Any adolescent girl with complaints of hirsutism, menstrual disorders, or obesity should be considered for polycystic ovary syndrome (PCOS). Acanthosis, anti-acne treatment, head hair loss, or excessive sweating may also be among the complaints, although these features are not always present. pCOS is characterized by ovulatory disturbances and hyperandrogenemia. A diagnosis of PCOS has a lifelong impact on increasing the risk of infertility, metabolic syndrome, and type 2 diabetes, and may also increase the incidence of cardiovascular disease and endometrial cancer. The treatment of adolescent PCOS focuses on its main clinical manifestations, which are.
1. abnormal uterine bleeding – irregular or excessive menstruation 2. skin hyperandrogenism – mainly hirsutism and persistent acne 3. obesity and insulin resistance A number of treatment options are available for these symptoms in adults, and some options can address more than one of these symptoms. Few studies have been devoted to the treatment of adolescent PCOS, so their treatment is based primarily on studies of adult PCOS. This review discusses the management of PCOS and its associated symptoms for adolescents.
The choice of PCOS treatment depends on each adolescent’s symptoms and her goals and her own choices. First-line treatment is usually a combination of oral contraceptive pills (OCPs), as these correct menstrual disorders and hyperandrogenemia. If hirsutism is not satisfactorily controlled by cosmetic products and OCP therapy, physical hair removal methods and anti-androgen therapy will be added. Lifestyle changes are the first line of treatment for overweight and obesity. If dysglycemic tolerance or dyslipidemia of the metabolic syndrome cannot be normalized by weight loss, metformin is recommended at this time. This approach is consistent with the Endocrine Society guidelines for the treatment of adolescent PCOS.
Treatment of adolescent PCOS also includes evaluation of first-degree relatives, as there is a familial component to the hyperandrogenemia and metabolic syndrome components.
The optimal duration of treatment has not been determined. Given the usual persistence of PCOS, little is known about the natural history of adolescent PCOS, especially in those with mild disease. We recommend continued treatment until the patient reaches gynecologic maturity (5 years after menarche) or significant weight loss in overweight.
Treatment goals include addressing the following major symptoms.
1. Abnormal uterine bleeding: Adolescent PCOS is characterized by anovulation and presents with menstrual disorders and/or excessive menstrual flow (AUB). The thresholds defining the pattern of abnormal uterine bleeding in adolescents will be discussed separately.
2. Menstrual disorders: Menstrual disorders in adolescents with PCOS need to be treated not only because of psychosocial factors but also because of the increased risk of developing endometrial hyperplasia due to prolonged anovulation, which is associated with endometrial cancer. Progestin is a key component in the combined oral contraceptive pill and has the effect of inhibiting endometrial hyperplasia; progestin prevents the proliferative effect of unantagonized estrogen on the endometrium.
3. Excessive menstrual flow: Irregular excessive menstrual flow due to ovulatory dysfunction is a common manifestation of PCOS, while often being the initial complaint. Heavy uterine bleeding can cause severe anemia. Combination oral contraceptive pills or progestin therapy alone are often effective in treating these symptoms.
4. High androgen-induced skin problems: More than half of adolescents with PCOS have hirsutism or acne. If cosmetic products and dermatological treatments are not effective enough, medical endocrine therapy is needed.
The goal of hormone therapy is to reduce the effects of excess androgens on the body by.
1. Reducing androgen production by decreasing serum free androgen levels by increasing the binding of androgens to plasma binding proteins and blocking androgen action at the level of target organs (e.g. hair follicles).
OCPs reduce ovarian production of androgens primarily by decreasing serum gonadotropin levels, and the estrogen component of OCPs reduces serum free testosterone levels by increasing sex hormone-binding globulin (SHBG) levels; OCPs also reduce dehydroepiandrosterone (DHEA) sulfate levels as appropriate. Lowering androgen levels may prevent further conversion of millia to terminal hairs during androgen exposure. In most patients with PCOS, OCPs treatment is expected to stop the progression of hirsutism, reduce the need to shave in about half of patients, and improve acne within 3 months.
2. Anti-androgen therapy, which inhibits the binding of androgens to their receptors, is used in patients with hirsutism who do not respond well to OCP therapy.
Obesity and insulin resistance: Insulin resistance hyperinsulinemia is an important factor in the pathogenesis of PCOS and its complications. Insulin resistance reduction therapy can improve ovulation appropriately and improve hyperandrogenemia slightly. Obesity is an important factor in causing insulin resistance in PCOS, although insulin resistance is not proportional to the degree of obesity. Insulin resistance usually manifests as acanthosis and metabolic syndrome, although insulin resistance can sometimes be present in the absence of these clinical manifestations. Diet and exercise are the first line of treatment to address obesity in adolescent PCOS patients. Metformin is indicated for patients with abnormal glucose tolerance and is often used as an adjunctive treatment for OCPs.
Treatment: Hormonal therapy with estrogen-progestin combination contraceptives combined with weight management in obese patients is usually the first line of treatment for PCOS. Additional therapeutic measures may be added for patients with hyperandrogenic skin problems or abnormal glucose tolerance that cannot be adequately controlled by hormone therapy alone.
There are several treatment options available for adolescents with polycystic ovary syndrome. The choice of treatment depends on each adolescent’s symptoms, her treatment goals and options (e.g., cost).
We recommend the use of a combination of oral contraceptives as first-line treatment for adolescents with PCOS menstrual and skin symptoms over other treatments. The progestin component inhibits endometrial proliferation and prevents hyperplasia and the risk associated with developing endometrial cancer. The estrogen component reduces excess androgens, allowing for rapid correction of abnormal menstruation and improvement of hirsutism and acne, and the effects of OCPs in the treatment of hirsutism and acne can be seen after 3 to 6 months of treatment. In principle, OCPs need to be continued until the patient reaches gynecological maturity (5 years after menarche) or until significant weight loss in overweight. At this point in time, the trial treatment reasonably demonstrates the persistence of symptoms.
If adolescent patients are unable or unwilling to take a combination OCP, the other major treatment option for menstrual disorders is progestin.
For patients with severe hirsutism who have not achieved satisfactory results with cosmetic products (e.g., shaving, bleaching, depilatory agents) in combination with OCPs as initial treatment, we recommend either physical hair removal or anti-androgen therapy. The decision on treatment options involves patient selection, cost of treatment, tolerance of discomfort/pain, risk of complications, and outcomes.
Weight loss in obese adolescents with PCOS improves menstrual disorders, acanthosis nigricans, and hyperandrogenemia. Weight loss (e.g., exercise and diet) is also needed in obese patients without PCOS.