Diagnosis and Management of Polycystic Ovary Syndrome in Adolescents

 
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Diagnosis and Management of Polycystic Ovary Syndrome in Adolescents
Diagnosis and Management of
Polycystic Ovary Syndrome
in Adolescents
Maria Trent, MD, MPH,a Catherine M. Gordon, MD, MSb

               abstract               Polycystic ovary syndrome (PCOS) is a common female reproductive disorder that often
                                      manifests during adolescence and is associated with disruptions in health-related quality of
                                      life. Prompt evaluation and clinical support after diagnosis may prevent associated
                                      complications and optimize overall health management. This article incorporates the most
                                      recent evidence and consensus guidelines to provide an updated review of the pathogenesis,
                                      clinical presentation, diagnostic evaluation, and management strategies for adolescents with
                                      this complex condition. We will review the recent international guidelines on PCOS; because
                                      the diagnosis of PCOS remains controversial, management of this condition is inconsistent. In
                                      2019, PCOS remains a common, yet neglected, condition, in part, because of the lack of
                                      agreement around both diagnosis and management.

a
 Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland; and bDivision of Adolescent/Young Adult Medicine, Harvard Medical School, Harvard University and Boston
Children’s Hospital, Boston, Massachusetts

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
DOI: https://doi.org/10.1542/peds.2019-2056J
Accepted for publication Jan 29, 2020
Address correspondence to Catherine M. Gordon, MD, MS, Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston,
MA 02115. E-mail: catherine.gordon@childrens.harvard.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2020 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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SUPPLEMENT ARTICLE                                                                                     PEDIATRICS Volume 145, number s2, May 2020:e20192056J
Diagnosis and Management of Polycystic Ovary Syndrome in Adolescents
Polycystic ovary syndrome (PCOS) is             expression of this aberration is                 touch point with these patients who
a common, complex, and                          revealed in ovarian theca cells                  must be carefully managed with
heterogeneous familial disorder that            through increased expression of                  thoughtfulness and closely followed
affects 5% to 10% of females of                 cytochrome P450 enzymatic activity               to ensure the patient is successful
reproductive age and is seen across             (through the gene CYP17A1 or                     with its clinical management.
race and ethnicity, country of origin,          p450c17).10
                                                                                                 The associated clinical findings of
and other sociodemographic
                                                Adolescents with PCOS often                      PCOS usually begin to manifest
backgrounds.1 PCOS has become an
                                                demonstrate both insulin resistance              during adolescence with the
increasingly important adolescent
                                                (IR) and hyperandrogenism.                       presentation evolving into a clinical
reproductive health diagnosis, given
                                                Associated manifestations may be                 picture that can vary considerably.
the significant reductions in health-
                                                exacerbated in adolescents who are               The reproductive dysfunction
related quality of life observed among
                                                overweight or obese, which can                   presents with a range of menstrual
affected patients2,3; potential long-
                                                complicate management of PCOS.11,12              disorders, including amenorrhea,
term cardiovascular, metabolic, and
                                                The temporary decline in insulin                 oligomenorrhea, and abnormal
reproductive health outcomes4; and
                                                sensitivity observed during puberty              uterine bleeding associated with
annual clinical management costs that
                                                may be a critical moment in the                  anovulation or oligoovulation.
exceed $4 billion annually.5 In this
                                                development of IR and                            Patients may also present with
article, we will highlight current
                                                hyperinsulinemia in patients                     ovarian enlargement, endometrial
evidence, consensus, and controversy
                                                predisposed to developing PCOS. The              hyperplasia, and infertility.
among clinicians regarding the
                                                changes in insulin and androgen
pathogenesis, clinical presentation,                                                             Research has demonstrated that up to
                                                metabolism appear to be interrelated,
diagnostic evaluation, and                                                                       80% of patients with PCOS will
                                                as increases in androgens reduce
management of adolescents                                                                        exhibit clinical or laboratory evidence
                                                insulin sensitivity and insulin
with PCOS.                                                                                       of androgen excess. Manifestations
                                                elevations may potentiate androgen
                                                                                                 include hirsutism, acne, male-pattern
                                                secretion in fat tissue.13–15 Insulin
Although the etiology of PCOS                                                                    baldness or alopecia, and elevated
                                                also augments the ovarian response
remains unclear despite decades of                                                               androgens (eg, total testosterone, free
                                                to LH and enhances dysregulated LH
both basic science and clinical                                                                  testosterone,
                                                secretion from the pituitary gland.
research, multiple systems and                                                                   dehydroepiandrosterone sulfate, or
factors including ovarian function,                                                              androstenedione).15,16 Hirsutism is
steroidogenesis, metabolism,                    DIAGNOSIS                                        common among affected adolescents
neuroendocrinology, genetic, and                                                                 and women, but often patients have
environmental issues have been                  Clinical Presentation                            been using home remedies or
identified as contributing to the                Patients seek evaluation when the                professional services that range from
pathophysiology.6 Normally, there is            absence of or irregularity of menses             temporary (eg, tweezing, chemical
a highly functional and coordinated             becomes worrisome and they develop               depilatory agents, waxing) to
process through which follicular                physical findings, such as acne or                permanent (eg, electrolysis,
development occurs with each                    hirsutism. These physical                        thermolysis, laser) hair removal
menstrual cycle. In adolescents with            manifestations, for which home                   techniques. Although acne is
PCOS, there is an imbalance, resulting          treatments are no longer effective, are          a common presentation during
from an exaggerated luteinizing                 typically of great concern to the                adolescence, in combination with an
hormone (LH) response driving                   adolescent patient who is in a period            evolving menstrual disorder, it may
androgen production7 and                        of life when a semblance of normalcy             be a manifestation of androgen
inadequate follicle-stimulating                 with peers is critically important.              excess.17 Clinical tools, such as the
hormone (FSH), resulting in                     They may also have significant                    Ferriman-Gallwey scoring system,18
inadequate conversion of androgens              concerns about sexual health and                 have been used to document
to estradiol, with follicular arrest.8          their future fertility.14 Attention to           hirsutism for clinical management.
Anti-Müllerian hormone (AMH) plays              the details of their sexual and                  However, in more recent work,
a key role in regulating the                    reproductive health histories and                authors suggest that patient-, nurse-,
transitional development of follicles,          liberal use of office-based testing to            and pediatrician-rated hirsutism are
leading to a dominant follicle.                 assess for pregnancy in the absence              highly variable.19 Temporal recession
However, in adolescents with PCOS,              of menses can prevent the need for               and/or alopecia as a sign of
follicular growth is arrested, leading          a costly and unnecessary diagnostic              hyperandrogenism is also important
to the many small follicles stemming            workup. Nonetheless, the PCOS                    to document with tools such as the
from anovulation.9 The phenotypic               evaluation becomes an important                  Ludwig visual score.20 In an era of

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PEDIATRICS Volume 145, number s2, May 2020                                                                                          S211
electronic medical record                  ultrasound and severe cystic acne.              However, clinicians can intervene
documentation, use of images at            The consortium did not recommend                medically with an oral contraceptive
baseline and during follow-up visits       obesity or biochemical (eg, IR or               as first-line management after
may be an objective way to assess the      hyperinsulinemia) or clinical                   observance of hirsutism or alopecia,
clinical impact of hyperandrogenism        evidence (eg, acanthosis nigricans) of          given the known impacts of each on
and the effectiveness of interim           aberrant insulin metabolism; these              health-related quality of life. Early
treatment over time. It is critically      clinical factors may be associated but          intervention can serve as a preventive
important to assess preconsultation        are not sufficiently specific to PCOS to          measure to avoid more severe
hair removal or acne treatment being       make the diagnosis.6 AMH and                    cosmetic problems. For non–sexually
employed by the patient to                 testosterone-to-dihydrotestosterone             active patients, a 3-month hormonal
thoroughly assess the impacts of           ratios have emerged as potential                washout period can be undertaken to
hyperandrogenism when making the           diagnostic biomarkers for clinical use,         reassess hormonal status in patients
diagnosis and at each follow-up visit      given their association with follicular         who are uncertain about their
to ascertain the effectiveness of          development and adverse                         diagnosis and want to determine if
combined therapy, minimize side            phenotypes, respectively.22–25                  their menses will resume on
effects, and examine the burden of         However, additional research is                 their own.
treatment on health-related quality        warranted to define their diagnostic
of life.                                   potential in adolescents; therefore,
                                                                                           CLINICAL ASSESSMENT
                                           they are not recommended in
Clinical Guidelines                        laboratory evaluation for these                 History and Physical Examination
Given the heterogeneity of clinical        patients. The new guideline also
                                                                                           As with all adolescent visits,
findings observed in patients with          stressed the point that a definitive
                                                                                           a detailed, patient-centered interview
PCOS, demonstrating engagement of          diagnosis of PCOS cannot be made
                                                                                           is critical; this includes an assessment
multiple endocrine signaling               until 2 years postmenarche and,
                                                                                           of present illness(es) focused on the
networks as a manifestation of             echoing earlier guidelines, other
                                                                                           patient’s clinical symptoms, past
systems-level disease is critical.         causes of hyperandrogenism are first
                                                                                           medical history, reproductive health
Several expert consensus meetings          ruled out (eg, nonclassic congenital
                                                                                           history (including details of puberty),
have been convened to generate             adrenal hyperplasia, Cushing’s
                                                                                           menstrual history, social history
evidence-based diagnostic criteria to      syndrome, etc).7
                                                                                           (including sexual behaviors and
facilitate a uniform approach to
                                                                                           pregnancy history), and contraceptive
identifying and managing this              Another recent international
                                                                                           use.15 The review of systems can be
disorder, which is characterized by        guideline on PCOS from the
                                                                                           useful in determining the presence of
both disordered menstrual cycles and       International PCOS Network is also
                                                                                           symptoms that are consistent with
the clinical symptoms of androgen          worth consideration, which reviews
                                                                                           PCOS (eg, weight, hair, or skin
excess. The multiple clinical              the available evidence to support
                                                                                           changes) and assessing for other
guidelines that have been published        both diagnosis and management in
                                                                                           disorders that may impact menstrual
over the years have led to confusion       both adolescents and women.20 This
                                                                                           function (neck enlargement
among clinicians who seek to care for      guideline notes the evidence for both
                                                                                           [thyromegaly], headaches,
these patients who present in              assessment and management of PCOS
                                                                                           galactorrhea, weight changes, skin
a variety of ways. Most recently,          to be of low-to-moderate quality.
                                                                                           and/or nail changes). Use of
a collaborative group under the            They also recommend an increased
                                                                                           prescription and over-the-counter
International Consortium of Pediatric      focus on patient education, lifestyle
                                                                                           medications and cosmetic procedures
Endocrinology provided an update to        modifications, emotional well-being,
                                                                                           to reduce symptoms can also be
the pathophysiology, diagnosis, and        and quality of life as critical
                                                                                           assessed. Adolescents may not be as
treatment of PCOS care specific to the      components of intervention. The
                                                                                           aware of family history; therefore,
management of adolescents with the         guideline also asserts that the
                                                                                           collection of key historical data from
disorder.6 These recommendations           evidence supports allowing for only
                                                                                           parents before engaging in alone time
outline the required clinical features     1 year of menstrual irregularity
                                                                                           with the patient may be useful for
and appear to follow most closely the      postmenarche before becoming
                                                                                           completing the clinical story of
1990 National Institutes of Health         concerned about oligo- or
                                                                                           a patient.
guidelines,21 which include irregular      anovulation. Importantly, this
menses and/or oligomenorrhea and           guideline allows for a patient to be “at        A comprehensive physical
biochemical or clinical evidence of        risk for PCOS” with longitudinal                examination can be done that
hyperandrogenism.6 Optional factors        follow-up as an acceptable alternative          includes vital signs, anthropometric
include polycystic ovaries on              to making an early diagnosis.                   assessment, general appearance, skin

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S212                                                                                                               TRENT and GORDON
survey to detect alopecia, male-                                                                    follicles) are not recommended to
pattern baldness, acanthosis                                                                        diagnose PCOS in adolescents.26
nigricans (Fig 1), acne, hirsutism                                                                  Although ultrasound findings have
(Fig 2), Tanner staging, examination                                                                been shown to be supportive of the
of the external genitalia to assess for                                                             diagnosis in women, these findings
virilization (indicated by a clitoris                                                               are not specific to the disorder and
glans width .5 mm), and bimanual                                                                    the diagnosis can often be made
examination, if tolerated, to assess for                                                            without an ultrasound.25 There is also
an ovarian mass.15,16                                                                               significant overlap between normal
                                                                                                    adolescent and PCOS morphology. A
Laboratory Evaluation                                                                               liver ultrasound is warranted for the
The goals of laboratory assessment                                                                  patient who is obese with evidence of
                                                FIGURE 2
are to support the diagnosis of PCOS            Hirsutism in an adolescent with PCOS. (Der-
                                                                                                    nonalcoholic fatty liver disease.
to exclude other causes of menstrual            mAtlas: Online Dermatology Image Library, with
irregularity and clinical                       permission [Cohen, B (ed)], All rights reserved).
hyperandrogenism and assess for                                                                     TREATMENT
associated clinical issues, such as             calculation cannot be used to make                  Because PCOS in adolescence can
diabetes and hyperlipidemia. Free               the diagnosis in isolation; many                    have lifelong implications for
and total testosterone (employing               patients with the disorder will not                 metabolic and reproductive health,
high-quality assays, such as liquid             have elevations, and the elevated                   early treatment is critical, and the
chromatography tandem mass                      ratio can be seen both in patients                  goals of therapy should be discussed
spectrometry and extraction or                  with PCOS and in those who are                      with each patient.6,15,16 These goals
chromatography)26 and                           ovulating. As previously noted, AMH                 include decreasing the risk of
dehydroepiandrosterone sulfate are              levels are associated with the                      endometrial cancer (for unopposed
routinely measured to assess for the            anovulation and fertility issues                    estrogen stimulation, which can lead
contribution of ovarian and adrenal             observed in adult women with PCOS,                  to endometrial hyperplasia),
androgens and consider the                      but this promising biomarker is                     managing irregular menses
possibility of an adrenal or ovarian            currently not recommended for                       (oligomenorrhea and abnormal
tumor. If late-onset congenital adrenal         diagnostic decision-making because                  uterine bleeding), reducing hirsutism
hyperplasia is suspected, a morning             guidelines for use have not been                    and acne, decreasing the risk for
serum 17-hydroxyprogesterone can                established for adolescents.24,26                   development of type 2 diabetes,
be obtained. A serum FSH can be                                                                     reducing cardiovascular risks,
                                                Patients suspected of having PCOS
measured to ensure that the ovary is                                                                improving quality of life, and
                                                can also be screened for thyroid
functioning and assess for ovarian                                                                  preserving fertility. Affected
                                                disease (thyroxine and thyroid-
insufficiency. Given the aberrant                                                                    adolescents have an increased
                                                stimulating hormone),
changes in LH, this is often ordered to                                                             prevalence of multiple metabolic
                                                hyperprolactinemia (prolactin), and
assess the ratio of LH to FSH.                                                                      derangements, each of which can
                                                metabolic abnormalities, such as type
Although the LH-to-FSH ratio is often                                                               present a target condition that merits
                                                2 diabetes mellitus (fasting glucose or
elevated in patients with PCOS, this                                                                treatment. Examples include markers
                                                hemoglobin A1c) and hyperlipidemia
                                                                                                    for obesity, IR, dyslipidemia, and
                                                (fasting lipid profile). Patients with
                                                                                                    hypertension. Obesity is one of the
                                                PCOS who are significantly obese and
                                                                                                    most common findings in patients,
                                                have profound chemical metabolic
                                                                                                    with 40% to 80% of women with
                                                abnormalities may present with
                                                                                                    PCOS meeting criteria for being
                                                nonalcoholic fatty liver disease;
                                                                                                    overweight or obese.26 Obesity can
                                                therefore, liver function (aspartate
                                                                                                    lead to ovarian inflammation, reduced
                                                aminotransferase, alanine
                                                                                                    oocyte quality, and abnormal
                                                aminotransferase) testing is
                                                                                                    ovulatory patterns that can manifest
                                                warranted in this subgroup.6,15,16
                                                                                                    as infertility. Although both metabolic
                                                Radiologic procedures, such as pelvic               and reproductive abnormalities are
                                                sonograms, to determine the                         well characterized, there remain
FIGURE 1                                        presence of the classic ovarian                     many questions regarding the best
Acanthosis nigricans in an adolescent with
PCOS. (DermAtlas: Online Dermatology Image
                                                morphology (increased ovarian                       long-term management strategies for
Library, with permission [Cohen, B (ed)], All   volume with a thickened white                       adolescents or women with this
rights reserved).                               capsule and multiple small 2–8-mm                   diagnosis.27,28

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PEDIATRICS Volume 145, number s2, May 2020                                                                                             S213
Lifestyle modifications, such dietary         increased thrombotic risk with                  therapy, plucking, waxing, shaving,
changes, exercise, and weight loss, are      a combined patch, but these have not            and bleaching to achieve the desired
first-line interventions for                  been substantiated across reports.34            cosmetic result)1,15,38,39 and topical
adolescents with PCOS27 and are              The combined preparations suppress              therapies for acne. Eflornithine
endorsed by the Endocrine Society’s          the hypothalamic-pituitary ovarian              hydrochloride (13.9%) cream (which
clinical practice guideline28 as well as     axis and decrease ovarian and                   blocks the enzyme ornithine
the recent international evidence-           adrenal androgen production. As                 decarboxylase, needed for hair
based guideline on PCOS.20 This              a result, unwanted hair growth                  growth) is another option to lessen
nonpharmacologic therapy is                  improves in 50% to 70% of hirsute               facial hirsutism and can augment the
a critical first step for patients who        women treated with an oral COC,                 effects of laser therapy.15 However,
are overweight or obese, which               which represents the most effective             the benefits of this cream and other
exacerbates the PCOS phenotype.29            therapy for management of                       topical strategies can be outweighed
Weight loss as a sole maneuver can           hirsutism.14,28 However, insulin                by their side effects (eg, burning,
decrease androgen production,30              sensitivity does not change.35                  folliculitis, etc).15,36 For acne, topical
improving insulin sensitivity and            Because there is often the common               retinoic acid and antibiotics can be
reducing cardiovascular risk. Lifestyle      goal of treating hyperandrogenism               helpful adjuncts to oral antibiotics,
modifications, including a calorie-           and providing contraception for an              hormonal therapy, or antiandrogens.
restricted diet and/or physical              adolescent, a COC can address both
                                                                                             Because IR is common in PCOS,
activity, has proven effective in            issues.
                                                                                             insulin-sensitizing agents are among
altering the disease course of PCOS.26
                                             Antiandrogens can be helpful for                the most frequently studied agents.
One small study of women with PCOS
                                             severe cases of hirsutism, as an                Metformin is a biguanide that acts to
revealed that exercise markedly
                                             adjunct to a COC, especially when               decrease hepatic glucose production
improved hyperlipidemia.31 In
                                             alopecia is present and if hirsutism            and increase peripheral insulin
another study, the authors examined
                                             has not improved after 6 months of              sensitivity.28,40 IR, important within
the effectiveness of exercise and/or
                                             a COC as monotherapy.20 Many young              the pathophysiology of PCOS,
dietary interventions for affected
                                             women seek pharmacologic                        predisposes patients to metabolic
adolescents and found beneficial
                                             treatment because of the stigma                 dysfunction and increases the risk of
effects of exercise for a range of
                                             associated with the male-pattern hair           type 2 diabetes mellitus. As an
metabolic, anthropometric, and
                                             growth, even before a diagnosis of              insulin-sensitizing agent, metformin
cardiorespiratory fitness-related
                                             PCOS is made. Pediatricians can                 has the potential to improve glycemic
outcomes.32 Subgroup analyses
                                             consider cultural and societal factors          control and prevent or improve type
revealed the greatest improvements
                                             around the hirsutism and take into              2 diabetes, as well as address
in participants who were overweight
                                             account not only the severity of the            problems, such as dyslipidemia, that
or obese, and more outcomes
                                             hirsutism but also the patient’s                stem from the IR; it has been
improved when interventions were
                                             perception of the severity when                 endorsed by recent clinical
supervised, aerobic in nature, or
                                             determining appropriate treatment.36            guidelines.6,20
shorter in duration.
                                             Spironolactone is the most commonly
                                                                                             In a recent study, the authors
Estrogen and progestin combination           prescribed androgen receptor blocker
                                                                                             compared metformin and
therapy represent the first-line              and can be used in combination with
                                                                                             N-acetylcysteine on clinical,
pharmacologic therapy for                    oral contraceptives because this agent
                                                                                             metabolic, and hormonal parameters
                                             can lead to irregular menses and
adolescents with PCOS, most                                                                  in women with PCOS.41 Researchers
commonly as a combined oral                  potential teratogenicity (feminization
                                                                                             studied 100 patients with PCOS who
contraceptive (COC), with 20 to 35 mg        of a male fetus).14 The recommended
                                                                                             received metformin (1500 mg/day)
of ethinyl estradiol.20,33 This therapy      dose is 50 to 200 mg/day in 1
                                                                                             or N-acetylcysteine (1800 mg/day)
has the potential to mitigate both           to 2 divided doses.37 Other
                                                                                             for 24 weeks. There was significant
hirsutism and acne. A combined               options include cyproterone
                                                                                             improvement in BMI, waist
transdermal patch and the vaginal            acetate, flutamide, and finasteride,
                                                                                             circumference, and waist-to-hip ratio
ring are other options, but there is no      but hepatotoxicity has emerged
                                                                                             in the N-acetylcysteine group, but no
evidence to suggest one delivery             as a concern, and not all
                                                                                             significant difference was found in
method to be superior to the others.31       medications are available in the
                                                                                             weight reduction among the 2 groups.
However, the transdermal patch is not        United States.
                                                                                             Markers of IR, including fasting
recommended for girls or women               Systemic therapy can be augmented               insulin and the fasting glucose-to-
whose weight is .90 kg. There have           by topical and mechanical treatments            insulin ratio, improved significantly
been some concerns raised about an           for hirsutism (eg, electrolysis, laser          after N-acetylcysteine, and a greater

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S214                                                                                                                   TRENT and GORDON
reduction of total testosterone was             model assessment for IR. Anxiety and             cosupplementation, compared to
seen. Enhanced improvement of the               depression were measured by the                  a placebo, significantly improved BDI-
metabolic and hormonal profile was               Beck Anxiety Inventory and the Beck              II scores, general health questionnaire
observed in the N-acetylcysteine                Depression Inventory-II (BDI-II).                scores, as well as depression, anxiety,
group. Further study is needed, but             After 90 days of metformin treatment,            and stress scale scores. Vitamin D and
because of potentially fewer side               both Beck Anxiety Inventory and BDI-             probiotic cosupplementation were
effects compared to metformin, this             II scores decreased, and indicators of           associated with a significant
therapy may arise as a new option to            IR and obesity were improved. The                reduction in total testosterone,
consider over metformin in the                  findings suggest that metformin can               hirsutism, and high-sensitivity
treatment of PCOS.                              decrease IR and improve mood, both               C-reactive protein and an increase in
                                                in adolescents and adults with PCOS.             total antioxidant capacity compared
Adolescents with PCOS often seek
                                                In another recent study, researchers             to the placebo. In a systematic review
care regarding irregular menses,
                                                explored the use of a psychological              and meta-analysis, authors similarly
infertility, hirsutism, and acne. For
                                                approach in caring for adolescents               concluded that vitamin D
hirsutism, viewed by many
                                                with this diagnosis.43 The researchers           supplementation may be beneficial
adolescents as a “cosmetic
                                                examined the prevalence of coping                for follicular development and
emergency,” COCs are a first-line
                                                and depression in adolescent girls               menstrual regulation in patients with
therapy, as endorsed by recent
                                                with PCOS. Adolescent girls 13 to                PCOS45; however, confirmatory trials
guidelines.6,20 More than 2 decades
                                                18 years of age with this diagnosis              are needed. Omega-3 fatty acid
ago, we examined whether quality of
                                                completed questionnaires and                     supplementation has been shown to
life was compromised in young
                                                answered interview questions                     have short-term (ie, 12 weeks)
adolescents with PCOS.3 We observed
                                                regarding how they coped with their              beneficial effects for mental health
that scores on assessments of health-
                                                disease and depression. Adolescents              parameters, IR, androgens, and
related quality of life were lower than
                                                perceived little control over many               inflammatory markers.28 However,
healthy control subjects, and the issue
                                                aspects of PCOS, with menstrual                  a meta-analysis46 suggests that IR
that generated the most concern was
                                                irregularities and the threat of                 was not beneficially impacted by
infertility. Although adolescent
                                                infertility reported as the most                 omega-3 fatty acids.
specialists typically try to prevent
                                                stressful and least controllable
pregnancy, it is important to
                                                aspects of PCOS. Lower control was               In a recent review, authors examined
acknowledge that concerns about
                                                a predictor of more significant                   the cardiovascular profile of
infertility may be seen even in the
                                                depression among the participants.               pharmacologic agents that have been
young adolescent patient. The
                                                These results remind pediatricians to            used for the management of PCOS.47
effect of this diagnosis on quality
                                                be aware of and screen for depression            It has been unclear whether PCOS is
of life continues to be mentioned,
                                                in this population.                              associated with increased
including in recent clinical
                                                                                                 cardiovascular events in later years,
guidelines.6,20
                                                Authors of a few recent studies have             independent of the presence of type 2
Mood disturbances are common                    explored whether vitamins and                    diabetes. The medications reviewed
among adolescent girls with PCOS                supplements are of benefit to                     included COCs, antiandrogens,
and have been the subject of recent             adolescents and/or women with                    clomiphene, and drugs specifically
research. The propensity for obesity            PCOS; one study was used to examine              used in diabetes therapy, including
and cosmetic concerns (eg, hirsutism,           vitamin D and probiotic                          metformin. In the review, the authors
acne, etc) may lead to poor self-               cosupplementation.44 In                          concluded that therapies used to treat
esteem and depression. In a recent              a randomized, double-blind, placebo-             these patients do not confer an
pilot study, the authors examined               controlled trial in 60 adult women               increased cardiovascular risk and that
mood disturbances as well as IR in              (18–40 years of age) with PCOS, the              there is no evidence that any
adolescents and adult women with                effect of vitamin D and probiotic                interventional medical therapy may
PCOS at baseline and after metformin            coadministration on mental health,               prevent the onset of diabetes in
therapy (1500 mg/day).42 Nineteen               hormonal, and inflammatory and                    patients with PCOS. However, in the
adolescents (#18 years old) and 25              oxidative stress parameters was                  case of metformin, this agent was
women ($18 years old) were                      examined. The intervention was oral              suggested to be beneficial in
enrolled and had their baseline and             50 000-IU vitamin D3 every 2 weeks               preventing the development of
90-day anthropometric data tracked              plus 8 3 109 colony-forming units                gestational diabetes. Lastly, orlistat is
as well as measurements of glucose,             per day of the probiotic (n = 30) or             a noteworthy medication that reduces
androgens, and lipids; IR was                   placebo (n = 30) for 12 weeks.                   weight and, therefore, might lead to
calculated by using the homeostasis             Vitamin D and probiotic                          decreased cardiovascular risk.

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PEDIATRICS Volume 145, number s2, May 2020                                                                                            S215
Considering agents that a clinician          loss and improve glucose tolerance in           REFERENCES
might prescribe for the long-term            many patients in randomized                       1. Wang S, Alvero R. Racial and ethnic
management of PCOS, orlistat is one          controlled clinical trials. Additionally,            differences in physiology and clinical
that has been suggested to have the          androgen receptor blockers, such as                  symptoms of polycystic ovary
potential to help achieve weight loss        spironolactone, can aid in the                       syndrome. Semin Reprod Med. 2013;
and improve lipid and glucose                treatment of hirsutism, acne, and                    31(5):365–369
metabolism.27 In a recent systematic         alopecia, which are the issues of most            2. Upadhya K, Trent M. Effects of polycystic
review, the authors suggested orlistat       concern to adolescents. Patients with                ovary syndrome on health-related
to be more effective in improving            PCOS may also benefit from an                         quality of life. Expert Rev
ovulation rate, weight loss, and lipid       adolescent medicine or pediatric                     Pharmacoecon Outcomes Res. 2007;
profiles in women with PCOS.48                endocrinology referral for diagnostic                7(6):597–603
Lastly, a 2018 study revealed that           evaluation and dermatology                        3. Trent M, Austin SB, Rich M, Gordon CM.
orlistat is more effective and               services for optimal management                      Overweight status of adolescent girls
has fewer side effects than                  of hirsutism and acne. As an adjunct                 with polycystic ovary syndrome: body
metformin.49                                 to treatment by subspecialty                         mass index as mediator of quality of
                                             clinicians, local listings for                       life. Ambul Pediatr. 2005;5(2):107–111
                                             adolescent-friendly cosmetology                   4. Fields EL, Trent ME. Treatment
CONCLUSIONS                                  services are important for access to                 considerations for the cardiometabolic
Long-term individualized                     temporary and permanent hair                         signs of polycystic ovary syndrome:
management that integrates                   removal methods because medical                      a review of the literature since the 2013
evidence-based practice using                treatments such as laser therapy are                 Endocrine Society clinical practice
a combination of pharmacologic               expensive and may not be covered by                  guidelines. JAMA Pediatr. 2016;170(5):
                                                                                                  502–507
interventions, topical dermatologic          insurance despite the potential
treatments, lifestyle intervention, and      positive impact on health-related                 5. Azziz R, Marin C, Hoq L, Badamgarav E,
social support for patients with PCOS        quality of life. Finally, attention to               Song P. Health care-related economic
is needed to normalize menses,               social, emotional, and vocational                    burden of the polycystic ovary
effectively treat associated                 development is critically important,                 syndrome during the reproductive life
                                                                                                  span. J Clin Endocrinol Metab. 2005;
dermatologic issues (eg, hirsutism           given the observed quality of life
                                                                                                  90(8):4650–4658
and acne), achieve fertility, reduce the     issues observed in this population, as
burden of obesity and risk of                well as the potential need for                    6. Ibáñez L, Oberfield SE, Witchel S, et al.
metabolic related diseases, and              alternative financial resources to                    An International Consortium update:
                                                                                                  pathophysiology, diagnosis, and
address health-related quality of life       enable access to assisted
                                                                                                  treatment of polycystic ovarian
issues associated with the disorder.         reproductive technologies to address
                                                                                                  syndrome in adolescence. Horm Res
Surprisingly, the PCOS field is               potential fertility issues in adulthood.             Paediatr. 2017;88(6):371–395
advancing slowly to attain new               Attention to both the physical and
                                                                                               7. Patel K, Coffler MS, Dahan MH, Malcom
evidence that would change practice.         emotional health of affected
                                                                                                  PJ, Deutsch R, Chang RJ. Relationship of
PCOS is a common diagnosis but is far        adolescents is paramount as part of
                                                                                                  GnRH-stimulated LH release to episodic
from “one size fits all” with respect to      a personalized management strategy                   LH secretion and baseline endocrine-
treatment. Optimal treatment uses            designed to improve the overall                      metabolic measures in women with
a multimodal approach, including             longitudinal health outcomes for                     polycystic ovary syndrome. Clin
nutrition and exercise interventions         affected adolescents and emerging                    Endocrinol (Oxf). 2004;60(1):67–74
in adolescents. Pharmacologic                adults.                                           8. Franks S, Stark J, Hardy K. Follicle
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menstrual irregularity, protect the            ABBREVIATIONS
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the most effective strategy for the                   II                                          2003;362(9389):1017–1021
management of hirsutism and acne in           COC: combined oral contraceptive                10. Nelson VL, Legro RS, Strauss JF III,
both adolescents and women with               FSH: follicle-stimulating hormone                   McAllister JM. Augmented androgen
PCOS. Metabolic dysfunction can be            IR: insulin resistance                              production is a stable steroidogenic
mitigated by using insulin-sensitizing        LH: luteinizing hormone                             phenotype of propagated theca cells
agents, such as metformin, which also         PCOS: polycystic ovary syndrome                     from polycystic ovaries. Mol Endocrinol.
have shown to induce some weight                                                                  1999;13(6):946–957

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S218                                                                                                                           TRENT and GORDON
Diagnosis and Management of Polycystic Ovary Syndrome in Adolescents
                   Maria Trent and Catherine M. Gordon
                        Pediatrics 2020;145;S210
                     DOI: 10.1542/peds.2019-2056J

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Diagnosis and Management of Polycystic Ovary Syndrome in Adolescents
                   Maria Trent and Catherine M. Gordon
                        Pediatrics 2020;145;S210
                     DOI: 10.1542/peds.2019-2056J

The online version of this article, along with updated information and services, is
                       located on the World Wide Web at:
     http://pediatrics.aappublications.org/content/145/Supplement_2/S210

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