Management of adolescent PCOS- a real challenge

Polycystic ovary syndrome (PCOS) is a complex disorder that affects 1 in 15 women and 4-6% of adolescents.  The disorder is usually defined as “the association of hyperandrogenism with chronic anovulation in women without specific underlying diseases of the adrenal or pituitary glands.” Hyperandrogenism is characterized clinically by hirsutism, acne and androgen-dependent alopecia as well as biochemically elevated serum androgens, particularly testosterone and androstenedione.

PCOS is the most common endocrine disorder, but symptoms in adolescents overlap with normal puberty symptoms leading to both over and under diagnosis of the condition. The condition has been linked to a number of others including; hyperandrogenism, menstrual disturbance, infertility, obesity, cardiovascular disease and diabetes.

So how can we accurately diagnose PCOS in adolescents?

The diagnosis of PCOS is usually dependent on the presence of any two of the following criteria:

- Ultrasonographic PCO- this can be of limited value in adolescents as ovarianmorphology changes over time

-  Olgio Anovulation

-  Biochemical or clinical evidence of hyperandrogenism

Diagnosis can be difficult as adolescents are often embarrassed by their symptoms and not honest about the difficulties they are experiencing. Differential diagnosis may also include; congenital adrenal hyperplasia, hypothyroidism, intake of anabolic drugs and hormone producing tumours.

This is compounded by the fact that pathogenesis of PCOS remain uncertain, although evidence suggests that both genetic and environmental factors may play a role in causing impaired insulin sensitivity and ovarian hyperandrogenism. It is thought that LH secretion increases which when coupled with increased insulin results in excess androgen. This in turn leads to decreased SHBG resulting in impaired glucose tolerance and dyslipidemia to occur.

Treatment for PCOS in adolescents is primarily targeted at anovulation, hyperandrogenism and obesity. It is thought that the main focus should be on lifestyle modification. If diet and exercise alone are not enough, insulin reducing therapy and lipid lowering agents can be used, often counselling can also be hugely beneficial as well as liaising with dietician and psychiatrists to help women of a young age achieve a normal body weight. Hormonal contraceptives such as low-dose oral contraceptives (OCP) may also be an option to reduce uterine bleeding, and also reduce LH secretion. For adolescents who are contemplating sexual activity, OCP should be the first line therapy with the correct choice of progestin.

With symptoms often mistaken for something else it can be difficult to accurately diagnose PCOS in adolescents. After diagnosis we must help them to improve their lifestyle. A proper diet and exercise should be the first port of call as well as OCP for adolescents who may be sexually active.