INTRODUCTION:

An estimated 8–13% of women who are of reproductive age have PCOS, or polycystic ovarian syndrome. In the world, up to 70% of afflicted women are still untreated. One of the main causes of infertility and the most common cause of anovulation is PCOS. Many chronic health issues affecting both physical and mental well- being are linked to PCOS. Although PCOS is inherited, there are ethnic differences in the symptoms and effects of the disease.^1,2A growing percentage of women between puberty and menopause are affected with polycystic ovarian syndrome, a prevalent hormonal condition. Because it describes several symptoms that are felt concurrently, it is referred to as a syndrome.

It is sometimes referred to as hyperandrogen angulation syndrome, stein-Leventhal syndrome, and polycystic ovarian disease. The main characteristics are anovulation, which causes irregular menstruation, amenorrhea, infertility linked to ovulation and polycrystalline ovaries, excessive levels of androgenic hormones, which cause acne and hirsutism, and insulin resistance, which is frequently linked to obesity, type 2 diabetes, and high cholesterol.^3,4It is a serious matter for public health. Unwanted alterations in women's bodies are noticed. It may cause major health problems like diabetes, weight gain, and heart disease if left untreated. Women's ovaries are found to have several small cysts. It is named for this reason. The occurrence of PCOS is significantly influenced by a number of genetic and environmental factors. Beyond just harming the reproductive system, this complex illness also affects a woman's metabolism, heart health, immunity, and general well-being.^5,6The understanding of PCOS pathophysiology has significantly improved over the last ten years thanks to genome wide association studies (GWASs). These studies have identified a number of critical genes that are thought to be the most promising ones involved in PCOS. These genes include those related to steroidogenesis, the hypothalamic-pituitary pathway, gonadotropin action, insulin action and secretion, adipose tissue disturbances, homeostasis, lipid metabolism, and chronic inflammation. LHR, FSHR, INSR, FRB, THADA, and HMGA2 are a few of these genes^7-11.There is currently no recognized cure for PCOS, and its true etiology is still unknown. Ovarian steroids and implants are the primary causes of this illness, which must largely affect adult females between the ages of 25 and 30. There is no denying the link between endometriosis and the effects it has on women's physical, emotional, and social wellbeing. Studies indicate that the pathophysiology of endometriosis is not well understood^12,13.

Figure.1: Normal ovary and Polycyst Ovary

Organs Involved in PCOS:

· Ovary- The female gonad organ present at either side of uterus.

· Adrenal Gland-The gland which are placed just above the both the kidneys

· Pancreas-Gland that produces insulin in our body.

· Pitutary Gland –The gland just below the brain, which is responsible for all the hormonal control¹⁴.

Ovarian follicle maturation is inhibited by the ovaries' increased synthesis of Androgen." Ovum thus does not develop correctly and does not anovulation is caused by the release. During sexual contact, sperm and ovum combine to form a fertilized egg. Because of the inability to produce an ovum, a woman with PCOS will therefore have difficulty getting pregnant. Anatomical abnormalities of many kinds are linked to PCOS. PCOS, also known as ovarian cysts, causes the ovaries to swell two to five times their natural size. Stroma is raised¹⁵.

Pearly white in color, the capsule has thickened. There are several cysts inside the typically oval-shaped ovary. An analysis of lifestyle factors indicates that poor eating is the primary cause of PCOS.Women with PCOS who are young, stressed often consume excessive amounts if fat, sugar, carbonated beverages, and highly processed carbohydrates, leading to an unhealthful rise in insulin level. Insulin stimulates androgen receptors outside of the ovary, which contributes to the characteristic symptoms of PCOS and inhibits the follicle’s ability to release ovum. This kind of diet will result in obesity, which will exacerbate PCOS and cause that is connected to obesity to develop. PCOS is one of the numerous diseases that are accelerated or caused by the stressful modern lifestyle and eating habits^16-18.

Types of PCOS:¹⁹

Type-I PCOS	(a) Insulin-resistant PCOS (b) Non-Insulin resistant PCOS
Type-II PCOS	Pill-induced PCOS or post- pill PCOS
Type-III PCOS	Inflammatory PCOS
Type-IV PCOS	Hidden-cause PCOS

Type 1 PCOS:

Insulin-resistant PCOS:

Insulin resistance and leptin resistance will develop in this kind of PCOS because of incorrect signaling from these metabolic hormones, which prevent ovulation and stimulate the production of testosterone by the ovaries. Weight gain is primarily caused by an issue with the metabolic hormones. When insulin and leptin sensitivity improve, symptoms of high testosterone, like acne and facial hair, will also improve.

Insulin resistance and Type 1 PCOS causes include:

· Resistance to leptin

· Excessive sugar intake

· Toxins that disrupt hormones, like bisphenol A

· Smoking

· Birth control tablets.

Non-insulin- resistant types of PCOS:

Multiple immature follicles may be visible on the ultrasonography. There may be an increase in luteinizing hormone (LH) and irregular menstruation. A normal or high testosterone level is possible. Acne and facial hair occur when oestrogen levels are too low in relation to testosterone, even when testosterone levels are acceptable. One's body weight may be typical. Insulin inhibited the ovaries from ovulating in the insulin-resistant type. There are other forms of PCOS when the ovaries are unable to ovulate for an unexplained cause.

Type 2 PCOS:

Pill-induced PCOS or post-pill PCOS:

Ovulation is suppressed by birth control pills. Ovulation will often return quite soon after the pill is stopped for the majority of women, thus that is only a temporary impact. But for some women, the suppression of ovulation might last for months or even years. Receiving a PCOS diagnosis during that period is not out of the ordinary. This is the second most prevalent kind of PCOS.

Type 3 PCOS:

Inflammatory PCOS:

Stress, pollutants in the environment, intestinal permeability, and inflammatory foods like gluten or A1 casein all contribute to inflammation or chronic immunological activation. Due to its interference with ovulation, disruption of hormone receptors, and stimulation of adrenal androgens such dehydroepiandrosterone and androstenedione, inflammation is problematic for PCOS.

Type 4 PCOS:

Hidden-cause PCOS:

Ovulation is being hindered by one easy thing. This kind of PCOS normally goes away in 3–4 months once that one issue is resolved. Typical hidden reasons of PCOS include:

· Iodine deficiency because ovaries require iodine

· Thyroid disease because your ovaries require T3 thyroid hormone

· Vegetarian diet because it causes zinc deficiency

· Artificial sweeteners because they interfere with insulin and leptin signaling

· Dietary starch levels are too low since the hormone system requires gradual carbohydrates.

CAUSES OF PCOS:

Although the exact etiology of PCOD is unknown, it is thought to be related to an imbalance in hormones. A multitude of anomalies have been reported in women with PCOD^20,21. Generic (inherited) cause: PCOD frequently runs in families. It can be passed down from mother, aunt, or sister, who may also exhibit the same symptoms. An individual's chance of developing PCOD may rise as a result²². Insulin Resistance: The majority of women with PCOD have increased insulin production as a result of their insulin resistance. The amount of glucose (a form of sugar) in the blood is regulated by the insulin hormone that the pancreas secretes. Insulin resistance, a condition associated with PCOD, is the body's inability to react to insulin. The result is an increase in glucose levels. Insulin is produced at higher levels in order to stop the rise. Overproduction of insulin results in the production of androgen, a male hormone that exacerbates PCOD symptoms such as weight gain, acne, irregular periods, and difficulty ovulating. Prolactin, which increases the production of milk by the breast glands, luteinizing hormones (LH), which bind sex hormones, and globulin are other hormones that are elevated in PCOS. When they are elevated, they have an aberrant effect on the ovaries and lower excessive levels of testosterone^23,24.

· Genetics:

The synergistic illness Multifactorial and polygenic PCOS is present. In certain instances, PCOS can run in families. Despite having an autosomal dominant genetic inheritance, PCOS has several gene origins, according to the most recent studies. Genome-wide association studies have revealed a number of genetic loci and specific genes that are linked to this illness²⁵.

· Stress:

Stress is recognized to be a contributing factor in PCOS, especially when it comes to the outward manifestations of the illness, including excessive body and face hair. Depression and anxiety may result from this stress. It primarily affects younger PCOS-afflicted women²⁶.

· Hormonal imbalance:

PCOS individuals generate small levels of luteinizing hormone (LH), which initiates ovulation. If concentrations of this hormone are too high, it can have a harmful effect on the ovaries. Additionally, PCOS patients have been found to have an imbalance in testosterone and an excessive amount of this hormone. Higher concentrations of prolactin—a hormone that boosts breast milk production during pregnancy—were linked to lower levels of SHBG, a blood protein that binds to testosterone and decreases its effects (although only in some PCOS-affected women). The precise cause of these hormonal fluctuations is uncertain²⁷.

· Oral Contraceptives:

The OCPs are separated into progesterone-only and mixed pills that contain progesterone (norethisterone, desogestrel) and oestrogen (estradiol dosage up to 50μg). For women who are experiencing irregular menstruation and do not want to ovulate, they are the first line of treatment. OCPs increase SHBG, which lowers the levels of androgens in the blood. Although OCP use reduces the incidence of ovarian cancer, women with PCOS are nonetheless at risk for cancer. While OCP use does not impact insulin resistance, it does reveal lipid profile fluctuation that could result in metabolic disruptions. In light of this, OCP use should be based on risk grade and should end right away in the event of a discrepancy^28-30.

· Insulin Resistance:

In PCOD, insulin resistance is the main etiologic cause. Women with PCOD frequently have hyperinsulinemia and insulin resistance. The insulin resistance associated with PCOD has been identified in adipocytes by a post-binding error in insulin receptor-mediated signal transduction in skeletal muscle. This is caused by an excess of testosterone, which increases insulin resistance in peripheral tissues. Infertility, hyperandrogenism, hirsutism, and problems related to irregular menstruation are all increased by obesity, both directly and indirectly, by aggravating the insulin resistance associated with PCOD. Thirty to sixty percent of PCOD patients have a BMI of more than thirty kilograms per square meter, and obesity is linked to hyperinsulinemia. Insulin resistance is present in even slim women with PCOD, and it gets worse as body mass index (BMI) rises³¹.

· Excess androgen:

High quantities of androgen may be produced by the ovaries in PCOS. An excess of androgen prevents ovulation. This indicates that eggs do not regularly grow and are not discharged from the follicles in which they do so. Acne and hirsutism are further consequences of excess androgen³².

RISK FACTOS³³:

Diabetes	By the age of 40, more than half of PCOS-afflicted women have type 2 diabetes.
Infertility	The majority of PCOS infertility cases result from: Hormone imbalances, such as elevated testosterone levels, that impair ovulation. Irregular cycle of menstruation, Insufficient uterine lining hindering the implantation of eggs.
High Cholesterol	High cholesterol increase the risk of heart disease.
Risk of endometrial cancer	The endometrium’s extended exposure to unopposed estrogen brought on by anovulation is the main factor contributing to PCOS’s increased risk of endometrial cancer Endometrial hyperplasia and endometrial cancer may result from this extended exposure.
High risk of gestational diabetes	(diabetes during pregnancy)-which increase the risk of type 2 diabetes in later life for both the mother and the child and puts pregnancy and infant at risk.
Hypertension	Affects heart, brain, kidney.
Heart Disease	The risk with increase in age.
Sleep Apnea	Disorder leads to stop breathing during sleep and increase the risk of type 2 diabetes and heart disease.
Stroke	Plaque (Cholesterol and white blood cells) Formation of blood clots which may leads to stroke.

SIGNS AND SYMPTOMS OF PCOS:

PCOS symptoms can range from moderate to severe, some women may experience irregular periods, infertility or both. Typical signs and symptoms of PCOS include:

· Obesity (50%)

· Diabetes due to insulin resistance (75%)

· Obstructive sleep apnea

· Oligomenorrhoea/amenorrhea

· Acanthosis nigricans

· Infertility/First trimester miscarriage

PATHOPHYSIOLOGY³⁴:

Follicles that don't ovulate develop PCOS. It was brought on by GnRH's (gonadotropin-releasing hormone) aberrant activity. GnRH was released by the hypothalamus. Normally, the blood travels to the anterior pituitary cells to trigger the release of luteinizing hormone, or LH, and Follicle stimulating hormone, or FSH, in a pulsatile fashion (pulsatile drug delivery system is rapid & transient release of certain amount of drug molecules within short time period immediately after a predetermined off release period). The ovary receives LH and FSH through the bloodstream, where they interact with the granulosa and thecal cells to stimulate the production of oestrogen before to ovulation. Mainly progesterone following ovulation during the lactal phase and during the follicular phase A crucial role for progesterone is played in this ovulation. This progesterone has an adverse feedback mechanism that GnRH to lower its frequency within the usual range, maintaining the proper ratio of LH to FSH. PCOS is caused by an increase in the hypothalamus's regular pulsatile production of GnRH, and the absence of elevated progesterone during the lactal phase is the cause of the increased GnRH pulse frequency observed in PCOS. A corpus lutearpus luteam is not formed if the follicles do not ovulate during the lactal phase, and progesterone does not rise in the absence of corpus luteum. Consequently, there is a greater level of LH than FSH. To encourage a follicle to the point where it can ovulation in PCOS, FSH is required. In comparison, LH is higher while FSH follicles not developed enough to operate as functional graphene follicles capable of ovulation are caused by decreased FSH. The cysts that develop on the ovary in PCOS patients are the non-ovulating follicles.

Figure.2: Pathophysiology of PCOS

MANAGEMENT OF PCOS^35-39:

Be active. Getting exercise lowers blood sugar. Increasing your daily activity and exercising frequently can help treat or possibly prevent insulin resistance if you have PCOS. Maintaining an active lifestyle can also help you prevent diabetes and regulate your weight.

· Suryanamaskar:

Meditation and Surya Namaskar are beneficial for health and overall wellbeing. Coping Strategies for Women with Polycystic Ovarian Syndrome: Surya namaskar and Meditation for Social Physical Anxiety and Body Dissatisfaction.

· Bow Pose (Dhanurasana):

Dhanurasana, according to Bhanote, may assist regulate menstrual flow, stimulate reproductive organs, and ease discomfort associated with menstruation. "It releases tension from abdominal organs, improves circulation to the pelvic area, and stretches the muscles in the neck, shoulders, and legs," the woman explains. All in all, it could decrease tension and increase anxiety.

· Garland Pose (Malasana):

Malasana can expand the hips and improve the abdominal core and pelvic floor. According to Bhanote, this can help people with PCOS by boosting blood flow and circulation to the pelvic area, enhancing metabolism, and facilitating digestion.

· Bridge Pose (Setu Bandhasana):

By releasing tension in the back muscles, Bridge Pose helps relax the brain and lessen stress and anxiety.

· Butterfly or Bound Angle Pose

(Supta baddhakonasana):

According to Burnett, this is a very healing pose that opens the hips and heart, gently releases tension from the shoulders and chest, and fully supports the spine and back body. Every level is suitable for this position. Use cushions or blankets below the thighs, below the head at an angle, and below the shoulders.

TREATMENT OF PCOD:

Different secondary metabolites helps in treatment of PCOS by the following mechanism:

· Anti-androgenic effect

· Alteration of prolactin level

· Effective ovulation induction

· Promoting FSH and decreasing LH secretions

· Restoring glucose sensitivity and estrus cyclicity

A. Synthetic Medication^40-42:

The neuroendocrine system, obesity sedentary lifestyle, genetics, and food are risk factors that lead to PCOS development. While synthetic medications like metformin and oral contraceptive tablets are available for use in treatment, there are concerns over their negative effects. Multiple organ systems are affected by the complex condition of PCOS. Based on the patient’s appearance and desire for pregnancy, a customized course of treatment should be implemented.

B. Herbal Medication:

Herbs are known for their medicinal properties and applications. In a circumstance where modern man has encountered the negative effects and complexities of chemical drug use, one can revert back to nature and employ natural and plant-based medications. Research has shown that a variety of complementary medicine techniques, such as the use of herbs to treat certain conditions, are both safe and effective⁴³.

The use of herbal plants in the treatment of polycystic ovarian syndrome (PCOS) has been documented. These extracts have been shown to improve ovulation, insulin resistance, hyperandrogenism, sex hormone levels, and PCOS symptoms⁴⁴.

Ginger:

Zingiber officinale a member of the Zingiberaceae family. Ginger rhizomes are widely utilized for many reasons and have therapeutic qualities. Antimicrobial, anticancer, antiviral, analgesic, antidiabetic, antioxidant, nephron- protective, sedative, hepato-protective, anti-inflammatory, and antiemetic properties are the main uses for it^45-51. Ginger contains active ingredients such 6-gingerol, shogaol, 6-gingerol, zingiberene, zingeberone, and gingerenone, which are responsible for many biological activities^52,53. PCOD's main concerns are obesity and insulin sensitivity. Ginger significantly lowers body weight via raising High Density Lipoproteins and improving insulin sensitivity, both of which are related to type 2 diabetes^54,55. For individuals with insulin resistance, ginger may be a promising supplemental treatment. A few studies have also shown that 6-gingerol's anti-oxidant and anti-inflammatory qualities lower sex hormone levels and enhance ovulation in Wistar rats with PCOD.Ginger therapy is an adjuvant option for PCOD treatment.

Shatapushpa:

Seeds from the Apiaceae plant, Foeniculum vulgare, are a useful complement for PCOS treatment. They contain a wealth of phytoestrogens. The phytoestrogens in fennel aid in lowering PCOS inflammation and decreasing insulin resistance. It's also thought to aid in lessening the cellular imbalance that causes PCOS's metabolic problems⁵⁶. These days, a variety of ailments, especially those affecting the digestive system, are treated with various portions of this plant. Additionally, it helps a lot with kidney stones, diabetes, bronchitis, chronic cough, nausea, and vomiting⁵⁷.

Maca:

Traditional herbal medicine Lepidium meyenii, which belongs to the Brassicaceae family, is used to treat menopausal symptoms. It also acts as a natural hormone balancer with no negative consequences. The body's progesterone and estrogen hormones aid in promoting a regular menstrual cycle. It's a superfood that increases fertility and an adaptogen. Male testosterone levels are restored with Lepidium meyenii⁵⁹.

Coconut Palm:

Cocos nucifera is a member of the Arecaceae family, which is also known as naral in Marathi and nariyal in Hindi. The active ingredients in C. nucifera have antioxidant, antihypertensive, and antibacterial properties^60,61. The main symptoms of letrozole-induced PCOD in female rats are lessened by the Cocos nucifera blossoms. Monitoring revealed that it exhibits an estrogenic impact, increasing the weight of the ovary, raises the amount of HDLs, and helps treat polycystic ovaries because of its potent antioxidants⁶². The extract of C. nucifera has a hypoglycemic effect by bringing the high levels of hormones, such as FSH and LH, back to normal. It also contains flavonoids, such as 3, 5-Dihydroxy-6-methyl-2 and 3-dihydro-4Hpyran-4-one. For PCOD, cocos nucifera can therefore be used as a supplemental therapy^63,64.

Turmeric:

Curcumin longa, a plant utilized for medicinal purposes, is found in plant rhizomes. Curcumin is a member of the zingiberaceae family and is commonly added to cuisine⁶⁵. Certain flavonoids, volatile oils, turmerone, and other substances found in curcumin have anti-inflammatory, antioxidant, and hypoglycemic properties⁶⁶. In Wistar rats given letrozole, curcumin significantly lowers or avoids blood sugar spikes, lowers increased hormone levels, and improves lipid profiles. It enhances ovulation as well. Therefore, antihyperlipidemic and hypoglycemic actions can be utilized in PCOD therapy because of potent antioxidants⁶⁷.

Cinnamon:

Lauraceae is the family that includes cinnamon. It is utilized in a variety of meals, for fragrance, and in medical settings. Cinnamaldehyde, essential oils, polyphenols, and procyanidins are the active ingredients in cinnamon; these substances have anti-oxidant, anti-inflammatory, anti-microbial, and hypoglycemic properties⁶⁸. It has been discovered that in women with PCOD, the polyphenols and procyanidins in cinnamon extract improve insulin sensitivity and lower low density lipoproteins. It increases insulin's potentiation. It demonstrates how cinnamon may help with PCOD therapy. Cinnamon supplements greatly control the menstrual cycle and are quite beneficial for treating polycystic ovarian disease^69,70.

Peppermint:

Mentha piperita, also known as peppermint, is a member of the Lamiaceae family and has several medicinal use. Essential oils include acetaldehyde, amyl alcohol, limone, citronellol, menthol, and some flavonoids and phenolic acids make up peppermint^71,72. In a study using an animal model, peppermint oil lowers testosterone levels and weight in PCOD patients. One of the main issues with PCOD that causes anovulation is infertility. Consuming peppermint can enhance ovulation⁷³. In PCOD-induced rats, the administration of peppermint and flaxseed extract substantially enhanced endocrine hormone secretions and restored ovarian shape⁷⁴. Antioxidant characteristic Supplementing with peppermint oil improved ovarian cysts, necrosed luminal epithelial cell hyperplasia, and stimulated stromal mesenchymal cells⁷⁵.

Aloe vera:

The plant most frequently employed for its therapeutic properties is aloe vera. Steroidogenesis was successfully restored by the phytosterols found in aloe vera. Anthraquinones, chromones, polysaccharides, and enzymes with hypoglycemic, anti-inflammatory, and antioxidant properties are the main phytoconstituents⁷⁶. Aloe vera effectively enhances insulin sensitivity; a woman with PCOD frequently had insulin resistance⁷⁷. A female rat given the aromatase inhibitor letrozole to develop PCOD. After that, the rat received an oral dosage of 1 milliliter of aloe vera gel every day for 45 days. Rats have been shown to recover the steroidogenesis and estrus cycle. It raises levels of high density lipoprotein and lowers triglycerides⁷⁸.

Fenugreek:

Ayurvedic herb fenugreek, a member of the Fabaceae family, is widely distributed worldwide and has been found in a few studies to enhance oestrogen and testosterone levels. In addition to its ability to successfully lower blood glucose, the plant is carminative, antioxidant, anti-inflammatory, and hypolipidemic⁷⁹. The menstrual cycle and sonographic outcomes were enhanced in PCOS women taking fenugreek seeds together with metformin⁸⁰. due to increased amounts of proinflammatory cytokines, painful cramps that happen during menstruation⁸¹. The main prescription used to treat PCOD is on-steroidal anti-inflammatory drugs (NSAIDs), although these have side effects that can be problematic. For pain during menstruation research, fenugreek has been used traditionally^82-84.

Liquorice:

Liquorice is a member of the Leguminosae family, which is used to treat a number of illnesses. According to reports, licorice possesses pharmacological properties that include anti-inflammatory, antiviral, antifungal, anticancer, anti-allergenic, anti-diabetic, anti-oxidant, anti-thrombic, anti-malarial, antibacterial, immune- stimulating, and more. Liquorice contains flavonoids such as rhamnoliquirilin, isoliquertin, liquiritigenin, and liquirtin as well as glycyrrhizic acid as an active ingredient^85,86. The chemical components of liquorice, glabrene and glabridin, decrease low density lipoproteins and mimic the effects of oestrogen. In mice with PCOD, liquorice was found to dramatically boost oocyte fertilization rates and enhance embryo growth. When liquorice and spironolactone are used together, it greatly helps women with PCOD⁸⁷.

Comparison of Synthetic drugs and Herbal drugs:

In addition to curing illness, synthetic medications have serious negative effects on the human body. There are numerous examples related to the adverse effects caused by synthetic medications. e.g; Pioglitazone can cause cardiovascular diseases as major side effect. Eflornithin causes heartburn. Spironolactone also causes hyperkalemia, hypotension. Whereas, Spices, such as cinnamon, cloves and turmeric, have therapeutic effects on the human body in addition to herbs. For instance, curcumin, which is present in turmeric, may be effective in treating a variety of illnesses, including arthritis, depression, pain, inflammation, and skin conditions.

CONCLUSION:

PCOS, or polycystic ovarian syndrome, is a prevalent endocrine condition in women that can lead to infertility. Two out of every ten women in India and 116 million women globally, or roughly 3.4% of all women, suffer with PCOS. PCOS is thought to be a primary cause of female subfertility that arises from both genetic and environmental factors. Women now face a significant health risk from PCOS, which frequently manifests as hirsutism, acne, cystic ovaries, obesity, and hair loss. It shares several characteristics with the metabolic syndrome, such as the presentation of diabetes, obesity, and insulin resistance. Herbal medications show steady efficacy and little adverse effects, making them a promising option for treating PCOS. Herbal medications strengthen the immune system and support menstrual cycle regulation without interfering with hormone levels. PCOS can be managed with a balanced diet, frequent exercise, alterations to lifestyle, and medication. Additionally, studies have indicated that yoga helps women with PCOS.

CONFLICT OF INTEREST:

No conflict of interest was declared by the authors. The authors alone are responsible for the content and writing of paper.

ACKNOWLEDGEMENTS:

The authors would like to acknowledge Principal, Yashoda Technical Campus, Satara, for their encouragement and guidance.

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Drug	Purpose of Therapy	Mechanism of Action	Side Effects
Combined Oral Contraceptives (Estrogen and Progesterone)	Menstrual cyclicity: Hirsutism, Acne	Suppresses LH 9(and FSH) and this ovarian androgen production, Increase sex hormone globulin, which decrease free testosterone	Breast tenderness, mood swings, breakthrough bleeding, lipido changes
Metformin	Hirsutism, acne, anovulation,	Decreases the serum lipid, androgen and	Nausea and vomiting,
	Androgen excess, Hyperinsulinemia	insulin; increase the pregnancy rate	Diarrhoea, Metallic taste, Lactic acidosis
Clomiphene Citrate	Ovulation induction	Secrete an increased amount of follicle stimulating hormone (FSH) and luteinizing hormone (LH)	Blurred vision, multiple gestations, vasomotor symptoms
Spironolactone	Hirsutism, acne	Acts as an anti-androgen by blocking androgen receptors	Hypotension, Hyperkalemia, Headache, Fatigue
Pioglitazone	Anovulation, Hirsutism, acne, Hyperinsulinemia, androgen excess	Improves insulin sensitivity at target-tissue level; may have direct effect on steroidogenesis	Weight gain, oedema, cardiovascular diseases
Eflornithine	Hirsutism	Acts by blocking the enzyme ornithine decarboxylase (ODC) that stimulates hair growth	Dry skin, dizziness, fatigue, heartburn
Letrozole	Infertility	Blocks conversion of androgen to estrogen in ovarian follicle	Increased cholesterol in the blood, hot flashes, joint pain

Types of PCOS:19