Adolescent PCOS

1. Adolescent
PCOS
Aboubakr Elnashar
Benha university,
Egypt
ABOUBAKR ELNASHAR

2. CONTENTS
1.DEFINITION
2.PREVALENCE
3.PRESENTATION
4.DIAGNOSIS
5.EVALUATION
6.TREATMENT
CONCLUSION
ABOUBAKR ELNASHAR

3. 1. DEFINITION
Adolescence
From Latin adolescere, meaning to grow up
Transitional stage of physical
and psychological development from puberty to
adulthood
Adolescents
Young people between the ages of 10 and 19 years
(WHO)
Adolescent PCOS
Unexplained persistent hyperandrogenic anovulation
(American Academy of Pediatrics, 2015).
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4. 2. PREVALENCE
1.8 and 15 %
depending on:
diagnostic criteria
ethnicity
[Li et al, 2013].
Increasing
{increasing prevalence of childhood obesity}
(Hassan et al, 2007).
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5. Risk factors
 Premature pubarche (before 8 yr old)
 Obesity
 Family Hx
 Ethnicity
more common in – African-American
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6. Course:
±Progressive course
:full-blown picture of adult PCOS
(evidence is contradictory)
(Coviello et al, 2006)
Risk for progress of adolescent to adult PCOS
•Persistent irregular cycles 6 y after menarche
• (Venturoli et al, 1987)
•Persistent anovulatory cycles 3y after
menarche
(Venturoli et al, 1994)
•Increased BMI
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7. 3. PRESENTATION
Menstrual irregularities
Chronic anovulation
Hyperandrogenism
Acne
 Hirsutism
 Androgenetic alopecia
Hyperandrogenemia
PCO on US
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8. If assumed pathological:
over diagnosis of PCOS
unnecessary psychological distress of having
a diagnosis associated with future subfertility.
If assumed physiological:
under diagnosis of PCOS
more likely to transition to adulthood and
suffer the long term consequences of PCOS.
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9. 4. DIAGNOSIS
Specific and very strict criteria:
Sultan and Paris (2006)
Requires 4 of 5:
1. Oligomenorrhoea or amenorrhoea
2. Clinical hyperandrogenism
3. Biochemical hyperandrogenism
4. Hyperinsulinaemia
5. Polycystic ovary morphology
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10. 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
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11. NIH criteria
The preferred diagnostic criteria in adolescents
[Hardy, Norman, 2013; Legro et al, 2013].
Androgen Excess Society Criteria
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12. 1. Chronic Anovulation /Oligomenorrhoea
(<6 cycles/year)
 For 2 ys since menarche or
 Primary amenorrhoea at 17 y
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13. 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).
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14. 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)
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15. 4. US criteria:
increased ovarian volume (>10 cm3).
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16. 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
(Yetim et al, 2016)
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17. 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)
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18. 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)
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19. 3. Depression
screening for depression and anxiety by
history and,
if identified: referral and/or treatment
(2++OO).
(Endocrine Society Clinical Practice, 2013)
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20. 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)
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21. 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).
 Rescreening:
/3–5 y
more frequently if:
central adiposity
substantial weight gain, and/or
symptoms of diabetes develop
(2++OO).
(Endocrine Society Clinical Practice, 2013)
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22. 6. Cardiovascular risk
screened for CVD risk factors:
family history
cigarette smoking,
IGT/T2DM
hypertension
dyslipidemia
OSA
obesity
especially increased abdominal adiposity
(1++OO).
(Endocrine Society Clinical Practice, 2013)
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23. 6. TREATMENT
Objectives:
symptomatic and prophylactic:
Restoration of body weight
Cycle regulation
Reducing signs of hyperandrogenism
Prevention of long term health hazards.
Infertility
Metabolic syndrome
Obesity
Diabetes
Heart disease.
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24. 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)
Individual PCOS manifestations:
(obesity, hirsutism, irregular menses) should
be treated.
(level B)
(ESHRE/ASRM; 2012)
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25. 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].
 ± Combine OCP with Met
±Combine Antiandrogen with OCP or Met
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26. 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).
wt loss 2-5%   testosterone by 21%
resume regular ovulation in 50% womenABOUBAKR ELNASHAR

27. 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 stressors
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28. 2. Hormonal contraceptives (HCs):
Indications:
First-line management for the
menstrual abnormalities
hirsutism/acne
(1++OO).
(Endocrine Society Clinical Practice, 2013)
ABOUBAKR ELNASHAR

29. Types:
OCP, patch, or vaginal ring
(2++OO).
can be used
OCPs either containing or not containing an
antiandrogen
(Italian society of endocrinology, 2015)
can be used
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30. 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)
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31. 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].
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32. 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
(Italian society of endocrinology, 2015)
ABOUBAKR ELNASHAR

33. BMI:
≤35 kg/m2 with no specific metabolic and/ or CV
abnormalities
Any type
Choice acc to:
preferences of the physician and patient
specific clinical characteristics of the patient.
(Italian society of endocrinology, 2015)
≥35 kg/m2 :
COC should be prescribed with caution
≥40 kg/m2:
Not used
(RCOG, 2011).
If contraception is needed:
alternative measures, such as progestin-only methods.
(Italian society of endocrinology, 2015)
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34. 3. Metformin:
Indications
To treat IGT/metabolic syndrome
(2++OO).
long-term resumption of ovulation
especially thos with an inadequate response
to lifestyle intervention.
Commonly used as
first line monotherapy or
 in combination with OCPs or
antiandrogen
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35. Dose:
Lean:
850 mg daily
Overweight and obese:
1.5 to 2.5 g daily.
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36. Met and COC*:
have comparable therapeutic effectiveness on cycle regularity
and hirsutism.
Met
significant improvement in insulin sensitivity
COC
deterioration of insulin sensitivity
*(30 µg EE and150µg desogestrel=Marvelon)
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37. 4. Combined metformin and OC
:
attenuating the adverse metabolic effects of OC
improving body composition
, as compared with OC alone
[Glintborg et al, 2014].
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38. 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)
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39. 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.
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40. AntiandrogenMetCOClifestylePCOS
+++++++Menstrual Dysfunction
++++++++Hirsutism
++++++++Acne
++++++++Hyperandrogenemia
+++obesity
++++++IGT/2DM
+Psychological
+++: strong evidence
+: some evidence
Morris et al, 2016
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41. CONCLUSIONS
Diagnosis:
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
Evaluation:
Metabolic
CV risks,
Psychologic
Dermatologic .
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42. Treatment
lifestyle modifications
Hormonal contraceptives
Metformin
Antiandrogen.
Limited data on the best treatment modalities
Should be individualized depending on:
Age
Symptoms
Personal and familial risk factors
Choices.
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43. Thanks
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