Summary of Criteria for Diagnosis of PCOS in Adolescents
(1) Irregular menstrual cycles or lack of menstrual cycles (see definitions above)
(2) Hyperandrogenism, defined as
· Hirsutism or severe acne or andoagenetic alopecia
· and/or biochemical hyperandrogenaemia confirmed using validated high-quality assays.
(3) Exclusion of other endocrine disorders that mimic PCOS including congenital adrenal hyperplasia, Cushing syndrome, prolactinomas, androgen secreting tumours, thyroid disease, hypothalamic amenorrhea, primary ovarian insufficiency and acromegaly.
Adolescents are said to be “at risk” if they have features of PCOS but do not meet diagnostic criteria above. These individuals require frequent re-evaluation.
Comment on Use of Ultrasound in Adolescents
I’m often asked in adolescents with suspected PCOS should have ultrasound examinations. The answer for most adolescents is quite straightforward: No! Ultrasounds are not helpful because polycystic ovarian morphology is so common normally in adolescents and does not mean the individuals has PCOS. Ultrasound tests are only useful if it has been MORE THAN 8 years since menarche.
But even if an individual is now more than 8 years since her first period and PCOS is a possible diagnosis that is being considered, an ultrasound is NOT necessary for the diagnosis of PCOSS if she has irregular periods and high androgens on blood tests. The diagnosis of PCOS has been confirmed without the need for ultrasound!
If it is decided that ultrasound is going to be done for further evaluation of PCOS, one really needs the patient to go to an experienced radiology clinic that scans a lot of women. It takes an experienced ultraound technician to generated a good and consistently helpful report. That’s another story but one must not forget this point. Second, one needs to decide if “transabdominal” or “transvaginal” ultrasound testing is going to be done. In a transabdominal scan, the ultrasound probe is placed on the abdomen. In a transvaginal scan, the probe is placed in the vagina.
Transvaginal ultrasound is best as it allows follicle number to be properly assessed – provided that modern ultrasound transducers are used to scan the patient. An accurate assessment of follicle number can not be done with transabdominal ultrasound. The same principle is true for both adolescents and adults. A transvaginal ultrasound is generally considered only if the patient is sexually active and the test is considered acceptable to the patient.
If transabdominal ultrasound is done, a “positive test result” would be the measurement of either ovary as more than 10 mL. There is no role for assessing follicle number with the transabdominal scan as the scan is not sensitive enough to assess this. If transvaginal ultrasound is done, a “positive test result” would be measurement of either ovary as more than 10 mL or the finding of more than 20 follicles per ovary. (The prior cut off was much lower so readers should note the new number of 20).
The diagnosis of PCOS in adolescents requires some evidence of “irregular periods” and some evidence of “hyperandrogenism.” Ultrasound scans are not to be done if it has been less than 8 years since the time of the first period. A proper history and physical examination along with blood tests are necessary to rule out other medical conditions.