The Cycles We Overlook: PCOS and the Discipline of Clinical Awareness

A. Universidad Autónoma de Guadalajara, School of Medicine, Guadalajara, México (MS2)

Menstrual cycles are often treated as routine, something predictable and secondary. But physiologically they’re far from simple. Each cycle reflects coordinated signaling between the hypothalamus, pituitary gland, ovaries, liver, pancreas, adipose tissue, and endometrium. Gonadotropin-releasing hormone pulses regulate LH and FSH secretion. Follicles develop in response to carefully balanced hormonal gradients. Metabolic signals modulate ovarian function.

The endometrium undergoes timed proliferation, differentiation and shedding. This orchestration requires stability across multiple systems. When that rhythm becomes persistently irregular, it usually reflects disruption somewhere along that axis. Yet irregular periods are often explained away. Stress. Long study nights. Caloric changes. Weight fluctuation. “That’s just how my cycle has always been.” In medical school we’re taught to approach physiologic deviations with attention. We’re trained to look for patterns. We are trained to ask what underlying mechanism might explain a clinical sign.

So it is worth asking why we sometimes apply that reasoning outward but hesitate to apply it inward.

The Endocrine Story Behind Irregular Cycle

Figure 1. Pathophysiology of Polycystic Ovary Syndrome.

Altered hypothalamic GnRH pulsatility favors increased luteinizing hormone (LH) secretion with relative follicle-stimulating hormone (FSH) deficiency. Elevated LH stimulates ovarian theca-cell androgen production, while hyperinsulinemia amplifies androgen synthesis and suppresses hepatic sex hormone–binding globulin (SHBG), increasing circulating free testosterone. The resulting hyperandrogenic environment disrupts follicular maturation, leading to chronic anovulation and menstrual irregularity.
Adapted from [4]

One of the most common causes of chronic menstrual irregularity is Polycystic Ovary Syndrome (PCOS), a complex endocrine and metabolic condition affecting roughly 6-15% of reproductive-aged individuals depending on the diagnostic criteria used [1]. It is frequently labeled a gynecologic disorder, but that framing is incomplete. PCOS represents systemic dysregulation that involves the hypothalamic-pituitary-ovarian axis and metabolic signaling pathways. Insulin resistance is central to its pathophysiology. Elevated insulin levels enhance LH-mediated stimulation of ovarian theca cells, increasing androgen production [2]. These excess androgens impair granulosa cell function and arrest follicular development, preventing ovulation. At the same time, insulin suppresses hepatic production of sex hormone-binding globulin, increasing free circulating testosterone [3]. Altered GnRH pulsatility shifts the LH-to-FSH ratio and sustains this imbalance.

This endocrine environment creates chronic anovulation. Cycles lengthen, ovulation becomes inconsistent or absent, and menstrual irregularity becomes clinically apparent. But what appears on the calendar is only the surface of a broader metabolic disturbance. The ovary is responding to signals originating from insulin pathways, adipose tissue and central neuroendocrine regulation. Irregular menstruation is not random. It is physiologic information.

When Hormonal Absence Becomes Risk

Ovulation isn’t simply about fertility. It’s part of cyclical hormonal balance. In a typica ovulatory cycle, progesterone produced after ovulation stabilizes and differentiates the endometrium. In chronic anovulation, progesterone exposure is reduced or absent. Estrogen continues to stimulate endometrial proliferation without opposition.

Over years, prolonged unopposed estrogen exposure increases the risk of endometrial hyperplasia and carcinoma [2,5]. This risk isn’t theoretical. It is why clinical guidelines recommend evaluation when cycles consistently exceed 35 days or when fewer than eight menses occur per year. This risk reflects prolonged proliferative signaling without progesterone-mediated differentiation of the endometrium. What is often minimized as “irregular periods” may represent sustained proliferative signaling at the endometrial level.

PCOS also extends into metabolic health. Individuals with PCOS have increased prevalence of insulin resistance, impaired glucose tolerance, type 2 diabetes mellitus, dyslipidemia, and metabolic syndrome [6]. The 2023 International PCOS Guideline recommends routine metabolic screening independent of BMI status [1].

Emerging research describes chronic low-grade inflammation, altered adipokine signaling, and disturbances in insulin signaling pathways such as PI3K/AKT. These findings reinforce that PCOS is not isolated to ovarian morphology. It reflects systemic metabolic vulnerability that may manifest years before overt disease develops.

Figure 2. Hormonal Patterns in Ovulatory vs Anovulatory Cycles.

Comparison of key reproductive hormone trends across a normal ovulatory cycle versus an anovulatory cycle. In the absence of ovulation, the luteal progesterone rise does not occur, and hormonal balance remains disrupted.
Adapted from [7]

Clinical Literacy Begins With How We Care for Ourselves

Figure 3. Multidimensional Consequences of Polycystic Ovary Syndrome.

This adapted schematic illustrates how PCOS affects multiple interrelated domains beyond the menstrual cycle. Reproductive, cardiometabolic, dermatologic, and psychological manifestations frequently coexist, underscoring that PCOS is a systemic endocrine-metabolic condition rather than a single-organ disorder.
Adapted from [8]

For medical students, this discussion isn’t abstract. We are trained to recognize endocrine abnormalities in patients. We identify oligomenorrhea, hyperandrogenism, insulin resistance, and metabolic risk as clinical clues.

But training environments often reward endurance over attention to health. Irregular sleep. Missed meals. Chronic stress. These become normalized. Physiologic shifts are attributed to workload.

Endocrine physiology does not adapt to academic calendars.

Taking care of ourselves as physicians in training requires the same principles we advocate for our patients. It begins with awareness. Tracking menstrual patterns rather than dismissing them. Recognizing when cycles consistently exceed 35 days. Seeking evaluation if amenorrhea persists beyond three months [1].

It also means acknowledging metabolic health as part of professional responsibility. Obtaining appropriate screening when indicated. Understanding personal risk factors.

Addressing insulin resistance through evidence-based strategies including regular physical activity, balanced macronutrient intake, and adequate sleep. Structured exercise interventions have demonstrated measurable improvements in insulin sensitivity and cardiometabolic markers in individuals with PCOS [8]. These behavioral factors influence insulin sensitivity and hormonal regulation.

Sleep itself modulates insulin signaling and hypothalamic function. Chronic sleep deprivation alters cortisol patterns and metabolic stability. For physicians in training, protecting sleep is not indulgence. It is endocrine protection.

Stress management is similarly physiologic, not cosmetic. Chronic activation of the hypothalamic-pituitary-adrenal axis interacts with metabolic and reproductive signaling. Structured exercise, restorative practices, and mental health support are not peripheral wellness trends. They influence endocrine balance directly.

Finally, self-advocacy matters. Seeking medical evaluation when symptoms persist. Requesting appropriate referrals. Not minimizing symptoms because we feel we “should handle it.” Preventive medicine does not exclude the provider. Ultimately, what begins as a calendar irregularity can reflect years of underlying endocrine signaling. If we believe early detection reduces long-term cardiometabolic and oncologic risk, that belief must apply inward. Ignoring persistent irregular cycles risks reinforcing the historical minimization of women’s symptoms and delayed endocrine diagnosis.

PCOS illustrates something larger than a diagnostic algorithm. It shows how reproductive health, metabolic regulation, oncologic risk, and psychological well-being are interconnected. Irregular periods are not trivial. They are physiologic signals. As future physicians, we are trained to interpret signals carefully. That responsibility does not end with patient encounters.

Menstrual health deserves the same seriousness we give every other vital sign.

References

1. International Evidence-Based Guideline for the Assessment and Management of Polycystic Ovary Syndrome 2018. Monash University; 2018. Updated 2023.
2. Legro RS, Arslanian SA, Ehrmann DA, et al. Diagnosis and treatment of polycystic ovary syndrome: An Endocrine Society clinical practice guideline. J Clin Endocrinol
Metab. 2013;98(12):4565-4592. doi:10.1210/jc.2013-2350
3. AMBOSS. Polycystic Ovary Syndrome. AMBOSS Medical Knowledge Library. Updated
2024. Available at: https://www.amboss.com
4. Rosenfield RL, Ehrmann DA. The pathogenesis of polycystic ovary syndrome. N Engl J
Med. 2016;374(1):54–64. doi:10.1056/NEJMra1415564
5. American College of Obstetricians and Gynecologists. Practice Bulletin No. 194:
Polycystic Ovary Syndrome. Obstet Gynecol. 2018;131(6):e157–e171.
doi:10.1097/AOG.0000000000002656
6. Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Lancet Diabetes Endocrinol. 2018;6(6):476–491.
doi:10.1016/S2213-8587(18)30045-5
7. MiraCare. Anovulatory Cycle Explained: What Is It and How to Prevent It. MiraCare
Blog. Available at: https://shop.miracare.com/en-int/blogs/resources/anovulatory-cycle-explained-what-is-itand-how-to-prevent-it
8. Sabag A. Exercise in the management of polycystic ovary syndrome. J Sci Med Sport.
2024. doi:10.1016/j.jsams.2024.05.01