How best to screen for PCO in adolescent girls? Tips form Dr S K Pal including dilemmas::

Hyperandrogenic ovulatory dysfunction commonly called as Polycystic Ovary Syndrome or simply PCOS is the most common reason for which an adolescent girl is referred to sonology unit of a radiology department. Quite often such girls are referred by a gynaecologist colleague with the solo complaint of oligomenorrhea and on further appraisal some of them show symptoms and signs of hyperandrogenism e.g. acne, hyperseborrhoea, male-pattern hair growth and alopecia. Few such teenagers also exhibit central obesity (high waist circumference) but it is uncommon to come across such young girls with other evidences of metabolic syndrome e.g. hypertension, dyslipidemia and overt insulin resistance (IR though there is no unanimously accepted definition of the metabolic syndrome (MetS) in children and adolescents^2,3 .Hyperinsulinaemia and associated metabolic defects may even predate the PCOS since it is most likely that the syndrome is genetic in nature⁴and many scientists now believe that adolescent PCOS is primary an adrenal hyperandrogenism rather than ovarian disease⁵

What is not known about adolescent PCOS? What are the grey areas in the syndrome of adolescent PCOS?   

The ever growing knowledge on different aspects of adult PCOS has perplexed many clinicians how best to suspect or diagnose the PCOS at an early stage of life but sadly there is as yet no well-defined, uniform set criteria for diagnosis of PCOS in adolescence and the various definitions used today are outcomes of consensus statements, namely the majority opinion, and not the robust and solid findings of clinical trial evidence. Whether androgen excess should be a sine qua non in PCOS diagnosis is still undecided ⁶ and  which of the usual four symptoms and signs (menstrual disorders, obesity,  androgen excess and altered ovarian morphology in sonography) is more relevant in the causation of cardiometabolic risks in later life is still unanswered. Likewise, there is no universally accepted set laboratory workup for this syndrome not to speak of a single test. Most importantly, though this syndrome is considered as an androgen excess disorder there is no universally accepted cut off value of for androgens for this syndrome. This has surprised the present author! Further, to what extent   adolescent PCOS  suffering from  one phenotype change to another as one  grow up and how does this transition affect their long-lasting health status has not been evaluated in any country  neither the magnitude of the societal obstacles in screening all adolescents for PCOS and cost of such screening has been assessed.

While acknowledging all these knowledge gaps, this review will critically analyze the opinions expressed by different international organizations and experts in this field so as to define which teenagers should be leveled as PCOS keeping in mind that the definition of this syndrome will evolve over time to incorporate new research findings.    The author also likes to highlight that the association of this syndrome with morphological appearance and ultrasonographic features of ovaries are fading out  ^8,9,    8)Duijkers IJ, Klipping C. - Polycystic Ovaries as defined by the 2003 Rotterdam consensus criteria are found to be very common in young healthy women.  Gynaecol Endocinol 2010; 26:152-160.

  9)  Jhonstone EB,RosenMP,Neril R, Trevithick D, Sternfeld B, Murphy R, Addauan-Andersen C, McConnell D, Pera RR , Cedars MI.  The polycystic ovary post-rotterdam: a common, age-dependent finding in ovulatory women without metabolic significance. J Clin Endocrinol Metab 2010; 95:4965-4972

 Transient but exaggagerated functional hyperandrogenism of adolescence.  The issue of ‘physiological hyperandrogenism’ and/ or ‘physiological hyperinsulinaemia’ of puberty in the causation of so called mini-PCOS or nascent PCOS.

Scientists now believe that most, but not all healthy adolescents reveal demonstrable hyperandrogeniaemia and or features of hyperandrogenism which is quite physiological and transitory in nature at this age group, ^{6, 10},   Cortet-Rudelli C, Dewailly D. Hyperandrogenism in adolescent girls. In Sultan C(ed) Paediatric and Adolescent Gynaecology, Evidence-Based Clinical Practice. Endocrine Dev. Basel, Karger, 2004, vol 7, pp148-62.

 Supraphysiological production of androgens or exaggerated response of androgen sensitive tissues is now proposed as the core defect of PCOS and augmented androgen levels is primarily produced in ovaries due to altered  sensitivity of ovaries to amplified LH secretion as observed in this age group5( Roe, AH, Dokras A-The Diagnosis of polycystic Ovary Syndrome in Adolescents.5^. The dynamics of acquisition of maturity of hypothalamo-pituitary axis and quantum of response of ovaries to amplified LH pulse frequency show an incongruity in different girls leading to overproduction of androgens in some girls. This action of LH may be potentiated by associated hyperinsulinaemia and diminution of insulin like growth factor binding protein -1(IGFBP-1) in few cases ^10,11 Ibanez L, Potau N, Carrascosa A: Possible genesis of polycystic ovary syndrome in periadolescent girl. Curr. Opin Endocrinol Diab. 1998, 5:19-25.

 Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, Janssen OE, Legro RS, Norman RJ, Taylor AE, et al. Position statement: criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an Androgen Excess Society guideline. J Clin Endocrinol Metab 2006; 91:4237-4245.) Azziz R, Carmina E, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, Janssen OE, Legro RS, Norman RJ, Taylor AE, Witchel SF-Criteria for defining Polycystic ovary Syndrome as a predominantly Hyperandrogenic Syndrome: An Androgen Excess Society Guideline” J Clinical Endocrinol Metab 2006;91:4237-4245.)