PCOS in Adolescents: A Diagnostic Conundrum

The diagnosis of polycystic ovary syndrome (PCOS) in teens is difficult. Many of the symptoms that are part of the diagnosis in adults reflect normal pubertal development in adolescents. The question is, at what point do the signs and symptoms cross over from normal teenage developmental irregularities to a pathologic state? Unfortunately that line is not clear.

Wide disparities in treatment regimens further point to the difficulties in diagnosis. If the diagnosis was straightforward, there would be a simple algorithm, and we would all follow it. Yet every week, I sit in my office talking with young women and their often-frantic mothers who have been handed an unequivocal diagnosis and been told that there is a high likelihood that she will be infertile.

Given the difficulty in diagnosing PCOS in adolescents, it seems rather presumptuous and even cruel to make such proclamations. That said, an accurate diagnosis is important, not just for its fertility implications (generally of most concern to patients) but because of the future risk of diabetes, cardiovascular disease, and metabolic syndrome.

Currently, there are no special criteria for the diagnosis of PCOS in adolescents. In fact, there remains controversy over which of the 3 criteria sets (Rotterdam, Androgen Excess Society, or National Institutes of Health) to use in adults. Overall, the Rotterdam criteria are used most often with adolescents, requiring that 2 of 3 conditions be met: oligoovulation or anovulation, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasound. In addition, other etiologies must be excluded.

In the adolescent, however, it can be difficult to determine whether oligomenorrhea/anovulation is pathologic or simply part of normal development. How can we know whether a girl’s acne is a sign of clinical hyperandrogenism? Because of these issues, several groups have proposed establishing stricter or more extensive criteria for the diagnosis of PCOS in adolescents to eliminate overdiagnosis and overtreatment. However, these recommendations currently are not endorsed by expert panels or societies in the field.¹

In considering oligomenorrhea, cycles of longer than 6 to 8 weeks are thought to be abnormal in adults. In the adolescent, anovulatory cycles soon after menarche may mimic this pattern. On average, 1 year after menarche, most girls will have regular monthly menses, although girls who begin to menstruate after age 13 may take longer to establish a regular cycle. Oligomenorrhea at age 15 or older, however, tends to persist and may be a more accurate indicator of a longer-term hormonal imbalance.¹

When looking at acne as a clinical sign of hyperandrogenism, it is important to remember that 80% to 90% of adolescents have acne and 25% require pharmacological treatment. While acne may be part of the normal adolescent experience, hirsutism is not. As such, excessive and inappropriate hair growth may be a better indicator of clinical hyperandrogenism in girls. Of course, laboratory evidence of elevated testosterone is the most reliable measure.¹

In adolescents who present with symptoms of PCOS, laboratory screening should be done. The usual panel is: FSH, LH, estradiol, prolactin, TSH, testosterone free and total hormone, DHEAS, and 17-OHP. Ultrasound of the ovaries can be ordered as well. If the laboratory test results indicate PCOS, then the additional tests of GTT, fasting lipids, hemoglobin A1c, and fasting insulin levels should be obtained. Patients need to be followed at least yearly to screen for the development of metabolic syndrome and diabetes.

Once the diagnosis of PCOS has been made, the question of treatment arises. Recent research has found discrepancies in treatment of adolescents with PCOS even among pediatric subspecialists in the same institution.² There was general agreement on treatment with combination oral contraceptives. Recommendations with respect to “lifestyle changes” (ie, exercise and weight loss), metformin, and antiandrogen agents varied significantly by specialty. In considering treatment modalities and long-term follow-up, we must also bear in mind that, if a girl is diagnosed at a young age with PCOS, by the time she is in her 30s her symptoms and metabolic abnormalities may have significantly diminished or disappeared entirely.³

In short, the diagnosis of PCOS in adolescents should be given cautiously, with significant patient and parental counseling. No one should tell these young women that they wouldn’t be able to conceive a child normally. We should be screening them on a regular basis to promptly diagnose possible diabetes or metabolic syndrome. In the interim, we should encourage these young women to exercise regularly, engage in a weight-loss regimen, and treat them symptomatically as needed.

References:

1. Roe AH, Dokras A. The diagnosis of polycystic ovary syndrome in adolescents. Rev Obstet Gynecol. 2011;4(2):45-51.
2. Auble B, Elder D, Gross A, Hillman JB. Differences in the management of adolescents with polycystic ovary syndrome across pediatric specialties. J Pediatr Adolesc Gynecol. 2013;26:234-238.
3. Carmina E, Campagna AM, Lobo RA. Polycystic ovary syndrome after 20 years. Obstet Gynecol. 2012;119(pt 1):263-269.