Abstract
Background:
Clinical manifestations associated with polycystic ovary syndrome (PCOS) significantly impact the lives of affected individuals, and understanding the clinical presentation is essential for early diagnosis, appropriate management, and improving patient outcomes.
Objective:
The aim of this study was to investigate and compare the clinical characteristics of patients with polycystic ovaries and those with normal ovarian morphology.
Methods:
This prospective-retrospective study included two randomly selected groups of 50 reproductive-age patients each: one group diagnosed with PCOS and a control group with normal ovaries.
Results:
To facilitate better comparison, patients in both groups were further divided into five age categories. Clinical evaluation focused on disorders identified through inspection, including obesity, hirsutism, acne, and alopecia. Significant differences were observed between patients with PCOS and those with normal ovaries regarding age at menarche, menstrual cycle regularity, and the prevalence of hirsutism and acne. PCOS is associated with ovarian dysfunction, reflected in disturbances of menstrual cycle rhythm, bleeding quality, and duration.
Conclusion:
In addition, hirsutism and acne were markedly more prevalent among patients with PCOS compared to the control group.
Keywords: Polycystic Ovary Syndrome (PCOS), Hirsutism, Menstrual irregularities
1. BACKGROUND
The ovary (ovarium, oophorus) is a paired gonad whose physiological role is the periodic release of an egg cell and the production of steroid hormones (estrogen and progesterone). The main clinical manifestation of the ovary is the menstrual cycle. The menstrual cycle results from a recurring interaction of the hypothalamic-pituitary-ovarian system and is associated with structural and functional changes in the reproductive tract. The hormonal events of the menstrual cycle, which consist of cyclic changes in gonadotropins, estradiol, and progesterone, are closely related to follicular development and ovulation. Hormonal changes, which are correlated with morphological and autocrine-paracrine events in the ovary, make the coordination in this system one of the most impressive events in biology (1). Without a complete understanding of the mechanisms involved in ovarian function and the regulation of the hypothalamic-pituitary feedback loop, there can be no rational diagnosis or treatment of such menstrual disorders as anovulation, which results in dysfunctional uterine bleeding, oligomenorrhea, and amenorrhea.
Polycystic ovary syndrome (PCOS) is a heterogeneous endocrine disorder characterized by a broad spectrum of clinical manifestations that can vary between individuals and may change over time (2). The same underlying anatomical and hormonal features can lead to different clinical presentations in different patients. At one end of this spectrum—commonly referred to as Stein-Leventhal syndrome—patients may exhibit a combination of hyperandrogenism (e.g., hirsutism, acne, alopecia, elevated serum testosterone), significant menstrual irregularities such as amenorrhea or oligomenorrhea. At the other end, PCOS may be present without any overt or clinically visible symptoms, making diagnosis and management more challenging (3).
In the literature on endocrinology and reproductive health, adult female acne is recognized as a potential clinical manifestation of hyperandrogenism (excess androgen), with the majority of polycystic ovary syndrome (PCOS) guidelines classifying acne as a sign of androgen excess (4). Hirsutism is characterized by the growth of terminal hair in women, following a male-pattern distribution. Although hirsutism affects approximately 4–11% of women in the general population, it is the primary manifestation of hyperandrogenism in women with polycystic ovary syndrome (PCOS), with prevalence rates ranging from 65–75% (5).
2. OBJECTIVE
The aim of this study was to analyse the androgenic effects of PCOS by evaluating cosmetic manifestations including acne and hirsutism, using standardized and internationally recognized scoring systems to objectify the findings. In addition to cosmetic characteristics patients in both groups were analysed for age at menarche and menstrual cycle patterns.
3. PATIENTS AND METHODS
Patients
The study included a total of 100 women of reproductive age, divided into two groups: 50 patients diagnosed with polycystic ovary syndrome (PCOS) and 50 women with normal ovarian morphology as the control group. Participants were randomly selected and further divided into five age subgroups to enable better comparison. All patients underwent transvaginal ultrasonography to evaluate ovarian morphology, including measurements of ovarian size and volume, follicular distribution, thickness of the tunica albuginea, and stromal development.
Criteria for inclusion in the study for the PCOS group were the presence of clinically observed disorders such as obesity, hirsutism and acne.
Control group inclusion criteria required the absence of these clinical signs—specifically, no evidence of obesity, hirsutism and acne.
Methods
Acne was classified into four stages: stage 0 indicated no acne; stage I referred to acne localized on the face, primarily in the T-zone; stage II represented widespread acne across the entire face with numerous lesions; and stage III described acne extending to seborrheic areas of the body, including the back, shoulders, and chest.
Hirsutism was assessed using the modified Ferriman-Gallwey scale, which evaluates terminal hair growth in nine androgen-sensitive regions of the body, scoring each area from 0 to 4. This scale excludes midline hair and considers androgen-independent body hair in its diagnostic criteria. A total score of 8–15 was interpreted as mild hirsutism, while scores above 15 indicated moderate to severe hirsutism.
In addition to evaluating cosmetic manifestations, the age at menarche and characteristics of the menstrual cycle (such as cycle regularity and duration) were assessed through patient interviews and clinical history in both the PCOS and control groups.
Statistical analysis
Data were analysed using the student t-test for continuous variables and the Chi-square (χ²) test for categorical variables. Statistical significance was set at p < 0.05. Data analysis and graphical presentation were performed using Microsoft Excel.
4. RESULTS AND DISCUSSION
Acne
The presence of acne after adolescence is also a good indicator of hyperandrogenism. The prevalence of acne is divided into 4 stages (O-no acne, stage appearance of acne on the face, the so-called T zone, stage II-acne appears on the entire face and is numerous, stage (I)-appearance of acne on seborrheic areas of the body; back, shoulders, chest) (6). It was found that acne occurs much more frequently in the group of patients with PCO Sy. Only 4 patients or 8% in the control group have acne, exclusively stage 1. In the PCO group, only 4 patients do not have acne, while acne in stage 1 occurs in 27 patients (54%), in stage 2 in 17 patients (34%) and in stage 3 in 2 patients or 4%. The difference between the groups was statistically significant (Chi-square test, p = 2.19948E-15) (Table 1). These data support the fact that acne occurs almost regularly as a clinical problem in patients with polycystic ovary syndrome.
Table 1. Prevalence of acne according to stage and group.
| Acne | CHI test 2,19948E-15 |
|||
| Control | PCO | Total | ||
| Stage 0 | 46 | 4 | 45 | |
| Stage 1 | 4 | 27 | 36 | |
| Stage 2 | 0 | 17 | 17 | |
| Stage 3 | 0 | 2 | 2 | |
| Total | 50 | 50 | 100 | |
Hirsutism
Since the assessment of these clinical phenomena is quite subjective, we used the internationally recognized modified Feriman-Gallwey hirsutism scale, according to which hirsutism is divided into 4 stages (7). We found that hirsutism occurs much more often in the group of patients with PCO. Only 4 patients or 8% in the control group have increased hairiness, exclusively stage 1. On the other hand, in the PCO group, only 8 patients, or 16% do not have hirsutism, while stage 1 is found in 28 patients (56%), stage 2 in 12 patients (24%), and stage 3 in 2 patients (4%). The difference between the control and PCO groups was statistically significant (Chi-square test, p = 1.09203E-12) (Table 2). These results indicate that hirsutism is a very common clinical manifestation of hyperandrogenism and that it occurs frequently compared to the population that does not have PCOS.
Table 2. Prevalence of hirsutism according to stage in the examined and control groups.
| Hirsutism | CHI test 1,09203E-12 |
|||
| Control | PCO | Total | ||
| Stage 0 | 46 | 8 | 50 | |
| Stage 1 | 4 | 28 | 36 | |
| Stage 2 | 0 | 12 | 12 | |
| Stage 3 | 0 | 2 | 2 | |
| Total | 50 | 50 | 100 | |
Menarche
Our study confirmed that the onset of the first menstrual bleeding (menarche) occurs earlier in patients with polycystic ovaries (8). The average age at menarche in the control group was 14.9 years, while in the group with polycystic ovaries it was 13.1 years, and this difference was statistically significant. Although patients with polycystic ovaries experience menarche earlier and are statistically in the reproductive phase for a longer period, they frequently develop menstrual cycle irregularities soon after menarche. As a result, regular ovulation does not occur, leading to impaired fertility. The difference in the age of menarche between the groups was statistically significant, with a p-value of 1.16E-08 (t-test) (Table 3).
Table 3. Average age of menarche in examined and control group.
| Menarche | CHI test 1,16E-08 |
||||
| group | average | Maximum age | Minimal age | StDev Menarche | |
| PCO group | 13,14 | 16 | 11 | 1,37038650886291 | |
| Control group | 14,92 | 18 | 12 | 1,48241391669404 | |
Menstrual cycle
Since the diagnostic criteria for polycystic ovary syndrome (PCOS) have been the subject of ongoing discussion from the outset, new consensus guidelines continue to emerge. In 2003, during a meeting in Rotterdam, the European Society of Human Reproduction and Embryology (ESHRE) and the American Society of Reproductive Medicine (ASRM) established a widely accepted definition of PCOS. It was agreed that the diagnosis requires the presence of at least two out of three criteria: (I) oligo- or anovulation, (II) clinical and/or biochemical signs of hyperandrogenism, and (III) polycystic ovarian morphology (9). These criteria highlight that menstrual cycle irregularities represent one of the key clinical features of the syndrome. In our study, menstrual cycle disorders were observed in all patients within the PCO group, whereas only two patients in the control group exhibited irregular cycles. The difference between the groups was statistically significant (Chi-square test, p = 7.41953E-22) (Table 4).
Table 4. Regularity of the menstrual cycle in PCOS and control group.
| Cycle regularity | CHI TEST 7,41953E-22 |
||
| Group | Cycle regular | Cycle disrupted | |
| Control group | 48 | 2 | |
| PCO group | 0 | 50 | |
5. CONCLUSION
The findings of our study clearly demonstrate that PCOS significantly impairs ovarian function, leading to irregular menstrual cycles, altered bleeding patterns, and changes in bleeding duration. Furthermore, clinical manifestations of hyperandrogenism, including hirsutism and acne, were notably more prevalent among patients with PCOS compared to the control group. These results are consistent with the established understanding of PCOS as a multisystem disorder and provide further evidence supporting the importance of early identification and comprehensive clinical assessment in affected individuals.
Author’s Contribution:
Both authors were involved in all steps of preparation this article, including final proofreading.
Conflict of Interest:
None.
Financial Support and Sponsorship:
None
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