Adolescent poly cystic ovaries is a vexing problem for caregivers.

1. Adolescent
PCOS
Dr. wael Naeem M.
Assistant Lecturer
Benha university

6. Outline
• Definition .
• Prevalence .
• Presentation and Dilemma in
Diagnosis .
• Evaluation .
• Treatment .
• Conclusion .

7. Definitions :
• Adolescence :
Transitional stage of
physical and psychological
development from puberty to
adulthood.
• adolescent female is (10-19

8. • Adolescent PCOS :
Unexplained persistent
hyperandrogenic
anovulation.
(American Academy of Pediatrics, 2015).

11. Prevalence :
( 2.2 – 18 ) %
depending on:
 diagnostic criteria
 ethnicity
[Goodman et al, 2015].
Increasing
 increasing prevalence
of childhood obesity.
 Improvement in
diagnosis .
(Hassan et al, 2007).

12. So prevalence depend
on Diagnostic criteria
 With strict NIH :
( 6-8 % )
With Rotterdam criteria
( 15-25 % )

13. Prevalence

14. Risk factors :
Premature pubarche
(before 8 yr old)
Obesity
Family Hx
Ethnicity
more common in –African
American

15. Course :
• ± Progressive
course : full-blown
picture of adult PCOS
(evidence is
contradictory)
(Coviello et al, 2006)

16. Risk factors for
progressive course
Persistent irregular cycles 6
y after menarche
(Venturoli
et al, 1987)
Persistent anovulatory cycles
3y after menarche
(Venturoli et al,
1994)
Increased BMI

18. Pathogenesis
• Insulin resistance.
• change GnRH pulstality .
• Genetic ..esp with VNTR.
• LBW and early pubarche .

19. Presentation and
Dilemma in Diagnosis
Menstrual irregularities.
Chronic anovulation.
Hyperandrogenism.
 Acne
 Hirsutism
 Androgeneic alopecia
Hyperandrogenemia.
PCO on US.

20. Where is the
Dilemma ?
 over diagnosis
of PCOS .
 Under
diagnosis of
PCOS .

21. Diagnosis
• Normal puberty changes
resemble PCOS
• Menstrual irregularities .
• Hyperandrogenism .
• Insulin resistance .
Specific and very strict
criteria:
should be fulfilled .

25. • Here is
The Big
Dilemma

30. • Carmina(2010)
• Requires the presence of all three
of the following:
• 1.Hyperandrogenism:
biochemical or progressive
hirsutism.
• 2. Ovulatory dysfunction
persisting beyond 2 years post-
menarche.
• 3. Polycystic ovarian morphology
ovarian volume > 10 mL.

32. • NIH criteria (1990)
The preferred diagnostic
criteria in adolescents.
[Hardy, Norman, 2013;
Legro et al, 2013].

33. • Androgen Excess Society
Criteria (2006)
• 1-Chronic
Anovulation/Oligomenorrhoea
(<6 cycles/year)
• For 2 ys since menarche or
• Primary amenorrhoea at 17
ys.

34. • 2- Hyperandrogenism
• Acne or hisutism is not criteria
for the diagnosis
• Acne unresponsive to topical
treatment : test for
hyperandrogenemia.
(Am Academy of Pediatrics,
2015).
• Progressive hirsutism: important
sign of adolescent PCOS .
(Jeffrey CR, Coffler, 2007).

35. • 3- Hyperandrogenaemia:
• Most consistent marker
• Extremely important
• No established normal ranges.
 FT ≥ 1.3 ng/dL , (Piltonen et al, 2005)
 TT >1 μg/ml
(The Rotterdam consensus workshop group, 2004).
• Adult cutoffs should be used until
appropriate pubertal levels are
defined.
(Endocrine Society Clinical Practice , 2013)

36. • 4- US criteria:
increased ovarian volume
(>10 cm3).

38. • AMH: ????
• Elevated: noninvasive screening
or diagnostic test for PCO
• No well-defined cutoffs
(Pawelczak et al, 2012 ; Rosenfield
et al, 2012).
• >4.5 ng/mL: useful as a substitute
for ovarian morphology when no
accurate ovarian US is available
(Dewailly et al, 2011).
• 6.1ng/mL (Yetimet al, 2016).

39. 5. EVALUATION
• 1- Cutaneous
manifestations;
Physical examination should
document cutaneous
manifestations of PCOS:
Terminal hair growth Acne
Alopecia , Acanthosis nigricans
Skin tags (1+++O).
(Endocrine Society Clinical
Practice, 2013)

40. • 2. Obesity
• {Increased adiposity, particularly
abdominal, is associated with
hyperandrogenemia and
increased metabolic risk }
 Screening for increased adiposity,
by
BMI calculation
measurement of WC
(1+++O).
(Endocrine Society Clinical
Practice, 2013)

41. • 3- Depression
• screening for depression and
anxiety by history and, if
identified: referral and/or
treatment,. (2++OO).
(Endocrine Society Clinical
Practice, 2013)

42. • 4. Sleep-disordered
breathing/obstructive
sleep apnea (OSA)
• screening overweight/obese
adolescents for symptoms
suggestive of OSA when
identified: definitive diagnosis
using polysomnography:
referred for tt (2++OO).
(Endocrine Society Clinical
Practice, 2013)

43. • 5. Type 2 diabetes
mellitus (T2DM)
• OGTT {they are at high risk for
such abnormalities} (1+++O).
• HgbA1c:if unable or unwilling
to complete OGTT (2++OO).

44. • Rescreening:
• Every 3–5 ys.
• more frequently if:
central adiposity
substantial weight gain,
and/or symptoms of diabetes
develop (2++OO).
(Endocrine Society Clinical
Practice, 2013)

45. • 6- Cardiovascular
risk
• screened for CVD risk factors:
family history
cigarette smoking
IGT/T2DM
hypertension
dyslipidemia
OSA
obesity especially increased
abdominal adiposity. (1++OO).

47. 6. TREATMENT
• Objectives:
symptomatic and prophylactic:
 Restoration of body weight
 Cycle regulation
 Reducing signs of
hyperandrogenism

48.  Prevention of long term
health hazards.
 Infertility
 Metabolic syndrome
 Obesity
 Diabetes
 Heart disease.

49. • Indications
Even in the absence of a
definitive diagnosis:
treatment that
 alleviate symptoms
 decrease the risk for
subsequent associated co
-morbidities (Level B).
(Androgen Excess PCOS
Society; Pediatric endocrine
society, 2015)

50. Individual PCOS
manifestations:
(obesity, hirsutism, irregular
menses) should be treated.
(level B) .
(ESHRE/ASRM;
2012)

51. Lines of therapy
• Endocrine Society guidelines
(2013):
• 1.Lifestyle changes (dietary and
exercise modification)
• 2.Followed by either:
OCP {control symptoms of
hyperandrogenism} or
Metformin in patients with
impaired glucose tolerance or
features of metabolic syndrome
[Legro et al, 2013].

52. Combine OCP with
Metformin .
±Combine Anti androgen
with OCP or Metformin.

53. 1.Lifestyle therapy:
• First-line strategy
• Weight loss
• Calorie-restricted diets (with no evidence
that one type of diet is superior)(2++OO).
• Beneficial for both reproductive and
metabolic dysfunction.
(Endocrine Society Clinical Practice,
2013)
• Why? {obesity during adolescence: an
important factor that conditions the
evolution of ovarian function
(McCartney et al, 2009).

54. Wt loss 2-5%
▼testosterone by 21%
resume regular ovulation in
50% women.

55. • Exercise
• in overweight and obese (2++OO)
.{ improves weight loss reduces
CV risk factors and diabetes risk}.
(Endocrine Society Clinical
Practice, 2013)
Avoid alcohol , smoking ,
psychosocial stress.

56. • 2- Hormonal contraceptives
(HCs):
• Indications:
First-line management for the
menstrual abnormalities
hirsutism/acne (1++OO).
(Endocrine Society Clinical
Practice, 2013)

57. • Types:
• OCP, patch, or vaginal ring
can be used (2++OO).
• OCPs either containing or not
containing an antiandrogen
can be used .
(Italian society of
endocrinology, 2015)

58. • Metabolic effects of COC
containing 30ug or less of EE:
• Mild Deterioration of glucose
tolerance
• Worsening of lipid profile
•Should not influence the choice
(Italian society of
endocrinology, 2015)

59. • VTE risk is not studied
Odds ratio
1.65 for BMI 25–30 kg/m2
1.84 for BMI 30–35 kg/m2
4.34 for BMI >35 kg/m2
[Murthy, 2010].
• Risk is further increased in CPA
or 3rd generation progestins,
including drospirenone
[Lenzer, 2011].

60. • Screening for
contraindications
via established criteria (1+++O).
lipid profile and the glucose
tolerance should be evaluated
before and after 3 months of
higher dose OC containing
cyproterone acetate (CPA)
(Italian society of endocrinology, 2015)

61. • 3-Metformin:
Indications
• To treat IGT/metabolic syndrome
(2++OO).
• long-term resumption of ovulation
especially those with an
inadequate response to lifestyle
intervention.
• Commonly used as first line mono
therapy or in combination with
OCPs or antiandrogen

62. Dose
Lean: 850 mg daily.
Overweight and obese:1.5 to
2.5 g daily.

63. • 4. Combined metformin and OC :
• attenuating the adverse metabolic effects
of OC improving body composition , as
compared with OC alone
[Glintborget al, 2014].
• Duration of HC or metformin
Not yet been determined.
until the patient is gynecologically
mature (5y postmenarcheal) or
has lost a substantial amount of
excess wt.
(Rosenfield;
2015)

64. • 5. Anti-androgenic
medications
• Spironolactone, flutamide, and
insulin sensitizing agents such as
pioglitazone
Indication: when OCP or
metformin fail to produce the
clinically desired outcomes
[Conway et
al, 2014].
• ±affect bone mass, short term
data: no effect.

65. Newer drugs still Evoloving
• NAC .
• DI.chrio .INOsitol.
• Chromium.
• Methyl folate .

66. TaKe home message
 Early and accurate diagnosis is
essential for implementation of
appropriate treatment .
 Criteria for the diagnosis differ
from those used for adult women.
 Hyperandrogenaemia: the most
consistent marker.

67. Evaluation:
 Metabolic
 CV risks,
 Psychologic
 Dermatologic .
Treatment :
lifestyle modifications
Hormonal contraceptives
Metformin
Antiandrogen.