Consensus has recently been reached by international pediatric subspecialty societies that otherwise unexplained persistent hyperandrogenic
anovulation using age- and stage-appropriate standards are appropriate diagnostic criteria for
polycystic ovary syndrome (PCOS) in adolescents. The purpose of this review is to summarize these recommendations and discuss their basis and implications.
Anovulation is indicated by abnormal
uterine bleeding, which exists when menstrual cycle length is outside the normal range or
bleeding is excessive: cycles outside 19 to 90 days are always abnormal, and most are 21 to 45 days even during the first postmenarcheal year. Continued menstrual abnormality in a hyperandrogenic adolescent for 1 year prognosticates at least 50% risk of persistence.
Hyperandrogenism is best indicated by persistent elevation of serum
testosterone above adult norms as determined in a reliable reference laboratory. Because hyperandrogenemia documentation can be problematic, moderate-severe
hirsutism constitutes clinical evidence of
hyperandrogenism. Moderate-severe inflammatory
acne vulgaris unresponsive to topical treatment is an indication to test for hyperandrogenemia. Treatment of PCOS is symptom-directed. Cyclic
estrogen-
progestin oral contraceptives are ordinarily the preferred first-line medical treatment because they reliably improve both the menstrual abnormality and
hyperandrogenism. First-line treatment of the comorbidities of
obesity and
insulin resistance is lifestyle modification with calorie restriction and increased exercise.
Metformin in conjunction with behavior modification is indicated for
glucose intolerance. Although persistence of hyperandrogenic
anovulation for ≥2 years ensures the distinction of PCOS from physiologic
anovulation, early workup is advisable to make a provisional diagnosis so that
combined oral contraceptive treatment, which will mask diagnosis by suppressing hyperandrogenemia, is not unnecessarily delayed.