Adolescent polycystic ovary syndrome according to the international evidence-based guideline

Key points

• Diagnosing polycystic ovary syndrome (PCOS) in adolescence is challenging because normal pubertal changes overlap with adult criteria. PCOS affects 8 to 13% of women of reproductive age and 6 to 18% of adolescent girls, depending on the criteria used.
• Diagnosis needs both irregular menstrual cycles, defined by years since menarche, and hyperandrogenism. Irregular cycles in the first year after menarche are normal pubertal transition.
• Pelvic ultrasound is not recommended for diagnosis within 8 years of menarche, and anti-Müllerian hormone (AMH) levels are not recommended for diagnosis.
• Adolescents with features of PCOS who do not meet the criteria can be considered 'at risk', treated for symptoms and re-evaluated.
• Screening for anxiety and depression is advised, healthy lifestyle measures are recommended, and the combined oral contraceptive pill and/or metformin may help symptoms.

Overview

PCOS is hard to diagnose in adolescents because irregular cycles, acne and a polycystic appearance of the ovaries on ultrasound can all be part of normal puberty. This paper presents the adolescent recommendations of the international evidence-based PCOS guideline, which aims to avoid both missed and over-diagnosis. The guideline followed AGREE II and GRADE methods, with 37 societies and organisations from 71 countries over a 15-month process and 60 prioritised clinical questions (40 evidence-based reviews and 20 narrative reviews). Adolescence is defined as ages 10 to 19, and the recommendations also refer to those within 8 years of their first period.

Diagnosis

Irregular cycles are defined by years since menarche: a single cycle over 90 days after more than 1 year; cycles under 21 or over 45 days from more than 1 to under 3 years; cycles under 21 or over 35 days after more than 3 years; and primary amenorrhoea by age 15 or more than 3 years after thelarche. Hyperandrogenism means hirsutism, severe acne and/or biochemical hyperandrogenaemia confirmed with validated high-quality assays, using calculated free testosterone, free androgen index or bioavailable testosterone. Hormonal contraception should be stopped for 3 months before testing, with contraception provided another way. Moderate or severe acne in early puberty or around menarche is uncommon (under 5%) and more likely related to hyperandrogenism, and hirsutism is scored with the modified Ferriman-Gallwey score, where 4 to 6 or more indicates hirsutism depending on ethnicity. Other causes must be excluded, including pregnancy, non-classic congenital adrenal hyperplasia (reported as 1 in 1000), hypothyroidism, hyperprolactinaemia, Cushing syndrome and androgen-secreting tumours. PCOS cannot be diagnosed in adolescence unless both irregular cycles and hyperandrogenism are present.

Tests that are not recommended

Pelvic ultrasound should not be used to diagnose PCOS within 8 years of menarche because multi-follicular ovaries are common at this stage, and adult ultrasound criteria were derived from transvaginal scans, which should be avoided in females who are not sexually active. AMH should not replace ultrasound or serve as a single test, because levels overlap between groups and studies differ in assays and populations. Ultrasound can still be used to look for other uterine or ovarian problems, for example in primary amenorrhoea.

The 'at risk' label and follow-up

Adolescents with features of PCOS who do not meet the criteria can be labelled 'at risk' and treated for symptoms. Cycles are re-evaluated by 3 years after menarche, and ultrasound can be considered after 8 years. If hormonal treatment was started, reassessment follows a washout of at least 3 months while contraception needs are met. The value and timing of assessment should be discussed with the adolescent and her family, considering psychosocial and cultural factors.

Wellbeing and treatment

Anxiety and depressive symptoms are probably more common in adolescents with PCOS, and the guideline advises routine screening at diagnosis. In one meta-analysis the standardised mean difference compared with controls was 0.54 for depression and 0.48 for anxiety, and assessment for eating disorders warrants consideration. Multi-component lifestyle interventions are recommended to prevent and treat excess weight. The combined oral contraceptive pill (COCP) alone should be considered in those with a clear diagnosis and could be considered in those at risk, for clinical hyperandrogenism and/or irregular cycles. Metformin with lifestyle measures could be considered, and the COCP plus metformin could be considered when BMI is above 25 kg/m2 and the COCP and lifestyle changes have not reached the goals. Antiandrogens are considered only after at least 6 months of the COCP with cosmetic therapy, with effective contraception because of their teratogenic potential. These drug recommendations are conditional and based on low or very low quality evidence, and the drugs are generally used off-label.

Frequently asked questions

Why is PCOS hard to diagnose in adolescents?

Irregular cycles, acne and polycystic ovarian morphology on ultrasound overlap with normal pubertal development, so adult criteria risk over-diagnosis.

Are pelvic ultrasound and AMH used to diagnose PCOS in teenagers?

No. Ultrasound is not recommended within 8 years of menarche, and AMH should not replace ultrasound or be used as a single test.

What if an adolescent has some features but does not meet the criteria?

An 'at risk' label can be considered, with treatment of symptoms and re-evaluation, including a review of cycles by 3 years after menarche.

Source

Peña AS, Witchel SF, Hoeger KM, Oberfield SE, Vogiatzi MG, Misso M, Garad R, Dabadghao P, Teede H, et al. Adolescent polycystic ovary syndrome according to the international evidence-based guideline. BMC Medicine 2020;18:72. DOI 10.1186/s12916-020-01516-x. Open access. This page is a summary prepared by Medpresso from the original publication. It is not a substitute for the full text or for medical advice.