Polycystic Ovary Morphology

Polycystic ovary morphology is defined as ≥20 follicles per ovary, evaluated using a transvaginal probe and high-resolution technology, per the Androgen Excess-PCOS Society Task Force.1,5 Assessment can be difficult in adolescent girls because increased gonadotropin stimulation can lead to increased ovarian volume and follicular growth, which in turn mimics the appearance of multifollicular ovaries.1

Considerations in Adolescents

According to the review from Dr Witchel and colleagues, the steps to evaluating an adolescent with symptoms suggestive of PCOS include a thorough history, a detailed family history, and a complete physical evaluation, including laboratory evaluation of thyroid function and levels of prolactin, total testosterone, androstenedione, sex hormone-binding globulin, DHEAS, and 17-hydroxyprogesterone.1 Although anti-Müllerian hormone concentrations alone cannot be used to diagnose PCOS, elevated levels may warrant further consideration.1


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Insulin resistance has been reported in up to two-thirds of adolescents with PCOS,³ but no current definitions, recommendations, or guidelines suggest that insulin resistance and/or hyperinsulinemia should be considered as a diagnostic feature of PCOS.¹

Ultimately, after the exclusion of other conditions associated with irregular menses or hyperandrogenism, a PCOS diagnosis can be considered in adolescent girls with persistent oligoamenorrhea for 3 to 4 years postmenarche and clinical and/or biochemical hyperandrogenism.¹

Managing PCOS

A 2018 guideline published in Fertility and Sterility outlined recommendations for the diagnosis and management of PCOS, with the goal of optimizing evidence-based, consistent care to improve the quality of life of women and adolescents with PCOS.6

Education and Fertility Counseling

Culturally sensitive, comprehensive, and age-appropriate explanations and discussions of PCOS should be conducted with each patient.1,7 Discussions should be empathetic and should promote self-care, highlighting peer support groups as appropriate.1 Counseling with regard to future fertility concerns is also important, as research suggests that adolescents with PCOS are more concerned about future fertility issues compared with their peers.7

One cross-sectional study of adolescents with and without PCOS found that although girls with PCOS were less likely to have had sexual intercourse, they were 3.4 times more likely to experience concerns about future fertility or pregnancies.7 Although concerns about clinical or perceived disease severity were not associated with having engaged in sexual intercourse, these concerns did result in a significantly lower quality of life.

The study researchers pointed out that while 80% of women with PCOS will experience infertility, adolescents with PCOS in the modern day need not be as concerned given widespread improvements in both medications and in vitro fertilization — resulting in a “drastically changed” landscape of fertility care.7

“Adolescent medicine providers and pediatric gynecologists can therefore be optimistic in answering questions about future fertility,” the investigators concluded.7 However, they also indicated that both parents and healthcare providers should remain aware of patient access to adult-oriented fertility materials that may negatively affect how an adolescent with PCOS perceives the condition as well as future treatment options.

Diet and Exercise

Many adolescents with PCOS are overweight, obese, or are at risk for excessive weight gain.¹ Therefore, lifestyle interventions involving both the adolescent and the family should be incorporated into all management plans.

Multiple studies have shown that the incorporation of lifestyle interventions into care plans for women with PCOS generally results in improvements in weight, hyperandrogenism, and insulin resistance.1 In adolescents, these interventions have also resulted in improved quality of life.

Data related to a specific diet to achieve weight loss in PCOS are limited.6 In their review, Dr Witchel and colleagues noted 5 randomized controlled trials that have assessed the role of diets in overweight adolescents with PCOS; of these trials, only 3 evaluated diet as the sole intervention. A low-carbohydrate diet and a hypocaloric diet over the course of 12 weeks improved both weight and menstrual irregularities.1

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One cross-sectional cohort study published in Fertility and Sterility examined the role of diet in 711 women with PCOS.8 Investigators found that hirsutism and obesity were the aspects of PCOS most closely linked to diet composition. Participants were divided into 4 diet-based cohorts (rural vegetarian, semiurban vegetarian, semiurban nonvegetarian, and urban nonvegetarian). Researchers indicated that in terms of PCOS symptoms, only hirsutism had a significant association with diet, with 89% of those in the urban nonvegetarian group presenting with this symptom compared with 22% of women in the rural vegetarian group.8

Low-carbohydrate, hypocaloric, low-glycemic load, and low-fat diets have all been shown to improve weight and/or menstrual irregularities in adolescents with PCOS. In addition to diet and nutrition education alone, the addition of exercise and behavioral therapy can result in weight loss accompanied by improved menstrual irregularities and androgen levels.1

Medication

In some adolescents with PCOS, medication may be an appropriate aspect of a personalized care plan. Metformin is most commonly used in adolescents between 15 and 19 years of age.1 Despite the off-label nature of this treatment, developers of evidence-based guidelines published in 2018 indicate that in addition to lifestyle-based interventions, the use of metformin can be considered with PCOS symptoms or diagnosis in adolescents. Several meta-analyses and randomized controlled trials have demonstrated the short-term benefits of metformin use, primarily in adolescents who are overweight or obese.1

In addition to metformin, combined oral contraceptive pills can be used to manage menstrual irregularity and/or clinical hyperandrogenism in patients with a PCOS diagnosis and those at risk for PCOS.1,6 Guideline developers suggest that the lowest effective estrogen dose (eg, 20-30 µg ethinyloestradiol or equivalent) should be considered.6

Both hirsutism and acne can be treated in a variety of ways. Hirsutism can be addressed using physical hair removal methods (eg, shaving, waxing, electrolysis) or through the use of topical medications like 13.9% eflornithine cream.1 Professional light-based therapies may also be considered as a prolonged solution after multiple treatments, and these therapies have generally been associated with an improvement in quality of life, anxiety, and depression in adolescents with PCOS.1

The primary goals of acne treatment are the reduction of sebum production, prevention of formation of microcomedones, suppression of Propionibacterium acnes, and reduction of inflammation in order to prevent scaring.1 Mild acne can be treated with topical over-the-counter treatments (eg, benzoyl peroxide 0.1%/2.5%, topical retinoids), while moderate and severe acne may require 3 to 4 months of treatment with systemic antibiotics.

Continuing Care

In order to ensure continuity of care, clinicians should spend time with patients to reinforce previous PCOS education, information about comorbidities, and the importance of appropriate lifestyle interventions, medical treatments, and long-term follow-up care. Dr Witchel and colleagues suggest in their review that patients with PCOS have a multidisciplinary care team — including endocrinologists and gynecologists in addition to general practitioners — who can work to manage the condition. As adolescents prepare to transition into adult care, therapeutic options should be discussed and adult providers should be chosen based on patient preference, primary health concerns, and the possibility of required fertility management in the future.1

Although PCOS is a complex disorder, the use of individualized treatment plans in adolescents can result in positive outcomes related to both physical health and self-esteem.

“Timely implementation of individualized therapeutic interventions will improve overall management of PCOS during adolescence, prevent associated comorbidities, and improve quality of life,” Dr Witchel and colleagues concluded.1

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References

1. Witchel SF, Oberfield SE, Peña AS. Polycystic ovary syndrome: pathophysiology, presentation, and treatment with emphasis on adolescent girls. J Endocr Soc. 2019;3(8):1545-1573.

2. National Institutes of Health. Evidence-based methodology workshop on polycystic ovary syndrome. https://prevention.nih.gov/sites/default/files/2018-06/FinalReport.pdf. Accessed September 25, 2019.

3. Rosenfield RL. The diagnosis of polycystic ovary syndrome in adolescents. Pediatrics. 2015;136(6):1154-1165.[WU1] 

4. Gunn HM, Tsai MC, McRae A, Steinbeck KS. Menstrual patters in the first gynecological year: a systematic review. J Pediatr Adolesc Gynecol. 2018;31(6):557-565.

5. Dewailly D, Lujan ME, Carmina E, et al. Definition and significance of polycystic ovarian morphology: a task force report from the Androgen Excess and Polycystic Ovary Syndrome Society. Hum Reprod Update. 2014;20(3):334-352.

6. Teede HJ, Misso ML, Costello MF, et al; for the International PCOS Network. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril. 2018;110(3):364-379.

7. Trent ME, Rich M, Austin SB, Gordon CM. Fertility concerns and sexual behavior in adolescent girls with polycystic ovary syndrome: implications for quality of life. J Pediatr Adolesc Gnyecol. 2003;16(1):33-37.

8. Kulkarni SD, Patil AN, Gudi A, Homburg R, Conway GS. Changes in diet composition with urbanization and its effect on the polycystic ovarian syndrome phenotype in a western Indian population. Fertil Steril. 2019;112(4):758-763.


 [WU1]Undergoing maintenance 10/17