Oshaz Fatima
Polycystic ovary syndrome is not a rare diagnosis confined to academic clinics. It is one of the most common endocrine disorders affecting reproductive aged women worldwide and imposes a profound toll on physical health, mental wellbeing, and social opportunity. Global meta analyses estimate prevalence between 5 and 12 percent depending on the diagnostic criteria used, translating into tens of millions of affected women. Even conservative estimates note that up to 70 percent of these women remain undiagnosed, allowing a treatable condition to progress into chronic disability.
Pakistan sits at the center of this crisis. Clinic and community based studies repeatedly report prevalence rates far higher than global averages. While worldwide prevalence ranges between 5 and 12 percent, Pakistani hospital based studies have documented prevalence as high as 21 to 30 percent. In different provinces, figures fluctuate widely but often cluster in the high teens to over thirty percent. Specialty infertility clinics show that PCOS is the leading cause of anovulatory infertility in women presenting for care. These numbers are reinforced by rising trends in obesity, insulin resistance, menstrual irregularity and psychological distress, all of which track closely with PCOS.
Several forces explain why the condition is both common and under recognised in Pakistan. South Asian women are genetically predisposed to insulin resistance and central obesity, and urbanisation, dietary westernisation and sedentary lifestyles magnify this risk. South Asian women also develop type 2 diabetes four to seven years earlier than women of European ancestry, and often at lower body mass indices. Around 50 to 70 percent of women with PCOS show insulin resistance. Despite this, cultural attitudes discourage open discussion of reproductive symptoms such as irregular menstruation or hirsutism. Surveys suggest more than 60 percent of Pakistani women first resort to traditional remedies before consulting a doctor for reproductive complaints. Primary care services do not routinely screen for menstrual disorders, and frontline clinicians are often not well trained in applying international diagnostic criteria. Consequently, women often present late, usually when infertility or overt metabolic disease emerges.
Diagnosing PCOS is conceptually straightforward but operationally difficult. Criteria require combinations of menstrual irregularity, hyperandrogenism and ovarian morphology. Yet there is variation between guideline sets, and differences in clinician interpretation. Ultrasound and biochemical testing are unevenly available, especially outside urban centers. As a result, prevalence estimates vary depending on whether studies use self reported surveys, biochemical screening or ultrasound criteria.
Treatment is effective but unevenly distributed. Lifestyle modification is the foundation; weight loss and physical activity can restore ovulatory cycles and improve metabolic outcomes. Metformin enhances insulin sensitivity, regulates cycles and facilitates ovulation.
PCOS is also under researched on a global scale. Although described decades ago, research has been concentrated on reproductive outcomes in high income countries. Few large scale longitudinal studies from low and middle income nations have mapped the long term metabolic and cardiovascular sequelae of PCOS. This is a critical gap because the South Asian phenotype differs markedly from that of women of European descent.
The way forward requires multipronged public health strategies. Primary care providers should be trained in pragmatic diagnostic algorithms that combine clinical features with affordable tests. School based education about menstrual health can reduce stigma and encourage timely help seeking. Training for general practitioners and gynaecologists must include early detection of metabolic risks and integration of mental health support. Policy makers should treat PCOS not merely as an individual reproductive disorder but as a significant contributor to the burden of non communicable disease. Population wide interventions to reduce obesity and improve nutrition will reduce PCOS morbidity. Fertility services need to be made affordable and equitably accessible.
Research efforts within Pakistan must expand. Standardised prevalence studies are needed to provide reliable national data. Prospective cohorts following adolescents into adulthood could illuminate the interaction between genetics and environment. Health systems research can identify practical models to deliver integrated care at the primary care level. Community engagement is essential to dismantle cultural taboos. Partnerships with schools and women’s organisations can spread the message that menstrual irregularity is a medical issue that warrants care.
When diagnosis and treatment are delivered early, outcomes improve dramatically. Regular cycles, improved fertility and better metabolic profiles are achievable. Just as importantly, the validation of women’s symptoms reduces psychological distress and restores dignity. Reframing PCOS as a common, treatable medical condition rather than a private source of shame will reduce stigma, encourage healthcare utilisation and allow health systems to allocate resources appropriately. Failing to act perpetuates a quiet epidemic that undermines individual lives and national health. The evidence base is already strong enough to justify national strategies that combine prevention, detection and treatment. Pakistan cannot afford to ignore this hidden burden any longer.
