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Caution needed in diagnosis, treatment of PCOS symptoms in adolescents

A diagnosis of polycystic ovary syndrome is not needed to effectively manage the underlying symptoms of the disorder in adolescent girls; however, concerns remain that, without a diagnosis, metabolic risk will not be properly managed.

“We’re concerned about mislabeling people with the diagnosis because it is very frightening,” Andrea E. Dunaif, MD, of the Northwestern University Feinberg School of Medicine, told Endocrine Today. “[However,] I think people take the presence of the whole syndrome as a target for risk reduction more seriously than they would just take the obesity, which is going to be the predominant adolescent symptom.”

Lack of adolescent guidelines

In a recent review of clinical practice guidelines and supporting studies appearing in Clinical Obesity, researchers noted that adolescent-specific guidelines for polycystic ovary syndrome (PCOS) have been proposed by several specialists; however, there is an absence of high-quality studies to support these models in clinical practice.

Matthew Sabin, MD, senior postdoctoral research fellow at the Murdoch Children’s Research Institute and University of Melbourne and director of endocrinology and diabetes at The Royal Children’s Hospital in Melbourne, Australia, and colleagues analyzed data from 17 studies conducted in the last 10 years addressing the diagnosis and management of PCOS during adolescence (girls aged 13 to 18 years). Analysis also included the Endocrine Society clinical practice guideline, a position statement from the European Society of Endocrinology and a consensus paper from the Pediatric Endocrine Society and International Pediatric and Adolescent Specialty Societies.

Andrea E. Dunaif

While some experts support delaying diagnosis where PCOS cannot be established with certainty, the majority of specialists emphasize the importance of identifying PCOS during adolescence given the increased metabolic risks, according to the researchers.

Cardiometabolic risk

Dunaif noted that PCOS remains the most powerful predictor of type 2 diabetes in young women.

“My one concern about not trying to make the diagnosis is ... there is consensus that there is an increased risk for type 2 diabetes, independent of the obesity, with [PCOS],” Dunaif said.

Without the diagnosis of PCOS, Dunaif said, a patient may not fully understand the importance of reducing cardiometabolic risk early on.

But with diagnosis also comes risk. Richard S. Legro, MD, FACOG, a reproductive endocrinologist with Penn State Hershey Obstetrics and Gynecology, said that diagnosis and treatment of PCOS in adolescents is still largely driven by opinion without adequate studies.

“One important take home message is the need for better and larger studies in this population to replace opinion with evidence in clinical management,” Legro told Endocrine Today. “[The analysis] appropriately recommends caution when applying a diagnosis that might not be applicable, as there is substantial overlap between some of the signs and symptoms of PCOS and normal pubertal development.

“It also appropriately states that medical symptoms or risk factors for other illnesses should be recognized and treated, even in the absence of a clear diagnosis,” Legro said.

Individual symptoms

Adolescent symptoms of PCOS typically include irregular menses, evidence of androgen excess, including severe acne or hirsutism, overweight or obesity. Polycystic ovaries are not criteria for diagnosis at this age, Dunaif said.

Often, girls with PCOS already have prediabetes and impaired glucose tolerance, Dunaif said.

“The preponderance of the evidence suggests that 2 years post-menarche, you can establish the diagnosis with confidence, based on the NIH criteria,” Dunaif said. “The average age of menarche in the U.S. is 12 years ... so you’re talking about 14-year-old girls who can corroborate a diagnosis, and those would be the ones to really target for intervention, be it lifestyle or metformin.”

There are minimal but intriguing data that long-term outcomes of the condition can be improved by treating early, Dunaif said, including preventing androgen stimulation of the hair follicle.

Richard S. Legro

“And then, on the metabolic side, the sooner you start treating obesity and preventing weight gain, that’s important,” Dunaif said.

In treating the individual symptoms of PCOS, clinicians still target the underlying metabolic and reproductive changes that are associated with the syndrome, according to the researchers.

“Throughout this review, it has become apparent that current guidelines recommend treating the individual manifestations of the syndrome irrespective of a diagnosis,” the researchers wrote. “This suggests that perhaps the label of ‘PCOS’ does not need to be applied to effectively treat the features associated with the syndrome.”

For adolescent girls with PCOS, early intervention is key to promoting better long-term outcomes, Dunaif said. Clinicians should always take time to ask any adolescent girl or woman about their menstrual cycle — when did menses begin, how many periods per year and the number of days between menstrual cycles.

“Menses should be a vital sign,” Dunaif said. “Menstrual history should be part of the baseline information you take from any woman of reproductive age. If she does not have regular menses, or has amenorrhea, the cause of that needs to be identified. It speaks. Eighty percent to 90% of the time, it’s going to be PCOS.”

Identifying symptoms early can help girls avoid diabetes later, Dunaif said. “You have an unbelievably important opportunity the earlier you catch these girls in adolescence to ameliorate and maybe prevent some of these morbidities, both reproductive and metabolic.” – by Regina Schaffer

Disclosure: The researchers and Dunaif report no relevant financial disclosures. Legro reports consulting fees from AstraZeneca, Clarus Therapeutics, Euroscreen, Kindex and Takeda, and research funding from AstraZeneca and Ferring.

A diagnosis of polycystic ovary syndrome is not needed to effectively manage the underlying symptoms of the disorder in adolescent girls; however, concerns remain that, without a diagnosis, metabolic risk will not be properly managed.

“We’re concerned about mislabeling people with the diagnosis because it is very frightening,” Andrea E. Dunaif, MD, of the Northwestern University Feinberg School of Medicine, told Endocrine Today. “[However,] I think people take the presence of the whole syndrome as a target for risk reduction more seriously than they would just take the obesity, which is going to be the predominant adolescent symptom.”

Lack of adolescent guidelines

In a recent review of clinical practice guidelines and supporting studies appearing in Clinical Obesity, researchers noted that adolescent-specific guidelines for polycystic ovary syndrome (PCOS) have been proposed by several specialists; however, there is an absence of high-quality studies to support these models in clinical practice.

Matthew Sabin, MD, senior postdoctoral research fellow at the Murdoch Children’s Research Institute and University of Melbourne and director of endocrinology and diabetes at The Royal Children’s Hospital in Melbourne, Australia, and colleagues analyzed data from 17 studies conducted in the last 10 years addressing the diagnosis and management of PCOS during adolescence (girls aged 13 to 18 years). Analysis also included the Endocrine Society clinical practice guideline, a position statement from the European Society of Endocrinology and a consensus paper from the Pediatric Endocrine Society and International Pediatric and Adolescent Specialty Societies.

Andrea E. Dunaif

While some experts support delaying diagnosis where PCOS cannot be established with certainty, the majority of specialists emphasize the importance of identifying PCOS during adolescence given the increased metabolic risks, according to the researchers.

Cardiometabolic risk

Dunaif noted that PCOS remains the most powerful predictor of type 2 diabetes in young women.

“My one concern about not trying to make the diagnosis is ... there is consensus that there is an increased risk for type 2 diabetes, independent of the obesity, with [PCOS],” Dunaif said.

Without the diagnosis of PCOS, Dunaif said, a patient may not fully understand the importance of reducing cardiometabolic risk early on.

But with diagnosis also comes risk. Richard S. Legro, MD, FACOG, a reproductive endocrinologist with Penn State Hershey Obstetrics and Gynecology, said that diagnosis and treatment of PCOS in adolescents is still largely driven by opinion without adequate studies.

“One important take home message is the need for better and larger studies in this population to replace opinion with evidence in clinical management,” Legro told Endocrine Today. “[The analysis] appropriately recommends caution when applying a diagnosis that might not be applicable, as there is substantial overlap between some of the signs and symptoms of PCOS and normal pubertal development.

“It also appropriately states that medical symptoms or risk factors for other illnesses should be recognized and treated, even in the absence of a clear diagnosis,” Legro said.

Individual symptoms

Adolescent symptoms of PCOS typically include irregular menses, evidence of androgen excess, including severe acne or hirsutism, overweight or obesity. Polycystic ovaries are not criteria for diagnosis at this age, Dunaif said.

Often, girls with PCOS already have prediabetes and impaired glucose tolerance, Dunaif said.

“The preponderance of the evidence suggests that 2 years post-menarche, you can establish the diagnosis with confidence, based on the NIH criteria,” Dunaif said. “The average age of menarche in the U.S. is 12 years ... so you’re talking about 14-year-old girls who can corroborate a diagnosis, and those would be the ones to really target for intervention, be it lifestyle or metformin.”

There are minimal but intriguing data that long-term outcomes of the condition can be improved by treating early, Dunaif said, including preventing androgen stimulation of the hair follicle.

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Richard S. Legro

“And then, on the metabolic side, the sooner you start treating obesity and preventing weight gain, that’s important,” Dunaif said.

In treating the individual symptoms of PCOS, clinicians still target the underlying metabolic and reproductive changes that are associated with the syndrome, according to the researchers.

“Throughout this review, it has become apparent that current guidelines recommend treating the individual manifestations of the syndrome irrespective of a diagnosis,” the researchers wrote. “This suggests that perhaps the label of ‘PCOS’ does not need to be applied to effectively treat the features associated with the syndrome.”

For adolescent girls with PCOS, early intervention is key to promoting better long-term outcomes, Dunaif said. Clinicians should always take time to ask any adolescent girl or woman about their menstrual cycle — when did menses begin, how many periods per year and the number of days between menstrual cycles.

“Menses should be a vital sign,” Dunaif said. “Menstrual history should be part of the baseline information you take from any woman of reproductive age. If she does not have regular menses, or has amenorrhea, the cause of that needs to be identified. It speaks. Eighty percent to 90% of the time, it’s going to be PCOS.”

Identifying symptoms early can help girls avoid diabetes later, Dunaif said. “You have an unbelievably important opportunity the earlier you catch these girls in adolescence to ameliorate and maybe prevent some of these morbidities, both reproductive and metabolic.” – by Regina Schaffer

Disclosure: The researchers and Dunaif report no relevant financial disclosures. Legro reports consulting fees from AstraZeneca, Clarus Therapeutics, Euroscreen, Kindex and Takeda, and research funding from AstraZeneca and Ferring.