Understanding PCOD: Evidence-Based Insights on Hormonal Imbalance, Metabolic Risks, and Treatment Approaches- A comprehensive scientific review.

 

Dr JK Avhad MBBS MD [Last updated 28.12.2025]

Polycystic Ovarian Disease (PCOD), often used interchangeably with Polycystic Ovary Syndrome (PCOS), is one of the most common endocrine–metabolic disorders affecting women of reproductive age. Worldwide, PCOD/PCOS affects 8–20% of women, though prevalence varies widely depending on diagnostic criteria, ethnicity, and lifestyle patterns. It is not only a reproductive disorder but also a systemic metabolic condition involving insulin resistance, chronic low-grade inflammation, dyslipidemia, and increased long-term cardiometabolic risk.

PCOD is characterized by ovarian dysfunction, multiple immature follicles in the ovaries, and hormonal imbalance, especially excess androgen production. Unlike PCOS, which is defined by a set of criteria (like Rotterdam, NIH, AE-PCOS), PCOD is often used in India and South Asia to describe ovarian cystic changes dominated by lifestyle driven hormonal dysregulation rather than classic syndrome-level metabolic involvement.

Although the terms overlap, modern research leans toward the unified name PCOS, since the ovarian cysts themselves are not the central issue, the endocrine disruption is. Still, many clinicians differentiate them as:

  • PCOD: A milder, reversible ovarian condition with irregular ovulation and cyst formation.
  • PCOS: A broader syndrome with metabolic, hormonal, and reproductive consequences.

Regardless of terminology, the underlying pathophysiology presents significant implications for menstrual health, fertility, long-term metabolic health, and quality of life.

Epidemiology and Global Trends

PCOD/PCOS prevalence varies across regions:

  • India: Estimates range from 12–36% depending on urbanization, diet, and diagnostic standards.
  • Global average: 10–15% among reproductive aged women.
  • Adolescents: Increasing incidence due to earlier puberty, sedentary lifestyle, and rising obesity rates.

There is a clear trend toward younger age of onset, often starting soon after menarche, and increasingly linked to modern diet and lifestyle patterns.

Factors associated with higher prevalence:

  • Urban life
  • High BMI
  • Sedentary lifestyle
  • High sugar and processed food consumption
  • Genetic predisposition [ family history of diabetes or PCOS ]

Pathophysiology of PCOD

PCOD arises from complex interactions between genetic factors, hormones, metabolism, and environmental factors. No single cause explains the disorder, instead, it is a cluster of interacting abnormalities.

Insulin Resistance: The Central culprit

Insulin resistance [ IR ] is found in 50–70% of women with PCOD/PCOS, even in those with normal body weight. IR triggers a cascade of hormonal events:

  • Elevated insulin → stimulates ovarian theca cells → increased androgen production.
  • Insulin inhibits hepatic production of sex hormone binding globulin (SHBG) → increasing free testosterone.
  • IR contributes to abdominal fat deposition → worsening inflammation and hormonal imbalance.

Hyperandrogenism

Excess androgens [ testosterone, androstenedione, DHEA-S ] lead to:

  • Hirsutism (Excessive facial, body hair)
  • Acne
  • Scalp hair thinning (androgenic alopecia)
  • Ovulatory dysfunction

The ovaries overstimulated by LH and insulin produce more androgens than normal.

Ovarian Dysfunction and Follicular Arrest

Normally, one follicle matures each cycle. In PCOD:

  • Follicles start developing → but do not mature → they accumulate.
  • Ovaries enlarge with multiple small follicles (2–9 mm).
  • The chronic anovulation leads to progesterone deficiency and unopposed estrogen dominance.

Chronic Low-Grade Inflammation

Women with PCOD often show elevated inflammatory markers (CRP, TNF-α, IL-6). Chronic inflammation contributes to:

  • Insulin resistance
  • Endothelial dysfunction [ Endothelium is inner lining of your blood vessels ]
  • Increased cardiovascular risk

Genetic Factors

Variants in genes related to insulin signaling, androgen production, and gonadotropin action have been linked to PCOD. Family clustering is common, particularly with type 2 diabetes, obesity, or metabolic syndrome.

Clinical Features

PCOD manifestations vary widely. Some women have mild symptoms; others experience a full spectrum of reproductive, metabolic, and psychological issues.

Menstrual Irregularities

  • Oligomenorrhea
  • Hypomenorrhea
  • Amenorrhea (no periods for 3–6 months)
  • Heavy bleeding due to endometrial buildup
  • Difficulty predicting cycles

Hyperandrogenic Symptoms

  • Moderate to severe acne
  • Increased facial and body hair
  • Hair thinning on scalp
  • Darkening of skin

Weight Issues

  • Tendency for central obesity
  • Difficulty losing weight
  • Water retention and bloating

Fertility Challenges

PCOD is one of the leading causes of female infertility due to anovulation.

Metabolic Symptoms

  • Sugar cravings
  • Fatigue
  • Rapid weight gain
  • Elevated cholesterol and triglycerides

Psychological Impact

Women frequently experience:

  • Anxiety
  • Depression
  • Low self-esteem
  • Body image issues.

Diagnostic Criteria

Rotterdam Criteria

A diagnosis is made if 2 out of 3 are present:

  1. Oligo- or anovulation
  2. Clinical or biochemical hyperandrogenism
  3. Polycystic ovaries on ultrasound [ ≥12 follicles OR ovarian volume >10 mL ]

Other causes must be excluded [ thyroid disorders, hyperprolactinemia, CAH, and more ]

Ultrasound Findings

  • Enlarged ovaries
  • Multiple small peripheral follicles (“string of pearls”)
  • Increased ovarian stroma

Blood Tests

  • Elevated LH levels or high LH:FSH ratio
  • High testosterone / DHEA-S
  • Elevated fasting insulin
  • Dyslipidemia: ↑ TG, ↓ HDL
  • Increased AMH (anti-Müllerian hormone)

PCOD vs PCOS: A Clear Distinction

Many patients and even some clinicians use the terms interchangeably, but in practice:

Feature

          PCOD

                   PCOS

Primary nature        

       Ovarian dysfunction

           Multi-system endocrine-metabolic syndrome

Severity

       Mild–moderate

           Often moderate–severe

Metabolic issues

      Less common

             Very common

Insulin resistance

      Can occur

             Frequently present

Long-term risks

      Lower

             Higher

Reversibility

Often lifestyle-correctable

             More chronic

Clinically, the management strategies overlap, but understanding this distinction helps tailor treatment intensity.

Complications of PCOD

Reproductive Complications

  • Infertility
  • Pregnancy complications: miscarriage, gestational diabetes mellitus (GDM), pregnancy induced hypertension (PIH)
  • Endometrial hyperplasia (due to chronic estrogen exposure)

Metabolic Complications

  • Insulin resistance → type 2 diabetes
  • Dyslipidemia
  • Non-alcoholic fatty liver disease (NAFLD)
  • Metabolic syndrome

Cardiovascular Risk

  • Hypertension
  • Atherosclerosis
  • Increased lifetime risk of heart disease

Psychological Effects

  • 3x higher prevalence of depression
  • 5x higher prevalence of anxiety
  • Eating disorders, especially binge eating

 

Management of PCOD

Management is personalized, focusing on symptom control, menstrual regularization, and long-term prevention of metabolic disease.

Lifestyle Modifications: The Foundation of Treatment

Dietary Interventions

Key dietary principles:

  • Low glycemic index foods
  • High fiber
  • High protein, moderate healthy fats
  • Avoid refined sugar, fried foods, ultra-processed foods
  • Regular meal timing to regulate insulin levels

Recommended eating patterns:

  • Mediterranean diet
  • Anti-inflammatory diet
  • Low-carbohydrate diet
  • Plate method (50% veggies, 25% protein, 25% whole grains)

Foods to focus on:

  • Whole grains, lentils, legumes
  • Leafy greens, cruciferous vegetables
  • Nuts, seeds, avocados
  • Oily fish (omega-3s)
  • Berries, citrus
  • Lean proteins

Foods to limit:

  • Sugary drinks
  • Pastries and white flour
  • Red and processed meats
  • Packaged snacks
  • High-salt foods

Weight Management

Even a 5–10% reduction in body weight improves:

  • Ovulation
  • Insulin sensitivity
  • Hormonal levels
  • Acne and hair fall

Exercise

Combination of:

  • Strength training (improves insulin sensitivity)
  • Cardio (fat loss)
  • High-intensity interval training
  • Yoga and Pilates (hormonal balance)

Minimum target: 150 minutes/week moderate exercise + strength training 3 days/week.

Medications

Metformin

  • Improves insulin sensitivity
  • Helps regulate periods
  • Aids weight loss in some women

Oral Contraceptives

  • Regulate menstrual cycle
  • Reduce acne and hair growth
  • Control androgen levels

Anti-Androgens

  • Spironolactone
  • Flutamide
  • Used for hirsutism and acne

Fertility Medications

  • Letrozole (first-line drug)
  • Clomiphene
  • Gonadotropins

Other Therapies

  • Inositols (Myo-inositol + D-chiro inositol)
  • Omega-3 supplements
  • Vitamin D correction
  • Chromium picolinate

PCOD and Fertility

PCOD is the most common cause of anovulatory infertility.

Mechanisms:

  • Irregular ovulation
  • Poor egg quality
  • Hormonal imbalance
  • Endometrial changes

Treatment approach:

  •  Lifestyle modification
  • Ovulation induction (Letrozole preferred)
  • Metformin for insulin-resistant cases
  • IVF/ICSI for resistant or complex cases

Success rates improve dramatically when weight and metabolism are optimized.

Long-Term Health Risks

Even after reproductive symptoms settle, the metabolic risks persist.

Diabetes

PCOD increases lifetime risk of type 2 diabetes by 400–700%.

Hypertension & Dyslipidemia

Due to chronic insulin resistance and inflammation.

Cardiovascular Disease

Higher lifetime risk for:

  • Heart attack
  • Stroke
  • Atherosclerosis

Endometrial Cancer

Chronic anovulation → unopposed estrogen → increased endometrial cell proliferation

Sleep Disorders

High prevalence of obstructive sleep apnea.

Monitoring is essential:

  • Annual glucose testing
  • Lipid profile
  • BP monitoring
  • Liver function tests
  • Mental health screening

PCOD in Adolescents

Diagnosing PCOD in teens is challenging because:

  • Irregular periods are normal in the first 1–2 years after menarche
  • Acne is common
  • Ovaries are naturally multicystic during puberty

Thus, strict criteria are needed to avoid over-diagnosis:

  • Persistent irregular cycles >2 years
  • Clear signs of hyperandrogenism
  • Biochemical confirmation

Lifestyle intervention is preferred over medications initially.

PCOD and Mental Health

Psychological effects are often overlooked but can be significant:

  • Reduced confidence due to acne, hirsutism, weight issues
  • Anxiety about fertility
  • Body image disturbances
  • Emotional eating
  • Depression linked to chronic inflammation and hormonal imbalance

Holistic care includes:

  • Therapy
  • Support groups
  • Stress management techniques
  • Yoga and mindfulness
  • Meditation

Modern Research and Future Directions

Emerging areas of interest:

  • Gut microbiome: Dysbiosis plays a major role in insulin resistance and inflammation.
  • Genetic profiling: Identifying high-risk individuals early.
  • Personalized medicine: Tailoring therapy based on metabolic phenotype.
  • Novel drugs: GLP-1 receptor agonists (e.g., semaglutide) for weight loss.
  • Advanced reproductive techniques: Improved IVF outcomes for PCOD patients.

Conclusion

PCOD is a complex, multifactorial condition affecting millions of women worldwide. While often misunderstood as a simple ovarian issue, PCOD is fundamentally tied to metabolic dysfunction, hormonal imbalance, and inflammatory pathways. It influences reproductive health, long-term metabolic risk, cardiovascular health, mental well-being, and quality of life.

However, early diagnosis, structured lifestyle changes, targeted medical treatment, and ongoing monitoring can significantly improve outcomes. In many cases, PCOD is highly manageable and even reversible, especially when lifestyle modification is prioritized.

A strong patient–clinician partnership, awareness of the condition, and individualized care remain key to effective long-term management.

This article is for informational purpose only and does not substitute for professional medical advise. For proper diagnosis and treatment seek the help of your healthcare provider.

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