PCOS IN ADOLESCENTS: EARLY

DETECTION AND INTERVENTION

R A C H A N A S H A H , M D M S T R

A S S I S TA N T P R O F E S S O R O F P E D I AT R I C S

D I V I S I O N O F E N D O C R I N O L O G Y A N D D I A B E T E S

DISCLOSURES

Off-label use of metformin in treatment of PCOS

OBJECTIVES

Review how PCOS develops

Understand clinical presentation of PCOS in teens

Describe the diagnosis of PCOS in teenagers

Understand short and long-term consequences of

PCOS in teens

Discuss treatment options for PCOS in teenagers

PCOS: HIDDEN MYSTERY?

6-10% of all reproductive age females

Most common endocrine disorder in

women

Major healthcare and economic

burden

Shockingly little known about

pathophysiology and underlying cause

Treatments symptomatic, no cure or

prevention

NOT JUST A MALE HORMONE

Testosterone made by

gonads & adrenal glands

In women: 60% made in

ovary

Most is turned into

estradiol in the ovary and

never reaches bloodstream MALE

FEM

ALE

FEM

ALE

PCOS

0

200

400

600

800

Te

sto

ste

ron

e n

g/d

l

ITS NOT JUST IN YOUR HEAD

Imbalance of

hormones from pituitary

(High LH, low FSH) lead to

more T released into

circulation

Low FSH leads to

abnormal follicular

maturation/anovulation

Adrenal androgen

production also increased

BRAIN

OVARIES

SKIN

WHOLE

BODY

PCOS IN ADOLESCENTS

Under diagnosed in teens, especially lean girls

Symptoms similar to those in adult women

Approach to treatment may be different

Timely diagnosis important to address & reduce

associated risks

DERMATOLOGIC ISSUES

Hirsutism—terminal

hair in MALE pattern

Does NOT correlate

with testosterone

levels

Found in 69% of

PCOS teens

Racial/ethnic

differences

important

Severity is variable!

HIRSUTISM SCORING

(MODIFIED FERRIMAN GALLWEY)

SKIN PROBLEMS

Acne—more severe (cystic, not responding to topical

treatments), different pattern (JAWLINE, back, chest),

worse with periods

Less specific, as 2/3 of normal teens have acne

SKIN PROBLEMS

Acanthosis nigricans (marker of insulin resistance)

Back of neck, undearms, groin, other skin folds

SKIN PROBLEMS

Androgenic alopecia: Scalp hair thinning in male pattern

Much less common, incidence not reported

Skin issues cause embarrassment, poor self-esteem

GYNECOLOGIC ISSUES

can have “regular” periods without ovulation (10-15%), increased

frequency, heavy bleeding

Oligomenorrhea (infrequent periods): >35 day cycles (45 in teens)

or 90 day

interval)

Risk of uterine cancer

“CYSTS”

“cysts” in PCOS are actually arrested follicles

Do not grow beyond 10mm in size

Do not cause discomfort, pelvic or abdominal

pain, or swelling

Do not require monitoring by ultrasound, will

not need surgery

FERTILITY IN PCOS

Spontaneous pregnancy possible, take usual contraceptive

measures!

Advise to discuss diagnosis with Gyn and get treatment early when

desiring pregnancy

METABOLIC RISK

PCOS increases risk compared to same weight/age

If overweight, even HIGHER

Insulin resistance worsens symptoms/high androgens worsen insulin resistance

Risks: Type 2 diabetes, cholesterol problems, fatty liver, high blood pressure,

sleep apnea, heart disease

LEAN LEAN

PCOS OBESE

OBESE

PCOS < <

Insulin

Resistance

High

Androgens

Screen for these at diagnosis

and annually!

PSYCHIATRIC RISKS Increased depression and anxiety

Disordered eating patterns (bulimia, binge eating)

Poor body image due to: weight, hirsutism, acne, and

fertility concerns

Providers need to ask and make patients feel comfortable

talking about it!

BRAIN/BODY

CONNECTION

DIAGNOSIS OF PCOS IN ADOLESCENCE

Clinical or biochemical hyperandrogenism

(hirsutism or elevated testosterone in blood)

AND

Irregular periods/lack of ovulation

>2 years after onset of first period

MAKING THE DIAGNOSIS

• Careful history

• Menstrual

• Dermatologic

• Metabolic

• Family

• Physical exam

• Blood tests if indicated

BUT I WANT TO SEE MY CYSTS!

Ultrasound not routinely recommended in adolescents due to lack of age

specific guidelines

PCOS-like ovaries seen in many other disease states!

May be performed for unusually high testosterone levels or other

symptoms beyond those of PCOS

If ultrasound needs to be done, TRANS-ABDOMINAL ultrasound is

sufficient in teen

LABORATORY TESTS Establish hyperandrogenism

Testosterone profile

Rule out other causes

Pregnancy Thyroid

Prolactin (pituitary disease) 17OHP(adrenal disorder)

LH, FSH (Pituitary hormones)

Bleeding disorders (if heavy/frequent)

Comorbidities

Glucose, hemoglobin A1c, insulin (consider OGTT) for diabetes

Fasting lipid profile for cholesterol issues

Liver enzymes for fatty liver disease

PCOS, OBESITY AND INSULIN RESISTANCE

In the US, at least 2/3 of women with

PCOS are overweight.

Increased insulin levels and decreased

sensitivity amplify the hormonal

features of PCOS.

Treatment of insulin resistance may

improve hyperandrogenism and even

restore ovulation.

GOALS OF PCOS TREATMENT

Reduce testosterone and its effects on skin (acne, hair)

Protect uterus from cancer risk

Reduce weight and heart disease risk with lifestyle changes

Improve insulin sensitivity

Restore fertility

Treatment tailored to specific symptoms

TREATMENT OPTIONS: HORMONAL

Combined estrogen/progesterone contraceptives

Contraindications: clot risk, migraine with aura, risk of

breast/uterine cancer

Side effects (common): breakthrough bleeding, mood

change, appetite change, headache nausea, breast change

Side effects (severe): stroke or blood clot, liver mass

Medroxyprogesterone or progesterone for 7-10 days of each

cycle (or every 3-4 months if no spontaneous period)

TREATMENT OPTIONS: METFORMIN

Metformin: useful even without IR

Insulin sensitizer

Results INDEPENDENT of weight

loss

GI side effects: nausea, diarrhea,

gas (resolve with time)

Difficult for many girls to take

TREATMENT OPTIONS: DERMATOLOGIC

Acne: topical treatments, antibiotics, retinoids

Hirsutism: topical eflornithine (Vaniqa), slows growth

Laser, electrolysis, waxing, shaving, depilatories, etc..

Even with androgen control, can slow growth & prevent new

growth---already present follicles will not regress

If considering “permanent” option, control androgens FIRST

Alopecia: Minoxidil (Rogaine) to affected areas

TREATMENT OPTIONS: ANTI-ANDROGENS

Spironolactone: reduction in hirsutism and acne

Lower blood pressure, potassium (high doses), dizziness/fainting

Teratogenic---can block formation of genitalia in male fetus--risky

to use without birth control

finasteride (5a reductase inhibitor) and Flutamide (non-steroidal

anti-androgen)—rarely used in teens or adults

TREATMENT OPTIONS: LIFESTYLE

With ANY treatment, simultaneous diet/exercise: Just 5% weight

loss can restore ovulation as well as lower metabolic risk

Currently no “best” diet recommendation, though many

recommend lower carbohydrate given insulin resistance

The “best” diet and exercise is the one you can stick to!!!

LIFESTYLE CHANGES FOR TEENS

Work best as a FAMILY approach

Seek an RD familiar with teens

Exercise should be ENJOYABLE

Nutrition should be FOR LIFE

Major life changes (college!) need to be pre-emptively

addressed to avoid setbacks

SUMMARY

PCOS is common but under-diagnosed in teens

Irregular periods > 2 years after first period should

be evaluated

Diagnosis can be made with careful

history/examination and laboratory tests

All girls with PCOS should be screened for

metabolic complications yearly

Girls with PCOS are at increased risk of mood

disorders and disordered eating and should be

screened regularly

SUMMARY

Treatment is tailored to the specific symptoms of the

patient

Treatment should ALWAYS include healthy lifestyle

guidance and many families benefit from meeting

with an RD

No cure yet, but proper management can make an

enormous difference!

CHOP ADOLESCENT PCOS CLINIC

Multidisciplinary, all pediatric providers

• Endocrinologist (Dr Rachana Shah)

• Dermatologist (Dr Marissa Perman)

• Nutritionist (Sarah Barnes, RD)

Patients/families meet with multiple providers at one clinic visit

to have all their needs met

Laser hair removal offered through Dermatology; may be able to

get insurance coverage