may be present in premenarchal adolescent girls with PCOS.

The American College of Obstetricians and Gynecologists (ACOG) recommends screening with 17-hydroxyprogesterone levels in women suspected of having PCOS who are at an increased risk for nonclassical congenital adrenal hyperplasia. [5]


A subset of women with PCOS is infertile. Most women with PCOS ovulate intermittently. Conception may take longer than in other women, or women with PCOS may have fewer children than they had planned. In addition, the rate of miscarriage is also higher in affected women.

Obesity and metabolic syndrome

Nearly half of all women with PCOS are clinically obese. A study comparing the body mass index (BMI) in American and Italian women with PCOS showed that American women had a BMI higher than that of their Italian counterparts. [41] Women with PCOS should be assessed for their cardiovascular risk by evaluating their BMI, fasting lipid and lipoprotein levels, and risk factors for metabolic syndrome. [5, 6]

Many patients with PCOS have characteristics of metabolic syndrome; one study showed a 43% prevalence of metabolic syndrome in women with PCOS. [28] In women, metabolic syndrome is characterized by abdominal obesity (waist circumference >35 in), dyslipidemia (triglyceride level >150 mg/dL, high-density lipoprotein cholesterol [HDL-C] level < 50 mg/dL), elevated blood pressure, a proinflammatory state characterized by an elevated C-reactive protein level, and a prothrombotic state characterized by elevated plasminogen activator inhibitor-1 (PAI-1) and fibrinogen levels. [28]

Women with PCOS have an increased prevalence of coronary artery calcification and thickened carotid intima media, which may be responsible for subclinical atherosclerosis. Prospective, long-term cardiovascular-outcome studies in PCOS are needed to assess whether the increased cardiovascular risk in PCOS results in the higher cardiovascular-event rates.

Diabetes mellitus

ACOG recommends screening for type 2 diabetes and impaired glucose tolerance in women with PCOS by obtaining a fasting glucose level and then a 2-hour glucose level after a 75-g glucose load. [5] Approximately 10% of women with PCOS have type 2 diabetes mellitus, and 30-40% of women with PCOS have impaired glucose tolerance by 40 years of age. [42, 43]

Sleep apnea

Many women with PCOS have obstructive sleep apnea syndrome (OSAS), which is an independent risk factor for cardiovascular disease. [6] Ask these patients and/or their partners about excessive daytime somnolence; individuals with obstructive sleep apnea experience apnea/hypopnea episodes during sleep. [44, 45] For women with PCOS with suspected OSAS, there should be a low threshold for referral for sleep assessment. Patients may also be screened for OSAS in the clinic using such tools as the Epworth sleepiness score.


Physical Examination

Hirsutism and virilizing signs

Patients may have excessive body hair in a male distribution pattern, as well as acne. Some patients have virilizing signs, such as male-pattern balding or alopecia, increased muscle mass, deepening voice, or clitoromegaly; these findings should prompt a search for other causes of hyperandrogenism.

The modified Ferriman-Gallwey (mFG) score grades 9 body areas from 0 (no hair) to 4 (frankly virile), including the upper lip, chin, chest, upper abdomen, lower abdomen, thighs, back, arm, and buttocks. A total score of 8 or more is considered abnormal for an adult white woman; a score of 36 is the most severe.


Approximately 50% of women with polycystic ovarian syndrome (PCOS) have abdominal obesity, characterized by a waist circumference greater than 35 inches (>88 cm).

Acanthosis nigricans

Acanthosis nigricans is a diffuse, velvety thickening and hyperpigmentation of the skin. It may be present at the nape of the neck, axillae, area beneath the breasts, intertriginous areas, and exposed areas (eg, elbows, knuckles). In patients with PCOS, acanthosis nigricans is thought to be the result of insulin resistance, although syndromic and familial variants are described. Acanthosis nigricans can also be a cutaneous marker of malignancy.

Acanthosis nigricans is staged according to the scoring system below:

  • Absent (0): Not detectable on close inspection

  • Present (1): Clearly present on close visual inspection, not visible to the casual observer, extent not measurable

  • Mild (2): Limited to the base of the skull, usually does not extend to the lateral margins of the neck

  • Moderate (3): Extends to the lateral margins of the neck but not visible anteriorly

  • Severe (4): Visible anteriorly

  • Severe (5): Circumferential

Blood pressure

Patients with signs and symptoms of metabolic syndrome may have elevated blood pressure, with a systolic blood pressure of 130 mm Hg or higher and a diastolic blood pressure of 85 mm Hg or higher.

Enlarged ovaries

Enlarged ovaries may not always be present. Evaluate for an ovarian mass.