Polycystic ovarian syndrome

Abstract

Polycystic Ovarian Syndrome (PCOS) is one of the most prevalent endocrine disorders affecting women and people with ovaries, yet it remains profoundly under-researched, under-diagnosed, and inadequately treated. Despite growing evidence that PCOS is a complex, lifelong metabolic, neuroendocrine, and psychological condition, first-line medical management continues to rely heavily on hormonal contraceptives, particularly the combined oral contraceptive pill. This paper critically examines the routine prescribing of the pill for PCOS, arguing that it represents a form of gendered medical neglect rooted in symptom suppression rather than disease treatment. Drawing on biomedical literature, feminist health theory, and patient-reported outcomes, the study explores the potential long-term consequences of hormonal masking, including infertility, diminished ovarian reserve, premature ovarian insufficiency, mental health deterioration, and delayed diagnosis. The paper further situates these practices within the structural failures of the UK National Health Service (NHS), highlighting how institutional sexism and reproductive essentialism contribute to systemic neglect. Ultimately, this study calls for a paradigm shift toward informed consent, metabolic-centred care, and feminist accountability in women’s healthcare. Introduction

Polycystic Ovarian Syndrome (PCOS) affects an estimated 8–13% of women of reproductive age worldwide, making it one of the most common endocrine disorders globally (Teede et al., 2018). Despite its prevalence, PCOS remains poorly understood, inconsistently diagnosed, and routinely trivialised within clinical practice. Characterised by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology, PCOS is now recognised as a multisystem disorder involving insulin resistance, chronic inflammation, hypothalamic–pituitary–ovarian axis dysregulation, and significant psychological morbidity (Azziz et al., 2016).

Yet, despite decades of research establishing the metabolic and neuroendocrine nature of PCOS, treatment pathways remain strikingly reductive. The combined oral contraceptive pill (COCP) continues to be prescribed as the default first-line intervention, often to adolescents shortly after menarche, frequently without full diagnostic evaluation or meaningful discussion of long-term implications. This practice raises urgent ethical, medical, and feminist concerns.

This paper argues that the routine prescription of the pill for PCOS constitutes a form of structural medical negligence. It prioritises the regulation of menstruation and suppression of visible symptoms over addressing underlying pathology, obscures disease progression, and disproportionately exposes women and girls to long-term reproductive and psychological harm. Within the NHS, these practices are further compounded by systemic underfunding of women’s health, entrenched gender bias in medicine, and the historic devaluation of female pain and chronic illness.

PCOS as a Complex, Lifelong Disorder

PCOS is not merely a reproductive condition; it is a chronic endocrine and metabolic disorder with lifelong consequences. Increasing evidence demonstrates that insulin resistance is present in up to 70% of individuals with PCOS, independent of body mass index (Dunaif, 1997). This insulin resistance contributes to hyperandrogenism, anovulation, and increased risk of type 2 diabetes, cardiovascular disease, and metabolic syndrome (Legro et al., 2005).

Neuroendocrine abnormalities are also central to PCOS pathophysiology. Altered gonadotropin-releasing hormone (GnRH) pulsatility leads to elevated luteinising hormone (LH) secretion, disrupting follicular development and ovulation (McCartney & Marshall, 2016). Chronic inflammation and dysregulated cortisol responses further complicate the clinical picture, reinforcing the need for holistic and long-term management.

Despite this complexity, treatment approaches remain narrowly focused on reproductive symptoms. This reductionist framing reflects broader patterns in women’s healthcare, wherein conditions are treated primarily in terms of fertility or menstrual regularity rather than overall health and quality of life (Perez, 2019).

Hormonal Contraception as Symptom Suppression

The combined oral contraceptive pill functions by suppressing ovulation, reducing androgen production, and inducing withdrawal bleeds that simulate menstrual regularity. While this may temporarily alleviate symptoms such as acne and hirsutism, it does not correct insulin resistance, inflammatory processes, or neuroendocrine dysfunction (Diamanti-Kandarakis et al., 2012).

Several studies have raised concerns regarding the metabolic effects of long-term COCP use in individuals with PCOS. Evidence suggests that certain formulations may worsen insulin resistance, alter lipid profiles, and contribute to weight gain—factors already elevated in this population (Glintborg et al., 2014). Furthermore, ovarian suppression may alter ovarian morphology and follicular dynamics, though long-term effects remain under-investigated due to ethical and methodological limitations.

Crucially, the pill masks ovulatory dysfunction rather than restoring physiological ovulation. When discontinued, many patients experience a return of symptoms, often with increased severity, revealing that disease progression has continued unchecked beneath hormonal suppression.

 

Informed Consent and Medical Negligence

A central ethical concern surrounding the use of hormonal contraception in PCOS management is the lack of informed consent. Adolescents are frequently prescribed the pill for “irregular periods” without comprehensive endocrine assessment or explanation of alternative management strategies. Patients are rarely informed that PCOS is a lifelong condition, that the pill does not treat its root causes, or that long-term reproductive implications remain uncertain.

This omission is particularly troubling when viewed through the lens of medical negligence. Informed consent requires disclosure of material risks, benefits, and uncertainties. The failure to discuss potential impacts on metabolic health, mental wellbeing, and fertility represents a breach of this principle, especially when treatment is initiated during critical periods of reproductive development.

Infertility, Diminished Ovarian Reserve, and Premature Ovarian Insufficiency

PCOS is traditionally associated with preserved or increased ovarian reserve; however, this assumption has been increasingly challenged. While anti-Müllerian hormone (AMH) levels are often elevated in PCOS, this does not guarantee lifelong ovarian function. Case studies and emerging cohort data suggest that a subset of individuals with PCOS experience accelerated follicular depletion, diminished ovarian reserve, or premature ovarian insufficiency (POI) (Sirmans & Pate, 2014).

The prolonged suppression of ovulation through hormonal contraception may delay the recognition of declining ovarian function. By preventing natural cycles, clinicians may miss early indicators of reproductive ageing, resulting in delayed fertility intervention and devastating diagnoses later in life.

Premature menopause and POI carry profound physical and psychological consequences, including increased cardiovascular risk, osteoporosis, sexual dysfunction, and grief related to infertility. The lack of longitudinal research examining the interaction between PCOS, hormonal suppression, and ovarian ageing represents a critical gap in women’s health research.

Mental Health and Psychological Harm

The psychological burden of PCOS is substantial and well-documented. Women with PCOS experience significantly higher rates of depression, anxiety, eating disorders, and reduced quality of life compared to controls (Barry et al., 2011). These outcomes are influenced by hormonal imbalance, metabolic dysfunction, chronic inflammation, and social stigma related to weight, body hair, and infertility.

Hormonal contraceptives have been independently associated with mood disturbances, particularly in adolescents (Skovlund et al., 2016). Emotional blunting, depressive symptoms, and reduced libido are frequently reported yet often dismissed by clinicians. For individuals with PCOS—already vulnerable to mental health challenges—this dismissal compounds psychological distress.

From a feminist perspective, the normalisation of women’s emotional suffering as “hormonal” reflects longstanding gender bias in medicine. Rather than investigating adverse drug effects, women are encouraged to tolerate distress in the name of reproductive control.

The NHS and Structural Gender Bias

Within the NHS, PCOS exemplifies the broader institutional neglect of women’s health. Despite its prevalence, PCOS lacks dedicated care pathways, specialist clinics, or consistent follow-up protocols. Patients frequently report diagnostic delays of several years, fragmented care between GPs and gynaecology, and minimal access to endocrinology or mental health support.

This neglect is not accidental but structural. Women’s health conditions that do not result in immediate mortality are systematically deprioritised in funding, research, and service provision (Criado Perez, 2019). PCOS, in particular, is often framed as a fertility issue rather than a serious metabolic disorder, rendering those not actively trying to conceive effectively invisible.

The reliance on the pill as a “quick fix” reflects institutional convenience rather than patient-centred care. It shifts responsibility onto women to manage symptoms privately while absolving healthcare systems of the obligation to provide comprehensive, long-term treatment.

Feminist Implications and Call for Reform

From a feminist standpoint, the management of PCOS reveals how women’s bodies are medicalised, controlled, and silenced. The prioritisation of menstrual regularity over metabolic health, the dismissal of pain and psychological distress, and the lack of informed consent all reflect patriarchal assumptions embedded in medical practice.

True reform requires a paradigm shift. PCOS must be recognised as a serious, lifelong condition requiring multidisciplinary care. Treatment should prioritise metabolic health, mental wellbeing, and patient autonomy rather than reproductive suppression. Most importantly, women must be treated as credible narrators of their own bodies.

 

Conclusion

The routine prescription of the combined oral contraceptive pill for PCOS represents a failure of evidence-based, ethical, and feminist medicine. By masking symptoms rather than addressing underlying pathology, current practices risk long-term harm to reproductive, metabolic, and psychological health. Within the NHS, these harms are compounded by systemic neglect and gender bias, leaving countless women underserved and unheard.

Addressing PCOS adequately is not merely a clinical challenge but a moral and political imperative. Without meaningful reform, the healthcare system will continue to fail generations of women whose suffering has long been deemed acceptable collateral.

 

 

 

 

References

.Azziz, R., et al. (2016). Polycystic ovary syndrome. Nature Reviews Disease Primers.

.Barry, J. A., et al. (2011). Anxiety and depression in PCOS. Human Reproduction.

.Criado Perez, C. (2019). Invisible Women: Data Bias in a World Designed for Men.

.Diamanti-Kandarakis, E., et al. (2012). Metabolic effects of oral contraceptives in PCOS. Endocrine Reviews.

.Dunaif, A. (1997). Insulin resistance in PCOS. Endocrine Reviews.

.Glintborg, D., et al. (2014). Oral contraceptives and metabolic risk. Journal of Clinical Endocrinology & Metabolism.

.Legro, R. S., et al. (2005). Long-term health risks in PCOS. Fertility and Sterility.

.McCartney, C. R., & Marshall, J. C. (2016). Neuroendocrine mechanisms in PCOS. Endocrine Reviews.

.Skovlund, C. W., et al. (2016). Hormonal contraception and depression. JAMA Psychiatry.

.Teede, H. J., et al. (2018). International PCOS guidelines. Human Reproduction.

 

 

 

 

 

 

BSc psychology. SFL