Polycystic Ovary Syndrome in South Asia: Diagnostic Diversity, Endocrine Drivers, and Comorbidity Patterns with a Focus on Pakistan

Abstract

Background: Polycystic Ovary Syndrome (PCOS) is a complex reproductive–endocrine disorder that manifests through ovulatory dysfunction, hyperandrogenism, and polycystic ovarian morphology. Despite its global prevalence, South-Asian populations—particularly in Pakistan—exhibit distinctive metabolic, endocrine, and phenotypic patterns influenced by genetics, lifestyle, and diagnostic heterogeneity. Inconsistent application of NIH, Rotterdam, and AE-PCOS criteria complicates prevalence estimation and comparative research, while data from Pakistan remain fragmented and small-scale. Objective: To synthesize regional evidence on diagnostic diversity, endocrine mechanisms, and comorbidity patterns of PCOS in South Asia, with a specific focus on Pakistani cohorts, and to propose a pragmatic diagnostic and management framework suitable for resource-variable healthcare settings. Methods: A narrative review was conducted using observational and interventional studies reporting PCOS prevalence, phenotypes, and endocrine or metabolic outcomes among South-Asian women. Pakistan-based studies were prioritized. Mechanistic and review articles were incorporated to integrate evidence on hormonal regulation, insulin resistance, and metabolic risk. Critical appraisal employed JBI and NOS tools, with attention to sampling frame, diagnostic criteria, and phenotype reporting. Results: Evidence demonstrates a high PCOS burden in South Asia, with wide prevalence variability (7–20%) driven by diagnostic criteria. South-Asian women show earlier onset and heightened metabolic risk—insulin resistance, dyslipidemia, and non-alcoholic fatty liver disease—even at lower BMI. Small Pakistani series reveal high symptomatic presentation (infertility and obesity) and possible urban–rural gradients in adolescents, alongside frequent thyroid comorbidity. Insulin resistance and hyperandrogenism form a feedback loop, modified by gonadotropins and AMH, underpinning both reproductive and metabolic dysfunctions. Conclusion: PCOS in South Asia represents a multifaceted metabolic–reproductive disorder intensified by ethnic and environmental factors. Harmonized diagnostic criteria, phenotype-resolved reporting, and longitudinal research are essential to clarify true prevalence and risk patterns in Pakistan. Integrated models combining endocrine, metabolic, and psychological care—supported by context-adapted diagnostic algorithms—are crucial for effective management and prevention of long-term complications.