Duke Medical Ethics Journal   

Polycystic Ovarian Syndrome, more commonly referred to as PCOS, is the most common endocrinopathy comprising women’s health challenges today. 1 in 10 women of reproductive age experience PCOS (USDHHS, 2014). Symptoms begin in adolescence, typically after the patient’s first period; they can include metabolic dysfunction, menstrual cycle changes, increased facial and body hair and acne, cysts in the ovaries, and, ultimately, infertility. However, many patients remain undiagnosed until they begin to have fertility issues (NICHD, 2019). 

Currently, diagnosis and treatment of PCOS is subject to variable diagnostic criteria, inconsistent provider knowledge, and failure to arrive at a consensus which poses major challenges (Witchel et. al., 2018). Given the accurate and discrete data yielded by analytic precision medicine techniques, diagnosis can become easily quantifiable while retaining the flexibility that accounts for differences among patients. In this way, provider knowledge about the illness and how to treat it will become more homogenous, and a systematic mechanism of treatment will be established. If implemented correctly, the rate of identification of “at-risk” individuals would increase at an earlier age and preventive care could be employed as a feasible intervention. Patients who have already been diagnosed would have more comprehensive and effective primary care to mitigate symptoms. Within each of these domains, the ethical challenges of implementation must be considered to support effectiveness for both patients and providers.

The etiology of PCOS is quite diverse and comprises a plethora of genetic and environmental factors. The condition has been proven to be moderately heritable due to the number of gene mutations that are implicated in its development: namely, proteins involved in the secretion and action of insulin, gonadotropin, and androgen (Ehrmann, 2005). While it has been considered a more dominant ovarian and hormonal disorder, research has more recently expanded this perspective to include metabolic dysfunction (Guo et. al., 2016).  This comes with  the emergence of studies that have supported a correlation between the etiology of PCOS and gut microbiota (Tremellen et. al., 2012; Liu et. al, 2017; Yurtdaş & Akdevelioğlu, 2020).). It is therefore noted that the multifactorial nature of the syndrome spans ovarian, hormonal, and metabolic physiological deficiencies that may bear a close resemblance to other disorders. This can easily become quite complicated,  making it difficult for doctors to detect the development of PCOS, identify at-risk females, and provide effective preventive care. 

There have been implementations to advance preventive care for PCOS within this decade. Researchers have been emphasizing the continued screening of all reproductive-aged women and adolescents for metabolic abnormalities including insulin resistance, as well as hormonal abnormalities such as excess androgen and lack of ovulation. Insulin-sensitizing agents should be prescribed for women who wish to conceive and oral contraceptives for those who do not (Ahles, 2000). While preventive care approaches do hold some importance, they also leave significant room for improvement.

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Because the common physiological signs that are screened for PCOS are also implicated in many other metabolic, ovarian, and endocrine conditions, they may not be the most accurate predictors of the condition for all patients. It has been proven that some women experience no PCOS symptoms and can only be diagnosed with ultrasound ovarian imaging (Hassan & Killick, 2001). Additionally, insulin-sensitizing agents and oral contraceptives welcome a plethora of side effects for women and may further exacerbate symptoms without addressing their root causes (Luque-Ramírez et. al., 2020; Nestler et. al., 2003). These medications, which may be helpful with symptom management to an extent, have the potential to do more than harm than good as long-term preventive solutions.