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.
The clinical impact of PCOS extends far beyond irregular cycles. Endocrine dysfunction drives insulin resistance, prediabetes, type two diabetes, dyslipidemia and the metabolic syndrome. Reproductive complications are profound; PCOS is implicated in nearly 40 percent of cases of anovulatory infertility in South Asian women. Women with PCOS experience repeated cycles of failed conception attempts and undergo invasive fertility treatments that impose significant economic and emotional strain. Mental health consequences are severe. International data show up to 40 percent of women with PCOS suffer depression and 34 to 57 percent report anxiety. Pakistani studies mirror these findings, with one reporting that 45 percent of women with PCOS screened positive for depression compared with 18 percent in controls. Visible symptoms such as hirsutism, acne and weight gain further erode confidence and expose women to shaming, compounding emotional distress.
The social consequences are no less damaging. Menstrual problems and infertility often carry stigma, and reproductive failure is frequently framed as a woman’s failing rather than a medical condition. Financial constraints and restricted female autonomy limit access to diagnostic testing and long term management. Women conceal or minimise their symptoms to avoid judgment, which lowers measured prevalence and creates the illusion that the problem is smaller than it is. This under reporting feeds back into public health planning, which in turn underestimates need. What results is a hidden epidemic in which cultural silence, poverty and medical neglect reinforce one another.
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. This methodological inconsistency complicates national planning. Moreover, metabolic risks often appear even in women who lack the full reproductive phenotype, arguing for broader case finding approaches in primary care rather than relying solely on symptomatic presentation.
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. Hormonal contraceptives are useful for menstrual regulation and reducing androgenic symptoms. For infertility, ovulation induction agents and assisted reproductive technologies are standard. But access is limited. Few women receive structured lifestyle programs or long term endocrinological follow up. Fertility care is concentrated in urban private centers and imposes catastrophic out of pocket costs for many families. The gap between evidence based interventions and their availability widens health inequity.
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. Without robust local data, health systems cannot design screening or prevention strategies tailored to Pakistani women. Global Burden of Disease data in 2021 estimated that PCOS accounts for more than 1.5 million disability adjusted life years worldwide, with middle sociodemographic regions including South Asia showing the fastest growth in prevalence and disability.
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.
