New criteria by Carmina et al =What was the classification proposed by Lady Endocrinologist ??

. a) Diagnosis of PCOS is certain if all three criteria are fulfilled b) Diagnosis of PCOS is probable but not certain if there is hyperandrogenism and oligomenorrhoea unassociated with polycystic ovaries. c) They have also admitted there is a subset of teenagers in whom diagnosis of PCOS is not possible during adolescence if there is combination of features of hyperandrogenism and polycystic ovaries (unassociated with oligomenorrhoea) or oligomenorrhoea with polycystic ovaries unaccompanied by hyperandrogenism. Carmina et al have also warned that presence of any of three features appearing in isolation should not at all be considered as PCOS¹².

 Roe and Dokras⁵, however, recently (2011) framed still another guideline for diagnosing PCOS during adolescence. They have proposed that during adolescence, a positive diagnosis of PCOS should require all elements of the Rotterdam consensus meant for adult women and not just two out of three. Additionally they have also insisted on laboratory documentation of hyperandrogenemia i.e. elevated blood androgens as observed by using sensitive assay i.e. liquid chromatography with tandem mass spectrometry which they considered as a must for accurate diagnosis of hyperandrogenaemia.²⁰ () Rosner W, Auchus RJ ,Aziz R, Sluss PM, Raff H- Utility ,limitations, and pitfalls in measuring testosterone : An Endocrine Society position statement . J Clin Endocrinol Metab 2007; 92:405-413.

? Where do we stand now?

The Third Consensus Workshop Group on Women’s Health aspects of polycystic ovary syndrome (PCOS) organized by ESHRE/ASRM in the year 2010 at Amsterdam²¹, though very rightly devoted one session on adolescent PCOS but disappointingly abortive to formulate any definite criteria for diagnosing or screening for adolescent PCOS!  . Similarly, the Board of Directors of one new society (Androgen Excess and PCOS society formed in 2000) failed to outline any ideal criteria of the above syndrome²². They however evaluated all girls and women suffering from androgen excess of any etiology. Surprisingly some members of the society were of opinion that there may be forms of PCOS without overt evidence of hyperandrogenism as well. They have documented as many as nine phenotypes of PCOS and according to present author the society has performed an admirable job by stratifying the probability of risk of metabolic malady according to each phenotype.

 At what age we should level an adolescent girl as PCOS? 

Diagnosing this disorder before or soon after onset of menarche is difficult because   girls with PCOS generally seek medical help   only when they suffer from irregular menses or skin changes for long time. This usually takes couple of years after the onset of menarche. To begin with PCOS may masquerade as simple obesity or idiopathic hirsutism and in most cases such symptoms disappear with time. Therefore very logically   Carmina et al (2010)⁷ have suggested avoiding making the diagnosis of PCOS until the age of 18 years. Unfortunately, this has made a sense of reluctance among many gynecologists to investigate an adolescent girl with persistent oligomenorrhoea at an early age of 15-17 years.

Are there any premonitory signs before the onset of full blown symptoms of PCOS? Can we identify children at risk of developing PCOS?

As a matter of fact, quite often PCOS women seen at late twenty can trace their symptoms to peripubertal years²³. (Franks S. Adult polycystic ovary syndromes begin in childhood. Best Pract Res Clin Endocrinol Metab 2002; 16:263-72).   Occasionally PCOS may emerge as premature pubarche or premature adrenarche (PA), a condition secondary to early maturation of zona reticularis of the adrenal gland which leads to premature androgen secretion and appearance of pubic hairs before the age of eight years of age²⁴. Ibanez L, Potau N, de Zegher F: Precocious pubarche, dyslipidaemia and low IGF binding protein -1 in girls: Relation to reduced prenatal growth. Paediatr. Res, 1999; 46:320-2)Ref article 2,        Premature adrenarche, a mild form of adrenal hyperandrogenism, potentially poses increased risk for the development of PCOS, particularly in obese girls ²⁵( Ref;Ibanez L, Virdis R, Potau

 N . Natural history of premature puberache: An auxological study. J. Clin Endocrinol. Metab 1992;74:254-7 .But it is now known that before the classical well recognized symptoms of PCOS appear there can be some laboratory evidences which may exist well before the full- blown disease²⁶,. Turhan NO, Toppare MF, Seckin NC, Dilmen G: ‘The Predictive Power of Endocrine Tests for the Diagnosis of Polycystic Ovaries in Women with Oligomenorrhoea’ Gynaecol Obstet Invest 1999;48:183-186.-)   

Depending upon the phenotypic presentation destined for the concerned adolescent it is theorized that early symptom of PCOS may vary, perplexing the family physicians.

There are several phenotypes of adolescent PCOS the role of genetic versus environmental factors in the causation of each phenotype has long been debated. It is now believed that quality of diet, exercise and environment modify the particular genetic alterations differently therefore culminating into different phenotypes. What is more important is that it may be possible to move from a phenotype to another as women ages.