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PCOS in Adolescents: A Diagnostic Conundrum

PCOS in Adolescents: A Diagnostic Conundrum

The diagnosis of polycystic ovary syndrome (PCOS) in teens is difficult. Many of the symptoms that are part of the diagnosis in adults reflect normal pubertal development in adolescents. The question is, at what point do the signs and symptoms cross over from normal teenage developmental irregularities to a pathologic state? Unfortunately that line is not clear.

Wide disparities in treatment regimens further point to the difficulties in diagnosis. If the diagnosis was straightforward, there would be a simple algorithm, and we would all follow it. Yet every week, I sit in my office talking with young women and their often-frantic mothers who have been handed an unequivocal diagnosis and been told that there is a high likelihood that she will be infertile.

Given the difficulty in diagnosing PCOS in adolescents, it seems rather presumptuous and even cruel to make such proclamations. That said, an accurate diagnosis is important, not just for its fertility implications (generally of most concern to patients) but because of the future risk of diabetes, cardiovascular disease, and metabolic syndrome.

Currently, there are no special criteria for the diagnosis of PCOS in adolescents. In fact, there remains controversy over which of the 3 criteria sets (Rotterdam, Androgen Excess Society, or National Institutes of Health) to use in adults. Overall, the Rotterdam criteria are used most often with adolescents, requiring that 2 of 3 conditions be met: oligoovulation or anovulation, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasound. In addition, other etiologies must be excluded.

In the adolescent, however, it can be difficult to determine whether oligomenorrhea/anovulation is pathologic or simply part of normal development. How can we know whether a girl’s acne is a sign of clinical hyperandrogenism? Because of these issues, several groups have proposed establishing stricter or more extensive criteria for the diagnosis of PCOS in adolescents to eliminate overdiagnosis and overtreatment. However, these recommendations currently are not endorsed by expert panels or societies in the field.1

In considering oligomenorrhea, cycles of longer than 6 to 8 weeks are thought to be abnormal in adults. In the adolescent, anovulatory cycles soon after menarche may mimic this pattern. On average, 1 year after menarche, most girls will have regular monthly menses, although girls who begin to menstruate after age 13 may take longer to establish a regular cycle. Oligomenorrhea at age 15 or older, however, tends to persist and may be a more accurate indicator of a longer-term hormonal imbalance.1

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