Adolescent PCO

What are the diagnostic criteria of  adolescent PCOS ?: No international consensus as yet:

Lack of well-defined diagnostic criteria makes identification of this common disease confusing to many clinicians. The polycystic ovary syndrome (PCOS) in a teenager is usually characterized by irregular menstrual cycles, generally less than six menses per year, and by clinical or biochemical features of hyperandrogenism. The definition of PCOs as proposed by National Institute of Health (1990) and Rotterdam Consensus workshop on diagnostic criteria and long term health risks pertaining to PCOS (2003) are aimed for adult women.  There is yet another definition of PCOS which was compiled by a task force report framed by Androgen Excess and PCOS Society .But all these criteria are not applicable for adolescent girls as characteristics of normal puberty often overlap with criteria as framed by those two international bodies.

 

However with passage of time many international academic bodies have attempted to define adolescent PCOS but unfortunately there as yet no universal agreement on this issue. Even the Consensus Workshop Group on Women’s Health aspects of polycystic ovary syndrome (PCOS) organized by ESHRE/ASRM in the year 2010 failed to formulate any definite criteria as to which adolescents should be leveled as PCOS!

 

Prof. Dr. Charles Sultan of Montpellier, France who by profession is a pediatric endocrinologist and his colleagues come forward to resolve this issue as to which adolescents should be called as PCOS. According to them there should be at least four of the five following criteria to qualify an adolescent as PCOS. These are   1) clinical hyperandrogenism or biological hyperandrogenemia, 2) insulin resistance 3) hyperinsulinaemia, 4) oligomenorrhea persisting for 2 years postmenarche and 5) polycystic ovaries on ultrasound.  A

Another group of investigators, Carmina et al are of opinion that any adolescent having all the features of Rotterdam Criteria (2003) should be primarily leveled as PCOS. Roe and Okras, however, recently (2011) proposed still another guideline for diagnosing PCOS during adolescence. They have been proposed that during adolescence, a positive diagnosis of PCOS should require all elements of the Rotterdam consensus (and not just two out of three). But they have insisted on laboratory documentation of hyperandrogenemia (elevated blood androgens found by using sensitive assays). They urged that some clinical findings such as acne and alopecia should be disregarded as an evidence of excess androgen in adolescent period but progressive hirsutism can be considered as a clinical manifestation of hyperandrogenism. In addition, oligo-amenorrhea should be present for at least 2 years, and the diagnosis of polycystic ovaries by abdominal ultrasound should also include increased ovarian volume (>10 cm3).. By adhering to such parameters, clinicians can confirm the diagnosis PCOS in adolescents, they added.

 

 What about girls who do not exhibit all the features of PCOS as formulated by those two international bodies?

It is conceivable that many such girls with incomplete features of adolescent PCOS at the age of 15-17 years will become perfectly normal as they cross the age 20 years.    Experts attending 3^rd PCOS Workshop (2010) as well as Carmina et al (2010) , therefore have cautioned that that those adolescents who exhibit only two of the three Rotterdam criteria should be kept under regular follow up as they are more prone to develop PCOS as they grow as adults. These three proposed criteria of diagnosing PCOS in adolescent are stricter than their adult counterparts, and therefore may limit inappropriate early diagnosis, but are currently not endorsed by expert panels or societies in the field. Many practicing   gynecologists, therefore maintain a cautious approach before embarking on diagnosing PCOS in otherwise healthy adolescents with incomplete criteria as recommended by Sultan et al (2006) and Carmina et al(2010).

 

 

 

 

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3)  What are the very early symptoms  of adolescent PCOS?

. But quite often PCOS  women seen at late twenty  can trace their symptoms to peripubertal year’s .(2-8,9)  .It is now known that before these classical well recognized symptoms appear there can be some other symptoms which can initiate an astute clinician about the possibility of occult PCOS. These symptoms are pubarche or premature adrenarche, a condition secondary to early maturation of zona reticularis of the adrenal gland which lead to premature androgen secretion and appearance of pubic hair before the age of eight years of age (2-10).In fact polycystic appearing ovaries have been found in girls as young as 6 years (2-8) and some girls are probably born with polycystic ovaries

As this syndrome is prone to myriad of variety of metabolic and cardiovascular risks so an early suspicion of the disease will go a long way to avoid long term health risks.

 PA, a mild form of adrenal hyperandrogenism, potentially poses increased risk for the development of PCOS, particularly in obese and African- American or Hispanic girls [ Rosenfield RL, “ Clinical Review : identifying  children at risk  for polycystic ovarian syndrome-J. Clinical  Endo. & Metab, 2007; 92(3):787-96]

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4)  . What are the common symptoms of adolescent PCOS? )   Of the four common symptoms of adolescent PCOS i.e. acne, hirsutism, obesity and menstrual disorders none is specific for PCOS. The present system of screening adolescent PCOS is based on scrutiny of menstrual history and searching for clinical features of hyperandrogenism.

If abnormalities are evident then such adolescents are   initially   leveled as ‘probable case of PCOS’. Such girls are then subjected to endocrine assessment, biochemical evaluation and     ovarian ultrasound to confirm or refute the diagnosis of PCOS. According to one recent community based study in Sri Lanka the prevalence of probable cases based solely on history and  clinical examination   was 7.5%  and as many as 91.1%  of clinically suspected cases of PCOS were finally proved to be suffering from PCOS by detailed laboratory tests    and sonography. Understandably the specificity of clinical suspicion, therefore is quite high in adolescent PCOS and clinicians must keep the possibility of such diagnosis whenever handling  any adolescent girl at their clinic. Attention of family physicians is also drawn in this regard as a high grade of suspicion will help to pick up a large number PCOS cases early in our community too, though there is no such campaign at national level in the foreseeable  future..