A presentation on PCOS in Adolescents. DR. KIRAN PANDEY and DR. PAVIKA LAL

1. Diagnosis of
Polycystic Ovary Syndrome
A DILEMMA &
A CHALLENGING CONCEPT
in ADOLESCENTS
Presented by:
Dr. Kiran Pandey
Professor & HOD
Deptt. Of Obs & Gyne
GSVM MEDICAL COLLEGE KANPUR
&
Dr. Pavika Lal
Assistant Professor
Deptt. Of Obs & Gyne
GSVM MEDICAL COLLEGE KANPUR

2. NAME : DR KIRAN PANDEY MD, FICOG, FIMSA, FICMCH, MAMS
DESIGNATION: Head of department , dept of OBG,
GSVM medical college, kanpur.
President 2016-18, kanpur obs & gynae society
Secretary upsc agoi 2017-2019
Vice-president state chapter (upcog) 2018-u.P.
CITY: KANPUR
AFFILIATIONS: GSVM MEDICAL COLLEGE, KANPUR
Organizing secretary : AGOI surgical video workshop & UPSC annual CME – Dec 2018
Organizing secretary : WWWCON – 2018
Organizing chairperson : adolescent workshop, emergency obstetrics workshop – oct 2018
Organizing chairperson : National Adolescent Conference Youth Summit And C.M.E 2017
Organising Secretary ,National Conf of Obs &Gynae 2015.
Organising Chairperson, Urogynaecology, NDVH, Pelvic Floor Repair Workshop, National Conference 2015
AWARDS: 11 National, 8 State level & 8 District level Awards & >30 awards at IMA
FOGSI facilitated with Nari Swasthya Award in AICOG(ODISHA) 2018.
Awarded “Certificate of Appreciation“ for excellent contribution in family welfare 2017-2018
Received “President Appreciation Award” from Adolescent Health Committee at AICOG.
Received “Matrashakti Samaan Award” on International Women’s day 2019
Honoured by Mr.Satyadev Pachauri Minister of Khadi and Village Industries organised by Amar Ujjala Aprajita
(100 million smiles).
 Received DR VC RASTOGI AWARD for Best women doctor in IMA UP State.
 Received WOMEN OF SUBSTANCE award on international women’s day 2009-10.
Working towards a new Innovation for early diagnosis of cervical cancer with IIT kanpur – ‘GYTI’AWARD
from NIF India at RASHTRAPATI BHAWAN
FOGSI AWARD for original research work ”Dr.Chitrathara and Dr.Gangadharan preventive &
research oncology award”
PUBLICATIONS: Published > 100 research Papers in National & International Journals
Contributed chapters in various books- Fetus in-utero, Abnormal Uterine Bleeding, Amniotic fluid embolism,
Gestational diabetes in “Current trends” , epilepsy in pregnancy, PCOS & auto immunity, maternal monitoring in pre
eclampsia
SPECIAL INTRESTS: GYNAE-Oncology, Infertility, Adolescent health, Uro-gynaecology, High risk pregnancy

3. (Dunaif 1995 , Norman etal 2002)

4. Prevalence
50% PCOS
20-33% PCO
5-25% PCOS

5. Polycystic Ovarian Syndrome
Multi-gene
environmental
interaction

6. Cause for PCOitial population of primordial
More PGC entering ovary?
More cell divisions?
More folliclesformed?
Lower rate of atresia?
Higher initial population of
primordial follicles?
Lower rate of atresia?

7. 0 10 20 30 40 50 60 70 80
SGA
Age
Premature
adrenarche
Adolescent
PCOS
GDM
Infertility
DM
Endometrial
ca
CVS disease
Consequences of PCOS spectrum is
seen across the entire lifespan of a woman
Multidisciplinary approach
Pediatrician Dermatologist Gynecologist Endocrinologist Diabetologist Cardiologist Geriatrics

8. Why define and diagnose PCOS?
 Obesity
 Hyperinsulinaemia and IR
 Elevated VEGF
 Elevated LH and
androgens
 Increased pre-antral and
small antral follicle cohort
 Excessive ovarian
response with OHSS
 Cycle cancellation
 Slow and poor growth
of follicles
 Poor oocyte quality
 Miscarriage
Identify Problems associated with PCOS during
infertility treatment

9. Why define and diagnose PCOS?
 Obesity
 Insulin resistance
 Hyperinsulinaemia
 Hyperandrogenism
 Anovulation
 Impaired glucose tolerance
 Type 2 diabetes
 Hypertension
 Dyslipidemia
 Increased CV risk
 ↑ risk of endometrial
hyperplasia/endometrial CA
 ? Breast CA
Identify Problems associated with PCOS resulting in
Metabolic syndrome and long term sequale

10. None of the criteria addressed insulin resistance
and metabolic manifestation
Diagnostic Criteria

11. Exclude other etiologies of androgen excess

12. Other etiologies Of Androgen Excess
 Congenital Adrenal Hyperplasia (CAH)
 Cushing's Syndrome
 Androgen producing tumor-ovary or adrenal
 Exogenous sex steroids
 Simple Obesity
 Severely insulin resistant states
 Other menstrual disorders

13. Other Causes Of Menstrual Irregularity

14. Characters of PCOS Phenotype
Andro
gen
levels
LH/FS
H
Insulin
resista
nce
CV
risk
PCOM MENS
PROB
Type I
Classic
PCOS/FR
ANK
Increa
sed
Increa
sed
Increas
ed
Increa
sed
+ OLIGO
Type II
NON PCO
PCOS
Increa
sed
Mild
increa
se
Increas
ed
Increa
sed
- OLIGO
Ovulatory
PCOS
Increa
sed
Norma
l
Mild
increas
e
Mild
increa
se
+ REGU
LAR
Normoandr
ogenic
PCOS(MILD)
Normal Increa
sed
Normal Norma
l?
+ OLIGO

15. Chronic
anovulation
Hyper
androgenism
Polycystic
ovaries
CA+
PCO
HA+
CA
PCO
+HA
PHENOTYPE
A/B(non PCO-PCOS )
PHENOTYPE D
(normo-androgenic PCOS)
PHENOTYPE C(ovulatory PCOS)
FRANK

16. REASONS FOR PHENOTYPING
• PCO syndrome presents with varied
combinations of clinical features each of
which has varied prevalence.
• ITS IMPORTANT TO IDENTIFY DIFFERENT
CLINICAL PHENOTYPES FOR RISK EVALUATION
AND TREATMENT ACCORDINGLY

17. Why LH/FSH ratio was excluded
from NIH 2012 criteria?
Difficulties with Using Serum LH/FSH levels to diagnosis
PCOS
Arroyo A et al. JCEM
1997;82:3728-3733

18. GUIDELINES FROM ENDOCRINE SOCIETY
RECOMMEND THAT ALL THE 3 OF THE
ROTTERDAMS CRITEREA SHOULD BE MET TO
LABEL AN ADOLESCENT PATIENT AS PCOS
ONLY MOST SEVERE PHENOTYPE TYPE 1 CLASSIC PCOS IS
DIAGNOSED
OTHER PCOS PHENOTYPES CANNOT BE DIAGNOSED
PATIENTS WITH INCOMPLETE SYMPTOMS KEPT UNDER
STRICT FOLLOW UP FINAL DIAGNOSIS AFTER 18YRS
DIAGNOSIS OF PCOS IN ADOLESCENTS

19. Carmina, Oberfield and Lobo. AJOG 2010
Proposed diagnostic criteria for PCOS
during Adolescence
Hyperandrogenism
biochemically confirmed
Menstrual irregularities
Present for at least 2 years post
menarche
Polycystic Ovaries
include both increased size(12 cucm as
compared to 10 cucm in adults) and
increased number of follicles
+
+

20. However all return to normal at
the end of normal puberty but
remain elevated in PCOS
Why Adult Criteria not
applicable to Young PCOS?
RCOG Scientific Study Group, 2010

21. Clinical Manifestations of PCOS
 Hirsutism
 Acne
 Amenorrhea/Oligomenorrhea
 Infertility
 Early pregnancy loss
Metabolic aspects:
 Obesity
 Insulin resistance
 Type 2 diabetes (10% by age 40s)
 Cardiovascular disease

23. Investigations
• ULTRASOUND
• ANDROGEN PROFILE
• TOTAL AND FREE <0.5nmol/L
• FAI (TOTAL TESTOSTERONE /SHBG * 100)
normal range- 7 to 10
• 17-OH-P normal range- 20 to 100ng/dL
• SHBG 16-119nmol/L
• FSH/LH/E2/PROLACTIN
• AMH
• TFTs
• LIPID PROFILE
• INSULIN RESISTANCE
• GLUCOSE TOLERANCE

24. Ultrasound Assessment of PCO
International Consensus Definitions
 Polycystic ovary contains 12 or more follicles
measuring 2-9 mm in diameter on day 2 or 3 of MC
and/or
 increased ovarian volume (>10 cm3)
No dominant follicle > 10mm or CL
Balen, Laven, Tan & Dewailly; Hum Reprod Update 2003; 9: 505
ESHRE/ASRM Consensus 2003
Does not apply to women taking OCP, as ovarian size is
reduced, even though the polycystic appearance may persist

25. For the definition of PCO morphology, the former
threshold of >12 for follicle number is no longer valid.
A serum AMH >35 pmol/l (or >5 ng/ml) appears to be
more sensitive and specific than a Follicle Number >19
and should be therefore included in the current
diagnostic classifications for PCOS.
FOR DEFINITION OF PCO MORPHOLOGY

26. Pigny et al JCEM 2003; 88:5957
Laven et al JCEM 2004; 89:318
Dewailly et al JCEM 2010; Hum Rep 2011
Revisiting The Criteria For Pcom: should we
keep the follicle count or switch to AMH?

29. Differences between women with
polycystic ovaries only and
with polycystic ovary syndrome?
 PCO represents a milder end of the
PCOS spectrum
 Longitudinal data still required
-Balen, Homburg, Franks, BMJ 2009
5 mm
2nd
millenium
3rd
millenium
F
th
no
U/S definition of
PCOM has
changed…
USG picture of unilateral increased ovarian volume with a
contralateral normal looking ovary should rise suspesion
of underlying tumor pathology

30. LH and IGF-I
effect
on theca cells
Cytochrome
p-450c 17-alpha
activity
Androgen secretion
Non-obese Obese
IGFBP-I
IGF-I
Insulin resistance
Hyperinsulinemia
SHBG
LH GH
Insler et al. Hum Reprod.
1993

31.  A diagnostic feature that allows for discrimination from
other causes of the combination of oilgomenorrhea and
polycystic ovaries
 The feature that is best associated with metabolic
abnormalities
 IR and Metabolic syndrome
 CVD Risk
 A prognostic factor for treatment succes
Androgens are not strong markers of PCOS but may be done
to rule out other etiologies
Should androgen testing be done in
all patients of PCOS?

32. Screening for Insulin Resistance(IR)
 Acanthosis nigricans
 Truncal Obesity
 OGTT
 Fasting Glucose/fasting Insulin<4.5 is suggestive of
IR ratio
Clinical markers of IR

33. Homeostatic
model
assassment-
HOMA-IR:
=I (mIU/L) X G
(mmol/L)/22.5
Quantitative
insulin sensitivity
check index-
QUICKI
=1/ log I (mIU/L) +
log G (mg/dl)
Both are markers of insulin resistance in
PCOS patients

34. Screening for Glucose Tolerance
in PCOS
HbA1c measures the efficacy of glucose lowering treatment
A normal HbA1c cannot exclude DM or IGT

35. Why Insulin Levels Should Not be
Used to diagnose PCOS

36. VITAMIN D
deficiency
Decreased
1,25 OHD
Decreased
Insulin
secretion
Insulin receptor
dysfunction
INSULIN RESISTANCE
Calcium
dysfunction
Follicular arrest
Anovulation
INFERTILITY
increased
testosterone
HIRSUITISM, ACNE,
HYPERANDROGENISM
Increased PTH&
decreased
SHBG
Currently there are no
standard guidelines for
vitamin D supplementations
for PCOS management

37. Circulating markers of oxidative stress are
abnormal in women with PCOS
independent of weight excess
may contribute in the pathophysiology of PCOS
However in light of current evidence neither the
routine measurement of markers of oxidative stress
nor the use of antioxidant therapies can be
recommended in PCOS

38. • PCOS IS AN ICE BERG WITH MULTIPLE
TIPS AND BROADENED BASE
• ITS IMPORTANT TO IDENTIFY DIFFERENT
CLINICAL PHENOTYPES FOR RISK
STRATIFICATION AND MANAGEMENT
ACCORDINGLY
• SERUM AMH≥ 35PMOL/L (5 NG/ML)
IS MORE SENSITIVE THAN U/S TO
DETECT PCOM
Take Home Messages

39. Take Home Messages
• IN ADOLESCENT PATIENTS ALL THE 3 OF THE
ROTTERDAMS CRITERIA SHOULD BE MET TO
LABEL HER AS PCOS
• ANDROGEN LEVEL & IR TESTING ARE NOT
DAGNOSTIC BUT ITS OF PROGNOSTIC
SIGNIFICANCE
• CURRENTLY THERE ARE NO
RECOMMENDATIONS FOR THE USE OF ANTI-
OXIDANT THERAPY OR VITAMIN D
SUPPLEMENTATIONS IN TREATMENT OF PCOS
• LH/FSH RATIO IS EXCLUDED FROM NIH 2012
CRITERIA

40. Thank
You