polycystic ovary syndrome in adolescents. DR. Nedaa Bahkali 2012. Menstrual cycles are often irregular in the first months after menarche. According to a study by WHO : the median length of the first cycle after menarche was 34 days, - PowerPoint PPT Presentation
polycystic ovary syndrome in adolescents
polycystic ovary syndrome in adolescentsDR. Nedaa Bahkali 2012Menstrual cycles are often irregular in the first months after menarche. According to a study by WHO : the median length of the first cycle after menarche was 34 days, with 38%of the cycles > 40 days and 7 % occurring 1.0 cc) or a corpus luteum.
Using these criteria, a polycystic ovary can be identified by ultrasonography in about 75 % of women with PCOS.UltrasonographyExcessive ovarian size is defined as an ovary with a volume >10.5 mL in adults >10.8 mL in adolescents. An alternate measure of increased volume is a maximal area >5.5 cm2. Most polycystic ovaries in PCOS are enlarged.
Excessive follicle number is defined by vaginal ultrasonography as a total follicle count of 12 per ovary. In adolescents in whom abdominal rather than vaginal ultrasonography is indicated, it is defined as 10 follicles per maximum plane . These follicles are typically 2 to 9 mm in diameter.Asymptomatic volunteers with a polycystic ovary are a functionally distinct but heterogeneous population, J Clin Endocrinol Metab. 2009, Section of Adult and Pediatric Endocrinology, The University of Chicago , USA.
UltrasonographyThe transabdominal ultrasonographic approach that is standard and appropriate in virginal adolescents may underestimate the prevalence of polycystic ovaries in comparison with the transvaginal approach used in adult women .
This difference is modest.
In a prospective study of patients with PCOS in which these criteria were used , a polycystic ovary was found in 69 percent of adolescents and 87 percent of adults (p = 0.12, unpublished data).
The advantage of the transabdominal approach is that a screening for an adrenal mass is facilitated.
Asymptomatic volunteers with a polycystic ovary are a functionally distinct but heterogeneous population, J Clin Endocrinol Metab. 2009, Section of Adult and Pediatric Endocrinology, The University of Chicago , USA.Gynecologic imaging: comparison of transabdominal and transvaginal sonography, Radiology. 1988, Department of Radiology, West Penn Hospital, Pittsburgh, PA
UltrasonographyWhile a polycystic ovary is a criterion for ovarian dysfunction in the setting of hyperandrogenism, in the absence of hyperandrogenism a polycystic ovary is usually a normal variant.Polycystic ovaries are common in the general population,found in about 10 % of regularly menstruating adolescents.Polycystic ovaries in adolescents and the relationship with menstrual cycle patterns, luteinizing hormone, androgens, and insulin, Fertil Steril. 2000, Division of Reproductive Endocrinology and Fertility, Vrije Universiteit Medical Center, Amsterdam, The Netherlands.ADDITIONAL EVALUATION OF PCOS PATIENTSOnce a diagnosis of PCOS has been established, identifying abnormal glucose tolerance or other features of the metabolic syndrome is important because PCOS is a risk factor for the early development of type 2 diabetes mellitus, metabolic syndrome, and their associated risks for sleep-disordered breathing and cardiovascular risk sequelae .Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: role of insulin resistance, J Clin Endocrinol Metab. 2001, Sleep Research and Treatment Center, Department of Psychiatry, Penn State University College of Medicine, USA. Relationships between sleep disordered breathing and glucose metabolism in polycystic ovary syndrome, J Clin Endocrinol Metab. 2006, Department of Medicine, University of Chicago, Chicago, USA.
About a quarter of adolescents with PCOS meet proposed adolescent criteria for the metabolic syndrome [17,23,24].
screening for abnormal glucose tolerance, performing an oral glucose tolerance test (OGTT) in adolescents with obesity or other risk factors for diabetes mellitus, even if the fasting blood sugar is normal.This is the recommendations made by the Rotterdam workshop ,the American Association of Clinical Endocrinologists, and the Androgen Excess and PCOS Society in adult women with PCOS.
The prevalence of diabetes was reported to be 2 % based on the fasting blood sugar in one series, and 8 % when based on OGTT criteria in another series of adolescents.In both series, almost all of the adolescents had no symptoms of diabetes.
Relationship of adolescent polycystic ovary syndrome to parental metabolic syndrome, J Clin Endocrinol Metab. 2006, University of Chicago Comer Children's Hospital, Section of Pediatric Endocrinology, USA.
Adolescent girls with polycystic ovary syndrome have an increased risk of the metabolic syndrome associated with increasing androgen levels independent of obesity and insulin resistance, J Clin Endocrinol Metab. 2006, Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, USAIn patients with PCOS:
Glucose tolerance should be monitored regularly because a substantial number will experience deterioration in glucose tolerance.
As an example, among 25 adolescent and young women followed for a mean of 34 months, the two hour blood glucose deteriorated at an average of 9 mg/dL (0.5 mmol/L) per year .
Among the 14 women with PCOS and normal glucose tolerance at baseline, 55 percent experienced deterioration of glucose tolerance when they were retested with an OGTT.
Among the 14 women with PCOS and impaired glucose tolerance at baseline, 29 percent progressed to diabetes.
Prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome, Diabetes Care. 1999, Department of Medicine, University of Chicago, Illinois, USA.
PCOS is a risk factor for endometrial carcinoma. The basis of the risk is multifactorial:arise from the combined effects of unopposed estrogens on the endometrium, caused by chronic oligo-anovulation and progesterone resistance, obesity, hyperinsulinemia, and hyperandrogenism.
Polycystic ovary syndrome and endometrial cancer, Semin Reprod Med. 2008, University Department of Obstetrics and Gynaecology, Royal Free and University College Medical School, University College London, London, United Kingdom.
Polycystic ovary syndrome increases the risk of endometrial cancer in women aged less than 50 years: an Australian case-control study, Cancer Causes Control. 2010, School of Population Health, The University of Queensland, Herston Road, Herston, QLD 4006, Australia.
Progesterone Resistance in PCOS Endometrium: A Microarray Analysis in Clomiphene Citrate-Treated and Artificial Menstrual Cycles, J Clin Endocrinol Metab. 2011, Department of Obstetrics and Gynecology, Greenville Hospital System, Greenville, South Carolina .EVALUATION OF FAMILY MEMBERS:There is a high frequency of PCOS and metabolic syndrome among immediate relatives of individuals with PCOS.
According to one study,approximately one-half of sisters of PCOS have an elevated serum testosterone level, and half of these in turn have menstrual irregularity and thus meet NIH criteria for PCOS .Evidence for a genetic basis for hyperandrogenemia in polycystic ovary syndrome, Proc Natl Acad Sci U S A. 1998 Department of Obstetrics and Gynecology, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA.In another study, of sisters met Rotterdam criteria for PCOS, having hyperandrogenism and a polycystic ovary, although menses were ovulatory .
Ovarian morphology is a marker of heritable biochemical traits in sisters with polycystic ovaries, J Clin Endocrinol Metab. 2008, Institute of Reproductive and Developmental Biology, Imperial College London,UK.Treatment of polycystic ovary syndrome in adolescents
Treatment for PCOS in adolescents is directed at the following clinical manifestations:
Menstrual irregularity Cutaneous hyperandrogenism, primarily hirsutism and acne .Obesity and insulin resistance.MENSTRUAL IRREGULARITYMenstrual irregularity should be treated in adolescents with PCOS:chronic anovulation increases the risk of developing endometrial hyperplasia, which is associated with endometrial carcinoma.
Anemia can result from dysfunctional uterine bleeding or menorrhagia. Combination OCPsthe first-line treatment.
OCPs induce regular menstrual periods with a higher degree of reliability than other forms of treatment.Combination OCPsCombination OCPsNorgestimate: a potent progestin with low androgenic effect and is combined with ethinyl estradiol: 35 mcg (in Ortho-Tri-Cyclen). It is especially useful for patients with associated acne vulgaris, for which it has received (FDA) approval. There is variable absorption of this medication, and adjustment of dose may be necessary.
Combination OCPsEthynodiol diacetate: a progestin of low androgenic potential, is combined with ethinyl estradiol: 35 or 50 mcg (in Zovia 1/35-28 or 1/50-28, respectively). The 1/50 preparation is useful for patients who require a large dose of estrogen, such as those with obesity or dysfunctional uterine bleeding.
Combination OCPsAfter three months, the efficacy of treatment is assessed by evaluating clinical symptoms and androgen levels.
If the treatment is effective, as a general rule, OCPs should be continued until the patient is gynecologically mature (five years postmenarcheal) or has lost a substantial amount of excess weight.
At that point, withholding treatment for a few months to allow recovery of suppression of pituitary-gonadal function and to ascertain whether the menstrual abnormality is persistent is advisable.
In doing so, however, one must keep in mind that the anovulatory cycles of PCOS lead to relative infertility, not absolute infertility.
Combination OCPsIf treatment is not successful in reducing androgen levels, the patient either