New Directions in Polycystic Ovary Syndrome

Richard S. Legro, M.D.

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy among women and is the leading cause of anovulatory infertility among women. It is also associated with an adverse risk profile for developing diabetes, heart disease, and endometrial cancer. Thus this disorder lies at the crossroads of women's health, and elucidating its roots would positively impact the reproductive and long-term health of all women. Though this disorder is found among women from all nations, the pathophysiology remains poorly understood, and treatment remains largely empirical.

This issue is devoted to giving voice to emerging leaders in the field who come from a broad and diverse geographic and scientific background. These leaders represent the next generation that will further our limited understanding of this enigmatic disorder. The issue will focus on three main areas within PCOS, first the genetics and racial effects of PCOS, then the reproductive and metabolic sequelae of PCOS, and finally will conclude with a series of articles devoted to current treatments of the disorder. Given the protean appearance of PCOS and the equally creative therapeutic approach, it is difficult to capture all the aspects of these three target areas, but the authors of these articles bring a wealth of research and clinical expertise to their contributions. Dr. Goodarzi highlights the difficulty of finding genes for a complex disorder with variable and maturation-dependent phenotypes and uncertain pathophysiology. Other articles discuss the phenotype and its presentation in distinct ethnic and racial subgroups. Drs. Ng and Ho discuss racial differences in response to treatment in Asians. Drs. Allahbadia and Merchant provide a fascinating discussion of the effects of various herbs used in Ayurvedic medicine in the Indian subcontinent on PCOS and related metabolic aspects of the disorder. Drs. Coney et al highlight the relative lack of study of the disorder among African Americans and the data to date that suggest similar phenotypes among Caucasians and African Americans with the disorder.

The second section focuses on medical and reproductive complications of PCOS. Dr. Dokras highlights the adverse cardiovascular risk profile in women with PCOS. Drs. Jansen et al summarize an emerging literature about the high prevalence of mood disorders and sexual dysfunction in women with PCOS. Drs. Dumesic and Abbott highlight factors that contribute to oocyte incompetence in women with PCOS. Drs. Navaratnarajah et al update both the clinical and basic science data of abnormal endometrial function and the predisposition toward endometrial cancer in this group, and Drs. Boomsma et al bring data from a recent meta-analysis about adverse pregnancy outcomes in women with PCOS. The findings of an increased risk of preterm labor (independent of multiple gestation) is an important clinical finding not previously suspected in this population.

The third section focuses on medical treatments, many of which have been around seemingly forever but have been underappreciated or in the case of oral contraceptive pills (OCPs) unfairly maligned. Drs. Moran et al and Dr. Hoeger discuss the role of exercise and diet in treating the syndrome, which though consistently recommended as the frontline therapy is often difficult to incorporate into a clinical practice of medicine. Drs. Seow et al cite the fairly strong data about the benefits of ovarian surgery in women with PCOS, and perhaps it is time to rethink the role of this therapy in the treatment of women with PCOS. Dr. Yildiz puts the quandary of OCP use into proper perspective highlighting the limited data available on adverse risks of OCP use in women with PCOS. Drs. Reinblatt and Buckett discuss the promise of in vitro maturation on preventing ovarian hyperstimulation and multiple pregnancy and the preliminary encouraging results with this intervention. Finally, Drs. Kodaman and Duleba tell the relatively new and exciting tale of the effects of statins on the ovary and PCOS, though their role in the treatment of PCOS remains at this point experimental.

The goal of this issue was to stimulate thought about PCOS by summarizing the literature and the experience of emerging clinical scientists in the field. There has been increasing communication between experts in the fields as evidenced by the ASRM/ESHRE consensus meetings on the diagnosis and treatment of infertility in PCOS. It is my aim that this issue of the journal will similarly stimulate inquiry and research into this common and worldwide disorder.