Polycystic Ovary Syndrome (PCOS) in Adolescents

Patient and Parent handouts on PCOS: youngwomenshealth.org

Last updated 10/10/2012 - Dr. Hina Talib

Pathophysiology (multifactorial)

  • Pituitary hypersensitivity to GnRH -> exaggerated LH release -> increased ovarian production of androstenedione, 17-OHP
  • Adrenal hyperresponsiveness to ACTH
  • Insulin potentiates GnRH and LH action and inhibits SHBG synthesis by liver -> increased free testosterone
  • Decreased SHBG + increased androgens -> increased adiposity
  • Adipose cell aromatase converts androgens -> estrogens -> adipocyte replication

Definition

Pathophysiology of PCOS

Pathophysiology of PCOS

Syndrome associated with ovulatory dysfunction, hyperandrogenism, hyperinsulinemia and insulin resistance that generally develops in peripubertal years

Epidemiology

  • Leading cause of anovulation, hirsutism and infertility in women of all ages
  • Prevalence: adults 3-23%, adolescents 5-10%

Diagnosis

  • 1990 NIH Criteria:  
    • Chronic oligomenorrhea/anovulation
    • Clinical and/or biochemical signs of hyperandrogenism
    • Exclusion of other etiologies
  • 2003 Rotterdam Criteria (2 of 3):
    • Oligo/anovulation
    • Clinical and/or biochemical signs of hyperandrogenism
    • Polycystic ovaries on sonogram
    • PCO = 12 or more follicles in each ovary measuring 2-9 mm in diameter, and/or increased ovarian volume (>10mL)
  • 2009 Androgen Society Criteria:
    • Excess androgen activity
    • Oligo/anovulation and/or polycystic ovaries
    • Exclusion of other etiologies of androgen excess

Differential Diagnosis and Laboratory Tests

  • PCOS: Elevated Total and free testosterone (diagnostic), decreased SHBG (suggestive), LH:FST ratio of 2:1 (suggestive)
  • Thyroid disease: TSH, free T4
  • Prolactinoma: prolactin
  • Adrenal tumor: DHEAS, if elevated CT with Adrenal Cuts
  • Late onset CAH: early AM 17-OH-P
  • Ovarian insufficiency: LH, FSH
  • Ovarian tumor: androstenedione
  • Cushing's syndrome
  • Iatrogenic, e.g., exogenous hormone use
  • Chronic disease: ESR
  • Pregnancy: urine B-HCG

Management

  • Weight loss
  • Ovarian suppression: OCPs to suppress LH, increase SHBG, decrease risk of endometrial cancer
    •   e.g. Sprintec (norgestimate 0.25mg and ethinyl estradiol 35 mcg) 1 pill daily
    •   Great choice if sexually active
  • Insulin sensitizer
    •   e.g. Metformin start at 750mg XR daily, with dinner, increase to BID after 3-6 weeks depending on tolerability of GI side effects
    •   Great choice if estrogen contraindications exist
  • Hirsutism Treatment
    •   Anti-androgens
    •   e.g. Spironolactone start at 25 mg BID and increase slowly to 200mg BID

Caveats in Adolescents

  • Difficult to distinguish physiologic anovulation from PCOS
  • Multifollicular ovaries can be normal in adolescence
  • Transvaginal U/S not reccomeded in virginal teens
  • Difficult to define androgen excess because there is little normative data about androgen levels

History and ROS

  • Menstrual irregularity after 2-3 years gyn age
  • Severe acne, hirsutism, deepened voice
  • Premature adrenarche, precocious puberty
  • Infertility
  • Headache, vision changes, galactorrhea
  • Joint pain, rashes
  • Heat or cold intolerance, constipation, hair changes

Physical Exam Findings

  • Elevated BP/BMI
  • Skin: acne, acanthosis nigricans, hirsutism, male pattern hair loss
  • Neck: thyromegaly
  • GU: clitoromegaly

Comorbidities To Screen For

  • Metabolic Syndrome
    • Diabetes/impaired glucose tolerance – 2-hour   OGTT (annually)
    •   Dyslipidemia – lipid panel (annually)
  • Infertility - fertility counseling when appropriate
  • Cardiovascular disease