Polycystic ovary syndrome (PCOS) is the most common endocrine condition affecting 6-18% of adolescent girls. Diagnosing PCOS during adolescence is challenging due to overlapping features with normal puberty. This document provides guidelines for the diagnosis of adolescent PCOS, including evaluating irregular menstrual cycles, clinical or biochemical signs of hyperandrogenism, and excluding other conditions through investigations. Pelvic ultrasound is not recommended for diagnosis in those under 8 years post-menarche due to high rates of multifollicular ovaries in normal adolescents.

1. dr. Mohamed Alajami
Higher Studies in Obs.Gyne- MD
Lecturer in HAMA University
Adolescent polycystic ovary
syndrome
International guideline on PCOS 2020

2.  Polycystic ovary syndrome (PCOS) is the most common endocrine
condition:
 ~ 8 - 13% of women of reproductive age
 6 - 18% -26% of adolescent girls
 depending on the population.
dr. Mohamed Alajami
Background
Hum Reprod. 2016;31(12):2841–55.
Hum Reprod. 2011; 26(6):1469–77.
Fertil Steril. 2013;100(2):470–7.

3.  ~ 50% of them are overweight
 PCOS is generally underdiagnosed during adolescence
 95% of adolescents with irregular menses
 85 % of androgen excess in adolescent girls
Background
dr. Mohamed Alajami

4.  Diagnosing polycystic ovary syndrome (PCOS) during
adolescence is both controversial and challenging.
 features of normal pubertal development overlap with adult
diagnostic criteria.
Background
dr. Mohamed Alajami

5.  We aimed to promote
 accurate and timely diagnosis
 optimize consistent care
 improve health outcomes for adolescents and women with
PCOS.
 identify girls ‘at risk’ of PCOS but not yet diagnosed,
including the need for future follow-up.
Background
dr. Mohamed Alajami

6.  Unknown
 Conflicting theories.
 Genetic linkage
 Complex interaction between genetic and environmental factors.
 Daughters of women with PCOS are at an increased risk.
 Hormonal imbalance
 High insulin levels.
 High androgen levels.
 High luteinizing hormone.
 Low estrogen/progesterone.
 Insulin resistance
 However, it is recognized that there is heterogeneity in PCOS
PCOS - Pathogenesis
dr. Mohamed Alajami

7. Rotterdam 2003
PCOS is a two of the following criteria:
 Chronic oligo- or anovulation for more than 6 months
 Clinical and/or biochemical evidence of hyperandrogenism
 Polycystic ovaries on ultrasound.
Other disorders that mimic the PCOS phenotype should be excluded

8.  The period between 10 and 19 years of age that includes
significant and critical changes in growth, development and
puberty.
dr. Mohamed Alajami
WHO
Adolescence

9. Adolescent PCOS
 PCOS is not one disorder/disease.
 PCOS is complex with reproductive, metabolic and psychological
features
ESHRE-ASRM 2018
֎Unexplained persistent hyperandrogenic anovulation.
AAP 2015

10.  Criteria required
1. Irregular menstrual cycles and ovulatory dysfunction
2. Hyperandrogenism
 Biochemical
 Clinical
3. Exclusion other conditions that can cause menstrual irregularities
and/or hyperandrogenism
dr. Mohamed Alajami
Adolescent PCOS Diagnosis

11. Level A
Adolescent PCOS Diagnosis

12. dr. Mohamed Alajami
Irregular menstrual cycles & ovulatory
dysfunction
Definition of irregular menstrual cyclesTime post menarche
Irregular menstrual cycles are normal pubertal
transition
< 1 year
< 21 or > 45 days> 1 to < 3 years
< 21 or > 35 days or < 8 cycles per year> 3 years
> 90 days for any one cycle> 1 year
Primary amenorrhea by age 15 years or > 3 years post thelarche; 15 years bone
age, if puberty onset was early
 irregular menstrual cycles according to time post menarche
CCR

13.  When irregular menstrual cycles are present, a diagnosis of PCOS
should be considered.
 Ovarian dysfunction can still occur in adolescents or women with
regular menstrual cycles and, if anovulation is suspected, serum
progesterone levels can be measured to confirm it.
dr. Mohamed Alajami
Irregular menstrual cycles & ovulatory
dysfunction
CPP
Up To Date 2018
ESHRE-ASRM 2018

14.  Biochemical
 Clinical
Hyperandrogenism
dr. Mohamed Alajami

15.  androgen levels in adolescents reach adult levels around the
time of menarche.
 Calculated free testosterone, free androgen index or
bioavailable testosterone should be used to assess biochemical
hyperandrogenism in the diagnosis of PCOS.
Biochemical Hyperandrogenism
dr. Mohamed Alajami
Gynecol Endocrinol. 2015;31(8):625–9.
EBR

16. Biochemical Hyperandrogenism
dr. Mohamed Alajami
 Persistent elevation of serum total and/or free testosterone is the
clearest support for the presence of hyperandrogenism in an
adolescent girl with symptoms of PCOS
ACOG 2017 Level BESHRE-ASRM 2018

17.  The upper limit approximates 55 ng/dL for total testosterone
and 9 pg/mL for free testosterone.
Biochemical Hyperandrogenism
dr. Mohamed Alajami
J Clin Endocrinol Metab. 2008;93(4):1105–1120
Hum Reprod Update. 2012;18(2): 146–170

18. Biochemical Hyperandrogenism
dr. Mohamed Alajami
ESHRE-ASRM 2018
֎Assessment of biochemical hyperandrogenism is most useful
when clinical signs of hyperandrogenism (in particular hirsutism)
are unclear or absent
CPP

19.  High-quality assays should be used for the most accurate
assessment of total or free testosterone in PCOS.
 such as liquid chromatography– mass spectrometry and
extraction/chromatography immunoassays
Biochemical Hyperandrogenism
dr. Mohamed Alajami
EBR

20.  Androstenedione and dehydroepiandrosterone sulfate (DHEAS)
 limited usefulness in the diagnosis of PCOS
 could be considered if total or free testosterone are not
elevated.
 more useful in excluding other causes of hyperandrogenism.
Biochemical Hyperandrogenism
dr. Mohamed Alajami
EBR

21.  Androstenedione
 elevated in nonclassical adrenal hyperplasia (NCAH).
 DHEAS
 predominantly adrenal androgen
 mild elevations can be seen in PCOS
 significant elevations and/or Virilization (clitoris glans width
>5 mm) can be seen in androgen-secreting adrenal tumors.
Biochemical Hyperandrogenism
dr. Mohamed Alajami

22.  Sex hormone binding globulin (SHBG) serum concentrations
 govern the fraction of testosterone that is free.
 SHBG is lowered by obesity and androgen excess itself.
 dihydrotestosterone generated in target tissue mediates most
testosterone effects, its serum level is of little diagnostic value.
dr. Mohamed Alajami
Biochemical Hyperandrogenism

23.  When androgen levels are markedly high:
 History of symptom onset and progression is critical in
assessing for neoplasia
 some androgen-secreting neoplasms may only induce mild to
moderate increases in biochemical hyperandrogenism.
Biochemical Hyperandrogenism
dr. Mohamed Alajami
CPP

24.  Avoid the assessment of biochemical hyperandrogenism in
women on hormonal contraception
 a drug withdrawal of > 3 months is recommended.
Biochemical Hyperandrogenism
dr. Mohamed Alajami
CPP

25.  The development of sexual hair (terminal hair that develops in
a male like pattern) and most sebaceous glands is dependent
on androgen.
Clinical Hyperandrogenism in
Adolescents
dr. Mohamed Alajami
Endocr Rev. 2000;21(4): 363–392

26.  Clinical hyperandrogenism in adolescents include
severe acne and hirsutism.
Clinical Hyperandrogenism
dr. Mohamed Alajami
strong recommendation
CCR

27.  Acne:
 moderate or severe comedonal acne (> 10 facial lesions) in
early puberty or
 moderate to severe inflammatory acne during the peri-
menarcheal years.
 that is persistent and poorly responsive to topical treatment
• indication to test for hyperandrogenemia before initiation of
any medical therapies
Clinical Hyperandrogenism
dr. Mohamed Alajami
Pediatrics. 2013;131(Suppl. 3):S163–86.
J Pediatr. 1997;130(1):30–9.Fertil Steril. 2001;75(5):889–2.
Level CACOG 2017
AAP 2015Up To Date 2020

28. Moderate acne
dr. Mohamed Alajami

29. dr. Mohamed Alajami
Severe acne

30. Moderate inflammatory acne
dr. Mohamed Alajami

31. dr. Mohamed Alajami
Severe cystic acne

32. dr. Mohamed Alajami
Severe acne

33. dr. Mohamed Alajami
Severe cystic acne

34. Clinical Hyperandrogenism
dr. Mohamed Alajami
֎Mild comedonal acne is common in adolescent girls and considered
normal.

35.  Hirsutism
 Presence of excessive terminal hair in androgen-sensitive areas
of the female body.
 Modified Ferriman–Gallwey score (mFG) ≥ 4–6.
 Self-treatment is common and can limit clinical assessment.
 higher hirsutism scores are related to higher testosterone levels
Clinical Hyperandrogenism
dr. Mohamed Alajami
J Clin Endocrinol Metab. 1961;21:1440–7.Hum Reprod Update. 2010;16(1):51–64.
J Clin Endocrinol Metab. 2013;98(4):1641–50.
Human Reproduction Update 2011ESHRE-ASRM 2018
Horm Res Paediatr. 2015;83(6):376–389

36.  Hirsutism
 Isolated mild hirsutism (mFG ~ 9 -15) may be normal in the
early postmenarcheal years.
 Moderate (mFG ~ 16 -25) to severe (mFG >25) hirsutism
 Progressive hirsutism
Clinical Hyperandrogenism
dr. Mohamed Alajami
Level CACOG 2017
Level BACOG 2017
Jeffrey CR, Coffler, 2007

37. Modified Ferriman–Gallwey score (mFG)
dr. Mohamed Alajami

38. Clinical Hyperandrogenism
dr. Mohamed Alajami
Hirsutism in an adolescent with PCOS

39. Clinical Hyperandrogenism
dr. Mohamed Alajami
Hirsutism in an adolescent with PCOS

40. Clinical Hyperandrogenism
dr. Mohamed Alajami

41.  Hirsutism must be distinguished from hypertrichosis.
© generalized excessive vellus hair growth distributed in a
nonsexual pattern, (predominantly on forearms or lower legs).
 This hair growth is not due to androgen excess.
 may have an ethnic/hereditary, basis or
 may result from malnutrition or
 certain medications, such as phenytoin or cyclosporine.
dr. Mohamed Alajami
Clinical Hyperandrogenism

42. dr. Mohamed Alajami
Hypertrichosis

43. Clinical Hyperandrogenism
dr. Mohamed Alajami
֎ No studies in adolescents evaluating alopecia in the context of
PCOS.
֎Frank Virilization is unusual in PCOS

44.  Recommended evidence of androgen excess include:
1. Moderate to severe hirsutism;
2. Persistent acne unresponsive to topical therapy;
3. Persistent elevation of serum total and/or free testosterone
level.
Hyperandrogenism
dr. Mohamed Alajami
 Total testosterone concentrations >55 ng/dL are generally
considered consistent with hyperandrogenism
 These hormone levels should preferably be drawn in the morning

45.  Be aware of the potential negative psychosocial impact of
clinical hyperandrogenism.
 Reported unwanted excess hair growth should be considered
important, regardless of apparent clinical severity.
Clinical Hyperandrogenism
dr. Mohamed Alajami
Hum Reprod Update. 2008;14(1):15–25.
ESHRE-ASRM 2018 CCR

46.  Pelvic ultrasound for PCOS diagnosis
 Anti-Müllerian hormone (AMH)
Investigations not recommended
dr. Mohamed Alajami

47.  Pelvic ultrasound should not be used for the diagnosis of PCOS
in those with a gynecological age of < 8 years (< 8 years post
menarche)
 due to the high incidence of multi-follicular ovaries (MFO) in
this life stage.
 PCOM may represent a marker of PCOS or may be normal in
young women.
Pelvic ultrasound for PCOS diagnosis
dr. Mohamed Alajami
strong recommendationCCR
Fertil Steril. 2011;95(2):702–6.e1–2

48.  PCOM is an ovary with a volume > 10.0 mL or a small antral
follicle (2–9 mm diameter) count >12 per ovary.
 newer high definition vaginal imaging techniques show that
small antral follicle counts up to 24 are normal.
 ensure no corpora lutea, cysts or dominant follicles are
present when measure ovarian volume.
Pelvic ultrasound for PCOS diagnosis
dr. Mohamed Alajami
CCR

49. dr. Mohamed Alajami
Pelvic ultrasound for PCOS diagnosis
 Multifollicular ovary (MFO):
 presence of > 6 follicles of 4-10 mm throughout the ovary
 without increase in ovarian volume
 stroma is not increased
 does not have a relationship with hyperandrogenism
 should not be considered a pathological finding
Level CACOG 2017
Fertil Steril. doi:10.1016/j.fertnstert.2015.08.002

50.  Ovarian volume changes over time with increased antral follicles
and stroma;
 ovarian size increases from ages 9 to 11
 the maximum volume at age 20
 mean ovarian volume >12 cc (or single ovary >15 cc)
considered enlarged in adolescents
dr. Mohamed Alajami
PLoS One. 2013;8(9):e71465
Clin Ultrasound. 2011;39(2):64–73AJR Am J Roentgenol. 2002;178(6): 1531–6J Clin Ultrasound. 2008;36(9):539–44.
Pelvic ultrasound for PCOS diagnosis
Level BACOG 2017

51.  Pelvic ultrasound can be used to investigate other possible
uterine or ovarian abnormalities in adolescent girls such as
those that present with primary amenorrhea.
dr. Mohamed Alajami
Pelvic ultrasound for PCOS diagnosis

52.  Pelvic ultrasound indicated if clinical findings are suggestive of
a Virilizing tumor
• Rapid progression
• Clitoromegaly
• Pelvic mass
• a total testosterone level >200 ng/dL
• disorder of sex development.
dr. Mohamed Alajami
Pelvic ultrasound for PCOS diagnosis

53.  AMH levels should not be used as an alternative for the
detection of PCOM or as a single test for the diagnosis of PCOS.
 AMH assays will become more accurate in the detection of
PCOM.
dr. Mohamed Alajami
Anti-Müllerian hormone (AMH)
EBR
CPP

54.  The diagnosis of PCOS is a diagnosis of exclusion
 all other etiologies that can cause menstrual irregularities and/or
hyperandrogenism must be excluded, regardless of the fact that
some etiologies are less common in adolescents.
Exclusion of other conditions
dr. Mohamed Alajami

55.  Menstrual irregularity alone could be due to gonadotropin
deficiency:
 functional hypothalamic amenorrhea
 secondary deficiency due to any systemic cause, or
 a primary gonadotropin defect.
Exclusion of other conditions
dr. Mohamed Alajami

56.  Many conditions can lead to hyperandrogenism:
© the most common is non-classic congenital adrenal
hyperplasia (NCAH)
Exclusion of other conditions
dr. Mohamed Alajami

57.  Non-classic congenital adrenal hyperplasia (NCAH)
 Diagnosis of NCAH is suspected if:
• adolescent girl has clitoromegaly and/or an early-morning, follicular
phase 17-hydroxyprogesterone (17-OHP) level of > 200 ng/dl (> 6
nmol/L)
 Confirmed at
• 17-OHP levels of > 1000–1500 ng/dl (35 nmol/L) 60 min after
administration of 250 μg of synthetic adrenocorticotropic hormone or
synacthen.
Exclusion of other conditions
dr. Mohamed Alajami
J Clin Endocrinol Metab. 2010;95(9):4133–60.
Clin Endocrinol (Oxf). 2015;82(4):543–549

58.  Menstrual irregularity and/or hyperandrogenism can caused
by:
1. Hypothyroidism
2. Hyperprolactinemia
3. glucocorticoid excess due to Cushing’s disease
4. glucocorticoid resistance
5. androgen-secreting ovarian or adrenal tumors
Exclusion of other conditions
dr. Mohamed Alajami
Eur J Clin Investig. 2012;42(1):86–94.

59.  A thorough history and physical examination are important to
look for signs of hypothyroidism, agalactorrhea, glucocorticoid
excess or Virilization in the evaluation of an adolescent girl with
suspected PCOS.
Exclusion of other conditions
dr. Mohamed Alajami

60.  Measurement of serum
1. TSH
2. Prolactin
3. Gonadotropins (FSH, LH)
4. androgen (SHBG, testosterone, androstenedione, DHEA-S)
5. and/or follicular phase 17-OHP levels is required
Exclusion of other conditions
dr. Mohamed Alajami

61.  If the androgen levels are twice above the upper limit, imaging
is also required to assess the ovary and/or adrenals.
 exclude Cushing’s syndrome only where the condition is
clinically suspected.
Exclusion of other conditions
dr. Mohamed Alajami

62.  Adolescents have features of PCOS but do not meet the
diagnostic criteria, are advised reassessment at or before full
reproductive maturity.
 at 3 years post menarche in relation to menstrual cycle
irregularity
 at 8 years post menarche in relation to the use of pelvic
ultrasound to identify a polycystic ovarian morphology.
Adolescents ‘at risk’ of PCOS
dr. Mohamed Alajami

63.  Reassessment is particularly important for adolescent girls with
 Persisting PCOS features
 Significant weight gain in adolescence
 Reassessment after hormonal therapy washout of >3 months.
Adolescents ‘at risk’ of PCOS
dr. Mohamed Alajami

64.  ‘Anxiety and depressive symptoms should be routinely screened
in all adolescents and women with PCOS at diagnosis’.
 If the screening results are positive, further evaluation and/or
referral for assessment and treatment.
 high prevalence of moderate to severe anxiety and depressive symptoms in
PCOS in adults and a likely increased prevalence in adolescence.
Emotional wellbeing
dr. Mohamed Alajami
Arch Pediatr Adolesc Med. 2002;156(6):556–0.
Hum Reprod Update. 2012;18(6): 638–51

65.  Women with PCOS indicate an increased prevalence of
disordered eating.
 the same applies to adolescent girls with PCOS is yet to be
determined.
Emotional wellbeing
dr. Mohamed Alajami

66. Screening, diagnostic assessment adolescent PCOS
֎Step 1: Irregular cycles + clinical hyperandrogenism
 (exclude other causes)* = diagnosis
֎Step 2: If no clinical hyperandrogenism
 Test for biochemical hyperandrogenism (exclude other causes)* = diagnosis
֎Step 3: If ONLY irregular cycles OR hyperandrogenism
 Adolescents ultrasound is not indicated = consider at risk of PCOS and
reassess later
 Adults - request ultrasound for PCOM, if positive (exclude other causes)* =
diagnosis.
ESHRE-ASRM 2018
dr. Mohamed Alajami

67. Screening, diagnostic assessment adolescent PCOS
* Exclusion of other causes requires:
1. TSH, Prolactin levels, FSH
2. if clinical status indicates other causes need to be excluded (e.g. CAH,
Cushing's, adrenal tumors etc)
3. Hypogonadotropic hypogonadism, generally due to low body fat or intensive
exercise, should also be excluded clinically and with LH and FSH levels.
ESHRE-ASRM 2018
dr. Mohamed Alajami

68.  All guidelines recommend screening for nonclassic congenital
adrenal hyperplasia (NCCAH).
 Most recommend screening for hypothyroidism
 Some recommend screening all hyperandrogenic women for
hyperprolactinemia.
dr. Mohamed Alajami
J Clin Endocrinol Metab. 2013; 98(12):4565–4592
Horm Res Paediatr. 2015;83(6):376–389
Eur J Clin Invest. 2012;42(1): 86–94
Gynecol Endocrinol. 2007;23:267–272
Screening, diagnostic assessment adolescent PCOS

69.  Goals of treatment are to improve quality of life and long-term
health outcomes.
 The treatment options for PCOS should be individualized to the
presentation, needs, and preferences of each patient.
dr. Mohamed Alajami
Treatment

70.  Lifestyle.
 Medications
1. COCP (estrogen and progestin preparations)
2. Combined COCP and metformin
3. Metformin
4. Antiandrogens
 No place for surgery
Treatment
dr. Mohamed Alajami

71.  Lifestyle modifications:
 including a calorie restricted diet and/or physical activity
 effective in altering the disease course of PCOS
 a critical first step for who are overweight or obese.
dr. Mohamed Alajami
Fertil Steril. 2018;110(3):364–379
Curr Pharm Des. 2018;24(39):4685–4692 J Clin Endocrinol Metab. 2013;98(12):4565–4592Med Sci Sports Exerc. 2009;41(3):497–504
Treatment/ Lifestyle

72.  Lifestyle modifications recommended as first-line interventions
in all adolescents with PCOS
 To prevent excess weight gain
 To achieve reductions in weight in those with excess weight
• decrease androgen production
• decrease central adiposity and insulin resistance
• weight loss 5–10% within 6 months considered
successful.
Treatment/ Lifestyle
dr. Mohamed Alajami
Fertil Steril. 2018;110(3):364–379
Curr Pharm Des. 2018;24(39):4685–4692
Med Sci Sports Exerc. 2009;41(3):497–504
EBR
CPP

73.  Weight gain is the number one priority expressed by young
women with PCOS.
 Obesity may induce PCOS by worsening features. (‘secondary
PCOS’??)
 exacerbates metabolic and psychological comorbidities in
adolescents with PCOS
Treatment/ Lifestyle
dr. Mohamed Alajami
Semin Reprod Med. 2018;36:35–41
J Obstet Gynaecol. 2017;37(8):1036–47
Ambul Pediatr. 2005;5(2):107–11

74.  Diet
 Exercise
 Weight loss
 Behavioral changes
 No smoking
Treatment/ Lifestyle
dr. Mohamed Alajami

75. 1. COCP (estrogen and progestin preparations)
2. Combined COCP and metformin
3. Metformin
4. Antiandrogens
Medications
dr. Mohamed Alajami

76.  The COCP alone for management of clinical hyperandrogenism
and/or irregular menstrual cycles
 should be in adolescents with a clear PCOS diagnosis or
 could be in those ‘at risk’ but not yet diagnosed with PCOS
COCP
dr. Mohamed Alajami
J Clin Endocrinol Metab. 2004;89(4):1592–7
J Clin Endocrinol Metab. 2008;93(11):4299–306
Pediatrics. 2016;137(5):e20154089
EBR

77. ֎ Improvement in menstrual pattern is generally noted within
the first 2 to 3 months.
֎ Duration of treatment with COC is not yet well defined.
 trial off the COC may be after one or more years of therapy
to allow for recovery of the HPO axis and observe if
spontaneous menstrual regularity returns.
dr. Mohamed Alajami
COCP

78.  Specific types or doses of progestins, estrogens or
combinations of COCP cannot currently be recommended
among women and adolescents with PCOS.
 COCPs with 35 μg of ethinylestradiol and cyproterone acetate
should not be used as first-line therapy due to
 No greater efficacy
 higher risks, including deep venous thrombosis.
dr. Mohamed Alajami
COCP
EBR
CCR

79.  Various COCP preparations have similar efficacy in treating
hirsutism.
 Lower-risk COCP preparations should be recommended as first-
line therapy.
 All COCPs are associated with an increased risk of DVT.
 higher with COCPs containing 30–35 μg of EE and gestodene, desogestrel
(Marvelon), cyproterone acetate (Dian) or drospirenone (Yasmin)
 Than COCP containing 20-30 μg of EE with levonorgestrel (Microgynon),
Norethisterone (norethindrone) or norgestimate.
dr. Mohamed Alajami
Cochrane. 2014
COCP
CPP
CPP

80.  The COCP in combination with metformin could be in
 adolescents with PCOS and a BMI > 25 kg/m2 where the
COCP and lifestyle changes do not achieve desired goals.
Combined COCP and metformin
dr. Mohamed Alajami
EBR

81.  Metformin in addition to lifestyle interventions could be
considered in adolescents with a clear PCOS diagnosis or with
symptoms of PCOS before a diagnosis is made.
 Metformin dose is 1500–2250 mg per day
 Starting at a low dose, with 500 mg increments 1–2 weekly and
extended release preparations may minimize side effects.
Metformin
dr. Mohamed Alajami
J Clin Endocrinol Metab. 2005;90(8):4593–8.
EBR
CPP

82.  The only clear indication for metformin is abnormal glucose
tolerance.
 A meta-analysis of RCT:
 metformin is effective as COC for treatment of hirsutism in
PCOS in adolescents.
Metformin
dr. Mohamed Alajami
Human Reproduction Update. 2015;21(5):560–574
Pediatrics 2016;137

83.  Recommend use of the COCP alone with cosmetic therapy for
at least 6 months prior to considering antiandrogens.
 Antiandrogens must be used in combination with the COCP
 antiandrogens could be used alone if COCPs are contraindicated
or poorly tolerated.
 Specific types or doses of antiandrogens cannot currently be
recommended with inadequate evidence in PCOS.
Antiandrogens
dr. Mohamed Alajami
EBR
EBR
CPP
EBR

84.  Antiandrogens are teratogenic (impairment of external genital
development in male fetuses).
 Use antiandrogen alone or in combination with a diet intervention.
 Flutamide
 finasteride
 spironolactone
Antiandrogens
dr. Mohamed Alajami
Fertil Steril. 2004;82(3):752–5
J Clin Endocrinol Metab. 2006;91(10):3970–80
J Reprod Infertil. 2014;15(4):205–13

85. ֎ Potent anti-androgen
֎ can be used in conjunction with COC or metformin.
֎ Combination metformin and spironolactone is superior to
either drug alone in improving hirsutism, serum androgen levels,
and insulin resistance.
Spironolactone
dr. Mohamed Alajami
J Clin Endocrinol Metab 2013;98:3599-607.

86. ֎ intermittent low-dose oral finasteride is effective for treatment
of hirsutism in adolescent girls with PCOS or idiopathic
hirsutism.
Finasteride
dr. Mohamed Alajami
J Pediatr Adolesc Gynecol 2014;27:161-5.

87. ֎ May offer more immediate results than pharmacotherapy.
֎ Electrolysis and laser hair removal therapies more effective.
֎ Eflornithine for topical hair removal offers benefit for hirsutism.
֎ Eflornithine can be combined with laser therapy for more rapid
reduction in facial hair.
Cosmetic hair removal
dr. Mohamed Alajami
Dermatol Surg 2006;32:1237-43.
J Am Acad Dermatol 2007;57:54-9.

88.  acne that is persistent and poorly responsive to topical
dermatologic therapy are:
 assessed for hyperandrogenemia before instituting
systemic medical treatments.
 ordinarily treated by (COC) pills or the systemic retinoid
Accutane.
Retinoid Accutane
dr. Mohamed Alajami
Pediatrics. 2013;131(suppl 3):S163–S186
Horm Res Paediatr. 2015;83(6):376–389

89. Retinoid Accutane
dr. Mohamed Alajami

90.  Appropriate diagnostic criteria for PCOS in adolescents are
otherwise unexplained persistent hyperandrogenic anovulation
using age- and stage-appropriate standards
 Great caution before labeling hyperandrogenic adolescents as
having PCOS if the menstrual abnormality has not persisted for
2 years or more.
 Before that point in time, they recommended that such girls be
considered to be “at-risk for PCOS”
dr. Mohamed Alajami
CONCLUSION

91.  initiation of a diagnostic workup should not be unnecessarily
delayed.
 initiation of diagnostic testing is advisable within 1 year if
treatment is required to control abnormal menstrual bleeding or
comorbidities or if symptoms suggestive of PCOS coexist
 Excessive uterine bleeding may mandate emergency evaluation
early in the course.
 Primary amenorrhea should be evaluated when recognized.
dr. Mohamed Alajami
CONCLUSION

92.  Importantly, a definitive diagnosis of PCOS is not needed to
initiate treatment.
 Treatment may decrease risk of future comorbidity even in the
absence of a definitive diagnosis.
 Deferring diagnosis, while providing symptom treatment and
regular/ frequent follow-up of symptomology, is a
recommended option.
CONCLUSION
dr. Mohamed Alajami

93.  Currently the only certain way to differentiate the
hyperandrogenemia of PCOS from that of physiologic
adolescent anovulation is by the persistence of PCOS into
adulthood.
dr. Mohamed Alajami
CONCLUSION

94. dr. Mohamed Alajami
Dear My colleagues,
Welcome to the city of Abi Al-Feda

95. dr. Mohamed Alajami
dr. Mohamed Alajami
have a nice evening